OPHTHALMOLOGY​ L​ ecturer: DR ELENOR REINA AQUINO-ALEGRE 

S3-03: ACUTE VISUAL LOSS​ Date: 02-24-2021

OUTLINE ● 📣 Very important to know the anatomy to be able

● 📣 It is very important for the ophthalmologic

I. Anatomy of the Eye to identify any pathologies
II. Evaluation of Visual Loss
III. Causes of Visual Loss evaluation. The most important would be the

● 📣 ​(Referring to the photo) As the light would

a. Media opacities visual acuity.
b. Corneal edema
c. Hyphema enter the eye through the clear media (cornea,
d. Cataract lens, and other structures), if there are any
e. Vitreous hemorrhage problems with those structures, Acute Visual Loss
IV. Retinal Disease (AVL) may occur.
a. Retinal detachment ● ⭐ ​Please refer to the previous lecture/trans
b. Macular disease (S03-01: Anatomy of the Eye)
c. Retinal vein occlusion

i. Central retinal artery occlusion (CRAO)
ii. Branch retinal artery occlusion (BRAO)
iii. Central retinal vein occlusion (CRVO)
d. Optic neuritis
e. Retrobulbar optic neuritis
f. Papillitis
g. Papilledema
h. Ischemic optic neuropathy
i. Giant cell arteritis
j. Traumatic optic neuropathy
V. Q&A
VI. Post Quiz
📣
II. EVALUATION OF VISUAL LOSS
● These are the examinations we could do to
evaluate any visual loss:
○ Visual Acuity
■ Usually, this is the first thing that we determine
in evaluating AVL
■ If the patient has spectacles with the best
available correction, you could check that as
well.
○ Confrontation Field Testing

References: Lecture Recording, Powerpoint 📖

■ To check for the peripheral vision
■ Normal acuity does not assure that
significant vision has not been lost, because
Presentation, and Basic Ophthalmology: Essentials
for Medical Students, 10th ed. the entire visual field, including peripheral
vision, must be considered.

📖
Legend ● For example, a patient who has lost all of

📣 Reference textbook the peripheral vision on 1 side in both eyes

💡 Audio from lecture recording —a homonymous hemianopia—may have

Nice-to-Know normal visual acuity.

❗
⭐ TG Notes
Important ○ Pupillary Reactions
■ To assess the reaction of the pupils to light
✔ Revised/Corrected from previous trans
■ Useful in evaluating AVL, especially if its
I. ANATOMY OF THE EYE
■ 📣
asymmetric
​Swinging Flashlight Test
■ Check for Marcus Gunn pupils or Relative
Afferent Pupillary Defect (RAPD)
● Marcus Gunn Pupil - relative afferent
pupillary defect caused by an optic nerve
lesion or extensive retinal disease
■ Very important in evaluating monocular visual
loss

Figure 1​ Anatomy of the eye

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B. CORNEAL EDEMA

Figure 4​ (​ LEFT) Corneal Edema​; with dilated pupil, haziness,

hyperemic conjunctiva, and ciliary flush. Commonly diagnosed
with Glaucoma. Patients with this presentation would usually
​ arcus Gunn Pupil
Figure 2 M be complaining of AVL.​ (RIGHT) Granular Dystrophy​; may be
hereditary or genetic

■ 📣
○ Ophthalmoscopy
​Most important technique ● 📣 (LEFT figure) Glaucoma patient, to be specific,
Acute Angle Closure Glaucoma
■ Allows inspection of the fundus and
assessment of the refractive media ○ Usually, using a penlight we can examine this
patient

📣
○ Penlight Examination ○ Commonly, patient would be complaining of eye
■ Visually, we can check if there are any pain
abnormalities on the external eye such as the ○ Should be referred immediately to an
lids, cornea, and other structures ophthalmologist
○ Needs immediate management

📣
○ Tonometry ■ Anti-glaucoma medications to lower the
■
■ 📣 To check the intraocular pressure (IOP)
To confirm other diseases related to the ● 📣 pressure
Another cause of corneal edema would be
pressure of the eye
● e.g., Glaucoma ● 📣
increased intraocular pressure
Another cause would be ​corneal endothelial
cell dysfunction​ such as dystrophies
III. CAUSES OF VISUAL LOSS ○ e.g. Granular Dystrophy - may be hereditary or
genetic; can cause corneal edema
A. MEDIA OPACITIES ■ Some patients are not aware of the visual loss
■ Dystrophies are gradual in onset in cases of
AVL
○ Infections may also cause AVL or blurring of
vision
■ e.g., Keratitis

C. HYPHEMA

Figure 3​ (LEFT) Fluorescein dye uptake; (RIGHT) Corneal

foreign body due to trauma and very common among patients
using motorcycles.

