Acute Vision Loss No laughing matter…

2. Acute Vision LossNo laughing matter… Dr Aaron J Wong MH Intern 26 April 2012

3. Ms Smith • 70F with no previous ophthalmic history • Sudden loss of vision in R eye • No improvement over 6hr • What do you do?

4. Outline • Ophthalmic emergencies - Acute visual loss • Anatomical sieve to the eye • Causes - immediate, emergent, urgent • History & Exam • Cases • Questions

5. Ophthalmic emergencies Most sight-threatening conditions present as: • trauma, including chemical burns • acute loss of vision • +/- painful red eye(s) reduced vision + red eye = emergency

6. Vision Loss • Rapidity is the most important factor • Acute = minutes to hours; Subacute = days • Chronic = weeks to months • Chronic>>> acute, but ACUTE = EMERGENCY • Acute persistent visual loss (PVL) = a sudden deficit in visual function in one or both eyes lasting more than 24 hours • Acute transient visual loss aka. amaurosisfugax • Ddx for amaurosisfugax are few (temporary vascular occlusion/carotid artery disease, or temporary neuronal depression related to seizure or migraine, ?temporal arteritis) • Ddx of PVL is large.

7. Approach to Acute Visual Loss • Sudden loss or blurring of vision is an emergency > characterize properly • Always exclude temporal arteritis because of immediate risk to other eye • Refer, refer, refer! Stratify by • Immediate • Emergent (same day) • Urgent (24-48hr)

8. Ddx • ABCDEFG – ED/Trauma • Probability – Very common, common, uncommon, rare • VITAMIN CD • Masquerades • Anatomical

9. Anatomical Sieve Ocular Extraocular MediaRetinal Neural visual pathway Taken from: http://www.garetina.com/about-the-eye

10. Anatomical Sieve Ocular Extraocular MediaRetinal Neural visual pathway Keratitis +/- !endophthalmitis Cornealedema Trauma !AACG Hyphema Lens changes Uveitis !Retinal artery occlusion Retinal veinocclusion Retinal detachment +/- Vitreoushemorrhage Acute maculopathy Optic nerve disease !Arteritic – GCA Non-arteritic Optic neuritis Chiasmal Pituitary apoplexy !Retrochiasmal Stroke/TIA Tumor+haemorrhage Other – Drugs/Neoplasia

11. Effects of Trauma Ocular Extraocular MediaRetinal Neural visual pathway Keratitis +/- !endophthalmitis Cornealedema Trauma !AACG Hyphema Lens changes Uveitis !Retinal artery occlusion Retinal veinocclusion Retinal detachment +/- Vitreoushemorrhage Acute maculopathy Optic nerve disease !Arteritic – GCANon-arteritic Optic neuritis Chiasmal Pituitary apoplexy !Retrochiasmal Stroke/TIA Tumor+haemorrhage Other – Drugs/Neoplasia

13. History (HOPC) • Timing —sudden onset of visual loss vs. sudden discovery of preexisting visual loss • Laterality • Monocular > anterochiasmal/ocular; • Bilateral > retrochiasmal/extraocular/systemic • Quality • Diffuse/localized • Across midline • Severity • Onset • Acute (minutes to hours) • Subacute (days) • Chronic (weeks to years) • Progression & Duration

15. History (AssocSx) • Trauma • Flashes +/- floaters > retinal detachment/haemorrhage +/- PVD • Diplopia • Pain - presence / absence not as useful; unless pain is severe! • Anterior segment • Keratitis > sharp superficial pain • AACG > deep brow ache with N&V • Endophthalmitis > deep boring pain • Optic neuritis > pain worse with eye movement • Redness — Anterior segment disease + uveitis • Other neurological sx- weakness, numbness/tingling, slurred speech, vertigo/ataxia • Headache - rarely due to a refractive cause • Systemic features - scalp tenderness, jaw claudication, proximal weakness, fever, night sweats, weight loss

16. History (Relevant PMHx) • Ophthalmic history • Pastepisodes - amaurosisfugax • Recent cataract surgery > retinal detachment, endopthalmitis • Myopia>retinaldetachment; Hypermetropia > AACG • Contact lens use - Corneal ulceration in contact lens wearers • Chronic conditions ie. AMD, Glaucoma > acute on chronic presentation • Familyhx - Glaucoma • Systemicdiseases/risk factors • Diabetes - RVO, neovascularization +/- vitreous haemorrhage, iris neovasculization > glaucoma, optic neuropathy, myopic lens shifts, cataracts, corneal abnormalities • Hypertension > ocular vascular diseases • Coronoary artery disease, PVD, hyperviscosity states

17. History (Medications) • Eye drops vs systemic • Anticholinergics: loss of accommodation, angle closure glaucoma • Topiramate: angle closure glaucoma. • Sildenafil: blue vision, ischemicopticneuropathy • Digoxin: yellow vision • Amiodarone - progressive vision loss • Bisphosphonates: uveitis • Rifabutin: uveitis • Sulfonamides: myopia • Toxins - methanol consumption

18. Exam • ABCDEFG – General Inspection of head and neck for trauma • Visual acuity –one eye at the time, best corrected+/- 1mm pinhole; distance & near • Confrontation visual fields - red object • Evaluation of EOM • Pupils - symmetry, reactivity to light, pupillary reflex, RAPD!!! • Fundoscopy +/- slit lamp • +/- Fluoresceinapplication • +/- Intraocular pressure testing (by tonometry or palpation)

