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Sudden Loss of Vision

Sudden Loss of Vision. Simon Taylor MA PhD FRCOphth Clinical Senior Lecturer & Consultant Ophthalmic Surgeon. “My vision just went…”. Sudden onset vs. suddenly noticed Patient can be very insistent it only just happened! Who needs urgent referral? What investigations do I need to do?. 2.

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Sudden Loss of Vision

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  1. Sudden Loss of Vision Simon Taylor MA PhD FRCOphth Clinical Senior Lecturer & Consultant Ophthalmic Surgeon

  2. “My vision just went…” • Sudden onset vs. suddenly noticed • Patient can be very insistent it only just happened! • Who needs urgent referral? • What investigations do I need to do? 2

  3. “My vision just went…” • History • Sudden onset or just noticed? • Painful or painless? • Monocular or binocular? • Transient or persistent? • Associated systemic hypertension, diabetes, hypercholesterolaemia • Examination • Visual acuity • Afferent pupillary defect • Field loss (finger-counting fields) • Then dilate and perform fundoscopy 3

  4. Categories of acute visual loss… • Transient monocular loss • Amaurosis, intermittent angle closure, migraine • Persistent monocular loss • Central/branch retinal vein occlusion • Central/branch retinal artery occlusion • Retinal detachment • Angle closure glaucoma (* painful *) • Optic neuritis • Acute retinal necrosis if HZO • Transient binocular loss • Raised ICP (transient visual obscurations) • Persistent binocular loss • Bilateral monocular disease (GCA) • CVA 4

  5. Transient Monocular Loss • Amaurosis fugax • Emboli may be visible • Carotid bruit 5

  6. Retinal Emboli 6

  7. 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”) • Ophthalmoplegic, retinal migraine • Permanent visual loss can occur rarely 7

  8. Ophthalmic migraine 8

  9. Persistent Monocular Loss • Retinal arterial occlusion • Retinal vein occlusion • Retinal detachment • Angle closure glaucoma • Optic neuritis • Acute retinal necrosis 9

  10. Central Retinal Artery Occlusion • Profound visual loss • Need to exclude GCA 10

  11. Branch Retinal Artery Occlusion • Field loss • Loss of acuity variable 11

  12. Acute Ischaemic Optic Neuropathy • Altitudinal field defect • Arteritic vs. Non-arteritic 12

  13. Central retinal vein occlusion • Variable loss of acuity, but often quite severe • Associated with hypertension, diabetes, glaucoma 13

  14. Branch retinal vein occlusion • Investigate: • BP • BM 14

  15. Retinal Detachment • Flashes & floaters • Black curtain • Myopes 15

  16. Angle Closure Glaucoma • Symptoms: • Pain! • Blurred vision • Haloes • Signs: • Red eye • Fixed pupil • Hazy cornea • Hyperopes • History of intermittent angle closure

  17. Angle Closure Glaucoma • Press on the eye – rock hard; compare to other side • Needs urgent treatment to prevent visual loss • IOP lowering agents • Pilocarpine • Laser iridotomy 17

  18. Optic neuritis 18

  19. Optic neuritis • Sudden onset profound visual loss, pain on eye movement, flashes, usually resolves 3-4 weeks • Optic disc normal or swollen • Role of MRI scan • Acute management - steroids or not • If gradual onset…think of other causes, i.e. optic nerve compression 19

  20. Herpes zoster 20

  21. Herpes zoster • Spectrum of ocular involvement: • Corneal pseudodendrites • Anterior uveitis • Acute retinal necrosis 21

  22. Endophthalmitis

  23. Transient Binocular Visual Loss • Transient visual obscurations • Raised ICP • Papilloedema 23

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