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Rapid Onset Visual Issues: A Case-Based Guide

Understand sudden visual loss cases from expert Michael Karampelas. Learn key questions for assessment, examination techniques, and case studies of acute monocular visual loss scenarios. Dive into topics like Amaurosis Fugax, Ocular Migraine, and more. A valuable resource for healthcare professionals in the ophthalmology field.

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Rapid Onset Visual Issues: A Case-Based Guide

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  1. Sudden visual loss:a case based approachMichael KarampelasClinical Lead Ophthalmology DepartmentWatford General and St Albans City HospitalsRetinal specialist

  2. Sudden visual loss definition • rapid onset • minutes up to days

  3. Questions you need to ask • how long ago? • rapid or gradual onset? • course? • monocular or binocular? • transient or persistent? • painless or painful? • associated symptoms? • ophthalmic and medical history

  4. Examination • Visual acuity

  5. Examination • Visual acuity • Confrontation visual field testing

  6. Examination • Visual acuity • Confrontation visual field testing With the patient looking at your nose, ask if your nose and other facial features are seen clearly Inability to clearly see your: Nose => central scotoma Eyes or lips => paracentral scotoma Ears => peripheral visual field defect

  7. Examination • Visual acuity • Confrontation visual field testing • Relative Afferent Pupillary Defect (RAPD) Swinging flashlight test

  8. Relative Afferent Pupillary Defect Significant retinal or optic nerve disease, in one eye more than the other

  9. Examination • Visual acuity • Confrontation visual field testing • Relative Afferent Pupillary Defect (RAPD) • Direct ophthalmoscopy

  10. Acute monocular visual loss Transient Persistent

  11. Transient monocular acute visual loss • 74 year old man reports intermittent episodes of “fuzzy vision” lasting from 1 to 15 minutes. • unsure whether monocular or binocular • no other symptoms reported • pMH: coronary artery disease, hypertension, hyperlipidemia • pOH: previous cataract operations

  12. Transient monocular acute visual loss • Visual acuity: 6/9 in both eyes • No RAPD • No gross visual field abnormality • No significant issue on retinoscopy

  13. Transient monocular acute visual loss • U/S carotid doppler: 50-79% right carotid stenosis

  14. AmaurosisFugax • Painless transient loss of vision, partial or complete, related to retinal arterial microembolization or hypoperfusion • If bilateral it may indicate Vertebrobasilar Insufficiency

  15. AmaurosisFugax • Visual disturbance: Dark, foggy, gray, white • Minutes (1-5 minutes, occasionally longer); full resolution takes 10-20 minutes • Painless • Usually occurs in isolation • Assessment of cardiovascular risk factors • U/S carotid doppler

  16. Transient monocular acute visual loss • A 30-year-old woman began to experience transient visual loss in the right eye 3 days before presentation • Episodes lasted from one to several minutes and consisted of flashing lights, grey-outs and episodes of reduced vision to her right eye • She did not experience headaches, diplopia or any other focal neurologic phenomena

  17. Transient monocular acute visual loss • pMH: Migraines • pOH: free

  18. Transient monocular acute visual loss • Visual acuity: 6/6 RE, 6/6 LE • no RAPD • normal visual fields

  19. Transient monocular acute visual loss • Ophthalmoscopy : normal

  20. Ocular migraine • Migraine with aura (“classic”) Jagged lines, fortification spectra, blind spots, flashing lights Generally start 5-30 mins before headache and last for 20-60 mins • Migraine without aura (“common”) • Ocular migraine: aura without headache

  21. Acute monocular visual loss Transient Persistent AmaurosisFugax Ocular Migraine

  22. Acute monocular visual loss Transient Persistent AmaurosisFugax Ocular Migraine Painful Painless

  23. Persistent painful monocular acute visual loss • 64 year old woman reports severe pain in her right eye started suddenly 1 day ago • pain radiates to temple • hazy vision – haloes around lights • mild nausea • pMH: hypertension, hyperlipidemia history of migraines • pOH: hypermetropia

  24. Persistent painful monocular acute visual loss • Visual acuity: RE: hand movements LE: 6/9 • no RAPD but RE pupil do not react to light • difficult to assess visual fields in RE. LE:normal • difficult to perform retinoscopy

  25. Persistent painful monocular acute visual loss • “Shadow sign” – shallow anterior chamber

  26. Acute angle closure glaucoma

  27. Acute angle closure glaucoma • significantly decreased visual acuity • red and painfull eye • nausea- vomiting • fixed semi- dilated pupil Needs immediate referral to ophthalmic A&E

