2. Sudden Painless Loss of Vision
Maj
Ahsan Mukhtar
FCPS, FRCS (Ophth)
Classified Eye Specialist
Registrar VR Surgery
AFIO

3. Objectives Know Imp points in History and Exam Enumerate common Causes
Know the clinical appearance of various diseases

5. History True sudden vision loss OR sudden realisation of visual loss?
One eye or both eyes?
Onset and progression
Associated visual symptoms
flashes suggest retinal traction (but can be cortical e.g. CVA, migraine)
floaters suggest vitreous debris

6. History Past ocular history Systems review
trauma and myopia are risk factors for retinal detachment
Systems review
in elderly patients, ask about headache and polmyalgia (temporal arteritis)
history of diabetes
cardiovascular disease, TIA symptoms suggest emboli

7. Examination External ocular appearance Visual acuity
Colour vision assessment
Pupil Examination
Visual field assessment
Fundoscopy
Palpation of temporal arteries
Cardiovascular examination
Neurological examination

9. RAPD
Darken the room
Have the patient fix on a distant target (e.g. the top letter on a Snellen chart)
Alternate a bright light rapidly (<1 second) between the two eyes, spending 2 seconds on each eye

12. CAUSES

13. Media opacity (No RAPD)
giant cell arteritis
corneal edema
Hypoxia
hyphema
shock
vitreous hemorrhage
g-LOC (an aviation related problem)
Retinal disease (RAPD)
simply standing up suddenly, especially if sick or otherwise infirm
retinal detachment
macular disease (e.g., macular degeneration);
Visual pathway disorder
retinal vascular occlusions
homonymous hemianopia
Optic nerve disease (RAPD)
cortical blindness
optic neuritis, retrobulbar neuritis, and papillitis
Trauma
Functional disorder
papilledema
glaucoma
ischemic optic neuropathy

14. Media opacity (No RAPD)
giant cell arteritis
corneal edema
Hypoxia
hyphema
shock
vitreous hemorrhage
g-LOC (an aviation related problem)
Retinal disease (RAPD)
simply standing up suddenly, especially if sick or otherwise infirm
retinal detachment
macular disease (e.g., macular degeneration);
Visual pathway disorder
retinal vascular occlusions
homonymous hemianopia
Optic nerve disease (RAPD)
cortical blindness
optic neuritis, retrobulbar neuritis, and papillitis
Trauma
Functional disorder
papilledema
glaucoma
ischemic optic neuropathy

18. Media opacity (No RAPD)
giant cell arteritis
corneal edema
Hypoxia
hyphema
shock
vitreous hemorrhage
g-LOC (an aviation related problem)
Retinal disease (RAPD)
simply standing up suddenly, especially if sick or otherwise infirm
retinal detachment
macular disease (e.g., macular degeneration);
Visual pathway disorder
retinal vascular occlusions
homonymous hemianopia
Optic nerve disease (RAPD)
cortical blindness
optic neuritis, retrobulbar neuritis, and papillitis
Trauma
Functional disorder
papilledema
glaucoma
ischemic optic neuropathy

24. Media opacity (No RAPD)
giant cell arteritis
corneal edema
Hypoxia
hyphema
shock
vitreous hemorrhage
g-LOC (an aviation related problem)
Retinal disease (RAPD)
simply standing up suddenly, especially if sick or otherwise infirm
retinal detachment
macular disease (e.g., macular degeneration);
Visual pathway disorder
retinal vascular occlusions
homonymous hemianopia
Optic nerve disease (RAPD)
cortical blindness
optic neuritis, retrobulbar neuritis, and papillitis
Trauma
Functional disorder
papilledema
glaucoma
ischemic optic neuropathy

27. Methyl alcohol metabolized very slowly,
stay longer period
Oxidised in to formic acid & formaldehyde
oedema
Degenaration of ganglion cell of retina
Complete blindness

31. Media opacity (No RAPD)
giant cell arteritis
corneal edema
Hypoxia
hyphema
shock
vitreous hemorrhage
g-LOC (an aviation related problem)
Retinal disease (RAPD)
simply standing up suddenly, especially if sick or otherwise infirm
retinal detachment
macular disease (e.g., macular degeneration);
Visual pathway disorder
retinal vascular occlusions
Visual field defects
Optic nerve disease (RAPD)
homonymous hemianopia
optic neuritis, retrobulbar neuritis, and papillitis
cortical blindness
Trauma
papilledema
Functional disorder
glaucoma
ischemic optic neuropathy

34. Media opacity (No RAPD)
giant cell arteritis
corneal edema
Hypoxia
hyphema
shock
vitreous hemorrhage
g-LOC (an aviation related problem)
Retinal disease (RAPD)
simply standing up suddenly, especially if sick or otherwise infirm
retinal detachment
macular disease (e.g., macular degeneration);
Visual pathway disorder
retinal vascular occlusions
homonymous hemianopia
Optic nerve disease (RAPD)
cortical blindness
optic neuritis, retrobulbar neuritis, and papillitis
Trauma
Functional disorder
papilledema
glaucoma
ischemic optic neuropathy

