Download Dr Chen Acute visual disturbance

Back to Basics Ophthalmology:
Acute visual disturbance/loss
Sylvia Chen
PGY-3 Ophthalmology
Outline
• History
• Exam
• Acute visual loss
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Trauma
Acute angle closure glaucoma
Retinal detachment
Retinal vascular occlusion
Diabetic retinopathy
Wet macular degeneration
Optic nerve disease
Ophthalmology Consult Pet-Peeves
• Examples
– “floaters”
• Vision? Which eye? How long? Flashes of light? Curtain over vision?
– “decreased vision”
• Vision - 20/30 vs 20/200? Sudden onset vs. gradual? RAPD?
DM/HTN/Cholesterolemia/CAD/headache
– “red eye”
• Vision? Recent viral illness? Discharge? Photophobia?
– “swollen eye – can’t see eye”
• Vision?
• Trauma? Mechanism? Allergy? Recent illness/Infection?
• Blood? From where? – lid/conjunctiva/inside eye (hyphema)
History
• Onset
– Acute vs. chronic
• Acute onset vs acute perception of visual loss
– One eye or both eyes
– Trauma?
• Mechanism
• Character
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Sudden vs. gradual
Permanent vs. transient
Flashes
Floaters “flies, cobwebs”
Veil covering vision
“Curtain coming down”
• Associated symptoms
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Headache
Pain on eye movement
Photophobia
Temporal headache, jaw claudication, weakness, fever, wt loss,
loss of appetite
• Past Medical History
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DM
HTN
Dyslipidemia
Afib
CAD
PMR
Arthritis
• FamHx
– Any ocular probs
• RD, macular degeneration, glaucoma, blindness
• Meds
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Plaquenil/chloroquine for RA
Diamox for glaucoma
Anticholinergics – allergy meds, antidepressants
Eye drops
• Social
– Tobacco
– EtOH abuse
• Trauma
– Tetanus, last meal, allergies
Past Ocular History
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Visual history
– Lazy eye, crossed eyes, asymmetric vision as child
– Glasses (hyperope/myope), CL use
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Eye Injury
– Treatment required? Visual outcome?
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Eye Surgery
– Cataract, glaucoma, retinal detachment (buckle, gas bubble), crossed
eyes
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Laser Treatment
– DM, Glaucoma, after cataract surgery, retinal hole or detachment
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Drops
– Prescription or not? For glaucoma (eye pressure)? Post-op? Steroid?
Antibiotics?
Examination
• Visual acuity
– 20/30 vs. 20/200
• Pupils/Iris
– RAPD
– peaked pupil
• Muscles
– Movements
External Exam
• Lids
• Conjunctiva
– injection
– chemosis
• Corneal
– abrasion
– haze
• Anterior chamber
– Blood?
• IOP
• Visual field
Fundus – a bonus if you can see it!
• Optic nerve swelling
• Macula
– Drusen
– Exudates
– Blood
• Vessels
– Dilated
– Tortuous
– Retinal blood
• Vitreous haze/hemorrhage
Acute vision loss: TRAUMA
• Mechanism of injury
• Globe Rupture
• Ophthalmic Emergency!
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Vision
Tetanus
Ancef
NPO
CT orbits
OR tonite!
Hyphema
• Blunt trauma
– Soccer ball / baseball
– Bungee cord
– Punch
• Associated corneal abrasion
• Occult globe rupture? – check IOP
Angle Closure Glaucoma
• Symptoms
– Pain
– Nausea & vomiting
– Decreased vision
• History
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Hyperope (short eye)
F>M
Increasing age
Meds: anticholinergics, antidepressants
• Signs
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Cloudy cornea
Red eyes
Mid-dilation of the pupil
Forward bowing iris
(narrow drainage angle)
– High intraocular
pressure (as high as 4X
normal pressure)
• Ophtho today
Retinal Detachment
• Risk factors
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Myopia
Personal history of tear/detachment
Family history of tear/detachment
Intraocular surgery
Pseudophakia
• Signs
– Floaters
• 50-100 new “flies”
– Flashes
• Lightning flashes
– Veil covering vision
– Painless
• Macula on
– Ophtho today
• Macula-off
– can wait till
tomorrow
Branch retinal vein occlusion (BRVO)
• Painless loss in vision
• Visual field defect
• Not an emergency
Central retinal vein occlusion (CRVO)
• Painless vision loss
• May have an RAPD
• If young
– hypercoagulation workup
• Not an emergency
Branch retinal artery occlusion (BRAO)
• Painless vision loss
• Embolic work-up
– ECG, Echo, Carotid
dopplers
• RF management
– Chol, BP, DM
• Not an emergency
Central retinal artery occlusion (CRAO)
• Painless vision loss
• May have an RAPD
• If within first 90 minutes
– Ocular massage
• Embolic work-up
– ECG, Echo, Carotid dopplers
• RF management – Chol, BP, DM
• Not an emergency
Stroke
• Both eyes affected
• Homonymous visual defect
Diabetic Retinopathy
• Glucose control?
– HgA1c
• BP control?
• Nephropathy/neuropathy?
• Proliferative disease
– Look at fellow eye
– Prior laser treatment?
Vitreous hemorrhage
• Most commonly
from proliferative
diabetic retinopathy
• Also retinal tear,
trauma, tumour…
• Refer to
Ophthalmology
Neovascular glaucoma
• Neovascularization of the iris
• Diabetes
• Ocular ischemia
– CRVO
• 90-day glaucoma
Wet AMD
• Risk factors
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White
Female
>65 y.o.
Smoker
History of dry AMD
• 10% year convert to wet
– Family history
• Amsler grid
– Scotoma
– Distortion
Optic nerve disease: Optic neuritis
• Young
• Female
• Progressive vision loss over few
days
• Decreased colour vision
• RAPD
• Pain with eye movement (90%)
• Optic nerve swelling (2/3)
Optic nerve disease: Giant Cell Arteritis
• History
– Age > 60 y.o.
– Vision loss (curtain coming down), temporal headache, jaw
claudication, fever, wt loss, anemia, proximal muscle weakness
(associated with PMR)
• Decreased vision +/- RAPD, +/- disc swelling or heme
• Rest of exam normal
• Labs: CBC, ESR, CRP
• Oral prednisone: 1mg/kg/day
– 80% risk of vision loss in other eye!
• Then refer to Ophtho
Referral to Ophtho
• Emergency
– Globe rupture
• Same day
– Acute angle closure
glaucoma
– Mac-on RD
– Hyphema
• Next day
– GCA
• Do CBC, ESR, CRP, start
steroids
– Mac-off RD
– Hyphema
• Head elevated, limit
activity
– VH in non-DM
• Same week
– Vitreous hemorrhage in DM
– New wet AMD
– Optic neuritis
• Non-urgent
– Retinal vascular occlusion
(BRVO/CRVO,
BRAO/CRAO)
– Stroke
Summary
• Take a good history
– You can determine the diagnosis with history in
90% of patients!
• Take a vision!
• Don’t miss a globe rupture
• Do you best on the rest of the exam