Back to Basics Ophthalmology: Acute visual disturbance/loss

1. Back to Basics Ophthalmology:Acute visual disturbance/loss Sylvia Chen PGY-3 Ophthalmology

2. Outline • History • Exam • Acute visual loss • Trauma • Acute angle closure glaucoma • Retinal detachment • Retinal vascular occlusion • Diabetic retinopathy • Wet macular degeneration • Optic nerve disease

3. Ophthalmology Consult Pet-Peeves • Examples • “floaters” • Vision? Which eye? How long? Flashes of light? Curtain over vision? • “decreased vision” • Vision - 20/30 vs 20/200? Sudden onset vs. gradual? RAPD? DM/HTN/Cholesterolemia/CAD/headache • “red eye” • Vision? Recent viral illness? Discharge? Photophobia? • “swollen eye – can’t see eye” • Vision? • Trauma? Mechanism? Allergy? Recent illness/Infection? • Blood? From where? – lid/conjunctiva/inside eye (hyphema)

4. History • Onset • Acute vs. chronic • Acute onset vs acute perception of visual loss • One eye or both eyes • Trauma? • Mechanism • Character • Sudden vs. gradual • Permanent vs. transient • Flashes • Floaters “flies, cobwebs” • Veil covering vision • “Curtain coming down”

5. Associated symptoms • Headache • Pain on eye movement • Photophobia • Temporal headache, jaw claudication, weakness, fever, wt loss, loss of appetite • Past Medical History • DM • HTN • Dyslipidemia • Afib • CAD • PMR • Arthritis

6. FamHx • Any ocular probs • RD, macular degeneration, glaucoma, blindness • Meds • Plaquenil/chloroquine for RA • Diamox for glaucoma • Anticholinergics – allergy meds, antidepressants • Eye drops • Social • Tobacco • EtOH abuse • Trauma • Tetanus, last meal, allergies

7. Past Ocular History • Visual history • Lazy eye, crossed eyes, asymmetric vision as child • Glasses (hyperope/myope), CL use • Eye Injury • Treatment required? Visual outcome? • Eye Surgery • Cataract, glaucoma, retinal detachment (buckle, gas bubble), crossed eyes • Laser Treatment • DM, Glaucoma, after cataract surgery, retinal hole or detachment • Drops • Prescription or not? For glaucoma (eye pressure)? Post-op? Steroid? Antibiotics?

8. Examination • Visual acuity • 20/30 vs. 20/200 • Pupils/Iris • RAPD • peaked pupil • Muscles • Movements

9. External Exam • Lids • Conjunctiva • injection • chemosis • Corneal • abrasion • haze • Anterior chamber • Blood? • IOP • Visual field

10. Fundus – a bonus if you can see it! • Optic nerve swelling • Macula • Drusen • Exudates • Blood • Vessels • Dilated • Tortuous • Retinal blood • Vitreous haze/hemorrhage

11. Acute vision loss: TRAUMA • Mechanism of injury • Globe Rupture • Ophthalmic Emergency! • Vision • Tetanus • Ancef • NPO • CT orbits • OR tonite!

13. Hyphema • Blunt trauma • Soccer ball / baseball • Bungee cord • Punch • Associated corneal abrasion • Occult globe rupture? – check IOP

14. Angle Closure Glaucoma • Symptoms • Pain • Nausea & vomiting • Decreased vision • History • Hyperope (short eye) • F>M • Increasing age • Meds: anticholinergics, antidepressants

15. Signs Cloudy cornea Red eyes Mid-dilation of the pupil Forward bowing iris (narrow drainage angle) High intraocular pressure (as high as 4X normal pressure) Ophtho today

16. Retinal Detachment • Risk factors • Myopia • Personal history of tear/detachment • Family history of tear/detachment • Intraocular surgery • Pseudophakia • Signs • Floaters • 50-100 new “flies” • Flashes • Lightning flashes • Veil covering vision • Painless

17. Macula on • Ophtho today • Macula-off • can wait till tomorrow

18. Branch retinal vein occlusion (BRVO) • Painless loss in vision • Visual field defect • Not an emergency

19. Central retinal vein occlusion (CRVO) • Painless vision loss • May have an RAPD • If young • hypercoagulation workup • Not an emergency

20. Branch retinal artery occlusion (BRAO) • Painless vision loss • Embolic work-up • ECG, Echo, Carotid dopplers • RF management • Chol, BP, DM • Not an emergency

21. Central retinal artery occlusion (CRAO) • Painless vision loss • May have an RAPD • If within first 90 minutes • Ocular massage • Embolic work-up • ECG, Echo, Carotid dopplers • RF management – Chol, BP, DM • Not an emergency

22. Stroke • Both eyes affected • Homonymous visual defect

23. Diabetic Retinopathy • Glucose control? • HgA1c • BP control? • Nephropathy/neuropathy? • Proliferative disease • Look at fellow eye • Prior laser treatment?

24. Most commonly from proliferative diabetic retinopathy Also retinal tear, trauma, tumour… Refer to Ophthalmology Vitreous hemorrhage

25. Neovascular glaucoma • Neovascularization of the iris • Diabetes • Ocular ischemia • CRVO • 90-day glaucoma

26. Wet AMD • Risk factors • White • Female • >65 y.o. • Smoker • History of dry AMD • 10% year convert to wet • Family history

27. Amsler grid • Scotoma • Distortion

28. Young Female Progressive vision loss over few days Decreased colour vision RAPD Pain with eye movement (90%) Optic nerve swelling (2/3) Optic nerve disease: Optic neuritis

29. Optic nerve disease: Giant Cell Arteritis • History • Age > 60 y.o. • Vision loss (curtain coming down), temporal headache, jaw claudication, fever, wt loss, anemia, proximal muscle weakness (associated with PMR) • Decreased vision +/- RAPD, +/- disc swelling or heme • Rest of exam normal • Labs: CBC, ESR, CRP • Oral prednisone: 1mg/kg/day • 80% risk of vision loss in other eye! • Then refer to Ophtho

30. Emergency Globe rupture Same day Acute angle closure glaucoma Mac-on RD Hyphema Next day GCA Do CBC, ESR, CRP, start steroids Mac-off RD Hyphema Head elevated, limit activity VH in non-DM Same week Vitreous hemorrhage in DM New wet AMD Optic neuritis Non-urgent Retinal vascular occlusion (BRVO/CRVO, BRAO/CRAO) Stroke Referral to Ophtho

31. Summary • Take a good history • You can determine the diagnosis with history in 90% of patients! • Take a vision! • Don’t miss a globe rupture • Do you best on the rest of the exam