○ 📣
● Fluorescein Dye Uptake
Can cause acute visual loss in a patient with

○ 📣
uptake due to trauma or contact lens use
Management
■ Topical antibiotics
■ Lubricants (Artificial tears)
Figure 5​ Hyphema

📣
● Corneal Foreign Body
📣
📣
○ Due to trauma ● Hyphema - term used if there is blood in the

● 📣 Any significant hyphema would cause blurring

○ ​Very common among patients using anterior chamber

○ 📣
motorcycles
Management:
■ Removal of foreign body
of vision and sometimes some patients would
complain of very poor vision (​counting of fingers
■ Antibiotics (after removal)
● 📣
na lang)​
​Caused by​:
○ Blunt trauma (usually, secondary to trauma)
○ Iris vessel abnormalities or ​Rubeosis Iridis
○ Diabetes mellitus
○ Ocular tumor

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● 📣
○ May be secondary to surgery
​Problems commonly encountered in pts with 📣Posterior pole
E. VITREOUS HEMORRHAGE

📣Presence of blood can affect the vision

●
hyphema​: ● of
○ Corneal staining
■ Long term hyphema could result to staining the patient
○ High IOP ● May be due to:
○ Inflammation ○ Trauma
● Management: ○ Certain conditions that can cause retinal
■ High back rest neovascularization (i.e. Proliferative diabetic
■ Anti-glaucoma medications
➢ If IOP is high ● 📣
retinopathy, vein occlusion)
In severe hemorrhage: cannot view the other
structures of the eye (i.e. Optic nerve, arteries,
■ Topical steroids
➢ Due to concomitant inflammation
■ Cycloplegics ○ 📣
veins)
Can cause acute visual loss
➢ Given to prevent peripheral anterior
synechiae ○ 📣
● Management:

📣 Refer these patients to an ophthalmologist

■ Stop any anti-coagulants
○ If the hyphema is uncontrolled and unresponsive
○
○
○
📣
📣📣
Advise high backrest
Ask for history and comorbidities and refer
Management is depends on the cause
to management, surgery becomes an option
■ Anterior Chamber Washout ( ​tatanggalin
yung blood sa anterior chamber)
📣 ■
■ 📣 Inject intravitreal anti-VEGF
Surgical: Pars plana vitrectomy

📣
D. CATARACT

○ 📣 Some px interpret the rapid progression of

● Most cataracts develop slowly

■ 📣 Can be ​acute​ or ​chronic​ visual loss

the cataract as ​sudden visual loss

● 📣 Some conditions (i.e. diabetes, changes in

blood sugar, serum electrolytes) alter the

○ 📣
hydration of the lens
Result in large fluctuations in the refractive
error of the patient → causing cataract

Figure 8​ Vitreous hemorrhage figure

Figure 6​ Senile mature cataract; in these patient you cannot do

refraction. Management: phacoemulsification with intraocular
lens

Figure 9​ Severe vitreous hemorrhage

IV. RETINAL DISEASE

📣
A. RETINAL DETACHMENT
●
● 📣 Acute visual loss is a feature
Complains:
○ Flashes of lights
○ Floaters

📣
Figure 7​ Cataract; Lens is displaced superiorly and medially; ○ Sudden blurring of vision
Zonular fibers present; (+) Lens subluxation; seen in px with
● Examination:
Marfan’s syndrome; Management: remove cataract, use
special lens (Scleral fixated intraocular lens or Iris claw) ○ Reduced visual acuity
○ Marcus Gunn pupil - (+) Relative afferent

●
●
📣
pupillary defect (RAPD)

📣Dilated fundus exam - guaranteed

Management: Surgical

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Figure 10​ Severe retinal detachment in a patient with myopia; Figure 12​ Dilated fundus exam of Amaurosis Fugax; (+)
wrinkling of the retina can be observed Hollenhorst plaque

📣 📣
B. MACULAR DISEASE i. CENTRAL RETINAL ARTERY OCCLUSION (CRAO)
● ​Age-related macular degeneration ● Prolonged interruption of blood flow into retina
○ Metamorphopsia ​- distortion in vision → permanent damage to ganglion and
○ Dry AMD surrounding cells → CRAO
■ Management: Vitamins and supplements (i.e. ● Sudden painless severe visual loss