35. THANK YOU

36. Sudden Painless Visual Loss
Alarming to both the patient and clinician alike
Requires careful history and examination to determine underlying cause
Visual Obscuration may range from
a symptom of dry eye
or it may herald the onset of irreversible visual loss or stroke

37. Aims Focused history to identify the anatomic site of the pathology
Focused examination
Know the causes
Understand the importance of Simple examination techniques such as
visual acuity measurement
confrontational visual field testing
pupil assessment
fundoscopy

38. Retinal Detachment
Patients may notice an enlarging shadow in peripheral vision(not just a floater)
Sudden loss of central vision occurs when the macula detaches
Flashes and floaters are common associated symptoms
Ocular history of trauma, surgery and myopia.

39. Retinal Detachment Acuity normal = macula "on"
Acuity poor = macula "off'
RAPD
Visual field defect corresponding to area of detached retina
Fundus examination is diagnostic (but may be difficult to pick with direct ophthalmoscope)

40. Vitreous Haemorrhage Causes
Proliferative diabetic retinopathy (new vessels present)
BRVO with new vessels
Retinal tears (tear through a retinal vessel)

41. Vitreous Haemorrhage History
Blurred vision with floaters
Diabetes(may be undiagnosed)
Vision: varies with severity of haemorrhage (6/6 to PL)
Pupils: NO RAPD (unless retina detached as well)
Fundus: reduced red reflex and difficult to see retinal detail

42. Central Retinal Artery Occlusion
Sudden total loss of vision
Previous episodes of amaurosis fugax
Cardiovascular disease
Vision may be NPL
Afferent pupil defect
Total field loss

43. Central Retinal Artery Occlusion
Cloudy swelling of infarcted posterior retina
Cherry red spot at fovea (where retina thinnest)
Segmentation of blood columm in retinal veins (slow flow)
Look for emboli in the retinal arteries

44. Central retinal vein occlusion (CRVO)
Patients usually>50 yrs
Strong association with hypertension and cardiovascular disease
Sudden painless bIur of vision
Vision varies with severity (from 6/6 to hand movements)
Afferent pupil defect if severe CRVO (HM vision)

45. Central retinal vein occlusion (CRVO)
extensive retinal haemorrhages in all quadrants
retinal venous distension
optic disc swelling

46. AION Elderly patients (age >65)
Sudden and severe loss of vision in one eye initially
Systemic symptoms are headaches, scalp tendemess,malaise, jaw claudication
Vision 6/60 or worse RAPD
Extensive visual field loss
Pale swollen optic disc (anterior ischaemic optic neuropathy), rarely CRAO.

47. AION Aim to prevent loss of the other eye! Urgent ESR (expect >60)
Prednisolone l00mg stat
Urgent referral
Temporal artery biopsy will confirm the diagnosis

48. Optic Neuritis Typically affects one eye of young women
Vision progressively dims over 48 hours (not truly "sudden")
Ache around eye at onset (worse with eye movement)
Reduced acuity and colour vision
A relative afferent pupil defect (RAPD) is present

49. Optic Neuritis Fundus may be normal (retrobulbar neuritis)
Recovery over 6 weeks, more rapid if IV methylprednisolone.
Strong association with MS (MRI Brain will help predict risk)

50. Alcohol Amblyopia Acute onset
Resulting in optic atrophy & permanent blindness
Etiology-
Intake of wood alcohol spirit in cheap adulterated beverages
Inhalation of fumes in industries

51. Methyl alcohol metabolized very slowly,
stay longer period
Oxidised in to formic acid & formaldehyde
oedema
Degenaration of ganglion cell of retina
Complete blindness

52. Methyl alcohol amblyopia
Mild disc oedema
Markedly narrowed blood vessels
Bilateral optic atrophy

54. Eye Pain
RAPD
Key findings
CRAO No
Yes
Pale retina, cherry-red spot
CRVO
+/-
Blood and thunder / “Ketchup” fundus RD
May have localized field defect, cloudy veil. But suspect on history
AION
Swollen pale disc, signs of temporal arteritis
Optic Neuritis
Painful EOM, young female pt

55. Urgency
Can wait till AM?
ED Treatment
CRAO
CALL
IMMEDIATELY
Only if subacute (Many days old)
Orbital massage Lower the IOP
CRVO
CALL when convenient
Yes, wait
ASA RD
At their discretion
Bed rest supine
Eye shield
AION
CALL if TA, severe sx, uncertain dx, can wait if not TA
Steroids if TA
Optic Neuritis
Yes, for ophth
AVOID oral steroids