Contents
- 1 Causes
- 2 Retinal detachment
- 3 Temporal Arteritis
- 4 Management
- 5 Vitreous haemorrhage
- 6 Central Retinal Vein Occlusion (CRVO)
- 7 Amaurosis Fugax
- 8 Central retinal artery occlusion
- 9 Wet Age-related macular degeneration
- 10 Optic Neuritis (Acute Optic Neuropathy / Retrobulbar neuritis)
- 11 Posterior Vitreous Detachment
- 12 Decision Tree
- 13 References
- 14 Related Articles
- Have acuity that does not improve with pinhole
- Have any optic disc abnormalities
- Have any acute visual disturbance of unknown cause – it is unlikely you will be able to make an exact diagnosis in primary care or even in the emergency department – unless you are particularly experienced with and have access to a slit lamp.
Causes
- Retinal detachment
- Temporal Arteritis
- Vitreous haemorrhage
- Retinal vein occlusion
- Retinal artery occlusion
- Wet age related macular degeneration
- Anterior ischemic optic neuropathy
- Optic neuritis
- Posterior Vitreous Detachment
- Cerebrovascular accident
- Migraine
Retinal detachment
- Sudden painless loss of vision
- Preceded by flashing lights (photopia), floaters, visual field defects
- Classically –Â “a curtain falling down over my vision”
- Macula involved = Central vision loss
- Macula NOT involved = peripheral field loss and visual acuity maybe normal
- Relative Afferent Pupillary Defect – (affected eye pupil dilates in response to light)
- Sometimes cause by trauma
- More common in:
- Myopic individuals as they tend to have a thinner retina
- Diabetic retinopathy
- Previous surgery (eg. cataracts)
Ophthalmoscopy
- Abnormal red reflex
- If a large detachment you may be able to see the detached retina as a grey and wrinkled fold
- Normal examination does not exclude diagnosisÂ
Management
- If small or minor – Â then laser to retinal tears – this burns the retina and this burns process encourages inflammation and subsequent healing around the affected area
- If true retinal detachment (i.e. large pieces has detached) then – retinal surgery +/- vitrectomy
Temporal Arteritis
- Sudden loss of vision (often with pain) – central scotoma
- May be bilateral – often starts unilateral and then becomes bilateral
- Due to occlusion of the ciliary arteries which supply the optic nerves
- There may also be central retinal involvement
- Usually patient over 65
- Associated temporal headache and / or tenderness over the temporal arteries
- Afferent pupillary defect
- ESR elevated usually >40
Ophthalmoscopy
- Swollen optic disc – later atrophies
- Disc may appear normal
Management
- Always remember to test the other eye too!
- Steroids –Â give a stat dose of prednisolone 60-100mg, and continue for at least a week before tapering
- Biopsy of temporal artery can confirm diagnosis
Also see full article on temporal arteritis
Vitreous haemorrhage
- Sudden painless loss of vision (extent of loss depends on degree of haemorrhage)
- large haemorrhage = TOTAL visual loss
- small haemorrhage = presents as floaters and normal/slight reduced visual acuity
- Sudden appearance of black spots/ cobwebs/ haze in vision
- Can be diagnosed with ultrasound
Ophthalmoscopy
- Decreased red reflex
- RBC in anterior vitreous
- May see blood clots in the vitreous that look like dark swirling clouds
Causes
- Proliferative diabetic retinopathy
- Retinal detachment
- Trauma
- Age related macular detachment
- Results from haemorrhage of retinal vessels
- Can sometimes be spontaneous without an underlying cause
Management
- Refer to ophthalmologist and determine cause – main reason for referral is often to rule out other differentials such as retinal detachment
- Mange complications – e.g. glaucoma due to RBC occluding trabecular meshwork
- Often resolves spontaneously – and bed rest may help encourage resolution
- Rarely a surgical vitrectomy is required to stop the bleeding
Central Retinal Vein Occlusion (CRVO)
- Sudden painless loss of vision – particularly central vision
- Unilateral
- Vision not improved with pinhole
- If severe = RAPD (relative afferent pupillary defect)
- Typically occurs in elderly patients
Ophthalmoscopy
- Hyperaemic retina with engorged veins
- Swollen optic disc
- Multiple haemorrhages
- Cotton wool spots
- ‘Stormy sunset’ appearance
Causes
- Raised intraocular pressure (chronic glaucoma, hypertension)
- Hyperviscosity syndromes (polycythemia)
- Vessel wall disease (e.g. diabetes, sarcoidosis, hyperlipidaemia)
Management
- No treatment is effective
- Treat the cause
- Fibrinolysin may benefit some patients
- Occasionally laser therapy is needed later – to treat neovascularisation
- CRVO associated with arteriosclerosis – check BP
Amaurosis Fugax
This is basically a TIA (transient ischaemic attack) of the retina.
