Vision Loss: Acute and Chronic Amit Tandon, MD Clinical Assistant Professor Department of Ophthalmology & Visual Science Amit.Tandon@osumc.edu

Learning Objectives Primary Learning Objectives: utilize symptoms, clinical presentations and examination findings to recognize common causes of chronic and acute vision loss. Secondary Learning Objectives: interpret the meaning of ocular symptoms differentiate common causes of vison loss recognize ocular manifestations of systemic diseases

Visual loss The most important presenting eye problem that you will encounter as a physician. Differentiating sight (and life threatening) causes from more benign causes is crucial. A number of questions must be answered to arrive at the diagnosis. The most important presenting eye problem that you will encounter as a physician. Differentiating sight (and life threatening) causes from more benign causes is crucial. A number of questions must be answered to arrive at the diagnosis.

History Onset Duration Location Differentiates brain vs eye problem Acute – over several minutes, hours or days Chronic – Progressive over weeks to months Duration Transient, permanent or intermittent Location Monocular or binocular? Differentiates brain vs eye problem Onset Acute – over several minutes, hours or days Chronic – Progressive over weeks to months Duration Transient, permanent or intermittent Location Monocular or binocular? Differentiates brain vs eye problem Monocular = Eye problem (proximal to optic Chiasm)   Binocular = Brain problem (from optic chiasm to occipital lobe)

Optic Nerve Pathway www.kellogg.umich.edu Schematic showing the pathway of the visual pathway. If the lesion occurs from the eyeball to the optic chiasm then the symptoms will be in just one eye. If the lesion happens between the optic chiasm and the visual cortex then the symptoms will present in both eyes. Knowing your anatomy will help narrow the location of the lesion. www.kellogg.umich.edu

History Previous episodes of visual loss Associated Symptoms: Diplopia Eye pain/photophobia Red Eye Nausea/emesis Discharge Previous Ocular History Eye surgery or trauma Previous episodes of visual loss Associated Symptoms: Diplopia Eye pain/photophobia Red Eye Nausea/emesis Discharge Previous Ocular History Eye surgery or trauma

Physical – Eye Examination Visual acuity With correction Each eye separately Confrontational visual fields Pupillary reactions External/slit lamp examination Tonometry Ophthalmoscopy Visual acuity With correction Each eye separately Confrontational visual fields Pupillary reactions External/slit lamp examination Tonometry Ophthalmoscopy

Quiz1

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical As we go through this lecture we will describe vision loss that occurs from every different part of the eye. We will start with refractive conditions causing vision loss.

Refractive error Must be excluded prior to considering other, more serious, alternatives. Myopia Hyperopia Astigmatism Presbyopia Use of the pinhole www.tnhealth.org/tsbcsdis.htm Must be excluded prior to considering other, more serious, alternatives. Myopia Hyperopia Astigmatism Presbyopia Use of the pinhole

Correction of refractive error Spectacles Contact Lenses Corneal Refractive Surgery PRK vs LASIK Lenticular Refractive Surgery Lensectomy with implant Piggyback IOL Spectacles Contact Lenses Corneal Refractive Surgery PRK vs LASIK Lenticular Refractive Surgery Lensectomy with implant Piggyback IOL

Quiz2

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical The next area we will cover regarding vision loss is the eyelid.

Ptosis Acute eyelid drooping (ptosis) so severe that it obstructs vision is extremely rare May herald the development of a cerebral aneurysm (posterior communicating artery) causing a third cranial nerve palsy. Complete ptosis will block the visual axis and cause an obvious case of vision loss. If the eyelid is lifted, the vision is again normal. Ptosis is especially important because it can be a sign of a third nerve palsy which may indicate a life threatening cerebral aneurysm.

Ptosis Associated with normal vision when the lid is lifted Other signs of a IIIcn palsy Mydriasis Inability to move the eye inward, upward, or downward. . Other causes of a third nerve palsy Vascular diseases (diabetes and hypertension) Vascular disease will often spare the pupil Trauma Tumor Urgent evaluation of a third nerve palsy is required Other signs of a third nerve palsy include mydriasis (dilated pupil) and inability to move the affected eye in, up or down. www.neurology.arizona.edu

Quiz3

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical The cornea is the next section we will cover regarding vision loss.

Cornea Any disruption of the tear film or corneal surface will cause blurred vision. Loss of transparency of the deeper structure of the cornea (stroma) usually indicates edema, infection, inflammation, or scar. Any disruption of the tear film or corneal surface will cause blurred vision. Loss of transparency of the deeper structure of the cornea (stroma) usually indicates edema, infection, inflammation, or scar.