📣
Lutein) ● Narrowing of arterial blood columns
○ Wet AMD ● Interruptions of venous blood columns - ​Back
■ Subretinal hemorrhage - patient complains of scarring

📣
blurriness in the center of their vision ● Cherry red spot

📣
■ Presence of macular edema ○ Retinal whitening around the area
■ Management: ​MORE AGGRESSIVE ○ Not pathognomonic for CRAO
➢ Anti-VEGF injections ■ Tay-sachs disease
➢ Monitoring is important → Dilated fundus ■ Niemann pick disease
exam ➢ Ganglion cells become opaque because of

📣
● Amsler grid​ - examination to test macular function deposition of intermediate metabolites.
●
● 📣 RAPD is usually present
​Considered a ​true ophthalmic emergency
○ Golden period: ​90 minutes
■ Need to restore blood flow within this time to

○ 📣restore the patient’s vision.

​First aid
■ Orbital massage - attempt clot dislodgement
■ Reduction of intraocular pressure
■ Give vasodilators

Figure 11​ Dry and Wet AMD correlated with an Optical

Coherence Tomography

📣
C. RETINAL VEIN OCCLUSION
Figure 13​ Central Retinal Artery Occlusion; (+) Cherry red spot
● Relatively common cause of acute vision loss
● Amaurosis Fugax ii. BRANCH RETINAL ARTERY OCCLUSION (BRAO)
○ Transient monocular visual loss due to
arterial insufficiency.
○ Visual loss lasting for several minutes. ○ ❗
● Only a branch​ is occluded
Embolus ​- more likely
● Symptoms
○ 📣
○ Ipsilateral carotid circulation (atheroma).
Referred for management because of ○ Vision loss
● Management
○ 📣
problems of ​Carotid circulation
​Management: Refer to internal medicine for
further evaluation.
○ Fluorescein angiography
■ Asses the integrity of other vessels
○ Laser
○ Co-manage with other specialty
■ Internal Medicine

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​ igure 14​ Branch Retinal Artery Occlusion.

F Figure 16​ Optic Neuritis
Embolus​ is encircled
e. RETROBULBAR OPTIC NEURITIS
iii. CENTRAL RETINAL VEIN OCCLUSION ● Monocular, progressive loss of vision over hours
● Loss of vision may be severe to days (or weeks)
○ Hypertension ● Young patients
○ Arteriosclerotic vascular disease ● Symptoms
○ Diabetic ○ Pain on eye movement
○ Older ○ Poor vision
● Disc swelling ○ RAPD
○ Cannot determine border ● Normal fundus examination
● Venous engorgement ● Differentials
● Cotton wool spots ○ Compressive optic neuropathy
○ Small yellowish, whitish
● Retinal hemorrhages
○ Indicates CRVO
●❗ ■ CT/MRI to rule out
Perimetry - request

● “Blood and thunder”

● Management
○ Laser
○ Anti-VEGF Intra-vitreous injection
■ Macular edema
● Needs medical evaluation
○ IOP needs to be checked because can develop
neovascular glaucoma

❗
Figure 15 C​ entral Retinal Vein Occlusion;
​Blood and thunder appearance

d. OPTIC NEURITIS
● Demyelinating inflammation of the optic nerve
● Edematous optic disc Figure 17​ Retrobulbar Optic Neuritis Perimetry
● Causes

○❗
○ Idiopathic
Multiple sclerosis​ - often
○ Infectious
● Complete work up needed
● Symptoms
○ Reduced VA and (+) RAPD
■ Sudden loss of monocular vision
■ Pain in eye movement
○ Colors are desaturated
■ Appear darker than normal eye
○ Optic disc hyperemia and swollen optic margin
■ Cannot delineate the nerve
Figure 18​ Retrobulbar Optic Neuritis
○❗
● Management
High dose IV corticosteroids

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f. PAPILLITIS ● 📖 Swelling of the disc accompanied by vision loss
in an older adult is likely to represent a vascular
● Inflammation of the optic disc or ​papilla

● 📣As you can see on the photo, there is swelling

● Subtype of optic neuritis event rather than inflammation.
● Symptoms

● 📣Pale, swollen optic disc; usually there are

○ Vision is significantly decreased of the disc and usually there is visual loss.
■ VA and (+) RAPD
● Swollen optic nerve, cannot see margins, splinter hemorrhages that results to:

