ACUTE VISUAL LOSSUBC Ophthalmology Interest Group Seminar Series1.18.2012

ANATOMY REVIEW

24 mm

Photo courtesy: Heather O’Donnell, PGY2, UBC

PRIMARY CARE APPROACH History

Onset ie. minutes vs days, following trauma?

Transient vs permanent Mono vs binocular Associated symptoms eg. pain, swelling,

floaters Other medical conditions and eye history Medications

Eye Exam Visual acuity

Equivalent to vitals for the eye

VISUAL ACUITY TESTING

Eye Exam Visual acuity

Equivalent to vitals for the eye Pupils, RAPD

Another ‘vitals’, from eye/neuro/trauma point of view Confrontational visual field Extraocular movement Tonometry External examination Slit lamp: lids, conjunctiva, AC Dilated examination, fundoscopy

CASE 1 Previously well 75F presents to ED for

sudden R eye pain and blurry vision while watching TV at night

c/o “halo” around lights Symptoms not resolved Hx: cataract in both eye, mild HTN No medications

CASE 1 OD CF, OS 20/25 R pupil fixed 4mm Rock hard globe Corneal edema Conj injections Opposite eye looks

normal Nausea, vomit x 1

Photo courtesy: A. Doan, MD, University of Iowa

IMPRESSION AND PLAN? A. Urgent head CT r/o mass lesion in

brain causing high ICP B. Acute bacterial conjunctivitis, pt

needs abx eye drops C. Chemical keratitis, rinse eye in

sterile water for 10 min immediately D. Acute angle closure glaucoma,

consult ophthalmology STAT

ACUTE ANGLE CLOSURE GLAUCOMA Results from aqueous outflow obstruction

by iris, rise in IOP, ischemia and permanent glaucomatous damage: emergency!

IOP = 42 mmHg (normal 12-20mmHg) Acetazolamide and timolol were given

initially, followed by pilocarpine 1 hour later.

IOP decreased to 19 mmHg Laser peripheral iridotomy arranged the

next day is the definitive treatment

LASER PERIPHERAL IRIDOTOMY

Photo courtesy: A. Doan, MD, University of Iowa

CASE 2 50M highly myopic

pt sees GP for c/o new onset of “flashing lights and floaters”

Blurry vision but no pain

Otherwise healthyRev Ophthalmol, 2006, 6:15

CASE 2 OD 20/80, OS

20/20 Pupils, anterior

segment normal Vitreous: tobacco

dust IOP: OD 10

mmHg, OS 13 mmHgRev Ophthalmol, 2006, 6:15

RETINAL DETACHMENT Rhegmatogenous most common, start as a

tear, fluid build up beneath neuroretina separates it from retinal pigment epithelium

High myopia is a risk factor In office: avoid pressure on globe, protect the

eye Immediate ophthalmological consult required Surgery is definitive treatment, often urgent

CASE 3 75F with sudden

painless loss of vision OD yesterday comes to GP office

A “grey spot” in her vision, grown over 10 min

Hx incl. CAD, HTN, TIA

Denies eye problemsPhoto courtesy: AAO 2011

CASE 3 OD CF, OS 20/30 R pupil sluggish

3mm RAPD EOM full Cornea, AC

grossly normal IOP 10mmHg B/L Cranial nerves

intactPhoto courtesy: AAO 2011

MANAGEMENT A. Assure pt that her vision is

unsalvageable, she needs to start Plavix to prevent a stroke

B. Send pt to emergency department STAT C. Compress and release the eye right now D. You don’t know what this is, so you

make a regular referral to ophthalmologist in 2-3 weeks

CRAO Central retinal artery occlusion often

secondary to embolus in a vasculopathic patient

Ophthalmological emergency Immediate restoration of retinal blood

flow is necessary to save sight Even with compress, sight is often not

salvageable. Need to evaluate etiology

CASE 4 85F comes to GP for sudden vision loss

today 2 months of transient double vision She has been feeling fatigued with

muscle and joint aches for the last 6 months

New headache in her R temple particularly when she combs her hair

Her jaw is painful when she’s eating

BMJ 2011, 343d4783

CASE 4 OD LP, OS 20/40 R pupil 3mm RAPD EOM full VF: wide spread loss Anterior segment

normal ESR from last week:

80 mm/h

Dx: A. Temporal arteritisB. Amaurosis fugaxC. Multiple sclerosisD. Compressive

optic neuropathy

NEXT STEP? A. Urgent neurology referral as stroke is

imminent B. Start patient on high dose steroids

empirically because benefits outweigh risks C. Ophthalmology referral for a temporal

artery biopsy to confirm diagnosis D. Urgent MRI of brain as it’s most sensitive

and specific for confirming a central lesion

TEMPORAL ARTERITIS Aka giant cell arteritis. Another classic

ophthalmological emergency Suspect in older women with new

headache, vision loss, and systemic sx Elevated ESR/CRP helps to rule in dx Must initiate high dose steroids

immediately followed by temporal artery biopsy

SUMMARY Approach: Hx, Va, Pupils, out to in, front to

back Acute vision loss is often a sign of serious

ocular disease process: Acute angle closure glaucoma Retinal detachment Central retinal artery occlusion Temporal arteritis

Urgent ophthalmological referral is needed (timeframe usually minutes to hours)

Immediate action is also required; time is sight

QUESTIONS ? Acknowledgement

Case editor: Steven Schendel, PGY-4 UBC

Contact R Tom Liu, UBC Med 2013 rztom.liu@gmail.com