Sudden visual loss
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| History | ➥ duration, permanent/transient, progression ➥ where affected: degree, central/peripheral ➥ distribution (unilat/bilat), painful (anterior cause) ➥ Associated s/s: Headache, ophthalmoplegia, flashers/floaters ➥ Risk factors: AF, bleeding disorders, Poorly controlled DM, Amaurosis fugax ➥ DHx: methanol, quinine (in overdose) |
| Examination | General inspection - outer to inner, surface to deep ➥ eyelid, eyelashes, conjunctiva, corneal opacities, foreign bodies ➥ corneal reflex - will be blunted by local anaesthetic! ➥ Acuity - Snellen chart (can print off), pt wearing glasses if they usually wear ➥ Colour vision - use red object if no Ishihara plates ➥ Fundoscopy - most important in non-ophthal setting is to check optic disk -- optimise: dark room, pt to fixate on a faraway spot -- Document what you try |
| Diagnostic investigations | See fundoscopy findings below. |
| Differentials | ➥ embolic: amaurosis fugax, CRAO ➥ CRVO (central retinal vein occlusion) - sudden, painless, unilateral ➥ Ischaemic optic neuropathy ➥ vitreous haemorrhage ➥ optic neuritis ➥ fat embolus - in trauma context ➥ retinal detachment: sudden painless, progressive visual field loss with new floaters/flashers |
| Immediate management | ➥ CRAO: treat like stroke with risk factor management; possible role for ocular massage?! ➥ See Acute closed-angle glaucoma ➥ Temporal arteritis: 60mg prednisolone and arrange temporal artery biopsy ➥ retinal detachment: same day ophthal r/v if any sight-threatening disease |
| Ongoing management | CRVO: control risk factors +/- vasculitis/hypercoagulability workup Retinal detachment: laser/cryotherapy; inform DVLA; vitrectomy |
fundoscopy findings
because we're all experts at fundoscopy.
| Retinal detachment | Absent red reflex May be normal |
| Central retinal vein occlusion | 'Stormy sunset' Tortuous dilated vessels Optic disc swelling Retinal haemorrhages Cotton wool spots |
| Central retinal artery occlusion | Pale retina Cherry red spot at macula |
| Vitreous haemorrhage | Large bleeds - retina not visible |
| Giant cell arteritis → ischaemic optic neuropathy | Pale swollen optic disc Cotton wool patches |
| Wet macular degeneration | Drusen Macular oedema Hard exudate Subretinal haemorrhages |