NORMAL EYE WITH SUDDENLY VISION LOSS

Yulisa Handayani

Retinal vein occlusion

Definiton

Vein occlusion occurs as a result of circulatory dysfunction in the central vein or one of its branches.

Epidemiology

The second most frequent vascular retinal disorder after diabetic retinopathy. The most frequent underlying systemic disorders are arterial hypertension and diabetes mellitus The most frequent underlying ocular disorder is glaucoma.

Ethiology

Pressure on the vein by a sclerotic retinal artery where the two share a common adventitia (e.g., just behind the lamina cribrosa and at arteriovenous crossings). Hyperviscosity of blood as in polycythemia, hyperlipidemia and macroglobulinemia. Periphlebitis retinae which can be central or peripheral. Raised introcular pressure. Local causes are orbital cellulitis, facial erysipelas and cavernous sinus thrombosis.

Classification
Central retinal vein occlusion Non ischaemic CRVO/ venous statis retinopathy

Ischaemic CRVO/ haemorrhagic retinophaty

Branch retinal vein occlusion

Non Ischaemic CRVO

symptom
Mild to moderate vision loss Mild venous congestion and tortuosity, a few superficial flame-shaped haemorrhages more in the peripheral than the posterior retina, mild papilloedema and mild or no macular oedema. sheathing around the main veins, and a few cilioretinal collaterals around the disc. Retinal haemorrhages are partly absorbed. Macula may show chronic cystoid oedema in moderate cases or may be normal in mild cases.

Fundus examination: Early stage

Fundus examination : late stage

Non-ischaemic CRVO Treatment

Treatment is not required The condition resolves with almost normal vision in about 50 percent cases. Visual loss chronic cystoid macular oedema no treatment is effective. Oral steroids for 8-12 weeks may be effective.

Ischaemic CRVO
symptom sudden complete occlusion of central retinal Vein sudden visual loss 660 1/300 massive engorgement, congestion and tortuousity of retinal veins, massive retinal haemorrhages splashed-tomato appearance, numerous soft exudates, and papilloedema. Macular area is full of haemorrhages and is severely oedematous. sheathing around veins and collaterals is seen around the disc. Neovascularisation may be seen at the disc (NVD) or in the periphery (NVE). Macula shows marked pigmentary changes and chronic cystoid oedema.

Fundus examination: Early stage

Fundus examination : late stage

Complication

Rubeosis iridis and neovascular glaucoma (NVG) occur in more than 50 percent cases within 3 months 90 days glaucoma vitreous haemorrhage and proliferative retinopathy.

Treatment

Panretinal photocoagulation (PRP) or cryoapplication prevent neovascular glaucoma in patients with widespread capillary occlusion. Photocoagulation most of the intraretinal blood is absorbed 3-4 months.

Branch Retinal Vein Occlusion

symptom
vision loss macular edema, macular ischemia, or vitreous hemorrhage Main branch at the disc margin hemispheric occlusion major branch vein away from the disc, at A-V crossing quadrantic occlusion & small macular or peripheral branch occlusion. Grid photocoagulation may be required in patients with chronic macular oedema. In patients with neovascularisation, scatter photocoagulation should be carried out.

location

treatment

Retinal Artery Occlusion

Definition

Retinal infarction due to occlusion of an artery in the lamina cribrosa or a branch retinal artery occlusion.

Epidemiology

About 1 in 10000 outpatient visits to the ophthalmologist. Men are affected than women in the ratio 2:1. The mean age at onset is about 60years, with a range of reported ages from the first to the ninth decade of life. Right eyes and left eyes appear affected with equal incidence. Bilateral involvement occurs in 12% of cases.

Ethiology

Atherosclerosis-related thrombosis at the level of lamina cribrosa Emboli from the carotid artery and those of cardiac origin Retinal arteritis with obliteration (associated with giant cell arteritis) and periarteritis (associated with polyarteritis nodosa, systemic lupus erythematosus, Wegners granulomatosis and scleroderma) Angiospasm is a rare cause of retinal artery occlusion. Raised intraocular pressure Thrombophilic disorders such as inherited defects

Central retinal artery occlusion

symptom sudden painless loss of vision.

sign

Direct pupillary light reflex is absent.

Fundus examination

retinal arteries are markedly narrowed. Retina becomes milky white oedema. Central part of the macular area shows cherry-red spot vascular choroid shining through the thin retina of this region. atrophic changes occur which include grossly attenuated thread-like arteries and consecutive optic atrophy

Branch retinal artery occlusion

painless loss of vision in the visual field corresponding to the territory of the obstructed artery. Fundus examination: Retinal whitening that corresponds to the areas of ischemia stops at adjacent retinal veins, as these vessels mark the extent of the territory of the retinal arteries. Retinal emboli are seen in over two thirds of branch retinal artery obstructions. Flame hemorrhages at the margins of the retinal ischemia are not uncommon, and local areas of more intense inner retinal whitening that resemble scattered cottonwool spots can develop.