Dry eye Keratoconjunctivitis sicca is often associated with intermittent blurred vision especially with reading. The result of break up of the tear film that is the primary optical surface of the eye. Vision is usually restored temporarily with each blink. Dry eye is a common cause of transient blurred vision. Vision is temporarily restored with each eye blink.

Keratoconjunctivitis Sicca This is an example of dry eye showing rose Bengal staining. The stain is taken up by damaged epithelial cells. In this case these cells are damaged from dry eye.

Corneal abrasion Severe Pain If central can dramatically affect vision Topical anesthetic will relieve the pain immediately Severe Pain If central can dramatically affect vision Topical anesthetic will relieve the pain immediately

Corneal edema The most common ACUTE cause of corneal edema (other than surgery or trauma) is angle closure glaucoma. The high intraocular pressure drives fluid into the cornea. The patient will also describe colored rainbows around lights due to the light scatter. Associated with eye pain and nausea. Edema will resolve and vision will clear rapidly once the intraocular pressure is lowered. The most common ACUTE cause of corneal edema (other than surgery or trauma) is angle closure glaucoma. The high intraocular pressure drives fluid into the cornea. The patient will also describe colored rainbows around lights due to the light scatter. Associated with eye pain and nausea. Edema will resolve and vision will clear rapidly once the intraocular pressure is lowered.

Angle Closure Glaucoma This is a photo of a patient with angle closure glaucoma. Note the mid-dilated pupil and the red angry eye. There is also corneal edema which can be appreciated by viewing the hazy corneal light reflex. In cases without corneal edema, the light reflex is sharp and well defined.

Corneal Edema Another photo showing corneal edema but this time not from angle closure glaucoma.

Corneal infiltration or inflammation This usually occurs in the face of an active infection. Accumulation of the offending organism along with the induced inflammation causes a localized opacity of the cornea. This usually occurs in the face of an active infection. Accumulation of the offending organism along with the induced inflammation causes a localized opacity of the cornea.

Corneal infiltrate There is usually a predisposing factor such as: Contact lens wear Corneal exposure (Bell’s Palsy) Topical steroid use Herpes simplex keratitis Previous surgery or injury There is usually a predisposing factor such as: Contact lens wear Corneal exposure (Bell’s Palsy) Topical steroid use Herpes simplex keratitis Previous surgery or injury You can see the white corneal infiltrate in the photo.

Corneal scar Result of a corneal infection or injury and will not be the cause of a true acute loss of vision. Result of a corneal infection or injury and will not be the cause of a true acute loss of vision.

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical The next area of vision loss we will cover is from the anterior chamber.

Anterior Chamber Most common – traumatic hyphema Usually caused by a blunt trauma. Exclude a globe rupture. Hyphema will clear within one week in most cases. Most common – traumatic hyphema Usually caused by a blunt trauma. Exclude a globe rupture. Hyphema will clear within one week in most cases. A hyphema refers to bleeding in the anterior chamber.

Hyphema Cycloplegia, topical steroids and rest are usually effective. Aminocaproic acid may be used to decrease the chance of rebleeds in high-risk cases. Patients at risk for sick cell anemia or trait should be checked because this may complicate recovery. Main risk of permanent loss of vision is secondary glaucoma. Treatment: Cycloplegia, topical steroids and rest are usually effective. Aminocaproic acid may be used to decrease the chance of rebleeds in high-risk cases (though rarely used in clinical practice) Patients at risk for sick cell anemia or trait should be checked because this may complicate recovery. Main risk of permanent loss of vision is secondary glaucoma.

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical We will now cover vision loss from the lens.

Cataract The hallmark of most cataracts is slowly progressive loss of vision however there are two instances when they may form acutely. One is the situation of uncontrolled diabetes with very high glucose levels. A dense cortical cataract may form due to osmotically induced fluid shifts. These may resolve once the diabetes is under control. The hallmark of most cataracts is slowly progressive loss of vision however there are two instances when they may form acutely. One is the situation of uncontrolled diabetes with very high glucose levels. A dense cortical cataract may form due to osmotically induced fluid shifts. These may resolve once the diabetes is under control.

Acute Cataracts The other situation is with penetrating or blunt trauma. The cataract that forms with ocular injury may be localized and nonprogressive or may be severe and rapidly progressive. The other situation is with penetrating or blunt trauma. The cataract that forms with ocular injury may be localized and nonprogressive or may be severe and rapidly progressive.

