Sudden Loss of Vision

Dr Alex Harper

Sudden loss of vision in one eye

Pathology must be in the eye (retina" vitreous) or optic nerve and you should be able to make
a diagnosis!

Loss of vision in both eyes

Most likely to be due to bilateral eye pathology, but consider the possibility of visual pathway
pathology ( eg bilateral occipital CVA) if the eyes appear normal.

Sudden loss of vision in one eye

Important causes that you must consider:

Temporal arteritis
Retinal detachment
Retinal artery occlusion
Retinal vein occlusion
Vitreous haemorrhage
Macular degeneration

Note: the eye is "white" with a normal anterior segment (clear cornea and lens)

Assessment of a patient presenting with loss of vision

History
One eye or both eyes?
Onset and progression
- very sudden onset suggests a vascular cause
- gradual deterioration suggests degenerative disease( eg cataract)
Associated visual symptoms
- flashes suggest retinal traction (but can be cortical eg CVA, migraine)
- floaters suggest vitreous debris
Past ocular history
- trauma and myopia are risk factors for retinal detachment
Systems review
- in elderly patients, ask about headache and polmyalgia(?temporal arteritis)
- any history of diabetes, including a "touch of sugar"
- cardiovascular disease, TIA symptoms suggest emboli

Examination
1. Visual acuity
2. Pupil reaction to light (? relative afferent pupil defect= RAPD)
3. Visual Field
4. Fundus examination
Temporal Arteritis

History
Elderly patients (age >65)
Sudden and severe loss of vision in one eye initially
Systemic symptoms are headaches, scalp tendemess,malaise, jaw claudication

Examination
Vision 6/60 or worse RAPD
Extensive visual field loss
Pale swollen optic disc (anterior ischaemic optic neuropathy), rarely CRAO.

Management
Aim to prevent loss of the other eye!
Urgent ESR (expect >60)
Prednisolone l00mg stat.
Urgent referral to ophthalmologist
Temporal artery biopsy will confirm the diagnosis

Retinal detachment

History
Patients may notice an enlarging shadow in peripheral vision(not just a floater)
Sudden loss of central vision occurs when the macula detaches
Flashes and floaters are common associated symptoms
Ocular history of trauma, surgery and myopia.

Examination
Acuity normal = macula "on"
Acuity poor = macula "off'
RAPD
Absolute field defect corresponding to area of detached retina
Fundus examination is diagnostic (but may be difficult to pick with direct ophthalmoscope)

Management
Urgent referral to ophthalmologist
Retinal reattachment surgery successful in 90%
Visual results better if macula "on",

Emboli entering the retinal circulation may cause any of the following:

Transient loss of vision (lasting minutes) known as amaurosis fugax (retinal emboli may be
visible on fimdoscopy)
Sudden partial loss of vision due to branch retinal artery occlusion (BRAO)
Sudden total loss of vision due to central retinal artery occlusion (CRAO)
Central retinal artery occlusion

Typically due to emboli (carotid or cardiac source).

Occasionally due to vasculitis (temporal arteritis,SLE)
Occasionally due to obstruction of larger vessels (internal carotid or ophthalmic artery)

History

Sudden total loss of vision

Previous episodes of amaurosis fugax
Cardiovascular disease

Examination

Vision may be NPL

Afferent pupil defect
Total field loss
Fundus(acutely) : Cloudy swelling of infarcted posterior retina
Cherry red spot at fovea (where retina thinnest)
Segmentation of blood columm in retinal veins(slow flow)
Look for emboli in the retinal arteries
Fundus (chronic): Pale optic disc
Attenuated retinal vessels

Management
Ocular massage( digital)
Diamox 500mg stat (to lower intraocular pressure)
Urgent referral to ophthalmologist
Anterior chamber paracentesis ( if < 24 hours, preferably within 6 hours)
ESR to exclude temporal arteritis as a possible cause
Systemic assessment for source of embolus (carotid doppler)
Long term aspirin or warfarin

Central retinal vein occlusion (CRVO)

History
Patients usually>50 yo
Strong association with hypertension and cardiovascular disease
Sudden painless bIur of vision

Examination
Vision varies with severity (from 6/6 to hand movements)
Afferent pupil defect if severe CRVO (HM vision)
Fundus : extensive retinal haemorrhages in all quadrants
retinal venous distension
optic disc swelling
Management
No immediate treatment of proven benefit
Assess cardiovascular risk factors
Retinal laser treatment for late complications (neovascular glaucoma)

Branch retinal vein occlusion (BRVO)

The commonest single retinal vascular pathology

Aetiology similar to CRVO
Vision loss may be moderate (if the vein draining the macula is involved)
Fundus examination acutely reveals a sector of retinal haemmorhages in the territory of the
obstructed vein.
Retinal laser treatment effective for late complications (macular oedema, new vessels)

Vitreous Haemorrhage

Aetiology
Proliferative diabetic retinopathy (new vessels present)
BRVO with new vessels
Retinal tears (tear through a retinal vessel)

History
Blurred vision with floaters
?diabetes(may be undiagnosed)

Examination
Vision: varies with severity of haemorrhage (6/6 to PL)
Pupils: NO RAPD (unless retina detached as well)
Fundus: reduced red reflex and difficult to see retinal detail

Management
Urgent referral to ophthalmologist
B scan ultrasound if no view of fundus
Vitrectomy surgery may be necessary

Age related macular degeneration (ARMD or AMD)

The commonest cause of legal blindness in the western world

Legal blindness is defined as vision less than 6/60 vision in both eyes
Both eyes are eventually affected in the majority of cases
Patients retain their peripheral field of vision for mobility

Atrophic ("dry") AMD causes gradual loss of vision due to loss of retinal photoreceptor cell
function in the macular region
Exudative ("wet") AMD is the major cause of blindness and may present with sudden loss of
vision due to haemorrhage from abnormal blood vessels beneath the macula

Exudative Macular Degeneration

History
Recent onset blur with distortion (straight lines appear bent)

Examination
Vision: better than 6/60 in early stage, less than 6/60 in late stage
Pupils: NO RAPD (area of retina involved by the disease is not large enough to result in an
afferent pupil defect)
Field: central scotoma only
Fundi: Haemorrhage, drusen (pale age related deposits) and pigment changes in the macula

Management
Refer urgently to ophthalmologist if any recent change in vision
Fluorescein angiogram
Argon laser ablation of abnormal vessels in early stages
Low vision aids to assist with reading

Other causes of sudden visual loss:

Optic neuritis
Typically affects one eye of young women
Vision progressively dims over 48 hours (not truly "sudden")
Ache around eye at onset (worse with eye movement)
Reduced acuity and colour vision
A relative afferent pupil defect (RAPD) is present
Fundus may be normal (retrobulbar neuritis)
Recovery over 6 weeks, more rapid if IV methylprednisolone.
Strong association with MS (MRI Brain will help predict risk)
CVA

Unilateral CV A will cause homoymous field defects, but usually not loss of acuity

Bilateral occipital CV A may cause loss of acuity (plus visual field loss)

Migraine

The visual aura of classical migraine is a common cause of transient (usually lasting 5 to 20
minutes) visual disturbance in young healthy patients. Patients describe shimmering, flashing
lights and jagged lines and often have a history of previous similar episodes. The visual
disturbance may affect one or both eyes. The visual aura is often (but not always) followed by
headache.