Chronic (gradual) Loss of Vision Definition: Symptoms which

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Chronic (gradual) Loss of Vision

• Definition
• Symptoms which have come on gradually over
  the course of weeks or months rather than
  minutes, hours or a few days

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History

• Chronic loss of vision is almost always painless 
• Determine whether the symptoms are uniocular or
  binocular
• Duration of history
• History of previous ocular disease
• Present medications, ocular and systemic
• Diabetes and hypertension. A positive family
  history of glaucoma prompts careful exclusion of
  this disorder.

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The Elderly patient with chronic loss of vision

• Chronic loss of vision in the elderly is often
  binocular but asymmetrical
• Aim to exclude each of the big three
• Cataract,
• Macular degeneration
• Chronic open angle glauoma
• Cataract
  (COMMON)
• Glaucomatous optic atrophy
  (COMMON)
• Age-related macular degeneration (ARMD) (COMMON)
• Diabetic maculopathy
  (COMMON)
• Corneal scarring
  (RARE)
• Optic atrophy
  (RARE)

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Systematic Approach

• Refractive Errors
• Cornea
• Anterior Chamber
• Lens
• Vitreous
• Macula
• Retina
• Optic Nerve

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Systematic Approach

• Refractive Errors

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Systematic Approach

• Refractive Errors
• Cornea
• Dystrophies
• Epithelium
• Stroma
• Endothelium
• Infective agents
• Others

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Systematic Approach

• Refractive Errors
• Cornea
• Anterior Chamber
• Lens
• Vitreous
• Macula
• Retina
• Optic Nerve

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Systematic Approach

• Refractive Errors
• Cornea
• Anterior Chamber
• Lens
• Vitreous
• Macula
• Retina
• Optic Nerve

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Systematic Approach

• Refractive Errors
• Cornea
• Anterior Chamber
• Lens
• Vitreous
• Macula
• Retina
• Optic Nerve

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Systematic Approach

• Refractive Errors
• Cornea
• Anterior Chamber
• Lens
• Vitreous
• Macula
• Retina
• Optic Nerve

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Phacoemulsification Of Cataract
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Posterior capsule opacification
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Capsulotomy
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Systematic Approach

• Refractive Errors
• Cornea
• Anterior Chamber
• Lens
• Vitreous
• Macula
• Retina
• Optic Nerve

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Normal retina
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Drusen
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Systematic Approach

• Refractive Errors
• Cornea
• Anterior Chamber
• Lens
• Vitreous
• Macula
• Retina
• Optic Nerve

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What do patients with AMD see?
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Macular hole
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Diabetic pathology
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Capillary microaneurysms
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Proliferative Diabetic Retinopathy
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Optic Disc
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• Chronic Loss of Vision In the Elderly
• History
• (one eye or both)
• ?
• Acuities and visual Fields
• (cortical field defects)
• ?
• Check cornea
• (Scarring or oedema)
• ?
• Red Reflex
• (Cataract or vitreous opacities)
• ?
• Pupils and IOP
• (Glaucoma)
• ?
• Dilate for Fundoscopy
• (ARMD,diabetic retionopathy,POAG,optic atrophy)

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Chronic Loss of VisionAdult working Age

• Early-onset, age-related changes (COMMON)
  (e.g. cataract and macula degeneration and
  diabetic retinopathy) must be considered IN ALL
  CASES as age increases, but another collection of
  pathologies must be kept in mind .

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Hypertensive Retinopathy
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Uniocular symptoms

• Cataract
  (COMMON)
• Corneal opacities
  (RARE)
• Opacities in the vitreous
  (RARE)
• Severe field loss in one eye
  (FAIRLY RARE)
• Chronic uniocular visual loss from macular
  disease (RARE)
• Optic nerve-related uniocular visual loss
  (RARE)

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Keratoconus
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Binocular Symptoms

• Cataract
  (COMMON)
• Maculopathies
  (COMMON)
• GIaucoma in the under-65s (RARE, but COMMONER in
  some races)
• Opacities in the vitreous of both eyes
  (RARE)
• Binocular field defects causing chronic visual
  loss (RARE)
• Bilateral optic atrophy
  (RARE)
• Corneal disease
  (RARE)
• Bilateral chronic Papilloedema
  (RARE)

