1. Acute Visual Loss Saeed Alwadani, MD Assistant Professor
Consultant Ophthalmologist
Ophthalmology Department
King Saud University
10/4/17

2. Definition
Acute visual loss: is develops within a few minutes to a couple of days.
You should be able to evaluate such a patient and be able to recognize situations requiring urgent action.

3. Pathophysiology AVL has 3 general causes: Media opacity.
Retinal abnormities.
Abnormities affecting the optic nerve or visual pathway.

4. History
1. Is the visual loss transient or persistent? 2. Is the visual loss monocular or binocular? 3. Did the visual loss occur suddenly or it developed over hours, days or weeks? 4. What is the patient’s age and general medical condition? 5.Did the patient have normal vision in the past and when was vision last tested 6. Associated symptom. last, as quite a number of people will realize loss of vision from one eye when they cover the good eye

5. Examination following tests: Visual acuity testing Tonometry
- Confrontation visual fields
- Pupillary reactions
- Ophthalmoscopy
- External examination of the eye with a pen light

6. Media opacities
Corneal edema: The cornea appears like a ground glass rather than its normal clear appearance. The most common cause of corneal edema is increased intraocular pressure and occurs typically in angle closure glaucoma. Any acute infection of the cornea by a corneal ulcer may mimic corneal edema.

7. Acute visual loss: Media opacities
Corneal ulcer:
When there is a corneal opacity due to destruction of tissue by infiltration of microorganisms and WBCs.
Could be viral, bacterial, fungal, protozoal or neurotrophic in etiology

8. Media opacities Hyphema Hyphema is blood in the anterior chamber
The hyphema is a direct consequence of blunt trauma to a normal eye.
However, it can occur with tumors, diabetes, intraocular surgery and chronic inflammation which all cause neovascularization.

9. Media opacities Vitreous hemorrhage
Any bleeding into vitreous will also reduce the visual acuity.
Trauma
Diabetics
Retinal vein occlusion
Accompany subarachnoid hemorrhage.
If you cannot appreciate a red reflex with an ophthalmoscope
B scan is important.

10. Central retinal artery occlusion
Blocked blood flow in the central retinal artery, which often occurs in one eye.
Symptoms: Sudden and painless loss of vision.
Signs:
The visual acuity is very poor, LP or HM and RAPD.
Fundus examination: Pale retina (abnormal and asymmetrical red reflex), cherry-red spot at macula due to cilioretinal sparing.
Delayed arterial filling on fluorescein angiogram.
Investigation: urgent (same day) ESR and CRP to exclude giant cell arteritis.
A chronic cherry red spot is also a feature of the storage diseases such as Tay-Sachs Pick disease disease and Niemann-Pick disease.
Management: Urgent (same day) referral to ophthalmologist to see whether any immediate treatment is possible.
Intensive intraocular pressure lowering (AC inhibitors and paracenthesis) may help in some cases.
A work-up for causes of Transient Ischaemic Attacks will need to be arranged.

12. Central retinal vein occlusion
Blocked blood flow through the central retinal vein.
Symptoms: Sudden and painless loss of vision.
Signs: Dilated tortuous veins, cotton wool spots, optic disc swelling, retinal haemorrhage visible in all four quadrants which may obscure much of fundus detail.
Predisposing factors include increasing age, hypertension and diabetes, as well as raised intraocular pressure.
Investigation and Management :
Screen for diabetes and hypertension, exclude glaucoma.
Routine referral for an ophthalmological opinion.
Fluorescein angiography is often performed to investigate how ischaemic the fundus is, and laser can be indicated to prevent neovascular glaucoma and recurrent vitreous haemorrhage.

14. Retinal vascular occlusion
Branch Retinal Artery Occlusion when only a branch of the central retinal artery is occluded, vision is only partially lost. This is more likely to be the result of an emboli and the source of the emboli should be sought. If the visual acuity is affected, attempts should be made to dislodge the emboli by ocular massage.

15. Example
BRAO OD
BRVO OS

16. Retinal diseases Retinal detachment Macula on Macula off
complain of flashing lights
large number of floaters
shade or blind covering
the visual field
An afferent pupillary defect
The diagnosis is confirmed by ophthalmoscopy through a dilated pupil, and retina appears elevated with folds and the choroidal background is indistinct.
Treatment: surgical emergency. RD repair within 72 h

18. Optic Nerve Disease
Optic Neuritis: Optic Neuritis is inflammation of the optic nerve and is usually associated with multiple sclerosis in a significant number. The visual acuity is markedly reduced and an afferent pupillary defect is present. Associated with pain on extraocular muscle movement in 90% of patients The optic disc initially appears hyperemic and swollen. The visual acuity usually recovers; however, repeated episodes of optic neuritis may lead to permanent loss of vision.

19. Visual Pathway Disorders
Homonymous hemianopia - is loss of vision on one side of both visual fields and may result from occlusion of one of the posterior cerebral arteries within fraction of the occipital lobe. Other vascular abnormalities occurring in the middle cerebral artery distribution may produce a hemianopia, but usually other neurological signs are prominent. Any patient with a hemianopia needs at CT or MRI to localize and identify the cause.

20. Summery
Loss of vision is usually considered acute if it develops within a few minutes to a couple of days.
It may affect one or both eyes.
All or part of the visual field.
Arise from pathology of any part of the visual pathway
Taking good history and considering the anatomy of the visual pathway is key in the proper evaluation of the patient with acute visual loss.

21. Case 1
A 32 yrs. old female presented with right sided acute onset painful visual loss which progressed within 2-3 hours. Pain was worse with eye movements.

22. On examination
VA:OD 6/60 with cecocentral scotoma on field testing, right sided relative afferent papillary defect (RAPD) on swinging flash light test, affected color vision.

24. Investigation: MRI
Treatment: Steroid

25. Case 2
A 60 year old male K/C of HTN and coronary artery disease presented with sudden painless loss of vision for one hour.
On Examination VA:OD LP, OS20/20
APD OD

27. Investigation: Urgent-Systemic work up
CRAO

28. CASE 3
A 65 year old lady K/C of HTN, glaucoma and presented with painless loss of vision in the left eye for 2 day.
O/E:
VA OD 20/20 OS 20/200

30. CASE 4
A 55 year-old male presented with dark curtain falling the view in the left for one day. He had history of floater and flashing for 7 days in the same eye.
O/E:
VA OD 20/20 OS 20/20

32. CASE 5
A 32 year-old female lens wearer presented with sever ocular pain and red eye for 2 days in the right eye
VA OD 20/100

34. CASE 6
A 69-year-old woman presents with acute onset of sever ocular pain, decreased vision, and halos around lights in the right eye associated with nausea and vomiting.
O/E: VA 20/200 OS 20/20
IOP OD 40 OS 19