19. RAPD

21. Mx (Stratification) • Immediate referral • Acute central retinal artery occlusion – 8hr window • ?GCA – save the remaining eye • IOP > 40 mm Hg + eye pain ie. AACG • intracranial pathology (stroke, tumor, bleed, or elevated ICP) r/f to neurological/neurosurgical. • Emergent referral (same day) • Retinal detachment • Infectious keratitis +/- Endophthalmitis • Hyphema • Urgent referral (24 – 48hr) • Central retinal veinocclusion. • Acute maculopathy. • Vitreoushemorrhage. • Optic neuritis • Non-infectious uveitis

22. Case 1 – Ms Smith • 70F with no previous ophthalmic hx • Hx • Sudden loss of vision in R eye <6hr ago • Painless, no redness • Transient blurring of vision 2wk ago but recovered • PMHx – IHD, diabetes (on meds) • O/E • VA (R eye) <6/60 • VA (L eye) 6/9 • RAPD

23. Case 1 – Ms Smith

24. Case 1 – CRAO • Hx • Rapid onset, painless • O/E • Pale retina • Arterial narowing • Cherry red macula (>4hr) • Embolus may be seen • Optic disc not pale or swollen

25. Case 1 – CRAO • Mx • Exclude GCA – Hx & urgent CRP/ESR • Immediate referral to ophthal; <8hr window • Lower IOP - azetazolamide 500mg stat • Ocular massage • Use index fingers of each hand • [5s pressure, 5s release] x20 • Start aspirin • Investigate for TIA • Cardiac exam • Carotid US • Echocardiogram • Lipids, fasting BSL (CV RF)

26. Case 2 – Ms Lee • 70F with no previous ophthalmic hx • Hx • Ongoing diplopia & blurred vision • Sudden loss of vision in R eye • Painless, no redness • Temporal headache, scalp tenderness • Jaw claudication, myalgia, fatigue • Fever/night sweats, anorexia, weight loss • PMHx – polymyalgia rheumatica • O/E • VA (R eye) hand movements • VA (L eye) 6/6 • RAPD

27. Case 2 – Ms Lee

28. Case 2 – GCA • Mx: • Immediate referral • Corticosteroids • Methylprednisolone 1 g IV, daily for 3 days • Prednis(ol)one 40 to 60 mg orally, daily in the morning for 2 to 4 weeks. • at weekly intervals reduce the daily dose by a maximum of 10%—provided the ESR and CRP levels remain normal • Aspirin 100 mg orally, daily • Ix • Urgent ESR, CRP • Temporal artery biopsy (3-5cm)

29. Case 3 – Mr Yao • 70M basketball player from China • Hx • Reduced vision in R eye • SEVERELY painful – deep brow ache/headache, red eye • Haloes around lights, photophobia • Abdo pain, N&V • Ophthalhx – hypermetropia, +3.0 D • O/E • Diffusely red eye • VA (R eye) 6/24 • VA (L eye) 6/6 • Mid-dilated, oval pupil • Dulled & irregular light reflex • Cloudy cornea • IOP 40mmHg, firm globe

30. Case 3 – Mr Yao

31. Case 3 – AACG • Mx • Immediate referral • Lower IOP • Medical • Pilocarpine 4% eye drops, 1 drop q5min for 1sthr • Acetazolamide 500mg po/IV, then 250mg po q6hr • Other eye drops ie. timolol, brimonidine, latanoprost • Laser perpiheraliridotomy to relieve pupil block; • May require trabeculectomy

32. Case 4 – Mr Wong • 40M amateur boxer, received blow to head • Hx • Sudden, marked visual loss in R eye • Rapidly progressive • Preceding flashes and floaters • No redness • Ophthalhx – myopic, uses contacts; -8.0 D • O/E • Bruise to head • VA (R eye) 6/60 • VA (L eye) 6/6 • VF (R eye) abnormal inferior hemisphere • Dulled red reflex • ?RAPD

33. Case 4 – Mr Wong

34. Case 4 – Retinal detachment • Mx • Urgent ophthal referral • Check the other eye! BL in 10% • Rhegmatogenous (primary) vs. tractional vs. exudative vs. haemorrhagic • Pre-detachment – Cryopexy or laser retinopexy • Scleral buckling + cryopexy/laser • Vitrectomy + cryopexy/laser • Pneumatic retinopexy

35. Case 5 – MrSchmoe • 60M, recent cataract surgery • Hx • Reduced vision over 2 days in R eye • Painful, red • Eyelid edema, congested eye • O/E • Diffusely red eye • Sediment in anterior chamber • VA (R eye) 6/24 • VA (L eye) 6/6

36. Case 5 – MrSchmoe

37. Case 5 – Endopthalmitis • Mx • Urgent ophthal referral • Ideally, Gram stain from hypopyon at surgery directs Abx regimen • If significant delay, give empirical Abx • Ciprofloxacin 750mg postat • Vancomycin up to 1.5g IV stat • DO NOT USE TOPICAL ANTIBIOTICS, AS PRESERVATIVES ARE TOXIC TO INTRAOCULAR CONTENTS

38. Keratitis

39. Vitreous haemorrhage

40. Acute maculopathy

41. CRVO

42. Optic neuritis

43. Occipital Cortex infarct

44. Questions?

45. Sources • BMJ Best Practice – Vision Loss • UpToDate - Approach to the adult with acute persistent visual loss • Therapeuticguidelines - Ophthalmicemergencies, acutevisionloss • RVEEH - Golden eyerules • Dr. Mark Daniel - Sudden Visual Loss • DrShuehWenLim–AcuteVisionLoss