Acute Visual Loss Dr Shueh Wen Lim

1. Acute Visual Loss Dr Shueh Wen Lim

2. Case 1 – Mrs Smith • 70yo woman presents with sudden onset loss of vision in her right eye half hour ago • No improvement since • No previous ophthalmic history • What are your DDx?

3. DDx • Retinal vessels • Central/ branch retinal artery occlusion • Central/ branch retinal vein occlusion • Vitreous • Vitreous haemorrhage (diabetic complications) • Retinal detachment • Macula • ARMD – ‘wet’ ARMD • Optic nerve • Anterior ischemic optic neuropathy: arteritic, non-artertic • Optic neuritis • Cerebral cortex • Stroke: homonymous hemianopia • Transient vision loss – amaurosisfugax

4. What else would you like to know about the patient?

5. Case 1 – Mrs Smith • Hx • Sudden onset while she was gardening • Painless, no associated redness • Hx of transient blurring of vision 2 weeks ago but recovered • Medhx – IHD, diabetes (on meds) • Ex • Visual acuity <6/60 right eye, 6/9 left eye • RAPD • Fundus exam

6. RAPD

7. What is the most likely dx?

8. CRAO • Pale oedematous retina • Thin attenuated vessels • Cherry red spot • Embolus may be seen • Optic disc not pale or swollen After 6 weeks: • Cherry red spot recedes • Optic disc pallor becomes evident

9. CRAO • Ix • CDV RFs – lipids, fasting BSL • ESR, CRP (r/o GCA) • Carotid US • Echocardiogram • ± Thrombophilia screen • Mx • Urgent referral to ophthal • Ocular massage • Lower IOP (diamox 500mg stat ± ant chamber paracentesis) • Long term aspirin?

10. Case 2 – Mr Lee • Similar hx • 65 yo p/w sudden and painless loss of vision in left eye • Hx of DM and HTN • Similar ex • 6/60 left eye, 6/9 right eye • RAPD • Fundus exam

11. What is the most likely dx?

12. CRVO • Intraretinal flame-shaped haemorrhages (visible in all four quadrants) • Optic disc swelling • Dilated, tortuous veins • Cotton wool spots

13. CRVO • Mx • Check BP • Screen for diabetes, hyperlipidemia • Thrombophilic screen in younger pts • 2 major complications • Macular edema • Neovascularisation of iris and retina

14. Case 3 – Mrs Abdullah • Hx • 70yo lady p/w sudden onset loss of vision in her right eye • Generalised muscle pain and weakness (but untreated for past 8 months) • Been feeling poor for the past 4 weeks with a flu and fever that she hasn’t been able to shake • Moderate severe headaches during the time • Unable to chew food properly because ‘it hurts’, lost 5kgs • Pmedhx: T2DM, smoker • Visual acuity • Hand movements in right eye, 6/6 left eye • RAPD in right eye

15. What is the most likely dx?

16. Anterior Ischemic Optic Neuropathy • Fundoscopy • Pale, swollen optic disc • Some haemorrhages, cotton wool spots • Mx • ESR (urgent!), CRP, plt count • Temporal artery biopsy • High dose systemic steroids (but always check for RFs that may C/I or complicate Rx with steroids)

17. Case 4 – Mr Holmes • Hx • 69yo man who p/w painless loss of vision • Recent hx of increased number of visual floaters and flashes • “Dark shadow” in the visual field of left eye • High myopia since 15yo, T2DM • Ex • Loss of red reflex • RAPD

18. What is the most likely dx?

19. Retinal detachment • Separation of sensory retina from the retinal pigment epithelium • Risk factors • High myopes • Ocular trauma • DM • Previous eye surgery eg cataract removal • Visual acuity will be affected only if central macula is affected • Examination • Abnormal red reflex • RAPD • ‘Tobacco dust’ • Detached retina (grey area) • Urgent opinion from ophthalmologist- surgery?

20. Wet (neovascular) AMD

21. Vitreous haemorrhage

22. Questions?