1. UBC Ophthalmology Interest Group Seminar Series 1.18.2012
Acute Visual loss

2. Anatomy review 24 mm Welcome to this workshop.
Objectives: 1. To have a basic approach to hx and px of pt with eye complaint
2. To use this approach to investigate acute visual loss
3. Understand the basic pathophysiology and presentation of 4 common causes of acute visual loss
4. Understand when to refer to specialist as a primary care provider
24 mm

3. Photo courtesy: Heather O’Donnell, PGY2, UBC

4. Primary care Approach History
Onset ie. minutes vs days, following trauma?
Transient vs permanent
Mono vs binocular
Associated symptoms eg. pain, swelling, floaters
Other medical conditions and eye history
Medications
Acute defined as dramatic decline from baseline acuity in a hour.
Previous eye history include whether this is the first episode or recurrence, history of DR, AMD, strabismus, myopia, RD, history of CAD, DM, HTN, arthritides.
Children requires special attention to history of congenital eye disorders, abuse, etc.

5. Eye Exam
Visual acuity
Equivalent to vitals for the eye

6. Visual acuity testing
VA testing using Snellen chart, or Tumbling E. Peds have pictures (Cardiff cards) so they can point. LogMar is another scale not often used. VA tests central vision (cones)
Need to get >1/2 of the letters to move on to the next line
After 20/200, CF, HM, LP, no LP
Indicate as 20/x +/- y. sc or cc, pinhole to correct for refractive error
Legally blind <20/200 cc, driving >20/50 for class 5

8. Eye Exam Visual acuity Pupils, RAPD Confrontational visual field
Equivalent to vitals for the eye
Pupils, RAPD
Another ‘vitals’, from eye/neuro/trauma point of view
Confrontational visual field
Extraocular movement
Tonometry
External examination
Slit lamp: lids, conjunctiva, AC
Dilated examination, fundoscopy
Remember to compare with previous recorded eye exam
These are exams capable of being done in office/ER setting
Note pupils direct vs consensual reaction to light, RAPD, shape size and symmetry, include red reflex
Pay attn to nystagmus and diplopia, which may be first sign of neurological disease eg MS
Lids/Conj: check for laceration or foreign body. Conjunctival swelling (chemosis) and injection are signs of some eye conditions
AC: look for obvious blood (hyphema) or exudate (hypopyon)
Fundoscopy: best with dilation and indirect ophthalmoscope, but at primary care use direct ophthalmoscope
Visuals possible? (unequal pupils, irregular pupils, strabismus, chemosis, hyphema, hypopyon, proptosis)

9. Case 1
Previously well 75F presents to ED for sudden R eye pain and blurry vision while watching TV at night
c/o “halo” around lights
Symptoms not resolved
Hx: cataract in both eye, mild HTN
No medications
Larger lens associated with cataract a risk for acg
IOL less risk
Asian, Inuits higher risks, Blacks less risk

10. Case 1 OD CF, OS 20/25 R pupil fixed 4mm Rock hard globe Corneal edema
Conj injections
Opposite eye looks normal
Nausea, vomit x 1
Photo courtesy: A. Doan, MD, University of Iowa

11. Impression and Plan?
A. Urgent head CT r/o mass lesion in brain causing high ICP
B. Acute bacterial conjunctivitis, pt needs abx eye drops
C. Chemical keratitis, rinse eye in sterile water for 10 min immediately
D. Acute angle closure glaucoma, consult ophthalmology STAT
Ans: D

12. Acute angle closure glaucoma
Results from aqueous outflow obstruction by iris, rise in IOP, ischemia and permanent glaucomatous damage: emergency!
IOP = 42 mmHg (normal 12-20mmHg)
Acetazolamide and timolol were given initially, followed by pilocarpine 1 hour later.
IOP decreased to 19 mmHg
Laser peripheral iridotomy arranged the next day is the definitive treatment
Dilation causes stuck on lens
Pilo constricts pupils and ciliary contraction opening the meshwork, parasympathetomimetic,
Also mannitol
Sent home on pilo QID
R/A to check for permenant scarring

14. Laser peripheral iridotomy
Photo courtesy: A. Doan, MD, University of Iowa

15. Case 2
50M highly myopic pt sees GP for c/o new onset of “flashing lights and floaters”
Blurry vision but no pain
Otherwise healthy
Rev Ophthalmol, 2006, 6:15

