Ophthalmology Sudden Visual Loss

Michael
Karampelas
Clinical Lead Ophthalmology Department
Watford General and St Albans City Hospitals
Retinal specialist
Sudden visual loss definition
• rapid onset
• minutes up to days
Questions you need to ask
• how long ago?

• rapid or gradual onset?
• course?
• monocular or binocular?
• transient or persistent?
• painless or painful?
• associated symptoms?
• ophthalmic and medical history
Examination
• Visual acuity
Examination
• Visual acuity
• Confrontation visual field testing
Examination
• Visual acuity
With the patient looking at your nose, ask if your nose and
other facial features are seen clearly
Inability to clearly see your:
Nose => central scotoma

Eyes or lips => paracentral scotoma
Ears => peripheral visual field defect
Examination
• Visual acuity
• Relative Afferent Pupillary Defect (RAPD)
Swinging flashlight test

Relative Afferent Pupillary
Defect
Significant retinal or optic nerve disease, in one eye
more than the other
Examination
• Visual acuity
• Relative Afferent Pupillary Defect (RAPD)
• Direct ophthalmoscopy
Acute monocular visual loss
Transient Persistent
Transient monocular acute visual loss
• 74 year old man reports intermittent episodes of

“fuzzy vision” lasting from 1 to 15 minutes.
• unsure whether monocular or binocular
• no other symptoms reported
• pMH: coronary artery disease, hypertension,

hyperlipidemia
• pOH: previous cataract operations
• Visual acuity: 6/9 in both eyes

• No RAPD
• No gross visual field abnormality
• No significant issue on retinoscopy
• U/S carotid doppler: 50-79% right carotid stenosis

Amaurosis Fugax
• Painless transient loss of vision, partial or

complete, related to retinal arterial microembolization
or hypoperfusion
• If bilateral it may indicate Vertebrobasilar
Insufficiency
Amaurosis Fugax
• Visual disturbance: Dark, foggy, gray, white

• Minutes (1-5 minutes, occasionally longer);
full resolution takes 10-20 minutes
• Painless
• Usually occurs in isolation
• Assessment of cardiovascular risk factors

• U/S carotid doppler
• A 30-year-old woman began to experience

transient visual loss in the right eye 3 days before
presentation
• Episodes lasted from one to several minutes and
consisted of flashing lights, grey-outs and episodes
of reduced vision to her right eye
• She did not experience headaches, diplopia or
any other focal neurologic phenomena
Transient monocular acute
visual loss
• pMH: Migraines
• pOH: free
visual loss
• Visual acuity: 6/6 RE, 6/6 LE
• no RAPD
• normal visual fields
visual loss
• Ophthalmoscopy : normal
Ocular migraine
• Migraine with aura (“classic”)
Jagged lines, fortification spectra, blind spots,
flashing lights
Generally start 5-30 mins before headache and
last for 20-60 mins
• Migraine without aura (“common”)
• Ocular migraine: aura without headache
Amaurosis Fugax
Ocular Migraine
Amaurosis Fugax Painful Painless

Ocular Migraine
Persistent painful monocular acute
visual loss
• 64 year old woman reports severe pain in her right
eye started suddenly 1 day ago
• pain radiates to temple
• hazy vision – haloes around lights
• mild nausea
• pMH: hypertension, hyperlipidemia

history of migraines
• pOH: hypermetropia
visual loss
• Visual acuity: RE: hand movements LE: 6/9
• no RAPD but RE pupil do not react to light
• difficult to assess visual fields in RE. LE:normal
• difficult to perform retinoscopy
visual loss
• “Shadow sign” – shallow anterior chamber
Acute angle closure glaucoma
• significantly decreased visual acuity

• red and painfull eye
• nausea- vomiting
• fixed semi- dilated
pupil
Needs immediate referral

to ophthalmic A&E
visual loss
• 70 year old man reports gradual reduction in his
RE vision of the last two days with some mild pain
and redness
• pMH: hypertension, hyperlipidemia
• pOH: cataract operation in the RE 1 week ago

visual loss
• Visual acuity: RE: light perception LE: 6/6
• no RAPD
• difficult to assess visual fields in RE.
• difficult to perform retinoscopy
visual loss
• inspection of the RE demonstrated conjunctival
chemosis as well as hypopyon
Endophthalmitis
• ~ 1:1000 risk after any type of intraocular surgery

