Amusing Slide 2013 WTD OPHTH Disclosure You may only access and use this PowerPoint presentation for educational purposes. You may not post this presentation online or distribute it without the permission of the author. I have no conflicts to declare. SUDDEN PAINLESS LOSS OF VISION
WALTER T. DELPERO MD FRCSC ASSISTANT PROFESSOR UNIVERSITY OF OTTAWA REVISED 2015 ALL RIGHTS RESERVED Objectives: Describe the most common and important causes of painless loss of vision. Link common types of visual loss to systemic disease. Describe appropriate investigations/screeningwhen such a condition is identified. 2015WTD OPHTH What will be discussed:
Vision anatomy review. Decreased vision due to mechanical blockage. Retinal problems: arterial or vein occlusion, retinal detachment or inflammation, macular degeneration. 2015WTD OPHTH What will be discussed:
Optic nerve:Optic neuritis, Anterior Ischemic Optic Neuropathy (ischemic and non-ischemic) 2015WTD OPHTH Ocular anatomy 2012WTD OPHTH Vision Pathway 2012 WTD OPHTH Central vision/retinal anatomy
2015 WTD OPHTH Anatomy of the pupillary reflex
2012 WTD OPHTH 2015 WTD OPHTH Something blocking the light from reaching the retina
2015 WTD OPHTH VITREOUS HEMORRHAGE Mechanical blockage of light.
Contraction of vitreous pulls at vessels on or over the retina. May be associated with a retinal tear. 2015 WTD OPHTH RED REFLEX : will identify an opacity along the visual axis
Normal Something blocking the light from shining back. 2014 WTD OPHTH Retinal Neovascularization:
caused by ischemia, can lead to hemorrhage,blocking light to retina 2012 WTD OPHTH Pre retinal Hb: boat shaped Hb Note you cannot see fovea.
Red reflex will be reduced. OPTIC NERVE FOVEA 2015 WTD OPHTH RED REFLEX: Normal Vitreous Hb Reduced on left 2012 WTD OPHTH OTHER CAUSES OF A VITREOUS HEMORRHAGE
Neovascualization from retinal ischemia. Diabetes Sickle cell Carotid artery disease Old Central Retinal Vein Occlusion (CRVO) CHECK THE RED REFLEX 2010 WTD OPHTH DIABETIC RETINOPATHY Normal Background DR Laser treatment
Proliferative DR Note the new blood vessel growth 2015 WTD OPHTH PROLIFERATIVE DIABETIC RENINOPATHY ENDSTAGE
Fibrotic Retina 2014 WTD OPHTH Panretinal Photocoagulation
Treatment options: Panretinal Photocoagulation Laser scars 1600 2000 Reduce production of Vascular endothelial growth factor. 2015 WTD OPHTH Ocular anatomy 2009 WTD OPHTH RETINAL DYSFUNCTION Central retinal artery occlusion.
Commonly secondary to embolic phenomena. Curtain coming down = Amaurosis Fugax Fundoscopy shows pale fundus with cherry red spot. 2015 WTD OPHTH 2015 WTD OPHTH Central Retinal Artery Occlusion (CRAO)
This is an embolic event, source typically carotid or cardiac CHERRY RED SPOT 2015 WTD OPHTH CENTRAL RETINAL ARTERY OCCLUSION
Cherry red spot 2015WTD OPHTH Branch Retinal Artery Occlusion (BRAO)
Embolus Retinal Edema 2015WTD OPHTH RETINAL DYSFUNCTION Central retinal vein occlusion shows diffuse hemorrhage and cotton wool spots. Blood and Thunder. R/Ounderlying disease, blood dyscrasia, HT, glaucoma. 2015WTD OPHTH Central Retinal Vein Occlusion (CRVO)
Blood and Thunder 2010WTD OPHTH Central Retinal Vein Occlusion (CRVO) Cotton wool spots (CWS)
Retinal Hemorrhages 2013 WTD OPHTH RETINAL DYSFUNCTION Branch retinal vein occlusion shows Hb and CWS localized. Edema may extend into the foveal area and decrease vision. Blockage occurs at arterial venous crossings, most commonly associated with longstanding HT. 2015 WTD OPHTH CWS Branch Retinal Vein Occlusion (BRVO) (Cotton wool spots)
Most common in Hypertensive patients. CWS (Cotton wool spots) 2015WTD OPHTH RETINAL DYSFUNCTION Cytomegalovirus Retinitis (CMV) Newborns
Immunocompromised: Iatrogenic, HIV-AIDS Visualized in posterior pole. Pizza Pie appearance. Early detection and treatment can preserve vision. 2015 WTD OPHTH CMV Retinitis: loss of actual retina.