○ Superior or inferior field defect - ❗altitudinal

hemorrhages and engorgement of vessels ○ Loss of visual acuity

● 📣Showing in the arrow - superior and inferior

pattern

segments of the margins of the optic disc are

● 📣The photo is very morphologic sign of anterior

actually obscured

● 📣Typical on elderly patients with history of

ischemic optic neuropathy

vascular problems such as diabetes and

hypertension

Figure 19​ Papillitis 📣

● Vascular disorder
● We can request for perimetry, usually superior
and inferior field pattern have the altitudinal defect
g. PAPILLEDEMA
● Swelling of the optic disc from increased
intracranial pressure

● ❗
● Both optic discs are affected (bilateral)
Visual acuity and pupillary reflexes are usually
normal unlike other conditions

Figure 22​ Perimetry

i. GIANT CELL ARTERITIS

● >60 years of age

Figure 20​ Papilledema

📣
● Temporal headache or tenderness
● Scalp tenderness - especially when brushing

● 📣 As you can see on the photo, blurred yung optic

the hair
● Carotidynia - 📣 📣Anterior neck discomfort
● Jaw claudication - Fatigue or pain when
disc margin then optic disc cupping is typically

● 📖 Urgent referral is recommended.

obliterated and very prominent ang mga vessels
● 📣
chewing
Some patients have concomitant problems

h. ISCHEMIC OPTIC NEUROPATHY ● 📣

such as weight loss, general malaise
They can also have polymyalgia rheumatica
● Diplopia or visual loss
● Sedimentation rate; C-reactive protein - 📣
usually
very elevated
● High dose IV corticosteroids - 📣mandatory in this

● 📣
condition

📣
Prompt early referral to an ophthalmologist
● Biopsy of the temporal artery - important in
diagnosis

Figure 21​ Ischemic Optic Neuropathy

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Figure 23​ Giant Cell Arteritis
● 📣 2nd picture shows chronic inflammation or
chronic inflammatory process which is composed
of lymphocytes, macrophages, and giant cells
which actually infiltrates the temporal artery wall
Table 1​ ACR Classification Criteria for Giant Cell Arteritis
j. TRAUMATIC OPTIC NEUROPATHY
● Head trauma shears the vascular supply to the
optic nerve
● High dose IV steroids - treatment
● Surgical decompression of the optical canal
Figure 24​ Traumatic Optic Neuropathy
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S3-03: ACUTE VISUAL LOSS
● Retrobulbar neuritis vs Papillitis ​(​Please see
Appendix 2)​
● Retrobulbar neuritis VS Papillitis VS
● 📣
Neuro-Papillitis​ (​Please see ​Appendix 3​)
In neuro-papillitis, there is an inflammation on
the macula; you should work up the patient for any
infectious cause.
V. 📣​ &A
Q
⭐ Q & A were translated to English and paraphrased
so as to ensure a more organized flow of
information.
● Q:​ Can you assess acute visual loss in an infant or
extraocular movement in teleconsult? How do you
assess visual loss in an infant? ---
○ A​: Actually, that would be very hard. Usually, the
fastest test you could do is the ​external eye
exam​, but if you shine the light [on the patient’s
eyes] and this light does not elicit a reaction,
most probably, the patient has ​visual loss​.
Determining if this is acute or chronic, though,
would be very difficult to assess [on teleconsult].
For ​extraocular movements​, sometimes, you
can instruct your patients to send you ​videos​,
not just photos, but this is very hard to examine
in teleconsult, so I highly encourage that they
seek face-to-face consultations. This is
especially applicable to those with ​optic nerve
problems​, ​sudden visual loss​, ​and acute
visual loss​; they have to be checked right
away, face-to face.
● Q:​ Is it possible to assess vision in a newborn? ---
○ A​: It would be ​very ​difficult to assess vision in a
newborn, because their vision is actually still
poor​, a few days or weeks after birth. Although,
you may try to use a ​“target [item],” like a
stuffed toy or anything that they can see, and
you can check if they will fix their gaze upon it or
follow it around. In newborns, though, this will
still be difficult to assess, so you may check if
they have ​ROR (Human Retinal Oxygenation
Response)​. Sometimes, if you shine a light on
them, their eyes will follow it or squint; this is one
option you could do to see if the newborn has
visual potential​.
● Q:​ Is giant cell arteritis (GCA) common in the PH
and is there anything we can do to relieve it? ---
○ A: During my (Doc’s) training in Ophthalmology,
I encountered two or three cases that are very
severe, and these patients are usually very old
(around 70 years old). It is ​not common​, but we
definitely have to determine if a patient has it
because it could lead to ​bilateral loss of vision
(if one eye is affected, the other one may be as
well). The patient’s main complaint was
headache​. What is important here is having a
high index of suspicion​, so we would know
which [diagnostic tests] to request or, in your
case, as interns on duty encountering such a
complaint from a patient, you would at least
think to ​refer to ophthalmology (immediate
 