• Usually within first week
• Blurred vision, red and painfull eye
Endophthalmitis
• Any case with suspicion of endophthalmitis needs

immediate referral to ophthalmic A&E
• Standard management includes obtaining vitreous
samples for microbiology as well as intravitreal
injection of antibiotics

Ocular Migraine
Acute angle
closure glaucoma
Endophthalmitis

Ocular Migraine
Acute angle Retina easily seen
closure glaucoma
Endophthalmitis
No Yes
Persistent painless monocular acute
visual loss with no good retinal view
• 50 year old woman reports a gradual fogginess in
her RE vision over the last 3 days with worsening
floaters
• pMH: DM Type II, hypertension, hyperlipidemia
• pOH: free
• has not been attending her eye clinic

appointments during the previous 3 years
visual loss with no good retinal view
• Visual acuity: 6/60 RE, 6/6 LE
• No RAPD
• difficult to assess visual fields
• difficult to obtain a retinal view. Diminished red-
reflex with direct ophthalmoscope
Vitreous Haemorrhage
Vitreous Haemorrhage
• Painless acute or subacute loss of vision

• May be preceded by floaters
• Retinal vasculopathies (DM,CRVO)
• Posterious vitreous detachment – Retinal
detachment
• Ocular trauma
• Valsava retinopathy
• Referral to retinal specialist within 2 weeks


Ocular Migraine
closure glaucoma
Endophthalmitis
No Yes
Vitreous
Haemorrhage

Ocular Migraine
closure glaucoma
Endophthalmitis
No Yes
Vitreous Normal retina

Haemorrhage
No Yes
visual loss with retinal abnormality
• 70 year old woman reports a sudden loss of vision
in her right eye noted this morning
• No pain
• She reports previous transient episodes of visual
loss
• pMH: DM Type II, hypertension
• pOH: free
• Visual acuity: CF RE, 6/6 LE
• RAPD RE
• Total loss of visual field RE
• Ophthalmocopy: cherry red spot
Central retinal artery occlusion
• Acute, painless, monocular, persistent and nearly

complete loss of vision
• Aetiology: Same as for any thromboembolic
disease
• 5 year mortality is 1/3rd of age matched controls
without CRAO
• No standard treatment of proven benefit
Need to exclude GCA

Branch retinal artery occlusion
• Assessment of cardiovascular
risk factors
• U/S carotid doppler
• Routine referral to retinal
specialist
• A 60 year old male complains of progressive loss
of vision in left eye over the last 2 days.
•No other symptoms
•Painless uniform dulling of vision.
• pMH: DM Type II, hypertension
• pOH: free
• Visual acuity is 6/6 RE – 6/60 LE
• Mild RAPD LE
• Constricted visual field LE
Central retinal vein occlusion
• Dilated and tortuous veins

• Flame haemorrhages
Central retinal vein occlusion
• 10 times more common than CRAO

• Most common risk factors: diabetes, hypertension,
hyperlipidaemia
• In patients <50 years old, haematologic and
autoimmune disease should be excluded.
• Lond term complications are macular oedema and
retinal neovascularisation
Branch retinal vein occlusion
• Assessment of hypertension
and hyperlipidaemia
• If patient is not known diabetic
check for diabetes
• Referral to retinal specialist
soon
• 30 old year woman reports a “black shadow” in
her inferior corner of her RE first noted yesterday
getting progressively worse. Today her vision is
blurry. No pain but had floaters and flashes during
the last week.
• pMH: free
• pOH: Myopia
• Visual acuity HM RE , 6/6 LE
• RAPD RE
• Inferior visual field defect
Retinal detachment
Retinal detachment
Macula ON Macula OFF

(Urgent referral to ophthalmic A/E) (Soon referral to ophthalmic A/E)
Retinal detachment
• Risk Factors : myopia, previous cataract surgery,

trauma
• 76 old year woman reports a sudden onset of
metamorphopsia and reduced vision in her right
eye over a period of 3 days. No other symptoms
• pMH: hypertension
• pOH: dry AMD

