Back to Basics Ophthalmology: Acute visual disturbance/loss Sylvia Chen PGY-3 Ophthalmology

Outline History Exam Acute visual loss 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 Character Acute vs. chronic One eye or both eyes Trauma? Acute onset vs acute perception of visual loss One eye or both eyes Trauma? Mechanism Character Sudden vs. gradual Permanent vs. transient Flashes Floaters “flies, cobwebs” Veil covering vision “Curtain coming down”

Associated symptoms Past Medical History Headache Pain on eye movement Photophobia Temporal headache, jaw claudication, weakness, fever, wt loss, loss of appetite Past Medical History DM HTN Dyslipidemia Afib CAD PMR Arthritis

FamHx Meds Social Trauma Any ocular probs Plaquenil/chloroquine for RA RD, macular degeneration, glaucoma, blindness Meds 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 Visual history Eye Injury Eye Surgery Lazy eye, crossed eyes, asymmetric vision as child Glasses (hyperope/myope), CL use Eye Injury Treatment required? Visual outcome? Eye Surgery Cataract, glaucoma, retinal detachment (buckle, gas bubble), crossed eyes Laser Treatment DM, Glaucoma, after cataract surgery, retinal hole or detachment Drops Prescription or not? For glaucoma (eye pressure)? Post-op? Steroid? Antibiotics?

Examination Visual acuity Pupils/Iris Muscles 20/30 vs. 20/200 RAPD peaked pupil Muscles Movements

External Exam Lids Conjunctiva Corneal Anterior chamber IOP 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! Vision Tetanus Ancef NPO CT orbits OR tonite!

Hyphema Blunt trauma Associated corneal abrasion Soccer ball / baseball Bungee cord Punch Associated corneal abrasion Occult globe rupture? – check IOP

Angle Closure Glaucoma Symptoms Pain Nausea & vomiting Decreased vision History Hyperope (short eye) F>M Increasing age Meds: anticholinergics, antidepressants

Signs Ophtho today 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 Signs 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? BP 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 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 Same day Next day Same week Non-urgent Globe rupture Same day Acute angle closure glaucoma Mac-on RD Hyphema Next day GCA Do CBC, ESR, CRP, start steroids Mac-off RD 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 Take a vision! Don’t miss a globe rupture 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