1. Acute Painless Loss of Vision
Syed Hasan

2. Acute Painless Loss of Vision
The second most common ophthalmic emergency (after red eye)

3. Loss of vision Painless Unilateral Bilateral Few seconds duration
Giant cell arteritis
Papilloedema
Impending central retinal vein occlusion
Ocular ischemic syndrome
Bilateral

4. Loss of vision Few minutes duration Unilateral Bilateral
Amaurosis fugax
Giant cell arthritis
Bilateral
Vertebrobasilar artery insufficiency
Up to one hour duration
Migraine

5. Loss of vision Persistent Central/Branch retinal artery occlusion
Central/Branch retinal vein occlusion
Retinal detachment/Viterous haemmorhage
Posterior uveitis
Anterior ischaemic optic neuropathy
Optic neuritis
Macular degeneration
Cortical blindness
Functional
Toxins/Drugs

6. Amaurosis Fugax Monocular or Binocular transient visual loss.
Monocular: Anterior to Chiasm
Binocular: At or posterior to Chiasm
Duration: Shorter duration=Thromboembolic, Longer Duration=Migraine.
D/D: Embolism, Retinal vasospasm, CRVO, Optic Neuropathy, migraine, presyncope, seizure, vertebrobasilar ischemia.
Full neurological and cardiovascular workup, ECG, Echo, Carotid Doppler, ESR and CRP if age >50
20% ultimately undergo carotid endarterectomy.
High risk of CVA.
Rx: Anticoagulants, Antiplatelet agents, Carotid Endarterectomy.
Retinal Ischemia- Ca channel blockers.

7. Central Retinal artery occlusion
Acute, painless, monocular, persistent and nearly complete loss of vision.
1-2% Bilateral.
60% are hypertensive, 20% with cardiac history and others with hypercoagulable conditions e.g diabetes.
5 year mortality is 1/3rd of age matched controls without CRAO.
O/E: Pale retina, Cherry red spot, Arteriolar segmentation
15-30% Cilio-retinal artery- Good prognosis
No standard treatment of proven benefit.
Ocular massage, reduction of IOP, Antiplatelet, Anticoagulant and Fibrinolytic therapy. Hyperbaric oxygen, Steroids
R/O GCA

8. Central/Branch retinal artery occlusion
Artheroscleotic plaque in the carotid
Embolus from a cardiac valve
Systemic vascular disease
Hyperviscosity syndromes
Trauma – fat emboli
Oral contraceptives
Systemic diseases – DM, syphilis, sickle cell
Injections of medications around the head and neck
Temporal arteritis
Drug abuse

9. Central Retinal Vein Occlusion
Acute, painless vision typically upon waking up.
Ischemic or Non ischemic
High IOP, Diabetes, Hypertension, Cardiovascular Disease, Hypercoagulable state.
Reduced visual acuity, RAPD and widespread retinal haemorrages.
Rx: Underlying condition, Aspirin
Macular edema: Intravitreal injections of Anti-VEGF agents and Steroids.
Complications: Rubeotic glaucoma

10. Central/Branch retinal vein occlusion
Artherosclerotic vascular disease
Arterial hypertension
Diabetes
Hyperviscosity
Open angle glaucoma, trauma closed angle glaucoma, vascular hypertension
Painless monocular visual loss

11. Ischaemic optic neuropathy
Incidence: 10/100,000/yr of over 50 age group.
5-10% are Giant Cell arteritis rest are Non-Arteretic AION.

12. ARTERETIC AION
Sudden loss of vision, Headache, Scalp tenderness, Jaw claudication, Wt loss, night sweats, myalgia, PMR
Rapd, Swollen disc, can present as CRAO, BRAO or cranial nerve palsies.
High ESR, CRP and platelets. TABx 90% sensitivity
Rx: 3 days of I/V methylprednisolone 1g, followed by oral prednisolone 60-80mg/ day. Taper treatment according to response. Aspirin helpful.
Risk of second eye involvement is 10% in treated case and upto 90% in untreated cases.
NON-ARTERETIC AION
Compromised circulation leads to disc swelling and infarction.
Major causes are Diabetes, Hypertension, Smoking, Hyperlipedemia, Hypotension, Aneamia, Obstructive sleep apnoea
ESR, CRP and PLTs normal.
No proven treatment
Second eye involvement 19% over 5 years.

13. Optic neuritis Papillitis, Reterobulbar-Neuritis, Neuroretinitis.
Most common cause is Demylenation
Incidence: 5/100,000/yr, F/M 3:1, usually unilateral.
70% in MS sufferer.
Rapid loss of vision within hours to days, recovery within 2 weeks.
Clinically reduced Contrast sensitivity, color vision, Field loss and reterobulbar pain. RAPD
Rx: Controversial role for steroids. I/V steroids hastens recovery.
90% show good recovery
Atypical Optic Neuritis.
D/D: SOL, Sarcoidosis, Vasculitis, AION, Toxic, Nutritional, Postviral.

14. Retinal detachment More common in men
Rate 10 per 100,000 people per year
Bilateral in up to one third
Associated with
Degenerative myopia
Lattice degeneration
Aphakia, Cataract Surgery
Diabetes, sickle cell disease

15. Vitreous haemmorhage 7 In 100,000 each year
Sudden dramatic painless loss of vision.
Preceded by floaters.
Diabetes, Hypertension, Sickle cell disease, macular degeretion, CRAO, CRVO, Valsalva, Retinal Detachment, Ocular Trauma, PVD with Tear, Blood disorders, Warfarin.
B-Scan
Rx: Viterectomy

16. Toxic/Drugs B12, Folate deficiency.
Amiodrone, Ethambutol, Methanol, CO, Isoniazid, Lead

17. THANK YOU