Sudden Painless Loss Of Vision

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Sudden Painless Loss Of Vision
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• By
• Minal G. Birambole.
• (internee)
• G.A.M R.C,
• Shiroda,Goa

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(No Transcript)
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• Sudden loss of vision is alarming to both the
  patient and the clinician alike.
• sudden transient visual loss or obstruction may
  simply be a symptom of dry eye or may herald the
  onset of irreversible visual loss or stroke.

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Causes of sudden loss of vision

• Central Retinal artery occlusion
• Vitreous hemorrhage
• Retinal detachment
• Central Retinal vein occlusion
• Optic neuritis
• Methyl alcohol amblypia

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Retinal artery occlusion

• Etiology-
• more common in patients suffering from
  hypertension.
• Thrombosis
• Embolism
• Retinal artritis
• Angiospasm

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Central retinal artery occlusion

• Clinical Features -
• More common in male
• Usually unilatral,rarely bilateral
• It is due to obstruction at the level of lamina
  cribriosa.

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• Symptom
• Painless sudden loss of vision

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• Signs-
• Direct pupilary reflex is absent.
• Retinal artery markly narrow.
• Retinal vein look normal.
• Retina become milky white.
• Chery red spot (central part of macular area)
• Blood coloum is segmented.

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ERGs of CRAO
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branch retinal artery occlusion

• Usually occurs following lodgment of embolus at
  bifercation.
• Retina distal to occlusion become odematous.
• Later on permanent sectorial visual field defect.

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• Management
• treatment is
  unsatisfactory as retinal tissue cant survive
  ischemia more than few hours.
• Emergency treatment-
• Immediate lowering of intraocular pressure
• by IV Mannitol
• intermittent occular massage
• paracentesis of anterior chamber

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• Vasodilator inhalation of mixture of 5
  carbon-di-oxide 95 of water.
• relive angiospasm
• Anticoagulant
• IV steroids

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• Complication-
• neovascular glaucoma with
  incidence varying from 1 to 5.

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Retinal vein occlusion

• Etiology -
• More common than artery occlusion
• Typically affects elderly patients in 6th or 7th
  decade in life
• Pressure on the vein by sclerotic retinal artery
• Hyperviscocity of blood as in polycythemia
• Periphlebitis retinae(central or peripheral)

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• Raised intraocular pressure,more common in
  primary open angle glaucoma
• Local cause-
• orbital cellulitis
• facial erysipelas
• cavernous sinus thrombosis

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Central retinal vein occlusion

• Non ischemic
• most common clinical variety
• Characterised by mild to moderate visual loss.
• Fundus examination-
• In early stage-
• mild venous congesion
• Tortusity
• Few superficial flame shaped haemorrhage more in
  periphery than posterior.

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• Mild papillodema
• Mild macular odema
• In later stage-
• Sheathing arround main vein
• Few cilioretinal collatrals around disc
• Retinal haemorrhage partly absorbed
• Macula shows chronic cystoid odema.

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• Treatment-
• Usually not required
• Condition resolve with almost normal vision in
  about 50 cases.
• No treatment is effective for chronic cystoid
  macular odema
• Course of oral steroids 8-12 weeks may be
  effective.

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• Ischemic-
• Refers to acute complete occlusion of central
  retinal vein
• Characterised by marked Sudden loss of vision

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• Fundus examination-
• in early stage-
• Massive engorgement
• Congestion
• Tortusity of veins
• Massive retinal haemorrhage
• Papilloedema
• Macular area oedematous

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• in later stage-
• Sheathing around vein collatrals seen around
  disc
• Neovascularisation at disc
• Macula-marked pigmentary change
• Chronic cystoid oedema

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Difference between ischemic from non ischemic

• Presence of relative afferent pupillary defect
• Visual field defect
• Reduced amplitude of b-wave of ERG.

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• Complication-
• Rubiosis iridis
• Neovascular glaucoma in more than 50 cases
  within 3 months
• Few develops vitreous hemorrhage

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• Treatment-
• Panretinal photocoagulation
• Cryo-application
• Photocoagulation
• Above is carried out when most of interretinal
  blood is absorbed.

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Branch retinal vein occlusion

• More common than central retinal vein occlusion
• Occur at following site
• main branch at disc margin
• Major branch vein away from disc
• At A-V crossing causing quadratic occlusion
• Small macular occlusion

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• Occlusion oedema haemorrhge are limited to area
  drain by affected vein.
• Vision is affected when macular area is involve.

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• Treatment-
• Grid photocoagulations-
• in chronic macular odema
• Scatter photocoagulations-
• in neovascularisation

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Vitreous haemorrhage

• Usually occur from retinal vessels
• Pre retinal intrageal
• haemorrhage haemorrhage
• 
  

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• Etiology-
• Associated with PVD
• Trauma to eye
• Inflamatory disease like chorioretinitis,periphleb
  itis retinae
• Vascular disoders like HTN retinopathy
• Metabolic disease like DM retinopathy
• Neoplasm
• idiopathic

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• Clinical features-
• Sign-
• Distant direct opthalmoscopy-
• black shadow against the red glow in
  small haemorrhage.
• Direct indirect opthalmoscopy-
• presence of blood in vitreous cavity
• Ultrasonography with B-scan-
• it help in diagnosis.

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• Symptoms-
• In less haemorrhage-
• sudden development of
  floaters.
• In more haemorrhage-
• sudden painless loss of
  vision

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• Treatment-
• Conservative treatment-
• bed rest
• elevation of patients head
• bilateral eye patches
• Treatment of cause-
• management of retinal
  break, phlebitis, proliferative retinopathy.

