Out of Sight

aka Ophthalmology Befuddler 028

We’re coming to the end of an absolutely eyeful Ophthalmology August here at LitFL. Over the month we’ve considered many different causes of loss of vision. Today’s Q&A’s will bring together all the different ways the ‘lights can go out’ — don’t forget keep your ultrasound machine handy…

Are you ready for the ‘out of sight / loss of vision challenge’?

Eiffel tower

Anyone else had an eyeful of ophthalmology yet? (photo by y.caradec --- click image for source)

Questions

Q1. What are the important nontraumatic causes of transient (<24h) monocular vision loss?

Common causes of non-traumatic transient visual loss include:

  • amaurosis fugax (usually minutes) — usually embolic or thrombotic; can occur secondary to hypoperfusion states, hyperviscosity or vasospasm.
  • migraine (can be without headache)
  • one eye closed!

Uncommon causes include:

Q2. What are the important nontraumatic causes of acute persistent monocular vision loss?

Painless acute persistent loss of vision:

Painful acute loss of vision:

Q3. What are the important nontraumatic causes of acute binocular loss of vision?

Transient

  • migraine
  • VBI (transient)

Prolonged

  • CVA
  • poisons/ toxic optic neuropathy (e.g. methanol, quinine, ethambutol, ergot alkaloids, salicylates)
  • posterior reversible encephalopathy (PRES)
  • optic or retrobulbar neuritis
  • hysteria
  • malingering

Q4. What are the important post-traumatic causes of loss of vision?

From ‘front to back':

Q5. What important cause(s) of visual loss should be suspected if the following features are present?

[Based on Jeff Mann's clinical clues]

central loss of vision

optic nerve disorders, macular degeneration, diabetes mellitus

visual loss that respects the horizontal midline (‘altitudinal’)

‘prechiasmal’ lesions — optic neuritis, optic neuropathies, glaucoma, branch retinal vein occlusion

visual loss that respects the vertical midline

‘postchiasmal’ lesions — ischaemia, hemorrhage, tumors, inflammation, trauma

Loss of vision in one eye

Eye or optic nerve pathology

Loss of vision in both eyes

Visual pathway pathology, bilateral optic neuritis, bilateral ischemic optic neuropathy (cerebral arteritis), toxic optic neuropathy

Sudden onset of painless loss of vision

Central retinal artery occlusion, acute ischemic optic neuropathy, vitreous hemorrhage

Patient does not complain of visual loss, but bumps into objects when ambulating

Temporal vision field defect with macular sparing

Cloudy vision with floaters

Retinal detachment, vitreous hemorrhage

Flashing lights experience

Retinal detachment

Curtain-like veil obscuring vision

Retinal detachment

Curtain coming across vision like a shutter from above or below

Central retinal artery occlusion

Vague central vision obscurations — “fluffy ball” or “puff of smoke”, or complaint of a sensation of “looking through ground glass”, or a claim that vision would be normal if he could only “see around it”

Optic neuritis

Transient visual obscurations during any movement or change of position such as bending, straining or getting up suddenly

Papilledema

Previous transient visual obscurations lasting seconds

Papilledema, retinal vein occlusion

Previous transient visual obscurations lasting minutes

Amaurosis fugax

Photopsias (positive visual phenomena — spontaneous flashing squares, flashes of light, showers of sparks) precipitated by eye movements

Optic neuritis

Visual blurring made worse by hot weather or hot shower

Optic neuritis

Visual distortions such as metamorphosia (straight lines are bent) or micropsia (objects appear smaller)

Retinal detachment, macular degeneration, sub-retinal hemorrhage or edema

Eye pain at rest

Iritis, acute angle-closure glaucoma, compressive intraorbital pathology

Eye pain with eye movements

Corneal lesions, iritis, optic neuritis, intraorbital infiltrative or compressive pathology

Diffuse or localised headache, pain on combing the hair, temporal area pain especially when laying the head down on a pillow, jaw claudication, prolonged unexplained fever, malaise, weight loss, proximal myalgias, age > 50

Temporal arteritis and secondary acute ischemic neuropathy or retinal artery occlusion

Visual loss with diplopia

Intra-orbital, orbital apex pathology

Visual loss with focal neurological symptoms or signs

CNS lesion (e.g. stroke) affecting the visual pathways

Recent trauma

Remember Q4?
Traumatic cause of loss of vision from ‘front to back’  include:
lid injury, corneal irregularity or laceration, hyphema, ruptured globe, traumatic cataractm lens dislocation, commotio retinae, retinal detachment, retinal or vitreous hemorrhage, intra-ocular foreign body, traumatic optic neuropathy or optic nerve avulsion, CNS injury

HIV

HIV retinitis, CMV retinitis, toxoplasmosis or histoplasmosis retinitis

And to finish, check out another fantastic video by Dr Sam Tapsell; this one summarizes the visual fields and vision loss:

References

  • Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition), Lippincott Williams & Wilkins 2008.
  • Jeff Mann’s EM Guidemaps. Loss of vision.
  • Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice ( 7th edition), Mosby 2009. [mdconsult.com]
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