GRADUAL LOSS OF

VISION
DR. JOSEPH KWARTENG
Specialist Ophthalmologist
(MbCHb, MGCS, FICO, MBA)
 Objectives:
1. To define gradual loss of vision
2. To discuss the various common causes of gradual loss of vision
3. To evaluate (clinically) a patient with gradual loss of vision
 DEFINITION
• Occurs over weeks to years
• Chronic
• Slowly progressive
• Generally painless
• Usually bilateral, but may be asymmetric
*Nb. Some patients may present complaining of ‘sudden’ loss of vision
 VISUAL ASSESSMENT
VISION…
• Acuity - Snellen chart
• Field - Confrontation, Humphrey VF Analyzer
• Colour - Ishihara plates
• Contrast - Pelli-Robson chart
• Pupils - RAPD
• Blindness is defined as “Visual acuity of less than 3/60, or a
corresponding visual field loss to less than 10 degrees around central
fixation, in the better eye with the best possible correction”.
• Visual impairment is divided into different categories, but generally refers
to visual acuity worse than 6/18 in the better eye.
 COMMON CAUSES
• Ocular
- Refractive error
- Media opacities
(cornea/AC/lens/vitreous)
- Retinal disorders (Macula: DME,
AMD. Periphery:RP)
- Optic Nerve Head (Glaucoma)
• Non-ocular/Neurologic
- Visual pathway disorders
i. Optic Nerve
ii. Optic Chiasm
iii. Optic Tract
iv. Optic Radiations
 COMMON CAUSES
• REVERSIBLE • IRREVERSIBLE
- Refractive Error - Glaucoma
- Corneal Blindness - Age-related Macular
- Cataract Degeneration

- Diabetic Macular Edema - Retinitis Pigmentosa

- Optic Atrophy
 1. REFRACTIVE ERROR
• Emmetropia – A situation in which an eye at rest (the unaccommodated
eye) brings objects onto a single focus on the retina.
• Ammetropia – A situation in which an eye at rest (the unaccommodated
eye) fails to bring objects onto a single focus on the retina.
i. Myopia – point focus is infront of retina
ii. Hypermetropia – point focus is behind the retina
iii. Astigmatism – failure to form a point focus
 Pinhole Test
• Screening test for refractive errors
• Generally, visual acuity improves when test is done on a patient with
refractive error
 Symptoms
• Blurry vision, either far or near
• Painless, usually bilateral
• May be associated with headache
• Asthenopia
 Myopia
• Unaccommodated eye brings objects to a point focus infront of the retina
• Also referred to as “short-sightedness”
• Corrected using concave (diverging) lenses
Correction of Myopia
 Hyperopia
• Unaccommodated eye brings objects to a point focus behind the retina
• Also referred to as “far-sightedness”
• Corrected using convex (converging) lenses
Correction of Hyperopia
 Presbyopia
• Presbyopia is the slow, progressive, universal decline in amplitude of
accommodation with age. Usually seen from the 5th decade of life.
• Accommodation: The process by which an eye focuses on near objects by
increasing its dioptric power
• Amplitude: The difference in dioptric power between the eye at rest
(unaccommodated eye) and the fully accommodated eye
 Accommodation
• During Accommodation:
- Ciliary muscles contract
- Lens zonules relax
- Lens assumes a more globular
shape
This results in increased dioptric
power, making close objects clearer
 Symptoms
• Difficulty with seeing at near (near work)
• Headaches
• Eye pain
• Asthenopia
 Management
• Glasses (reading glasses)
- Convex glasses
- Various configurations… plain, bifocal, progressive
• Surgery
- Cornea (Refractive surgery, intracorneal lenses and inlays)
- Lens (IOLs: Multifocal)
- Scleral
 2. CORNEAL BLINDNESS
• Poor vision resulting from opacification of the cornea
 Causes

• Trachoma
• Vitamin A deficiency
• Healed infectious corneal ulcers (bacterial, fungal, viral)
• Eye Trauma
• Interstitial Keratitis
• Congenital disease ( Peters anomaly, Congenital Glaucoma, Corneal
Dystrophies)
 Signs
• Loss of corneal clarity/transparency (white cornea)
• Dull/Absent Red Reflex
• Poor/no view of iris details
 Management
• Surgical – Corneal Transplant
 3. CATARACT
• “Clouding” or loss of clarity of the crystalline lens
• Commonest cause of reversible vision loss
 Types
• Congenital
- Familial
- Metabolic
- Idiopathic
• Acquired
- Senile / age-related
- Diabetes Mellitus
- Trauma
- Drugs eg Steroids, Amiodarone
- Infection (uveitis)
 Symptoms
• Blurry vision (gradual, painless)
• Glare
• Refractive changes
• “Myopic shift” (nuclear type)
• Colour and contrast sensitivity reduction
 Management - Surgery
• ICCE (intracapsular cataract extraction)
• ECCE (extracapsular cataract extraction)
- Traditional ECCE
- Small-incision ECCE / SICS
- Phacoemulsification +/- FSL
 4. DIABETIC MACULAR EDEMA
• Diabetic maculopathy (foveal edema, exudates or ischaemia) is the
commonest cause of visual impairment in diabetic patients
• Retinal edema is caused by leakage from microaneurisms
 Treatment
• Management of underlying condition (DM)
• Lasers
• Intravitreal injections
- Anti-VEGFs
- Steroids
 5. GLAUCOMA
A heterogenous group of eye diseases characterized by characteristic
progressive optic neuropathy, with associated specific visual field defects
 Types
• Anatomic Classification: Open-angle vs Closed-angle
• Aetiology: Primary vs Secondary
 Features (POAG)
• Progressive loss of retinal ganglion cell nerves
• Asymptomatic in early stages
• Loss of peripheral vision, progressing to central field
 Management
• Medical
• Lasers
• Surgical
 6. AGE-RELATED MACULAR
DEGENERATION (ARMD)
• Leading cause of blindness in the developed world in people over 50yrs
• Results in central vision loss; peripheral vision mostly spared (usually do
not therefore end up with complete loss of sight)
• There are 2 main types of AMD:
- Dry (non-exudative/non-neovascular)
- Wet (exudative/ neovascular)
 AMD
• ARMD is a degenerative disorder of the macular area, most often
clinically apparent after 50 yrs of age, and is characterized by:
- Drusen (discrete whitish-yellow spots)
- Hyperpigmentation associated with drusen
- Sharply demarcated areas of depigmentation/hypopigmentation of the
retinal pigment epithelium and associated drusen
 Risk Factors
• Increasing age (age>50yrs)
• White race
• Positive family history
• Hypertention
• Cigarette smoking
 Dry (non-exudative) AMD

