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12/07/2024 1
Approach to a patient with
sudden loss of vision
Dr Dagmawit Kifle(MD)

12/07/2024 2
Introduction
• To achieve clear vision, light
must follow an unhindered
path
• Alterations in function of
any of the structures along
the visual pathway may
cause vision loss.

12/07/2024 3
…cont.
• Sudden loss of vision
– Is a common compliant of patients
– Most cases are serious and have an associated
underlying systemic disease
– May be temporary or permanent, based on the
degree of damage

12/07/2024 4
…cont.
– With in minutes
• Embolic retinal event
– With in hours
• Ischemic event
involving ON
– Days- weeks
• Inflammatory
– Months – years
• Compressive lesions

12/07/2024 5
…cont.
• History
– Age
– Duration of visual loss or changes
– Laterality
– History of trauma
– Prior episodes

12/07/2024 6
…cont.
– Symptoms - Photophobia, headache, pain
– Loss of consciousness, dizziness, diplopia, focal
weakness
– Comorbid conditions
• HTN, hypercholesterolemia, collagen vascular disease
– Medication Hx- quinidine, sildenafil

12/07/2024 7
• P/E
– The appearance of the eye is key
– Extra ocular area & EOMs
– Visual Acuity
– Visual Field
– Pupil reactivity & RAPD
– SLE
…cont.

12/07/2024 8
Differential Diagnoses
• Vascular/ischemia
– CRVO/CRAO
– Vitreous hemorrhage
– Giant cell (temporal)
arteritis
– Anterior ischemic
optic neuropathy
(AION)
• Inflammation/ infection
– Keratitis
– Acute uvietis
– Optic neuritis
– Endophthalmitis
• Retinal detachment
• Acute glaucoma

12/07/2024 9
Laboratory Studies
• CBC and ESR
• Coagulation studies
• Serum cholesterol level
• VDRL, FBS
• Blood culture
Workup

12/07/2024 10
Imaging Studies
• Carotid Doppler
– To assess carotid arterial wall & estimate
degree of stenosis
• Echocardiography
…cont.

12/07/2024 11
Central Retinal Artery Occlusion
• Sudden painless monocular loss of vision
• May have history of previous transient
episodes
• Retina infarction => pallor, edema, less
transparency

12/07/2024 12
…cont.
• Irreversible damage begins at
90 min
• Cherry red spot may develop
in ~24hrs & macula remains
visible
• V/A may be normal if
cilioretinal vessel patent

12/07/2024 13
…cont.
• Causes
– Atherosclerosis related thrombosis at
lamina cribrosa
– Emboli (carotid, cardiac)
– Temporal arteritis

12/07/2024 14
…cont.
• Workup
– Locate source
• ESR & CRP for temporal arteritis
• ECG for Atrial fibrosis
• Medicine consult (Carotid doppler, ECHO…)

12/07/2024 15
…cont.
• Treatment
– Attempt moving embolus distally:
– Thrombolytics
– IOP lowering
• Digital massage
• Beta-blockers/CAI/alpha-agonists…

12/07/2024 16
Central Retinal Vein Occlusion
• More common than CRAO
• CRV impingement by lamina or atherosclerosis of
CRA
• Painless monocular loss of vision over hrs - days
• Vision may improve through the day

12/07/2024 17
…cont.
• Risk Factors
– Age > 50
– Diabetes & HTN
– Oral contraceptives and diuretics
– High IOP
– Smoking

12/07/2024 18
…cont.
• Signs
– Retinal hemorrhages,
– Dilated tortuous retinal veins,
– Cotton-wool spots,
– Macular edema and
– Optic disc edema
blood and thunder appearance

12/07/2024 19
CRVO
• Non-ischemic v/s ischemic
types
Non-ischemic
– Good vision
– Mild RAPD & VFD
– Fewer retinal hemorrhages
& cotton-wool spots

12/07/2024 20
CRVO
Ischemic
– Severe visual loss
– RAPD+
– Extensive retinal hemorrhage
and cotton-wool spots
– Marked retinal edema
• Poor visual prognosis

12/07/2024 21
…cont.
• Treatment
– Laser photocoagulation and medical therapy
– Treatment of associated medical conditions
– Consider:
• Anti-coagulant (ASA)
• Fibrinolytics
• Corticosteroids