16. Case 2 OD 20/80, OS 20/20 Pupils, anterior segment normal
Vitreous: tobacco dust
IOP: OD 10 mmHg, OS 13 mmHg
Question what is the diagnosis? Retinal detachment. Tobacco dust in vitreous is hemorrhage: Schaffer’s sign. Pressure is normal r/o glaucoma.
May have RAPD if large detachment
Macula off RD: curtain + poor vision
Macula on would have just a curtain
Rev Ophthalmol, 2006, 6:15

17. Retinal detachment
Rhegmatogenous most common, start as a tear, fluid build up beneath neuroretina separates it from retinal pigment epithelium
High myopia is a risk factor
In office: avoid pressure on globe, protect the eye
Immediate ophthalmological consult required
Surgery is definitive treatment, often urgent
Exudate and tractional other types
RPE cannot pump out fluids.
Other risks: recent head trauma, previous intraocular surgery incl ECCE, family hx
Macula off: less urgent. Macula on: more urgent

18. Case 3
75F with sudden painless loss of vision OD yesterday comes to GP office
A “grey spot” in her vision, grown over 10 min
Hx incl. CAD, HTN, TIA
Denies eye problems A
Photo courtesy: AAO 2011

19. Case 3 OD CF, OS 20/30 R pupil sluggish 3mm RAPD EOM full
Cornea, AC grossly normal
IOP 10mmHg B/L
Cranial nerves intact
Question: what’s the dx? Cherry red spot should clue in CRAO. It’s a consequence of nerve fibre layer infarct and edema surrounding the macula. Also box car retinal arteries.
Photo courtesy: AAO 2011

20. Management
A. Assure pt that her vision is unsalvageable, she needs to start Plavix to prevent a stroke
B. Send pt to emergency department STAT
C. Compress and release the eye right now
D. You don’t know what this is, so you make a regular referral to ophthalmologist in 2-3 weeks
Ans: C

21. Crao
Central retinal artery occlusion often secondary to embolus in a vasculopathic patient
Ophthalmological emergency
Immediate restoration of retinal blood flow is necessary to save sight
Even with compress, sight is often not salvageable.
Need to evaluate etiology
Typically carotid dz, AF
Try: digital compress (quite firmly), lowering IOP with drops, hypocarbia, thrombolysis no benefit
Send pt to stroke clinic. Younger pt <55, need workup for vasculitis

22. Case 4 85F comes to GP for sudden vision loss today
2 months of transient double vision
She has been feeling fatigued with muscle and joint aches for the last 6 months
New headache in her R temple particularly when she combs her hair
Her jaw is painful when she’s eating
Some weight loss too. Associated with condition called? PMR
More common in 80-90
Claudication after prolonged eating

23. BMJ 2011, 343d4783

24. Case 4 OD LP, OS 20/40 Dx: R pupil 3mm RAPD A. Temporal arteritis
EOM full
VF: wide spread loss
Anterior segment normal
ESR from last week: 80 mm/h
Dx:
A. Temporal arteritis
B. Amaurosis fugax
C. Multiple sclerosis
D. Compressive optic neuropathy
Ans: A
VA worse than CRAO

25. Next step? A. Urgent neurology referral as stroke is imminent
B. Start patient on high dose steroids empirically because benefits outweigh risks
C. Ophthalmology referral for a temporal artery biopsy to confirm diagnosis
D. Urgent MRI of brain as it’s most sensitive and specific for confirming a central lesion
Ans: B
Bx in a week
Acute tests: ESR, CRP, start on 1mg/kg prednisone
Also vasc surgery

26. Temporal arteritis
Aka giant cell arteritis. Another classic ophthalmological emergency
Suspect in older women with new headache, vision loss, and systemic sx
Elevated ESR/CRP helps to rule in dx
Must initiate high dose steroids immediately followed by temporal artery biopsy
Also refer to rheum and neurology
Should improve within a few days
Low dose steroids / MTX for a year, follow with CRP

27. summary Approach: Hx, Va, Pupils, out to in, front to back
Acute vision loss is often a sign of serious ocular disease process:
Acute angle closure glaucoma
Retinal detachment
Central retinal artery occlusion
Temporal arteritis
Urgent ophthalmological referral is needed (timeframe usually minutes to hours)
Immediate action is also required; time is sight

28. Questions ? Acknowledgement Contact
Case editor: Steven Schendel, PGY-4 UBC
Contact
R Tom Liu, UBC Med 2013