- Transient loss of vision (may be completed or partial) due to a temporary occlusion of a retinal artery.
- Typically lasts less than 60 minutes, and is usually due to an embolus from the carotid artery.
- There may be associated signs of cerebral ischaemia – TIA-like symptoms – such as hemiparesis or slurred speech.
- Risk of stroke in a patient who has had amaurosis fugal is about 2% per year.
- These patients need thorough work-up – like any other TIA patient.
Central retinal artery occlusion
If amaurosis fugal is a TIA of the retina, then central retinal artery occlusion is a stroke of the retina.
- Sudden painless loss of vision – Â Unilateral
- RAPD
- Visual acuity markedly reduced – often no perception of light
- Visual acuity not improved with pinhole
- Can also classically present with “a curtain falling across the vision”
- Need to rule out temporal arteritis as a cause (especially if painful) – do an ESR
Ophthalmoscopy
- Often normal, especially initially
- Retinal emboli may be visible
- Pale retina with cherry red spot (macula is spared as receives branches from posterior ciliary artery
Causes
- Arterial embolus from diseased carotid, valvular heart disease, AF
- Temporal Arteritis – high  ESR!
- Vasculitis (polyarteritis nodosa)
- Artherosclerotic process (diabetes, HT)
Management
- Check – BP, Pulse – AF?, Carotids – bruits? , Heart – murmur?
- If patient seen early (<30 minutes since onset of symptoms) – massage of the globe with fingers through closed eyelids may help to dislodge the embolus
- Rebreathe CO2 (paper bag)
- IV acetazolamide 500mg – helps to rapidly reduce globe pressure which has been shown to improve outcome
- Bloods for ESR – if temporal arteritis needs urgent steroids
- Refer urgently!
- Prognosis is extremely poor. Recovery is unlikely if not treated within 30 minutes. Cases of Amaurosis fugal will self resolve
- Occurs in the elderly
- Sudden distortion – straight lines seem curved and central blank patch of vision or, sudden blurring of vision
- This can be assessed with a grid pattern on a chart
- Decrease visual acuity with CENTRAL SCOTOMA
- Caused by choroidal neovascular membranes that develop under the macular. These can then spontaneously bleed or leak fluid – hence the name ‘wet’
- Peripheral vision remains normal
- As opposed to ‘dry’ macular degeneration which is
- Chronic slow process
- Accounts for 90% of cases of macular degeneration
- May be familial
- Common in old age – “Age related macular degeneration”
Ophthalmoscopy
- Drusen – yellow fatty deposits lipid under the retina
- Subretinal haemorrhages
- Hard exudates – appear white
- Macular oedema
- All of these features appear at the macula
Management
- Treatments not very effective
- Injection of antivascular endothelial growth factor medication into the vitreous (e.g. ranibizumab or bevacizumab)
- Age related MD
- Smoking Cessation
- Vitamin combinations may slow down progression (Vitamins A,C,E, zinc, beta-carotene)
Optic Neuritis (Acute Optic Neuropathy / Retrobulbar neuritis)
- Rapid progressive loss of vision – typically occurs over several days
- Unilateral or bilateral
- Maybe decreased colour vision
- Decreased visual acuity
- RAPD
- Symptoms of underlying disease (MS, nerve ischemia, artherosclerosis, syphilis)
- A proportion of patients later go on to develop multiple sclerosis
- Typically female aged 20-40
- Eye pain / discomfort on eye movement
- Usually central visual loss (central scotoma)
Ophthalmoscopy
- Normal or swollen optic disc
- Optica atrophy and disc pallor may appear later
Management
- Dont forget to also check the other eye
- Steroids –Â proven to improve recovery time and reduce the risk of another event
- MRI brain –Â to look for evidence of multiple sclerosis
- Most patients recover spontaneously, but many are left with reduce acuity long term
Posterior Vitreous Detachment
- With age, the body of the posterior vitreous shrinks and detaches from the retina
- A normal physiological process that occurs in the majority of individuals by late middle age
- Rarely it can also cause retinal detachment
- Sudden onset of floaters, with flashing lights
- Often asymptomatic
- Flashing lights are suggestive of retinal traction
- Visual acuity usually normal – if visual acuity is affected then consider associated retinal detachment
- Visualisation of the retina often normal – usually not possible to tell there is vitreous detachment
Management
- Refer urgently to ophthalmology to assess for retinal involvement – which we require urgent treatment (see above – retinal detachment)
Decision Tree
Have a go at this decision tree to differentiate the types of sudden visual loss
Adapted from table in Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt – Figure 77.5, Pg 884
References
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- LITFL - Loss of vision
- RACGP - Sudden loss of vision - Investigation and Management
- RACGP - Sudden loss of vision - History and Examination