   S3-03: ACUTE VISUAL LOSS
referral)​. To relieve the patient of symptoms, 3. This is most common in people who ride
first, you have to do ​workup on the patient; it is motorcycles everyday?
highly encouraged to perform a ​biopsy of the a. Cataract
temporal artery because the symptoms are b. Corneal Foreign Body
nonspecific, and the only way to diagnose this is c. Hyphema
through a biopsy. For symptomatic relief, they d. Glaucoma
may be prescribed ​steroids​. If there are any
concomitant conditions (these patients usually 4. All of the following can cause corneal edema,
have comorbidities), you have to [do] ​workup on except?
these patients and ​co-manage with Internal a. Surgery
Medicine​. b. Corneal endothelial cell dysfunction
c. Glaucoma
● Q​: What are the common [causes of] visual loss d. Keratitis
that you encounter aside from glaucoma, cataract,
retinal detachment, and trauma? --- 5. True of retinal detachment except:
○ A​: Based on my experience in the clinic, after a. Marcus Gunn pupil
the lockdown [was implemented], I saw many b. Complaints of floaters and flashes of light
patients with ​glaucoma​, especially ​acute angle c. (+) Relative Afferent Pupillary Defect
closure attacks​. Most probably, they were not d. Managed solely pharmacologically
able to instill their eye drops or had symptoms
but were not able to seek consult. My specialty 6. Cherry red spot is pathognomonic of central
is more on external disease [of the eyes], so I do retinal arterial occlusion. True or False?
not get to see patients with ​retinal detachment​;
they are usually referred to ​retina specialists​. I 7. Cataract may present as either acute or chronic
have seen around two to three cases of retinal visual loss. True or False?
detachment, and their only complaint was
flashes of light​. Depending on the severity of 8. Which of the following conditions is considered a
the retinal detachment, you can use a ​focal true ophthalmic emergency?
laser to avoid further detachment (for retinas a. Cataract
with just an area of a small tear). The ones I saw b. Central retinal arterial occlusion
recently required ​prompt surgery. ​Corneal c. Optic neuritis
foregin bodies are also very common, d. Papillitis
especially in ​welders​. ​Cataracts ​may be acute
or chronic, and sometimes, these patients are 9. Which of the following is part of the ACR criteria
unaware. They usually think it is relatively new for giant cell arteritis?
(acute), but if you analyze it, cataracts ​cannot a. Age >40 years old
develop very fast, unless it is caused by b. Chronic recurrent headache
trauma​. c. ESR of <50 mm/hour
d. Temporal artery abnormalities
● Q​: For hyphema, do we prescribe topical
corticosteroids? Is it not painful to apply? --- 10. In papilledema, visual acuity and pupillary
○ A​: You also have to check. In ​trauma patients reflexes are usually normal unlike other
(hyphema secondary to trauma), you should conditions. True or False?
check for ​corneal uptake​, because you ​cannot
give topical corticosteroids in these patients. Answers: 1false, 2C, 3B, 4A, 5D, 6false, 7true, 8b, 9d, 10true
You have to wait for the epithelium of the cornea
to heal, because the corticosteroids may
impede the healing of the cornea instead of
help. Instillation of topical corticosteroids will ​not
cause any pain if there is no corneal uptake​.

VI. POST QUIZ

1. True or False. In papillitis, the visual acuity and
the pupillary reflexes are usually normal.

2. All of the following are ACR classification criteria

for giant cell arteritis EXCEPT:
a. Age >50 years
b. Mononuclear cell infiltration in biopsy
c. ESR <50mm/hr
d. New onset headache

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VII. APPENDIX

Appendix 1​ Optic neuritis

​ etrobulbar neuritis vs Papillitis vs Neuroretinitis

Appendix 2 R

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Appendix 3​ Retrobulbar neuritis VS Papillitis VS Neuro-Papillitis

**********End of Transcription**********

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