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’?

Questions

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

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?
Answer and interpretation

Painless acute persistent loss of vision:

Painful acute loss of vision:


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

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?
Answer and interpretation

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

…show answer

optic nerve disorders, macular degeneration, diabetes mellitus


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

…show answer

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


visual loss that respects the vertical midline

…show answer

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


Loss of vision in one eye

…show answer

Eye or optic nerve pathology


Loss of vision in both eyes

…show answer

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


Sudden onset of painless loss of vision

…show answer

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


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

…show answer

Temporal vision field defect with macular sparing


Cloudy vision with floaters

…show answer

Retinal detachment, vitreous hemorrhage


Flashing lights experience

…show answer

Retinal detachment


Curtain-like veil obscuring vision

…show answer

Retinal detachment


Curtain coming across vision like a shutter from above or below

…show answer

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”

…show answer

Optic neuritis


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

…show answer

Papilledema


Previous transient visual obscurations lasting seconds

…show answer

Papilledema, retinal vein occlusion


Previous transient visual obscurations lasting minutes

…show answer

Amaurosis fugax


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

…show answer

Optic neuritis


Visual blurring made worse by hot weather or hot shower

…show answer

Optic neuritis


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

…show answer

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


Eye pain at rest

…show answer

Iritis, acute angle-closure glaucoma, compressive intraorbital pathology


Eye pain with eye movements

…show answer

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

…show answer

Temporal arteritis and secondary acute ischemic neuropathy or retinal artery occlusion


Visual loss with diplopia

…show answer

Intra-orbital, orbital apex pathology


Visual loss with focal neurological symptoms or signs

…show answer

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


Recent trauma

…show answer
  • 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

…show answer

HIV retinitis, CMV retinitis, toxoplasmosis or histoplasmosis retinitis

…and finally

Dr Sam Tapsell summarizes the visual fields and vision loss

References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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