Think immunosuppression 2015WTD OPHTH Loss of all retinal details
CMV RETINITIS Loss of all retinal details 2015WTD OPHTH Types of age related macular degeneration (AMD)
DryAMD Wet AMD TYPICALLY OVER AGE 65, FAMILY HISTORY A MAJOR FACTOR. PROGRESSION IS SLOW UNLESS COVERSION TO WET. DRY IS MANAGED WITH VITS WET WITH ANTI-VEGF INJ. 2015 WTD OPHTH SUBRETINAL HEMORRHAGE
Wetage relate macular degeneration (AMD) SUBRETINAL HEMORRHAGE 2015WTD OPHTH WET Age Related Macular Degeneration (AMD)
Elderly person (>65) Central painless loss of VA Treatment now available with anti-VEGF (Avastin/Lucentis) 2015 WTD OPHTH RETINAL DETACHMENT Retinal detachment: separation of the photoreceptors from the underlying RPE. Symptoms: Flashing lights, floaters, shadow in visual field. Can be determined with examination of red reflex and direct fundoscopy. 2015WTD OPHTH Retinal Detachment 2012WTD OPHTH Horseshoe tear with RD 2015WTD OPHTH RETINAL DETACHMENT Retina separating from Retinal Pigment Epithelium
2015 WTD OPHTH RETINAL DETACHMENT REPAIR
Scleral Buckle Buckle acts to reduce traction by the vitreous on the retina 2015 WTD OPHTH OPTIC NERVE DISEASE Metabolically and neurologically one of the most active pathways in the body. Any compromise of nutrition, compression, or local inflammationwill decrease function. 2015WTD OPHTH CENTRALRETINALARTERY
Optic Nerve 2015WTD OPHTH Relative Afferent Pupillary Defect (RAPD)
Checked by a swinging flashlight test. Pupillary reflex anatomy: both pupils appear the same size 2015WTD OPHTH Relative afferent pupillary defect (RAPD)
N.B : pupils appear equal inambiant light unless the defect is brought out by the swinging flashlight test. 2013 WTD OPHTH OPTIC NERVE DISEASE OPTIC NEURITIS: viral or autoimmune. Affects younger age group. Symptoms: Central scotoma, loss of colour vision, +/- pain, symps worsen with increased body temperature 2015WTD OPHTH OPTIC NERVE DISEASE Vision worsens over 1-2 weeks with slow improvement in 4 to 12 weeks. Vast majority improve to 20/40 or better. Signs: Relative afferent pupillary defect. Systemic findings of neurological impairment. 2015WTD OPHTH Normal Fundus RETROBULBAR NEURITIS Decreased vision with a normal red
reflex and fundus exam Normal Fundus 2014WTD OPHTH Colour Desaturation Test
2015 WTD OPHTH OPTIC NERVE DISEASE Treatment is controversial: No oral prednisone. Use I.V. methylprednisolone for first 3 days. Currently will give 1200mg of prednisone daily x 3D. Tincture of time is the mainstay of treatment. 2015WTD OPHTH OPTIC NERVE DISEASE Associated with MS development in 75% F and 35% M over 15 years. 2015WTD OPHTH OPTIC NERVE DISEASE Arteritic and Non-Arteritic Anterior ischemic optic neuropathy. (NAOIN and AION) 2015 WTD OPHTH OPTIC NERVE DISEASE TEMPORAL ARTERITIS: Giant cell arteritis (GCA), Vasculitic process affecting people over the age of 55. Compromises blood supply to optic nerve. Systemically can affect the heart, brain kidneys etc. 2015 WTD OPHTH Optic nerve edema ANTERIOR ISCHEMIC OPTIC NEUROPATHY
note loss of optic nerve edge details 2015 WTD OPHTH Optic nerve edema Flame Hemorrhage Cotton wool spot 2015WTD OPHTH OPTIC NERVE DISEASE Systemic symps: malaise, weight loss, muscle weakness or tenderness, jaw claudication. Common in arteritic-AION Poor circulation, DM, nocturnal hypotension in Non-arteritic AION. 2015WTD OPHTH OPTIC NERVE DISEASE Disc at Risk Crowded disc 2015WTD OPHTH OPTIC NERVE DISEASE RAPD may also be present with disc swelling. Lab test of choice is an ESR and CRP. Temporal artery biopsy is the gold standard. (Within 2 wks) IF SUSPICIOUS GIVE PREDNISONE. 2015 WTD OPHTH CASE HISTORY 67y/o male with hypertension, and poor compliance presents complaining of sudden decreased vision in the right eye. Hint: think vascular 2014WTD OPHTH CASE HISTORY 21y/o female states that over the last 2 days her vision has decreased in her right eye to counting fingers vision. She has only mild pain and denies trauma. Hint: Age 2014 WTD OPHTH CASE HISTORY 55y/o female 12hrs post coronary artery bypass surgery complains of being unable to see from her left eye. There is no pain and externally the eye appears normal. Hint: Vascular 2014 WTD OPHTH CASE HISTORY 40y/o male states he lost vision in his right eye after seeing flashing light and spider webs. He is a10.00 myope. Hint: Long eye, stretched retina. 2014 WTD OPHTH CASE HISTORY 77y/o female is sent to you from geriatrics. She was initially being worked up for lethargy and weight loss. Complained of vision coming and going for several days and now states she cannot see at all from either eye. 2014 WTD OPHTH CASE HISTORY 38y/o male with longstanding insulin dependant diabetes presents with sudden loss of vision in his left eye. He has had only moderate blood sugar control as he takes his insulin only when he feels he needs it. 2013 WTD OPHTH CASE HISTORY 32y/o male with HIV-AIDS, on antiretrovirals and a sulpha drug, presents withpainless loss of vision in his right eye. This has worsened over the last several days. Hint: retinal infection 2014 WTD OPHTH 2014 WTD OPHTH