Treatment

Immediate lowering of intraocular pressure by intravenous mannitol and intermittent ocular massage aid the arterial perfusion and also help in dislodging the embolus Vasodilators and inhalation of a mixture of 5 percent carbon dioxide and 95 percent oxygen relieving element of angiospasm. Anticoagulants Intravenous steroids are indicated in patients with giant cell arteritis

Optic Neuritis

Definition

An inflammation of the optic nerve that may occur within the globe (papillitis) or posterior to it (retrobulbar optic neuritis).

Epidemiology

35 per 100,000 per year prevalence is 115 per 100,000 between the ages of 20 and 50 years. Women are affected more commonly than men.

Ethiology

Idiopathic Hereditary optic neuritis (Lebers disease) Demyelinating disorders Parainfectious optic neuritis is associated with various viral infections measles, mumps, chickenpox, whooping cough and glandular fever. Infectious optic neuritis may be sinus related (with acute ethmoiditis) or associated with cat scratch fever, syphilis (during primary or secondary stage), lyme disease and cryptococcal meningitis in patients with AIDS. Toxic optic neuritis.

Classification

Papillitis involvement of the optic disc in inflammatory and demyelinating disorders. This condition is usually unilateral but sometimes may be bilateral. Neuroretinitis combined involvement of optic disc and surrounding retina in the macular area. Retrobulbar involvement of optic nerve behind the eyeball.

Symptom

Visual loss. Sudden, progressive and profound visual loss is the hallmark of acute optic neuritis. Dark adaptation may be lowered. Visual obscuration in bright light Impairment of colour vision Movement phosphenes and sound induced phosphenes may be percieved by patients with optic neuritis. Episodic transient obscuration of vision Depth perception Pain

Sign

Visual acuity is usually reduced markedly. Colour vision is often severely impaired. Pupil shows ill-sustained constriction to light. Marcus Gunn pupil which indicates relative afferent pupillary defect (RAPD) is a diagnostic sign swinging flash light test Ophthalmoscopic features: Papillitis hyperaemia of the disc and blurring of the margins. Disc becomes oedematous and physiological cup is obliterated. Retinal veins are congested and tortuous. Splinter haemorrhages and fine exudates may be seen on the disc.

Sign (2)

Slit-lamp examination : inflammatory cells in the vitreous. Inflammatory signs may also be present in the surrounding retina when papillitis is associated with macular star formation and the condition is labelled as neuroretinitis Visual field changes relative central or centrocaecal scotoma. Contrast sensitivity is impaired. Visually evoked response (VER) shows reduced amplitude and delay in the transmission time.

Differential Diagnose

Papillitis should be differentiated from papilloedema and pseudo-papilloedema Acute retrobulbar neuritis must be differentiated from malingering, hysterical blindness, cortical blindness and indirect optic neuropathy.

Treatment

Do brain MRI scan. If the brain shows lesions supportive of multiple sclerosis (MS), regardless of the severity of visual loss intravenous methylprednisolone (1 mg daily) for 3 days followed by oral prednisolone (1 mg/kg/day) for 11 days. Indications for intravenous methylprednisolone in acute optic neuritis patients with a normal brain MRI scan are: 1. Visual loss in both eyes simultaneously or subsequently within hours or days of each other. 2. When the only good eye is affected. 3. When the slow progressive visual loss continues to occur.

posterior uveitis

Definition

Refers to inflammation of the choroid (choroiditis). Since the outer layers of retina are in close contact with the choroid and also depend on it for the nourishment, the choroidal inflammation almost always involves the adjoining retina chorioretinitis.

Classification

Suppurative choroiditis Diffuse choroiditis

Non-suppurative choroiditis

Disseminated choroiditis

Focal choroiditis

Symptom

Defective vision Photopsia subjective sensation of flashes of light resulting due to irritation of rods and cones. Black spots floating in front of the eyes large exudative clumps in the vitreous. Metamorphopsia perceive distorted images of the object due to alteration in the retinal contour caused by a raised patch of choroiditis. Micropsia due to separation of visual cells is a common complaint Macropsia, i.e., perception of the objects larger than they are, may occur due to crowding together of rods and cones. Positive scotoma, i.e., perception of a fixed large spot in the field of vision, corresponding to the lesion may be noted by many patients.

sign

Vitreous opacity active stage looks as a pale-yellow or dirty white raised area with ill-defined edges exudation and cellular infiltration of the choroid which hide the choroidal vessels. The lesion is typically deeper to the retinal vessels. The overlying retina is often cloudy and oedematous. atrophic stage or healed stage when active inflammation subsides, the affected area becomes more sharply defined and delineated from the rest of the normal area. The involved area shows white sclera below the atrophic choroid and black pigmented clumps at the periphery of the lesion

complication

complicated cataract, vitreous degeneration, macular oedema, secondary periphlebitis retinae and retinal detachment.

Treatment

Non-specific therapy consists of topical and systemic corticosteroids. Posterior sub-tenon injections of depot corticosteroids are effective in checking the acute phase of posterior uveitis. Specific treatment is required for the causative disease such as toxoplasmosis, toxocariasis, tuberculosis, syphilis, etc.