Location This is a schematic showing the different types of cataract that can develop.

Cataract Cortical cataract seen against red reflex Extremely dense nuclear cataract Posterior subcapsular cataract Cortical cataract seen against red reflex Extremely dense nuclear cataract Posterior subcapsular cataract arapaho.nsuok.edu/~fulk/kanski.html

Traumatic Cataract This is a photo showing a traumatic cataract. You can see in the upper right portion of the lens that there is a hole in the lens capsule causing lens material to leak into the anterior chamber. This has caused the lens to develop a cataract.

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical We will now review vision loss emanating from the vitreous.

Vitreous Sudden visual loss in a patient with known diabetic retinopathy may be the result of a vitreous hemorrhage. This may cause severe visual loss, which may resolve over weeks to months. Sudden visual loss in a patient with known diabetic retinopathy may be the result of a vitreous hemorrhage. This may cause severe visual loss, which may resolve over weeks to months.

Vitreous Hemorrhage Retinal Tear Diabetic Retinopathy Central Retinal Vein Occlusion (CRVO) Branch Retinal Vein Occlusion (BRVO) There are 4 causes of vitreous hemorrhage: Retinal Tear Diabetic Retinopathy Central Retinal Vein Occlusion (CRVO) Branch Retinal Vein Occlusion (BRVO)

Quiz4

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical The retina is the next section we will review for vision loss.

Central Retinal Artery Occlusion (CRAO) Sudden, painless, complete loss of vision in one eye. Retinal vessels are narrow. The retina is pale except the macular region, which is thin, and choroidal circulation may be seen causing a cherry-red spot. Sudden, painless, complete loss of vision in one eye. Retinal vessels are narrow. The retina is pale except the macular region, which is thin, and choroidal circulation may be seen causing a cherry-red spot.

Central Retinal Artery Occlusion (CRAO) Workup for carotid and cardiac sources of the embolus is necessary along with screening for temporal arteritis in appropriate patients. An afferent pupillary defect (APD) is present with a CRAO. APD is typically an optic nerve problem, can occur in severe retinal problems. Should NOT occur with other types of eye pathology (other than retina/optic nerve). Technically it is a relative APD or RAPD, but often notated just as an APD.

BRAO Branch retinal artery occlusion may be asymptomatic unless it occurs near the fovea. Branch retinal artery occlusion may be asymptomatic unless it occurs near the fovea. The photograph shows the white edematous retina in the area supplied by the artery occlusion.

Marcus Gunn Pupil A Marcus Gunn Pupil is also known as a relative afferent pupillary defect (rAPD). This finding will be covered in your neuro-ophthalmology lectures.

Central retinal vein occlusion May also cause sudden painless loss of vision in one eye. This loss is usually not as extensive as that with CRAO’s. This may be associated with systemic hypertension and glaucoma. Neovascularization of the retina and iris may occur. Neovascular glaucoma may lead to blindness if not aggressively treated. May also cause sudden painless loss of vision in one eye. This loss is usually not as extensive as that with CRAO’s. This may be associated with systemic hypertension and glaucoma. Neovascularization of the retina and iris may occur. Neovascular glaucoma may lead to blindness if not aggressively treated.

Central Retinal Vein Occlusion This is a fundus photo and fluorescein angiogram showing a central retinal vein occlusion. You can see 360 degrees of intraretinal hemorrhage obscuring the view of the normal retina.

Retinal detachment Usually causes a dark shade over the visual field. It may be heralded by the onset of many floaters and flashing lights. Differentiate flashing lights from migraine phenomenon because migraine is both eyes, flashing lights from the retina is one eye only. The detached retina is usually easily seen through a dilated pupil. Usually causes a dark shade over the visual field. It may be heralded by the onset of many floaters and flashing lights. Differentiate flashing lights from migraine phenomenon because migraine is both eyes, flashing lights from the retina is one eye only. The detached retina is usually easily seen through a dilated pupil.

Retinal Detachment www.eyeweb.org The first photo “A” shows the vitreous detaching from the retina in a normal fashion. “B” shows the vitreous detaching that also causes a retinal tear. “C” shows the retinal tear with vitreous attached to the tip of the tear causing traction. The photo on the right shows a retinal detachment. www.eyeweb.org

Diabetic Retinopathy Two types: Nonproliferative diabetic retinopathy (NPDR) Proliferative diabetic retinopathy (PDR) Diabetic Macular edema is the most common cause of visual loss related to diabetes. Can occur in NPDR or PDR. It may be treated with focal argon laser photocoagulation. Two types: Nonproliferative diabetic retinopathy (NPDR) Proliferative diabetic retinopathy (PDR) Diabetic Macular edema is the most common cause of visual loss related to diabetes. Can occur in NPDR or PDR. It may be treated with focal argon laser photocoagulation.