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• Chronic Loss of Vision
• Adult working Age
• Uniocular system
  Binocular System
• History and acuities
  History and acuities
• ? ?
• Cornea and red reflex
  Cornea and red reflex
• (keratoconus, cataract,uveitis)
  (corneal
  dystrophies,cataract,uveitis)
• ? ?
• Visual Fields Visual
  fields
• (retinal detachment,meningioma)
  (retinitis pigmentosa,pituitary lesions)
• ? ?
• Pupils and IOP Pupils and IOP
• (glaucoma) (glaucoma)
• ? ?
• Dilate for fundoscopy
  Dilate for fundoscopy
• (malignant melanoma, optic atrophy)
  (maculopathies,optic
  atrophy,papilloedema)

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Acute Painless Visual Disturbance

• Definition
• Disorders of visual function which are
• painless and which have a well-defined onset
  (minutes,hours)

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Pupil Reactions
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Sympathetic system
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Uniocular predominantly central visual loss
normal pupils

• Macular and paramacular disease (COMMON)
• Acute media opacity (RELATIVELY COMMON)

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Uniocular predominantly central visual loss
abnormal pupil reaction

• Optic nerve disease (COMMON)
• Retinal disease (COMMON)
• Adies syndrome (RARE)

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Acute uniocular peripheral visual loss

• Acute rhegmatogenous retinal detachment
• Retinal branch artery occlusion
• Anterior Ischaemic Optic Neuropathy (AION)

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Uniocular acute visual disturbance

• Amaurosis fugax
• Visual intrusions
• benign floater
• vitreous heamorrhage
• posterior vitreous detachment
• Migraine

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Binocular acute central visual loss

• Retinal causes (RARE)
• Cytomegalovirus retinitis
• Acute rises in blood pressure may induce
  macular oedema e.g. pregnancy
• Optic nerve causes (RARE)
• Bilateral optic neuritis
• Cortical causes (RARE)

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Papilloedema

• Papilloedema
• Definition Swelling of the OPTIC DISK, usually
  in association with increased intracranial
  pressure, characterized by
• - Blind spot enlargement
• - Hyperemia,
• - Blurring of the disk margins
• - Microhaemorrhages
• - Engorgement of retinal veins.
• Chronic papilloedema may cause OPTIC ATROPHY and
  visual loss. (Miller et al., Clinical
  Neuro-Ophthalmology, 4th ed, p175).

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Binocular acute peripheral visual loss

• Homonymous defects retrochiasmal (COMMON)
• Bitemporal defects (chiasmal)

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Acute Painless Visual Disturbance

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THE ACUTE RED EYE
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ANGLE CLOSURE GLAUCOMA

• Symptoms
• Previous history
• Episodes of blurring pain or haloes for an
  hour or two in some early evenings for a few
  weeks
• Pain severe, radiating to forehead, with vomiting
  often
• Slight photophobia
• Watery secretion or discharge
• Visual acuity -Bad, usually
• Onset 2-3 hours
• Systemic symptoms- Often prostration and vomiting
  because of pain
• Laterality- Unilateral usually
• Age Usually 50

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• Signs
• Hyperaemia
• Circumcorneal purple diffuse,
  conjunctival
• Corneal epithelial oedema (fogged view of iris)
• Anterior chamber shallow (N.B. see fellow eye)
• Iris - Oedematous and
  hyperaemic
• Pupil - Dilated, oval
• Pupil light reflex - Absent or reduced
• Tension - Very high
• Tenderness - Marked

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ACUTE IRIDOCYCLITIS

• Symptoms
• Previous history- Any previous attack protracted
  for weeks
• Pain- moderate, localized to eye. Dull
• Photophobia - Moderate
• Secretion or discharge - Watery
• Visual acuity - Poor or slightly
  reduced
• Onset -Gradual (1-2
  days)
• Systemic symptoms -Usually none
• Laterality? - Unilateral
  usually
• Age -Usually 15-25

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• Signs
• Hyperaemia -Circumcorneal purple diffuse
  conjunctival
• Cornea -(Keratic) precipitates
• Anterior chamber -Exudate (flare, cells) often
  deep. Sometimes hypopyon
• Iris -Often hyperaemic and
  muddy
• Pupil -Contracted (due to
  Synechiae)
• Pupil light reflex - Reduced or absent
• Tension -High, normal or low
• Tenderness -Moderate to marked
• Other points ankylosing spondylitis in males
  sometimes

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CONJUNCTIVITIS

• Acute bacterial
• Symptoms
• Previous history -Possible
• Pain -Gritty,
  especially on blinking
• Photophobia -Slight
• Secretion or discharge -Muco-purulent. heavy.
  Neutrophils
• Visual acuity -Normal
• Onset -Within 1-2 days
  
• Systemic symptoms -None
• Laterality -Invariably
  bilateral
• Age -Any, but
  usually in children

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• Signs
• Hyperaemia -Conjunctival,severe and
  diffuse.Brick red
• Cornea -Clear and sparkling
• Anterior -Chamber Normal
• Iris -Normal
• Pupil -Normal
• Pupil light reflex -Normal
• Tension -Normal
• Tendernss -Slight
• Other points -Epidemic in school or family?

