1. Dr Amani Badawi ASSISTANT PROFESSOR OPHTHALMOLOGY
Visual loss
Dr Amani Badawi
ASSISTANT PROFESSOR
OPHTHALMOLOGY
Amani Badawi
4/23/2017

3. Acute Visual Loss

4. Acute visual loss

5. History Examination Age POH & PMH Onset Duration
Severity of visual loss compared to baseline
Monocular vs. binocular ?
Any associated symptoms
Visual acuity assessment
Visual fields
Pupillary reactions
Penlight or slit lamp examination
Intraocular pressure
Ophthalomoscopy
- red reflex
- assessment of clarity of media
- direct inspection of the fundus

6. 1-Central Retinal Artery Occlusion (CRAO)
True ophthalmic emergency!
Sudden painless and often severe visual loss
Permanent damage to the ganglion cells caused by prolonged interruption of retinal arterial blood flow
Characteristic “ cherry-red spot ”
Months later, pale disc (optic atrophy) due to death of ganglion cells and their axons

7. 1-Central Retinal Artery Occlusion (CRAO) treatment
As before +
Ocular massage:
-To dislodge a small embolus in CRA and restore circulation
-Pressing firmly for 10 seconds and then releasing for 10 seconds over a period of ~ 5 minutes
Ocular hypotensives, vasodilators, paracentesis of anterior chamber

8. 2-Branch Retinal Artery Occlusion (BRAO)
Sector of the retina is opacified and vision is partially lost
Most often due to
embolus
Treat as CRAO

9. 3-Central Retinal Vein Occlusion (CRVO)
Acute loss of vision
Disc swelling, venous engorgement, cotton-wool spots and diffuse retinal hemorrhage.
Needs medical evaluation
Long term complication: neovascular glaucoma, and macular edema so periodic ophthalmic follow up

10. 4-Optic Nerve Disease Non-Arteritic Ischemic Optic Neuropathy (NAION)
- vascular disorder
 pale, swollen disc +/- splinter hemorrhage
 loss of VA , VF ( often altitudinal )
Treatment : systemic steroids

11. 4-Optic Nerve Disease Optic neuritis
- idiopathic or associated with multiple sclerosis
- young adults
- Unilateral decreased visual acuity and colour vision
-RAPD
-pain with ocular movement
-bulbar (disc swelling) or retrobulbar (normal disc)

12. 5-Retinal Detachment Retinal detachment
- flashes, floaters, shade over vision
- elevated retina +/- folds
Macular disease
- decrease central vision
- metamorphopsia

13. Separation of sensory retina from RPE by subretinal fluid (SRF)
Rhegmatogenous - caused by a
retinal break
Non-rhegmatogenous - tractional or exudative
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14. 6-Trauma
Trauma

15. Hyphema

16. Ruptured globe
Open globe should be suspected in any patient who has a history of trauma to the eye, especially with a laceration or puncture wound that extends through the eyelid, followed by pain and decreased visual acuity &hyptony.

17. Anterior segment complications of blunt trauma
Hyphaema
Vossius ring
Sphincter tear
Iridodialysis
Cataract
Lens subluxation
Angle recession
Rupture of globe
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18. Posterior segment complications of blunt trauma
Choroidal rupture and
haemorrhage
Avulsion of vitreous base
and retinal dialysis
Commotio retinae RD
Macular hole
Optic neuropathy

19. Complications of penetrating trauma
Flat anterior chamber
Uveal prolapse
Damage to lens and iris
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Vitreous haemorrhage
Tractional retinal detachment
Endophthalmitis

20. 7-Media Opacities Corneal edema: Corneal abrasion &ulcer
- ground glass appearance
- as in acute congestive glaucoma
Corneal abrasion &ulcer
Vitreous hemorrhage
- traumatic
- retinal neovascularization

21. 8-Endophthalmitis
Background: Bacterial endophthalmitis is an inflammatory reaction of the intraocular fluids or tissues caused by microbial organisms.

22. History Exogenous Endogenous
Classification is based on routes of entry.
Exogenous
Endogenous

23. Physical Visual acuity decreased below the level expected Lid edema
General findings
Visual acuity decreased below the level expected
Lid edema
Conjunctival hyperemia
Corneal edema
Anterior chamber cells and flare &Hypopyon
Vitritis
Loss of red reflex
Retinal periphlebitis if view of fundus possible

24. 9-Visual Pathway Disorders
Hemianopia
- Causes: vascular or tumors
-Types
Cortical Blindness
- Extensive bilateral damage to cerebral pathways
- Normal pupillary reactions and fundi

25. Chronic Visual Loss

26. Case 1
A 75 year old woman is seen for an annual physical examination and complains of mild difficulty in reading and seeing street signs
Vision is especially worse at night
PHx: HTN, T2DM diet controlled
O/E: VA R 6/18 and L 6/12

27. Case 1
What is the likely diagnosis?

28. 1-Cataract Symptoms gradual over years 1. Reduction in visual acuity
Worsening of existing myopia
Correction of hyperopia “second sight of the aged”
2. Loss of contrast sensitivity in low light
3. Glare in bright light :Forward scatter of light

29. Case 2
A 76 year old man has noted visual distortion over the past week
Straight lines viewed through his right eye dipped down in the centre
Round plates seem to have “edges”
O/E: VA R 6/18 and L 6/6
What is the likely diagnosis?
What test are you going to do?

