Acute and Chronic visual loss By Dr. ABDULMAJID ALSHEHAH Ophthalmology consultant Anterior Segment and Uveitis consultant

DDx of acute vision loss Painful (usually) Corneal Abrasion Corneal ulcer acute angle closure glaucoma Acute uveitis (sometimes painless) Endophthalmitis Painless (usually) hyphema Vitreous hemorrhage. Retinal Artery Occlusion Retinal Vein Occlusion Retinal Detachment Optic Neuritis (can be associated with ocular pain on eye movement)

Acute visual loss In medicine, an acute disease is a disease with a rapid onset and/or a short course. minutes up to few weeks

History taking for a patient with loss of vision For how long? One or both eyes History of eye trauma History of eye surgery Associated symptoms (pain). Medical illnesses (DM)

Examining a patient with loss of vision VA Confrontation VF testing Pupillary reactions Ophthalmoscopy (red reflex+fundus). Penlight exam. Tonometry.

corneal epithelial defect (CED) or corneal abrasion

Corneal ulcer or microbial keratitis History of (trauma, CL wear) Need urgent referral to ophthalmologist Need samples for microbiology Might need hospitalization Treated with frequent application of topical broad spectrum antibiotics. If neglected can lead to corneal perforation and endophthalmitis

acute angle closure glaucoma C/O acute vision loss, pain, headache, vomiting Corneal edema Mid-dilated non-reactive pupil Ciliary injection High IOP (around 50s) Optic disc swelling Systemic IOP lowering medications YAG laser peripheral iridotomy ASAP

Acute uveitis Most commonly idiopathic can be associated with pain and high IOP Characterized by: ciliary injection, keratic precipitates (KPs), iris nodules, synechia, vitritis, vasculitis, chorioretinitis and/or papillitis. Any type of uveitis (anterior, intermediate and posterior) can cause acute loss of vision but usually posterior (toxoplasmosis retinitis) Rule out infection and malignancy Treatment is usually with Local or systemic immunosuppression

Endophthalmitis Painful loss of vision Usually Recent intraocular surgery. Usually unilateral (except septicemia) Need urgent referral to ophthalmologist. Need vitreous samples for microbiology Need intravitreal antibiotic injections Might need retina surgery.

Hyphema History of trauma (usually) Medical illness (DM, HTN) Painless loss of vision Rubiosis (NVI) due to CRVO or PDR High IOP Treat the cause Steroids and cycloplegic topical drops. Might need surgery (AC washout)

Vitreous hemorrhage History of trauma Medical illness (DM, HTN) Painless loss of vision Rubiosis (NVI) due to CRVO or PDR Retinal Hrg, NVD, NVE Treat the cause Might need surgery (PPV)

Retinal Artery Occlusion BRAO CRAO

Retinal Vein Occlusion BRVO CRVO

Retinal Detachment Typical black curtain complaint

Optic Neuritis RAPD Color vision VF

Chronic visual loss

DDX 1- amblyopia 2- corneal opacities 3- cataract 4- glaucoma 5- retinal vascular diseases 6- macular degeneration (rare in KSA) 7- chronic uveitis 8- neglected or persistent cause of acute visual loss

Corneal opacities Corneal scars (Trachoma, old trauma, old infection, advanced keratoconus) Corneal dystrophies (macular stromal corneal dystrophy, congenital hereditary corneal dystrophy CHED, Fuchs corneal dystrophy) Corneal degenerations (band keratopathy, CDK)

Treatment of corneal opacities Refraction Laser (if superficial opacity) Corneal transplant

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