"Acute loss of vision and Fundoscopic Abnormalities"

"It is not easy being so in love with you, but it is even worse not being able to see you everyday."
Anonymous

Time to begin.....Acute loss of vision is very much correctable if the clinician has the vision to
know what has gone wrong....and QUICKLY! Acute loss of vision can lead to permanent
blindness...imagine what you would feel if you could give sight back to someone who thinks
they may have lost if forever?

QUESTION 1)

A 69 year old man presents to the A&E with an acute onset of blurring of his vision. When
asked, he tells you that he is finding it difficult to see things on his right side. Here are the
findings of a visual field test as seen from the patient’s perspective:

Which part of the optic pathway is damaged?

A. Posterior to the optic chiasm
B. Within the optic chiasm
C. Within the macula
D. Within the optic nerve
E. The optic disc itself

The answer is A - this patient has a right homonymous hemianopia. The damage is posterior to
the optic chiasm within the left visual pathway. The site of the damage is likely the LEFT OPTIC
TRACT.
The picture clearly shows the visual field defects that occur when each part of the visual pathway are
affected. OPTIC NERVE = anopia of one eye / monocular vision loss; OPTIC CHIASM = bitemporal
hemianopia; OPTIC TRACT = homonymous hemianopia of the opposite eye; OPTIC RADIATION IN
PARIETAL LOBE = inferior quadrantanopia of opposite eye; OPTIC RADIATION IN TEMPORAL LOBE
(MEYER'S LOOP) = superior quadrantanopia of opposite eye; VISUAL CORETX = homonymous
hemianopia with macular sparing

Damage to the optic chiasm will produce a bitemporal hemianopia. This is usually due to compression of
the optic chiasm by a pituitary tumour.
Pathology within the macula will produce a central scotoma. This is central visual loss
surrounded by normal vision. The most common cause of a central scotoma is macular
degeneration.

The optic nerves lie anterior to the optic chiasm. Optic nerve damage will produce uniocular visual loss.

QUESTION 2)

With regards to the 69 year old patient (previous question) who experienced a sudden blurring of
vision in both eyes and whose visual field tests show a right homonymous hemianopia, what is
the most likely diagnosis?

A. Stroke
B. Brain tumour
C. Multiple sclerosis
D. Migraine
E. Head trauma

QUESTION 3)

A 70 year old man attends the emergency department following a sudden loss of vision in his
right eye four hours ago. He tells you that, in the last week, he has had five episodes of transient
loss of vision in the same eye, with each episode lasting only a few minutes. On examination, the
patient can only see hand movements. The vision in his left eye is normal. He has tenderness
over his temporal arteries and weakness in his proximal muscles. Which test should you request
first?
A. ESR
B. Temporal artery biopsy
C. CT scan head
D. MRI brain
E. Doppler US of carotids

The answer is A - never pick ANY other investigation in the initial assessment of suspected
GCA - Given the history and examination, the most likely diagnosis is giant cell arteritis. Giant
cell arteritis is a neuro-ophthalmic emergency!!!! Permanent reduction or loss of vision occurs in
more than half of patients. Patients with this condition may present with episodes of transient
loss of vision before experiencing complete loss of vision. This occurs as a result of reduced
blood flow due to inflammation (vasculitis) of small vessels supplying the eye.
The condition is associated with a high erythrocyte sedimentation rate; usually over 50 mm in
the first hour. Prompt treatment with steroids can prevent blindness. You should first treat with
intravenous corticosteroids at high doses (200 mg intravenous hydrocortisone) and oral
corticosteroids (up to 80 mg prednisolone). Once the erythrocyte sedimentation rate has
decreased, the oral steroids are gradually reduced over a period of up to two years.

GCA management flow-chart: ESR raised --> IV 200mg hydrocortisone for 3 days + oral
prednisolone (60-80mg/day) + temporal artery biopsy (within 72hours) --> diagnosis confirmed -
-> oral prednisolone (approx. 60mg/d) for 2-3 years

Note because oral prednisolone is given for many years must give gastroprotectors e.g. PPI
(lansoprazole) and bisphosphonates as long-term steroids can cause peptic ulceration and
osteoporosis

QUESTION 4)

A 68 year old man experiences a sudden blurring of the vision in his right eye.

What is the single most likely diagnosis?

A. Central retinal artery occlusion
B. Exudative age-related macular degeneration
C. Branch retinal vein occlusion
D. Central retinal vein occlusion
E. Diabetic maculopathy
the answer is actually C - This patient has occlusion of the branch retinal vein of the right eye. Patients
with this condition present with a sudden loss of vision. Scattered retinal haemorrhages and tortuous
retinal veins can be seen in the superior temporal segment of the retina.

In patients with occlusion of the central retinal vein (CRVO), scattered retinal haemorrhages and
tortuous retinal veins can be seen in all segments of the retina.
CRAO - pale retina + cherry red macula

WHAT WOULD YOU DO NEXT IN THIS PATIENT ?? Occlusion of the branch retinal vein is
associated with hypertension, SO THE FIRST THING TO DO IS CHECK THE PATIENT'S
BLOOD PRESSURE. If the blood pressure is raised, you should monitor and treat the patient.
Patients should be referred to an ophthalmologist within two weeks for monitoring of the
condition. Occlusion of the branch retinal vein usually has a benign course, and vision should
improve spontaneously within two months. The specialist may consider offering the patient laser
treatment if their vision has not returned to normal within three months
Patients < 50 years should get a thrombophilia screen.

QUESTION 5)

A 72 year old man presents to his GP 8 hours after a sudden loss of vision in his right eye. The
patient takes medication for hypertension. On examination, his blood pressure is 135/80 mm Hg.
His visual acuity is reduced in his right eye and so you examine his right retina.

What do you think the most likely diagnosis is?

A. Central retinal artery occlusion

B. CRVO
C. Branch retinal vein occlusion
D. Hypertensive retinopathy grade I
E. Hypertensive retinopathy grade II

This is clearly A - Central retinal artery occlusion - pale/ischaemic retina + cherry red macula

QUESTION 6)

You make a diagnosis of central retinal artery occlusion (CRAO). What should you do now?
A. Refer the patient to an eye clinic the next day
B. Doppler US of carotid
C. Refer the patient immediately to the on call ophthalmologist
D. Refer the patient to a stroke clinic
E. Refer the patient to a cardiologist to perform echocardiogram

QUESTION 7) My favourite question!

A 32 year old woman is seen by a doctor in the emergency department. The woman has been
troubled by early morning headaches associated with transient loss of vision in both eyes. Her
body mass index is 35. On examination, she has no neurological signs. The doctor examines her
fundi and cannot see any abnormalities. You see the patient in the medical admissions unit and
you dilate her pupils. You see the following on fundoscopy:

What should you do next?

A. Refer the patient urgently to a neurologist

B. Reassure the patient and advise her to take regular ibuprofen
C. Refer the patient urgently to an ophthalmologist
D. Request an MRI of her brain
E. Request a CT scan of the head