1. Back to Basics Ophthalmology: Acute visual disturbance/loss
Sylvia Chen
PGY-3 Ophthalmology

2. Outline History Exam Acute visual loss Trauma
Acute angle closure glaucoma
Retinal detachment
Retinal vascular occlusion
Diabetic retinopathy
Wet macular degeneration
Optic nerve disease

3. Ophthalmology Consult Pet-Peeves
Examples
“floaters”
Vision? Which eye? How long? Flashes of light? Curtain over vision?
“decreased vision”
Vision - 20/30 vs 20/200? Sudden onset vs. gradual? RAPD? DM/HTN/Cholesterolemia/CAD/headache
“red eye”
Vision? Recent viral illness? Discharge? Photophobia?
“swollen eye – can’t see eye”
Vision?
Trauma? Mechanism? Allergy? Recent illness/Infection?
Blood? From where? – lid/conjunctiva/inside eye (hyphema)

4. History Onset Character Acute vs. chronic One eye or both eyes Trauma?
Acute onset vs acute perception of visual loss
One eye or both eyes
Trauma?
Mechanism
Character
Sudden vs. gradual
Permanent vs. transient
Flashes
Floaters “flies, cobwebs”
Veil covering vision
“Curtain coming down”

5. Associated symptoms Past Medical History Headache Pain on eye movement
Photophobia
Temporal headache, jaw claudication, weakness, fever, wt loss, loss of appetite
Past Medical History DM
HTN
Dyslipidemia
Afib
CAD
PMR
Arthritis

6. FamHx Meds Social Trauma Any ocular probs Plaquenil/chloroquine for RA
RD, macular degeneration, glaucoma, blindness
Meds
Plaquenil/chloroquine for RA
Diamox for glaucoma
Anticholinergics – allergy meds, antidepressants
Eye drops
Social
Tobacco
EtOH abuse
Trauma
Tetanus, last meal, allergies

7. Past Ocular History Visual history Eye Injury Eye Surgery
Lazy eye, crossed eyes, asymmetric vision as child
Glasses (hyperope/myope), CL use
Eye Injury
Treatment required? Visual outcome?
Eye Surgery
Cataract, glaucoma, retinal detachment (buckle, gas bubble), crossed eyes
Laser Treatment
DM, Glaucoma, after cataract surgery, retinal hole or detachment
Drops
Prescription or not? For glaucoma (eye pressure)? Post-op? Steroid? Antibiotics?

8. Examination Visual acuity Pupils/Iris Muscles 20/30 vs. 20/200 RAPD
peaked pupil
Muscles
Movements

9. External Exam Lids Conjunctiva Corneal Anterior chamber IOP
injection
chemosis
Corneal
abrasion
haze
Anterior chamber
Blood?
IOP
Visual field

10. Fundus – a bonus if you can see it!
Optic nerve swelling
Macula
Drusen
Exudates
Blood
Vessels
Dilated
Tortuous
Retinal blood
Vitreous haze/hemorrhage

11. Acute vision loss: TRAUMA
Mechanism of injury
Globe Rupture
Ophthalmic Emergency!
Vision
Tetanus
Ancef
NPO
CT orbits
OR tonite!

13. Hyphema Blunt trauma Associated corneal abrasion
Soccer ball / baseball
Bungee cord
Punch
Associated corneal abrasion
Occult globe rupture? – check IOP

14. Angle Closure Glaucoma
Symptoms
Pain
Nausea & vomiting
Decreased vision
History
Hyperope (short eye)
F>M
Increasing age
Meds: anticholinergics, antidepressants

15. Signs Ophtho today Cloudy cornea Red eyes Mid-dilation of the pupil
Forward bowing iris (narrow drainage angle)
High intraocular pressure (as high as 4X normal pressure)
Ophtho today

16. Retinal Detachment Risk factors Signs Myopia
Personal history of tear/detachment
Family history of tear/detachment
Intraocular surgery
Pseudophakia
Signs
Floaters
new “flies”
Flashes
Lightning flashes
Veil covering vision
Painless

17. Macula on
Ophtho today
Macula-off
can wait till tomorrow

18. Branch retinal vein occlusion (BRVO)
Painless loss in vision
Visual field defect
Not an emergency

19. Central retinal vein occlusion (CRVO)
Painless vision loss
May have an RAPD
If young
hypercoagulation workup
Not an emergency

20. Branch retinal artery occlusion (BRAO)
Painless vision loss
Embolic work-up
ECG, Echo, Carotid dopplers
RF management
Chol, BP, DM
Not an emergency

21. Central retinal artery occlusion (CRAO)
Painless vision loss
May have an RAPD
If within first 90 minutes
Ocular massage
Embolic work-up
ECG, Echo, Carotid dopplers
RF management – Chol, BP, DM
Not an emergency

22. Stroke
Both eyes affected
Homonymous visual defect

23. Diabetic Retinopathy Glucose control? BP control?
HgA1c
BP control?
Nephropathy/neuropathy?
Proliferative disease
Look at fellow eye
Prior laser treatment?

24. Vitreous hemorrhage
Most commonly from proliferative diabetic retinopathy
Also retinal tear, trauma, tumour…
Refer to Ophthalmology

25. Neovascular glaucoma Neovascularization of the iris Diabetes
Ocular ischemia
CRVO
90-day glaucoma

26. Wet AMD Risk factors White Female >65 y.o. Smoker
History of dry AMD
10% year convert to wet
Family history

27. Amsler grid
Scotoma
Distortion

28. Optic nerve disease: Optic neuritis
Young
Female
Progressive vision loss over few days
Decreased colour vision
RAPD
Pain with eye movement (90%)
Optic nerve swelling (2/3)

29. Optic nerve disease: Giant Cell Arteritis
History
Age > 60 y.o.
Vision loss (curtain coming down), temporal headache, jaw claudication, fever, wt loss, anemia, proximal muscle weakness (associated with PMR)
Decreased vision +/- RAPD, +/- disc swelling or heme
Rest of exam normal
Labs: CBC, ESR, CRP
Oral prednisone: 1mg/kg/day
80% risk of vision loss in other eye!
Then refer to Ophtho

30. Referral to Ophtho Emergency Same day Next day Same week Non-urgent
Globe rupture
Same day
Acute angle closure glaucoma
Mac-on RD
Hyphema
Next day
GCA
Do CBC, ESR, CRP, start steroids
Mac-off RD
Head elevated, limit activity
VH in non-DM
Same week
Vitreous hemorrhage in DM
New wet AMD
Optic neuritis
Non-urgent
Retinal vascular occlusion (BRVO/CRVO, BRAO/CRAO)
Stroke

31. Summary Take a good history Take a vision! Don’t miss a globe rupture
You can determine the diagnosis with history in 90% of patients!
Take a vision!
Don’t miss a globe rupture
Do you best on the rest of the exam