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• Acute adenovirus
• Symptoms
• Previous history -Sometimes
• Pain -Gritty,
  especially on blinking
• Photophobia -Slight/moderate
• Secretion or discharge -Watery. Monocytes
• Visual acuity -Normal
• Onset -Several days
• Systemic symptoms -None
• Bilateral -Unilateral or
  bilateral
• Age -Any, but
  usually up to 25

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• Signs
• Hyperaemia -Conjunctival, mild. Often
  restricted to a sector next to limbus
• Cornea -Looks clear but fluorescein
  stain superficial punctate spots, seen with
  slitlamp microscope
• Anterior chamber -Normal
  
• Iris
  -Normal
• Pupil
  -Normal
• Pupil light reflex
  -Normal
• Tension
  -Normal
• Tendemess
  -Slight
• Other points -Pre-auricular lymph
  node swollen and tender. Epidemic school or
  work?

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• Chlamydial
• Symptoms
• Previous history -Frequent
  recurrences often chronic
• Pain -Variable
  discomfort, gritty
• Photophobia -Variable
• Secretion or discharge -Watery pus Neutrophils
  Inclusion bodies
• Visual acuity -Normal at first.
  If chronic, often eventual blindness
• Onset -Several days
• Systemic symptoms -None
• laterality -Bilateral (at
  first may be unilateral)
• Age -Any

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• Signs
• Hyperaemia Diffuse conjunctival
• Cornea clear. Late pannus and/or diffuse
  fibrosis, also of conjunctiva
• Anterior chamber -Normal
• Iris -Normal
• Pupil -Normal
• Pupil light reflex -Normal
• Tension -Normal
• Tendrness -Slight
• Other points -In newborn, mother /-
  father have GU infection.

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KERATITIS CORNEAL ULCERS

• Symptoms
• Previous history -Previous attacks frequent in
  viral types foregin body or other injury. Contact
  lenses
• Pain -Moderate to severe. Sharp
  on blinking
• Photophobia -Marked
• Secretion or discharge -Watery Monocytes in
  herpes simplex
• Visual acuity -Poor to bad, usually
• Onset -Gradual (1-2 day)
• Systemic symptoms -None
• laterality? -Unilateral usually
• Age -Any

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• Signs
• Hyperaemia -Circumcorneal purple
• Cornea -Grey area and/or stains
  with fluorescein. Dendritic pattern in herpes
  simplex
• Anterior chamber -Exudate (flare cells) Often
  deep. Sometimes hypopyon
• Iris -Usually hyperaemic
  
• Pupil -Can have synechiae
• Pupil light reflex -Reduced or absent if
  visible
• Tension -Usually normal to low
• Tenderness -Marked
• Other points -History of injury often
  present

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PTERYGIUM

• A pterygium is a triangular sheet of
  fibrovascular tissue which invades the cornea.
• Pterygia typically develop in patients who have
  been living in hot climates and may represent a
  response to chronic dryness and exposure to the
  sun.
• These may become inflamed and cause an acute red
  eye.

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PINGECULA

• A yellow-white deposit on the bulbar conjunctiva
  adjacent to the nasal or temporal aspect of the
  limbus
• These may become inflamed and cause an acute red
  eye
• Histological examination shows degeneration of
  the collagen fibres of the conjunctival stroma,
  thinning of the overlying epithelium.

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DIFFUSE SCLERITIS

• Scleritis is frequently bilateral and,
  characteristically, associated with pain.
• Purplish hue with involvement of the deep
  episcleral vessels
• Svstemic diseases, such as collagen vascular,
  ulcerative colitis, Crohns disease, and
  sarcoidosis, are present in 50 of patients.
• A topical steroid (such as Pred Forte) may be
  prescribed to reduce the inflammation
• A systemic nonsteroidal anti-inflammatory
  medication is recommended (indocid 25 mg orally)

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The Acute Red Eye
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