Acute and Chronic visual loss

ByDr. ABDULMAJID ALSHEHAH

Ophthalmology consultantAnterior Segment and Uveitis consultant

DDx of acute vision loss

Painful (usually)

•Corneal Abrasion•Corneal ulcer •acute angle closure glaucoma •Acute uveitis (sometimes painless)

•Endophthalmitis

Painless (usually)

•hyphema•Vitreous hemorrhage.•Retinal Artery Occlusion• Retinal Vein Occlusion•Retinal Detachment• Optic Neuritis (can be associated with ocular pain on eye movement)

Acute visual loss

• In medicine, an acute disease is a disease with a rapid onset and/or a short course.

• minutes up to few weeks

History taking for a patient with loss of vision

• For how long?• One or both eyes• History of eye trauma• History of eye surgery• Associated symptoms

(pain).• Medical illnesses (DM)

Examining a patient with loss of vision

• VA• Confrontation VF

testing• Pupillary reactions• Ophthalmoscopy (red

reflex+fundus).• Penlight exam.• Tonometry.

corneal epithelial defect (CED) or corneal abrasion

Corneal ulcer or microbial keratitis• History of (trauma, CL wear)• Need urgent referral to

ophthalmologist• Need samples for microbiology• Might need hospitalization• Treated with frequent application

of topical broad spectrum antibiotics.

• If neglected can lead to corneal perforation and endophthalmitis

acute angle closure glaucoma • C/O acute vision loss, pain,

headache, vomiting

• Corneal edema• Mid-dilated non-reactive pupil• Ciliary injection• High IOP (around 50s)• Optic disc swelling

• Systemic IOP lowering medications

• YAG laser peripheral iridotomy ASAP

Acute uveitis• Most commonly idiopathic

• can be associated with pain and high IOP• Characterized by: ciliary injection, keratic

precipitates (KPs), iris nodules, synechia, vitritis, vasculitis, chorioretinitis and/or papillitis.

• Any type of uveitis (anterior, intermediate and posterior) can cause acute loss of vision but usually posterior (toxoplasmosis retinitis)

• Rule out infection and malignancy• Treatment is usually with Local or systemic

immunosuppression

Endophthalmitis• Painful loss of vision• Usually Recent intraocular

surgery.• Usually unilateral (except

septicemia)• Need urgent referral to

ophthalmologist.• Need vitreous samples for

microbiology• Need intravitreal antibiotic

injections• Might need retina surgery.

Hyphema • History of trauma (usually) • Medical illness (DM, HTN)

• Painless loss of vision• Rubiosis (NVI) due to CRVO or

PDR• High IOP

• Treat the cause • Steroids and cycloplegic topical

drops.• Might need surgery (AC washout)

Vitreous hemorrhage• History of trauma • Medical illness (DM, HTN)

• Painless loss of vision• Rubiosis (NVI) due to CRVO or

PDR• Retinal Hrg, NVD, NVE

• Treat the cause • Might need surgery (PPV)

Retinal Artery Occlusion

• BRAO

• CRAO

Retinal Vein Occlusion

• BRVO

• CRVO

Retinal Detachment

• Typical black curtain complaint

Optic Neuritis

• RAPD• Color vision• VF

Chronic visual loss

Chronic visual loss

• DDX1- amblyopia2- corneal opacities3- cataract4- glaucoma5- retinal vascular diseases6- macular degeneration (rare in

KSA)7- chronic uveitis8- neglected or persistent cause of

acute visual loss

Corneal opacities

• Corneal scars (Trachoma, old trauma, old

infection, advanced keratoconus)

• Corneal dystrophies(macular stromal corneal dystrophy,

congenital hereditary corneal dystrophy CHED, Fuchs corneal dystrophy)

• Corneal degenerations(band keratopathy, CDK)

Treatment of corneal opacities

• Refraction • Laser (if superficial

opacity)• Corneal transplant

Qustions