- Commonest form, about 85-90% of

all AMD
- Drusen
- Widespread atrophic changes in the
macula
 Wet (exudative, neovascular) AMD

- Less common form, but responsible

for 90% of severe vision loss
- Abnormal growth of new blood
vessels from choroid (neovascularization) and
leakage of serous fluid and blood into the
macula
 Clinical Signs
• Funduscopy
- Drusen: Small, Intermediate, Large
- Pigmentary changes: Hyper- or hypopigmentation
- Choroidal neovascularization (CNV)
 Symptoms
• Loss of central vision (fine vision)
Amsler Grid Test
 Treatments
DRY AMD
• No FDA approved treatments are
available for this type of AMD
• A few are in clinical trials
• Strong evidence has shown that
supplements of vitamins A, C, and E can
slow the progression of the sight loss
• Recommended to wear UV protection
over eyes
WET AMD
• Lucentis
- Monthly eye injections inhibiting the
proteins that stimulate new blood vessel
growth
• Photodynamic Therapy
- Injection of Visudyne in the arm which is
activated in retinal blood vessels by laser
shining into the eye, producing chemical
reaction that kills new blood vessels
 7. RETINITIS PIGMENTOSA
• More recently referred to as Pigmentary Retinal Dystrophy
• A clinically and genetically diverse group of inherited diffuse retinal
degenerative diseases initially predominantly affecting the rod
photoreceptors, with later degeneration of cones
• Occurrence may be sporadic or inherited
• Inheritance may be AD, AR, or XLR
• Results in night blindness and loss of peripheral vision
 Signs
Classic Trilogy:
- Bone-spicule pigmentary
retinopathy (seen in med-
periphery)
- Arteriolar narrowing
- Waxy pale disc
 Symptoms
• Nyctalopia (night-blindness)
• Peripheral visual field loss
• May present with symptoms of cataract (a complication of RP)
 Treatment
• No specific treatment yet available
• Gene therapy shows promise for the future
• UV Sunglasses
• Avoid smoking
• High-dose Vit A?* (controversial)
• Life style modification (well-lit rooms, career choices, etc)
In case things are getting confusing…
 8. OPTIC ATROPHY
• Degeneration of the optic nerve, which occurs as an end result of any
pathologic process that damages axons in the anterior visual system (from
RGCs to LGB)
 Classification
• Clinical
i. Primary
ii. Secondary
iii. Glaucomatous or Cavernous
iv. Consecutive
 Primary Optic Atrophy
• Occurs without antecedent swelling of the optic nerve head
• May be from lesions affecting the visual pathway from optic nerve (retrolaminar)
to the LGB. May cause unilateral or bilateral optic atrophy depending on
location
• Signs:
- Flat, chalky white disc with clearly delineated margins
- Atrophy may be diffuse or sectoral
- Thinning of retinal nerve fibre layer
• Causes:
- Compression by tumors and aneurisms
- Hereditary optic neuropathies
- Optic neuritis
- Toxic
- Nutritional deficiency
- Trauma
 Secondary Optic Atrophy
• Preceded by long-standing swelling of the optic nerve head
• Signs: Raised dirty white or greyish disc with poorly delineated margins
• Causes:
- Chronic papilloedema
- Anterior ischaemic optic neuropathy
- Papillitis
- Neuroretinitis
 Glaucomatous Optic Atrophy
• Specific for glaucoma
• Characterised by deep and wide cupping of optic disc, and nasalization of
blood vessels
Optic Atrophy
 VISUAL PATHWAY DISORDERS
• Optic Nerve
• Optic Chiasm
• Optic Tract
• Lateral Geniculate Body
• Optic Radiations
• Brain (Visual Cortex)
APPPROACH TO THE PATIENT - HISTORY
- Demographics (Age)
- PC : Duration
- HPC : Central vs Peripheral
At near vs Distance
In Dim light vs Bright light
Field loss?
- Ocular History : Glasses, Surgery, Trauma
- PMSH : Diabetes Mellitus, Hypertension
- Drug History: eg Steroids
- Fam History: Glaucoma, AMD, RP
- Social History: Alcohol, Smoking
 APPPROACH TO THE PATIENT – EXAM

• Visual Acuity (far and near)

• Visual Field Testing
• Pupil Assessment
• Red Reflex
• Funduscopy
 References
• N Du Toit (Consultant Ophthalmic Surgeon) (2013) The gradual loss of
vision, South African Family Practice, 55:6, 493-500, DOI:
10.1080/20786204.2013.10874404
• American Academy of Ophthalmology Series, 2018-2019
• Kanski’s Clinical Ophthalmology, A Systemic Approach. 8th Edition, 2016
THANK YOU!