Non Proliferative Diabetic Retinopathy (NPDR) This photo shows many common findings of non proliferative diabetic retinopathy. Dot/blot hemorrhages Flame hemorrhages Microaneurysms Cotton Wool Spots Hard Exudate Dot/blot hemorrhages Flame hemorrhages Microaneurysms Cotton Wool Spots Hard Exudate www.southcoasteye.com/

Proliferative diabetic retinopathy (PDR) More severe form of diabetic retinopathy, which may occur with or without macular edema. Treated with panretinal photocoagulation. May occur without visual loss therefore routine ocular exams are crucial for diabetics. Proliferative diabetic retinopathy may lead to vitreous hemorrhage, traction retinal detachment and blindness. More severe form of diabetic retinopathy, which may occur with or without macular edema. Treated with panretinal photocoagulation. May occur without visual loss therefore routine ocular exams are crucial for diabetics. Proliferative diabetic retinopathy may lead to vitreous hemorrhage, traction retinal detachment and blindness.

PDR Neovascularization of the disc (NVD) Neovascularization A photo of showing neovascularization of the disc and neovascularization elsewhere. Neovascularization Elsewhere (NVE) medweb.bham.ac.uk/easdec/eyetextbook/dr.htm14.jpg

Age-related macular degeneration (ARMD) Dry age-related macular degeneration A disease of the retinal pigment epithelium causing slowly progressive loss of vision. May progress to the more severe form of wet age-related macular degeneration. Antioxidant vitamins (Vit C, E, beta carotene, and zinc) may decrease the chance of progression of this disease to the more advanced form. Dry age-related macular degeneration A disease of the retinal pigment epithelium causing slowly progressive loss of vision. May progress to the more severe form of wet age-related macular degeneration. Antioxidant vitamins (Vit C, E, beta carotene, and zinc) may decrease the chance of progression of this disease to the more advanced form.

ARMD Wet macular degeneration is characterized by the development of a subretinal neovascular membrane. Can acutely bleed and have visual loss. Visual distortion (metamorphopsia) is a hallmark of this disease. Anti-VEGF medications have improved the outlook of wet ARMD, but still a devastating disease Avastin and Lucentis Wet macular degeneration is characterized by the development of a subretinal neovascular membrane. Can acutely bleed and have visual loss. Visual distortion (metamorphopsia) is a hallmark of this disease. Anti-VEGF medications have improved the outlook of wet ARMD, but still a devastating disease Avastin and Lucentis

Dry ARMD These are photos showing armd. You can see it affects only the central retina (the macula). This causes central vision to be blurred with normal peripheral vision.

Wet ARMD Subfoveal Neovascular Membrane Wet ARMD indicates the same findings as dry ARMD with the addition of subretinal fluid or subretinal hemorrhage.

Quiz5

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical On to the optic nerve to describe vision loss.

Optic Nerve Glaucoma – the most common cause of optic nerve related visual loss is related to glaucoma. Open angle glaucoma is the most common form of glaucoma. No symptoms until it is very advanced. Visual loss involves the peripheral visual field. Visual loss is not reversible. Treatment involves lowering of intraocular pressure through medication and surgery. This disease will be covered in depth in your other eye lectures. Glaucoma – the most common cause of optic nerve related visual loss is related to glaucoma. Open angle glaucoma is the most common form of glaucoma. No symptoms until it is very advanced. Visual loss involves the peripheral visual field. Visual loss is not reversible. Treatment involves lowering of intraocular pressure through medication and surgery.

Glaucoma Normal Glaucoma An example of a normal optic nerve with a cup to disc ratio of about 0.2. On the right is an example of a glaucomatous optic nerve with a cup to disc ratio of about 0.9. Normal Glaucoma

Angle closure glaucoma Rare form of glaucoma which may occur in acute or chronic forms. Chronic angle closure glaucoma presents similarly to chronic open angle glaucoma. Acute angle closure glaucoma may present with eye pain, blurred vision, and nausea. Pupil may be fixed and mid dilated. Treatment of angle closure glaucoma is through the creation of a peripheral iridectomy using a laser. This again will be covered in your glaucoma lectures. Rare form of glaucoma which may occur in acute or chronic forms. Chronic angle closure glaucoma presents similarly to chronic open angle glaucoma. Acute angle closure glaucoma may present with eye pain, blurred vision, and nausea. Pupil may be fixed and mid dilated. Treatment of angle closure glaucoma is through the creation of a peripheral iridectomy using a laser.