  28. Acute angle closure glaucoma

  29. Persistent painful monocular acute visual loss • 70 year old man reports gradual reduction in his RE vision of the last two days with some mild pain and redness • pMH: hypertension, hyperlipidemia • pOH: cataract operation in the RE 1 week ago

  30. Persistent painful monocular acute visual loss • Visual acuity: RE: light perception LE: 6/6 • no RAPD • difficult to assess visual fields in RE. • difficult to perform retinoscopy

  31. Persistent painful monocular acute visual loss • inspection of the RE demonstrated conjunctival chemosis as well as hypopyon

  32. Endophthalmitis • ~ 1:1000 risk after any type of intraocular surgery • Usually within first week • Blurred vision, red and painfull eye

  33. Endophthalmitis • Any case with suspicion of endophthalmitis needs immediate referral to ophthalmic A&E • Standard management includes obtaining vitreous samples for microbiology as well as intravitreal injection of antibiotics

  34. Acute monocular visual loss Transient Persistent AmaurosisFugax Ocular Migraine Painful Painless Acute angle closure glaucoma Endophthalmitis

  35. Acute monocular visual loss Transient Persistent AmaurosisFugax Ocular Migraine Painful Painless Acute angle closure glaucoma Endophthalmitis Retina easily seen No Yes

  36. Persistent painless monocular acute visual loss with no good retinal view • 50 year old woman reports a gradual fogginess in her RE vision over the last 3 days with worsening floaters • pMH: DM Type II, hypertension, hyperlipidemia • pOH: free • has not been attending her eye clinic appointments during the previous 3 years

  37. Persistent painless monocular acute visual loss with no good retinal view • Visual acuity: 6/60 RE, 6/6 LE • No RAPD • difficult to assess visual fields • difficult to obtain a retinal view. Diminished red-reflex with direct ophthalmoscope

  38. Vitreous Haemorrhage

  39. Vitreous Haemorrhage • Painless acute or subacute loss of vision • May be preceded by floaters • Retinal vasculopathies (DM,CRVO) • Posterious vitreous detachment – Retinal detachment • Ocular trauma • Valsava retinopathy • Referral to retinal specialist within 2 weeks

  40. Acute monocular visual loss Transient Persistent AmaurosisFugax Ocular Migraine Painful Painless Acute angle closure glaucoma Endophthalmitis Retina easily seen No Yes Vitreous Haemorrhage

  41. Acute monocular visual loss Transient Persistent AmaurosisFugax Ocular Migraine Painful Painless Acute angle closure glaucoma Endophthalmitis Retina easily seen No Yes Vitreous Haemorrhage Normal retina No Yes

  42. Persistent painless monocular acute visual loss with retinal abnormality • 70 year old woman reports a sudden loss of vision in her right eye noted this morning • No pain • She reports previous transient episodes of visual loss • pMH: DM Type II, hypertension • pOH: free

  43. Persistent painless monocular acute visual loss with retinal abnormality • Visual acuity: CF RE, 6/6 LE • RAPD RE • Total loss of visual field RE

  44. Persistent painless monocular acute visual loss with retinal abnormality • Ophthalmocopy: cherry red spot

  45. Central retinal artery occlusion • Acute, painless, monocular, persistent and nearly complete loss of vision • Aetiology: Same as for any thromboembolic disease • 5 year mortality is 1/3rd of age matched controls without CRAO • No standard treatment of proven benefit Need to exclude GCA

  46. Branch retinal artery occlusion • Assessment of cardiovascular risk factors • U/S carotid doppler • Routine referral to retinal specialist

  47. Persistent painless monocular acute visual loss with retinal abnormality • A 60 year old male complains of progressive loss of vision in left eye over the last 2 days. • No other symptoms • Painless uniform dulling of vision. • pMH: DM Type II, hypertension • pOH: free

  48. Persistent painless monocular acute visual loss with retinal abnormality • Visual acuity is 6/6 RE – 6/60 LE • Mild RAPD LE • Constricted visual field LE

  49. Central retinal vein occlusion • Dilated and tortuous veins • Flame haemorrhages

  50. Central retinal vein occlusion • 10 times more common than CRAO • Most common risk factors: diabetes, hypertension, hyperlipidaemia • In patients <50 years old, haematologic and autoimmune disease should be excluded. • Lond term complications are macular oedema and retinal neovascularisation

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