30. Case 2

31. Case 2

32. Case 2

33. 2-Macular degeneration
Loss of central vision
Reading, recognizing faces impaired
Leading cause of legal blindness in developed world
Multifactorial
Age
Smoking, vascular disease, UV light, diet, FHx, …
Atrophic (dry) or exudative (wet)

34. Geographic atrophy – dry AMD
RPE atrophy – demarcated pale area, visible underlying choroidal vessels 34

35. Choroidal neovascularisation – wet AMD
OCT – RPE thickening, pre-retinal hemorrhage & elevation of retina 35

36. Macular scarring – wet AMD

37. Management – dry AMD Lifestyle
Stop smoking, reduce UV exposure, Zinc & antioxidants
Low vision aids
Legal blindness and driving
Monitoring with Amsler chart

38. Management – wet AMD =CNV
Observation
Laser photocoagulation
Photodynamic therapy (PDT)
Intra-vitreal injection of Anti-VEGF

39. Anti-VEGF therapies
VEGF-A stimulates angiogenesis and vascular permeability
Intravitreal injection of monoclonal antibodies
Ranibizumab (Lucentis)
Off-label Bevacizumab (Avastin)

40. Case 3
A 68 year old man was referred from his optometrist for visual field testing
He has not reported any problems with vision, but the test report shows a reduction in peripheral vision in the Right eye

41. Case 3 What is your likely diagnosis?
What further examination are you going to do?

42. Case 3 LE RE 1. generalised/focal enlargement of the cup
2. thinning of neuroretinal rim
3. asymmetry of cupping between patient’s eyes
4. Disc hemorrhage
5. parapapillary atrophy (more common inglaucomatous eyes). 42

43. 3-Glaucoma 1. Optic nerve damage (optic disc cupping) 2. Increased IOP
Increased Cup:disc ratio
Loss of neuroretinal rim
2. Increased IOP
3. Peripheral visual defects
IOP: 1. vascular dysfunction 2. mechanical compression 43

44. The trick of IOP Only 10% with IOP>21 have glaucoma
The rest have ocular hypertension
Only 50% of glaucoma patients have IOP>21
The rest have normal tension glaucoma

45. Glaucoma Types Primary Secondary Congenital Open angle (90%)
Closed angle
Secondary
Congenital

46. Primary open angle glaucoma
“The silent thief of sight”
Asymptomatic
Usually detected on routine examination
Risk factors: IOP, age, FHx, DM, myopia
Impaired drainage of aqueous humor through trabecular meshwork
Due to age-related morphological changes

47. Primary open angle glaucoma

48. Management Aim to stop progress
Medical – reduction of aqueous secretion
Beta-blockers (Timolol)
Alpha-agonists (Brimonidine)
Prostaglandin analogues (Latanoprost)
Parasympathomimetics (Pilocarpine)
Carbonic anhydrase inhibitors (Brinzolamide)

49. Management Surgical Argon and selective laser trabeculoplasty
Filtering surgery
Trabeculectomy
Laser peripheral iridotomy : Yag laser
AC  under conjunctiva, bleb 49

50. Case 4
A 13 year old girl is seen for physical examination at school. She admits to difficulty in reading the blackboard, but not in reading textbooks. She does not wear glasses.
O/E: VA R 6/36 ph 6/6 and L 6/36 ph 6/6
What is your diagnosis?

51. 4-Refractive error Corrects with pinhole
Management: glasses, contact lenses, refractive surgery

52. Case 5 – spot diagnosis

53. 5-Retinitis pigmentosa
Genetically inherited
Progressive retinal dystrophy
Night blindness, tunnel vision, legal blindness
Bony spicules from mottling of RPE
Incurable
Future: gene therapy, bionic eye, …?
Pallor of optic nerve head, attenuation of retinal vessels, cellophane maculopathy, CME, PSC 53

54. 6 – diabetic retinopathy
Microvascular retinal changes
Blindness is progressive, but preventable
Annual retinal examination
Tight T2DM control HbA1c 6-7%
laser treatment
Pre-proliferative retinopathy
Proliferative retinopathy
Also predisposes to cataract & glaucoma

55. Diabetic retinopathy Microaneurysms Dot & blot hemorrhages
Circinate exudate – retinal degeneration
CSME 55

56. Diabetic retinopathy
Cotton-wool spots – area of ischemia 56

57. Diabetic retinopathy
Venous tortuosity – IRMA (intra-retinal microvascular abnormalities) 57

58. Diabetic retinopathy
neovascularisation 58

59. Diabetic retinopathy
Neovascularisation of disc 59

60. Diabetic retinopathy
Focal diabetic maculopathy – amenable to focal photocoagulation, good prognosis 60

61. Diabetic retinopathy
Diffuse exudative maculopathy – amenable to grid photocoagulation, guarded prognosis 61

62. Diabetic retinopathy
Ischaemic maculopathy – not amenable to laser 62

63. Diabetic retinopathy
Vitreal hemorrhage and retinal detachment 63

64. Summary Causes of chronic visual loss Cataract Glaucoma
Age-related macular degeneration
Refractive error
Retinitis pigmentosa
Diabetic retinopathy

65. Thank you