Sudden Painless Loss Of Vision

1. Sudden Painless Loss Of Vision

2. By Minal G. Birambole. (internee) G.A.M &R.C, Shiroda,Goa

4. Sudden loss of vision is alarming to both the patient and the clinician alike. • sudden & transient visual loss or obstruction may simply be a symptom of dry eye or may herald the onset of irreversible visual loss or stroke.

5. Causes of sudden loss of vision • Central Retinal artery occlusion • Vitreous hemorrhage • Retinal detachment • Central Retinal vein occlusion • Optic neuritis • Methyl alcohol amblypia

6. Retinal artery occlusion Etiology- • more common in patients suffering from hypertension. • Thrombosis • Embolism • Retinal artritis • Angiospasm

7. Central retinal artery occlusion Clinical Features - • More common in male • Usually unilatral,rarely bilateral • It is due to obstruction at the level of lamina cribriosa.

8. Symptom – Painless sudden loss of vision

9. Signs- • Direct pupilary reflex is absent. • Retinal artery markly narrow. • Retinal vein look normal. • Retina become milky white. • Chery red spot (central part of macular area) • Blood coloum is segmented.

10. ERGs of CRAO

11. branch retinal artery occlusion • Usually occurs following lodgment of embolus at bifercation. • Retina distal to occlusion become odematous. • Later on permanent sectorial visual field defect.

12. Management– treatment is unsatisfactory as retinal tissue can’t survive ischemia more than few hours. Emergency treatment- • Immediate lowering of intraocular pressure by IV Mannitol intermittent occular massage paracentesis of anterior chamber

13. Vasodilator & inhalation of mixture of 5% carbon-di-oxide & 95% of water. relive angiospasm • Anticoagulant • IV steroids

14. Complication- neovascular glaucoma with incidence varying from 1% to 5%.

15. Retinal vein occlusion Etiology - • More common than artery occlusion • Typically affects elderly patients in 6th or 7th decade in life • Pressure on the vein by sclerotic retinal artery • Hyperviscocity of blood as in polycythemia • Periphlebitis retinae(central or peripheral)

16. Raised intraocular pressure,more common in primary open angle glaucoma • Local cause- orbital cellulitis facial erysipelas cavernous sinus thrombosis

17. Central retinal vein occlusion • Non ischemic • most common clinical variety • Characterised by mild to moderate visual loss. Fundus examination- In early stage- • mild venous congesion • Tortusity • Few superficial flame shaped haemorrhage more in periphery than posterior.

18. Mild papillodema • Mild macular odema In later stage- • Sheathing arround main vein • Few cilioretinal collatrals around disc • Retinal haemorrhage partly absorbed • Macula shows chronic cystoid odema.

19. Treatment- • Usually not required • Condition resolve with almost normal vision in about 50% cases. • No treatment is effective for chronic cystoid macular odema • Course of oral steroids 8-12 weeks may be effective.

20. Ischemic- Refers to acute complete occlusion of central retinal vein Characterised by marked Sudden loss of vision

21. Fundus examination- in early stage- • Massive engorgement • Congestion • Tortusity of veins • Massive retinal haemorrhage • Papilloedema • Macular area oedematous

22. in later stage- • Sheathing around vein & collatrals seen around disc • Neovascularisation at disc • Macula-marked pigmentary change • Chronic cystoid oedema

23. Difference between ischemic from non ischemic • Presence of relative afferent pupillary defect • Visual field defect • Reduced amplitude of b-wave of ERG.

24. Complication- • Rubiosis iridis • Neovascular glaucoma in more than 50% cases within 3 months • Few develops vitreous hemorrhage

25. Treatment- • Panretinal photocoagulation • Cryo-application • Photocoagulation Above is carried out when most of interretinal blood is absorbed.

26. Branch retinal vein occlusion • More common than central retinal vein occlusion • Occur at following site • main branch at disc margin • Major branch vein away from disc • At A-V crossing causing quadratic occlusion • Small macular occlusion

27. Occlusion oedema & haemorrhge are limited to area drain by affected vein. • Vision is affected when macular area is involve.

28. Treatment- • Grid photocoagulations- in chronic macular odema • Scatterphotocoagulations- in neovascularisation

29. Vitreous haemorrhage Usually occur from retinal vessels Pre retinal intrageal haemorrhage haemorrhage

30. Etiology- • Associated with PVD • Trauma to eye • Inflamatory disease like chorioretinitis,periphlebitis retinae • Vascular disoders like HTN retinopathy • Metabolic disease like DM retinopathy • Neoplasm • idiopathic

31. Clinical features- Sign- • Distant direct opthalmoscopy- black shadow against the red glow in small haemorrhage. • Direct & indirect opthalmoscopy- presence of blood in vitreous cavity • Ultrasonography with B-scan- it help in diagnosis.

32. Symptoms- • In less haemorrhage- sudden development of floaters. • In more haemorrhage- sudden painless loss of vision

33. Treatment- • Conservative treatment- bed rest elevation of patients head bilateral eye patches • Treatment of cause- management of retinal break, phlebitis, proliferative retinopathy.

34. Vitrectomy- by pars plana route, if haemorrhage is not absorb after 3 months.

35. Retinal detachment Separation of neurosensory retina proper from the pigment epithelium. Classification- • Primary retinal detachment • Secondary retinal detachment

36. Primary retinal detachment Usually associated with retinal break Sub retinal fluid seeps Separate the sensory retina from pigmentary epithelium

37. Etiology- • Most common in 40-60 yrs. • More in males • 40% cases are myopic • More common in aphakes • Retinal degenaration • Trauma • Senile post.vitreous detachment

38. Pathogenesis- Senile acute predisposing Post.vitreous retinal Detachment degenaration aphakia Retinal break trauma Degenarated fluid seeps through retinal breaks Retinal detachment

39. Clinical features- Prodromal symptom- dark spot in front of the eye photopsia Symptoms- • loss in field of vision which progress total loss when detachment progress to macular area. • Sudden painless loss of vision

40. A view from person having retinal detachment.

41. Sign- • External examination- eye is usually normal • Intraoccular pressure is low • Plain mirror examination- an altered red reflex in pupilary area.

42. Opthlmoscopy- • Detach retina gives grey reflex & raised anteriorly. • it thrown in to folds which oscilate with the movement of eye • Total detachment of retina funnel shaped, being attached only at disc & ora serrata • Retinal vessels appear dark tortuous.

43. Electroretinography- subnormal or absent • Ultrasonography- confirm the diagnosis

44. Complication- proliferative vitreoretinopathy complicated cataract uvelitis phthisis bulbi

45. Proliferative vitreoretinopathy

46. Uveitis

47. Pthisis bulbi

48. Treatment- • Sealing of retinal breaks- by producing aseptic chorioretinitis, cyocoagulation, photocoagulation • Scleral buckling- To bring the sclrochoroid & retina near to each other • Drainage of SRF

49. chororetinitis

50. Internal tamponade by SF6 gas or silicon oil • Pars plana vitrectomy