12/07/2024 22
…cont.
• Complications
– Ocular neovascularization
• Anterior => neovascular glaucoma
• Posterior => vitreous hemorrhage
• Evaluation requires
– Measurement of lOP
– Gonioscopy:- iris neovascularization
– Screening for atherosclerosis and other risk factors

12/07/2024 23
Anterior Ischemic Optic Neuropathy
• Is infarction of the optic nerve head due to occlusion
of the SPCAs
• Sudden unilateral loss of vision
• The affected part of the disc is pale and swollen
• “Chalky white”
• Arteritic or Non-arteritic

12/07/2024 24
…cont.
• Arteritic (AAION)
– Association with Temporal Arteritis
– Suspect if
• Age >60
• Headache
• Jaw pain on chewing (claudication)
• Scalp tenderness
– Puts other eye at up to 50% risk of same problem

12/07/2024 25
…cont.
• Treatment
– Send ESR and CRP
– Start steroid (Prednisone 1mg/kg PO/day)
– Temporal artery biopsy within 1 week

12/07/2024 26
…cont.
Non-Arteritic (NAAION)
• Presumably atherosclerotic
• Treatment
– Follow-up for atherosclerotic risk factors
– ASA

12/07/2024 27
Optic Neuritis
• Is an inflammatory, infective or demyelinating
process affecting the ON.
• Usually presents b/n the ages of 20 and 50 yrs
• Commonly, first manifestation of MS

12/07/2024 28
…cont.
• History
– May have preceding viral illness or previous episodes
– Usually monocular Vision loss
– Pain
• In or around the eye
• Worse on eye movement

12/07/2024 29
…cont.
• Exam
– Visual acuity variable (6/18 - 6/60)
– RAPD +
– Hyperemic and edematous disc (papillitis)
– Field defect
• Management
– Steroids
• Speeds recovery of Vision

12/07/2024 30
Retinal Detachment
• Separation of inner sensory
layers from underlying RPE
– Tear in retina
– Traction
– Subretinal fluid

12/07/2024 31
…cont.
• History
– Shower of black spots or floaters
– A “dark curtain” like shadow in peripheral VF
– Flashing lights
– Loss of vision or part of the VF

12/07/2024 32
…cont.
• P/E
– Visual field defects
– Fundoscopy
• Detachments start in
periphery
• Treatment
– Urgent surgery is
necessary if the vision is
still good and if the
detachment is recent

12/07/2024 33
Acute Angle Closure Glaucoma
• Blockage of normal drainage
and circulation of aqueous
humor
• Increasing IOP worsens
outflow as iris pushed forward
– Often 40-80 mm Hg

12/07/2024 34
…cont.
• History
– Sudden onset
– Precipitant
• Bending forward
• Pupillary dilation
– Pain Photophobia
– Vision: blurry, halos or starbursts around lights
– Nausea / Vomiting
May mimic migraine, heart or GI disease b/c of systemic
complaints

12/07/2024 35
…cont.
• SLE
– Decreased V/A
– Eyeball firm to palpation
– Corneal haziness
– Ciliary injection
– Shallow AC
– Pupil
• Irregular
• Mid-dilated
• Sluggish

12/07/2024 36
…cont.
Treatment
– Treat pain and nausea
– Avoid dilating drops
– Lower IOP
– LPI

12/07/2024 37
• Migraine
– Is the most common cause usually within first 3
decades
– characteristics:
• Flickering zigzags that migrate across the visual
hemifield of both eyes over a 20- 30min period
• Headache follows visual symptoms
SUDDEN BINOCULAR VISUAL LOSS

12/07/2024 38
…cont.
• Vertebrobasilar ischemia
– Common in pts >40 yrs of age
– Two mechanisms:
• Embolism from the arterial system or heart
• Severe stenosis with a brief dip in BP
– Workup & treatment
• Evaluate for
– Sources of emboli,
– Atherosclerosis and
– Hypercoagulable states

12/07/2024 39
• Patient Education
– Further Outpatient Care
• Patients should receive follow-up care as needed
– Complications & Prognosis
• Dependent upon etiology
FOLLOWUP

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6Approach to a patient with sudden loss of.pptx

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