Neovascular glaucoma An acute form of glaucoma related to retinal ischemia with diabetic retinopathy or retinal vein occlusions. Symptoms are similar to that with acute angle closure glaucoma. Treatment must be directed at both the causative retinal disease and the direct lowering of intraocular pressure. Another glaucoma variant that will be covered in other lectures. It is listed here for completeness. An acute form of glaucoma related to retinal ischemia with diabetic retinopathy or retinal vein occlusions. Symptoms are similar to that with acute angle closure glaucoma. Treatment must be directed at both the causative retinal disease and the direct lowering of intraocular pressure

Ischemic optic neuropathy (ION) 2 types: Arteritic or Non-arteritic Present with an APD Arteritic ischemic optic neuropathy (AION) is related to underlying inflammatory vascular disease such as temporal arteritis (giant cell arteritis). Elderly patients with concomitant jaw claudication, scalp tenderness, and proximal muscle pain are at risk. A sedimentation rate should be performed followed by a temporal artery biopsy if positive. Treatment is with systemic corticosteroids. IONs will be reviewed in your neuro-ophthalmology lectures. 2 types: Arteritic or Non-arteritic Present with an APD Arteritic ischemic optic neuropathy (AION) is related to underlying inflammatory vascular disease such as temporal arteritis (giant cell arteritis). Elderly patients with concomitant jaw claudication, scalp tenderness, and proximal muscle pain are at risk. A sedimentation rate should be performed followed by a temporal artery biopsy if positive. Treatment is with systemic corticosteroids.

Ischemic Optic Neuropathy Nonarteritic Optic nerve swelling Splinter hemorrhages Sudden loss of vision Altitudinal visual field loss This photo shows optic nerve swelling with splinter hemorrhages coming from the disc.

Ischemic optic neuropathy (ION) Nonarteritic ischemic optic neuropathy (NAION) causes sudden visual loss in the absence of vascular inflammation. Underlying diabetes and hypertension predispose to NAION. Nonarteritic ischemic optic neuropathy (NAION) causes sudden visual loss in the absence of vascular inflammation. Underlying diabetes and hypertension predispose to NAION.

Optic neuritis Sudden visual loss in relatively young people. Pain with eye movements is classic Present with an APD Commonly a manifestation of multiple sclerosis. Treatment with corticosteroids is controversial Vision will recover faster but in the long term has no additional benefit. Sudden visual loss in relatively young people. Pain with eye movements is classic Present with an APD Commonly a manifestation of multiple sclerosis. Treatment with corticosteroids is controversial Vision will recover faster but in the long term has no additional benefit.

Quiz6

Location of Visual Loss Refractive Eyelid Cornea Anterior Chamber Lens Vitreous Retinal Optic nerve Cortical The final part of the visual pathway that can cause vision loss is in the brain (cortical).

Visual Pathways Disease involving the visual pathways through the brain will manifest according to the location and type of disease (CVA –sudden, Tumor – slow). Disease involving the visual pathways through the brain will manifest according to the location and type of disease (CVA –sudden, Tumor – slow).

Visual Cortex in Occipital Lobes This will be reviewed in depth in your neuro-ophthalmology lectures. The photo shows what visual deficit would correspond with different lesions in the brain.

Summary Vision Loss is the most important eye complaint you will encounter as a physician. Utilize symptoms, clinical presentations and examination findings to recognize common causes of vision loss. Differentiating acute vs chronic vision loss will help narrow down the diagnosis. Vision Loss is the most important eye complaint you will encounter as a physician. Utilize symptoms, clinical presentations and examination findings to recognize common causes of vision loss. Differentiating acute vs chronic vision loss will help narrow down the diagnosis.

Any Questions? Amit.tandon@osumc.edu

Survey We would appreciate your feedback on this module. Click on the button below to complete a brief survey. Your responses and comments will be shared with the module’s author, the LSI EdTech team, and LSI curriculum leaders. We will use your feedback to improve future versions of the module. The survey is both optional and anonymous and should take less than 5 minutes to complete. Survey