• Visual acuity is 6/36 RE and 6/12 LE
• No RAPD
• Central defect in visual field testing
• Metamorphopsia in Amsler grid
Wet AMD
Wet AMD
• Choroidal neovascularization
• patients older than 55 years
• acute or subacute distortion
and vision reduction
• treated with intravitreal
Anti-VEGF injections
•
• Urgent Referral to
retinal specialist
• 68 year old man complains for blurred vision in his
RE noted this morning upon waking up. No other
symptoms
• pMH: hypertension, hyperlipaedimia
• pOH: free
• Visual acuity 6/36 RE and 6/6 LE
• RAPD RE
• Altitudinal visual field defect
• Optic disc oedema in ophthalmoscopy
Anterior ischaemic optic neuropathy
• Non-arteritic: Common cardiovascular risk factors

Not much in terms of treatment
• Arteritic: Autoimmune
Chronic oral steroids to protect
other eye
Giant cell arteritis
• Factors suggestive of GCA:

•Older than 50 years
•Headache
•Jaw pain or fatigue on chewing
(claudication)
•Scalp tenderness
•Elevated ESR,CRP
Start Prednisone (1 mg/kg)

Temporal artery biopsy within 1 week

Ocular Migraine
closure glaucoma
Endophthalmitis
No Yes

Haemorrhage
No Yes
CRAO,CRVO
wet AMD,RD,
AION,GCA
visual loss with normal retina
• 28 year old woman reports sudden loss of sight in
her RE with mild pain on eye movements.
• pMH: free
• pOH: free
visual loss with normal retina
• Visual acuity CF RE and 6/5 LE
• RAPD RE
• Total loss of visual field RE
• Normal ophthalmoscopy
Retrobulbar optic neuritis
• Usually in young adults

• Common first manifestation of MS
• Approx. 30% will go on to develop MS
• Normal optic disc in 2/3 of cases
• Vision usually improves over the following months
• No proven benefit of steroids for long-term vision
Referral to ophthalmologist soon to

confirm diagnosis

Ocular Migraine
closure glaucoma
Endophthalmitis
No Yes

Haemorrhage
No Yes
CRAO,CRVO
Retrobulbar
wet AMD,RD,
Optic Neuritis
AION,GCA

Ophthalmology Sudden Visual Loss

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Michael

• how long ago?

Nose => central scotoma

Swinging flashlight test

• 74 year old man reports intermittent episodes of

• pMH: coronary artery disease, hypertension,

• Visual acuity: 6/9 in both eyes

• U/S carotid doppler: 50-79% right carotid stenosis

• Painless transient loss of vision, partial or

• Visual disturbance: Dark, foggy, gray, white

• Assessment of cardiovascular risk factors

• A 30-year-old woman began to experience

Amaurosis Fugax Painful Painless

• pMH: hypertension, hyperlipidemia

• significantly decreased visual acuity

Needs immediate referral

• pMH: hypertension, hyperlipidemia

• pOH: cataract operation in the RE 1 week ago

• ~ 1:1000 risk after any type of intraocular surgery

• Any case with suspicion of endophthalmitis needs

Amaurosis Fugax Painful Painless

Amaurosis Fugax Painful Painless

• pMH: DM Type II, hypertension, hyperlipidemia

• has not been attending her eye clinic

• Painless acute or subacute loss of vision

• Referral to retinal specialist within 2 weeks

Amaurosis Fugax Painful Painless

Amaurosis Fugax Painful Painless

Vitreous Normal retina

• pMH: DM Type II, hypertension

• Acute, painless, monocular, persistent and nearly

Need to exclude GCA

• pMH: DM Type II, hypertension

• Dilated and tortuous veins

• 10 times more common than CRAO

Macula ON Macula OFF

• Risk Factors : myopia, previous cataract surgery,

• pOH: dry AMD

• pMH: hypertension, hyperlipaedimia

• Non-arteritic: Common cardiovascular risk factors

• Factors suggestive of GCA:

Start Prednisone (1 mg/kg)

Amaurosis Fugax Painful Painless

Vitreous Normal retina

• Usually in young adults

Referral to ophthalmologist soon to

Amaurosis Fugax Painful Painless

Vitreous Normal retina

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