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• Vitrectomy-
• by pars plana route, if haemorrhage
  is not absorb after 3 months.

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Retinal detachment

• Separation of neurosensory retina proper from the
  pigment epithelium.
• Classification-
• Primary retinal detachment
• Secondary retinal detachment

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Primary retinal detachment

• Usually associated with retinal break
• Sub retinal fluid seeps
• Separate the sensory retina from pigmentary
  epithelium

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• Etiology-
• Most common in 40-60 yrs.
• More in males
• 40 cases are myopic
• More common in aphakes
• Retinal degenaration
• Trauma
• Senile post.vitreous detachment

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• Pathogenesis-
• Senile acute predisposing
• Post.vitreous retinal
• Detachment degenaration
  aphakia
• Retinal break
  trauma
• Degenarated fluid seeps through retinal breaks
• Retinal detachment

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• Clinical features-
• Prodromal symptom-
• dark spot in front of the eye
• photopsia
• Symptoms-
• loss in field of vision which progress total loss
  when detachment progress to macular area.
• Sudden painless loss of vision

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A view from person having retinal detachment.
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• Sign-
• External examination-
• eye is usually normal
• Intraoccular pressure is low
• Plain mirror examination-
• an altered red reflex in pupilary
  area.

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• Opthlmoscopy-
• Detach retina gives grey reflex raised
  anteriorly.
• it thrown in to folds which oscilate with the
  movement of eye
• Total detachment of retina funnel shaped, being
  attached only at disc ora serrata
• Retinal vessels appear dark tortuous.

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• Electroretinography-
• subnormal or absent
• Ultrasonography-
• confirm the diagnosis

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• Complication-
• proliferative vitreoretinopathy
• complicated cataract
• uvelitis
• phthisis bulbi

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• Proliferative vitreoretinopathy

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• Uveitis

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• Pthisis bulbi

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• Treatment-
• Sealing of retinal breaks-
• by producing aseptic
  chorioretinitis,
• 
  cyocoagulation,
• 
  photocoagulation
• Scleral buckling-
• To bring the sclrochoroid
  retina near to each other
• Drainage of SRF

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• chororetinitis

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• Internal tamponade by SF6 gas or silicon oil
• Pars plana vitrectomy

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Solid retinal detachment

• Occurs due to retina being pushed sway by
  neoplasm or accumulation of fluid beneath the
  retina.
• Etiology-
• Systemic disease-
• toxaemia in pregnancy
• renal HTN
• blood dyscrasias
• polyarthritis nodosa

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• Occular disease-
• Inflammation like the Haradas disease, posterior
  scleritis,orbital cellulitis
• Vascular disease like central serous retinopathy
  exudative retinopathy
• Neoplasm like malignant melanoma of choroids

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• Clinical features-
• Can be differentiate from simple
• Absence of photopsia
• Holes or tears
• Folds
• Undulation
• Smooth convex detachment
• At summit of tumour,it usually rounded fixed
• Pattern of retinal vessel is disturbed

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• Treatment-
• Absorption of fluid
• Treatment of causative factor
• If tumour-enucleation

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Optic neuritis

• Includes inflammatory demyelinating disorder of
  optic nerve
• Etiology-
• Idiopathic
• Hereditary optic neuritis
• Demyelinating disorders-
• multiple sclerosis
• neuromyelitis optica

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• Clinical features-
• Classified in to three-
• Papilitis
• Neuroretinitis
• Retrobulber neuritis

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• Papilitis-
• It is inflammation of optic disc.
• Usually unilateral
• Symptom-
• Sudden profusal visual loss is hallmark of
  papilitis
• Dark adaptation is depressed
• Light brightness is depressed
• Colour object may look wash away
• Depth perception percularly for moving object may
  be impaird.

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• Signs-
• Visual acuty reduced markly
• colour vision often severly impaired
• Pupil-ill-stained constriction to light
• Ophthalmoscope-
• Hyperemia of disc
• Bluring of margin
• Disc become oedematous physiological cup is
  obliterated
• Retinal veins are congested
• Splinter haemorrhage is seen.

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• Visual field change-
• central or centroceacal scotoma.
• the field defect are more marked
  to red colour than white
• Visually evoked response (VER)shows reduced
  amplitude delayed in the transmission time.

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Methyl alcohol amblyopia

• Acute onset
• Resulting in optic atrophy permanent blindness
• Etiology-
• Intake of wood alcohol spirit in cheap
  adulterated beverages
• Inhalation of fumes in industries
• Absorbed from skin following prolonged daily use
  of linments

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• Pathogenesis-
• Methyl alcohol metabolized very slowly,
• stay longer period
• Oxidised in to formic acid formaldehyde
• oedema
• Degenaration of ganglion cell of retina
• Complete blindness

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• Clinical features-
• Headache
• Dizziness
• Nausea
• Vomiting
• Abdominal pain
• Delirium
• Stupor
• Even death

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• Diagnostic sign-
• Presence of charecteristic odour due to excretion
  of formaldehyde
• Occular features-
• mild disc oedema
• markedly narrowed blood vessels
• bilatral optic atrophy

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• Treatment-
• Gastric lavage
• Admission of alkali to overcame
  acidosis.sodabicarb may be given orally or IV
• Eliminative treatment by diaphoresis in the form
  of peritoneal dialysis
• Prognosis is usually poor, death may occur.

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• The eye is the lamp of the body
• If your eyes are good,
• Your whole body will be full of light,
• so
• Take care of your eyes.

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Thank you