Presentation ALOV

8/8/2019 Presentation ALOV

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Loss of VisionOpthalmology Presentation :

Painful Acute Loss of Vision1. Acute Closed Angle Glaucoma

2. Optic Neuritis

3.T emporal Arthritis (Giant Cell Arthritis)

4. Anterior Ischaemic Optic Neuropathy

5. T rauma



Acute Closed Angle Glaucoma

- typically pr imary glaucoma

Pathogenesis :- Sudden obstruction of drainage angle by per ipher al ir is- The aqueous flow f r om poster ior to anter ior chamber impaired- There is no dr ainage of aqueous thr ough tr abecular meshwork

R Increase in Intraocular Pressure

- Contact of per ipher al ir is eventually may causes adhesionR Peripheral Anterior Synechiae

Risk factors:- Age : Aver age age 60 year s old- Female : Male = 4 : 1

- More common in South East Asians- Increased r isk in 1st degree relative



Risk factors:- Age : Aver age age 60 year s old- Female : Male = 4 : 1- More common in South East Asians- Increased r isk in 1st degree relative

Anatomical predisposing factors:- Lens size increase thr oughout lif e, gr owth br ings anter ior sur face to the cor nea- Small cor nea diameter usually smaller about 0.25mm comparedto nor mal- Short axial length lens located more anter ior ly



Symptoms- Severe pain- Photophobia- Loss of vision- Coloured haloes- Nausea + Vomiting

- Previous symptoms of attack (subacute)

Signs- Decreased vision- Cloudy cor nea- Oval, non-reactive pupil- Loss of red reflex

- Ciliary injection- Increased Intr aocular pressure



Investigations

- Fundoscopy- Increase Cup : Disc r atio- Thinning of neur oretinal r im- DOES NOT RULE OUT

- Tonometry- Intr aocular Pressure Measurement : Pressure > 20

- Gonioscopy - gain a view of the anatomical angle for med between the eyes cor nea andir is

- help distinguish open and closed angle



Management :

- Reduce the intr aocular pressure- IV Acetazolamide 500mg ; Or al Acetazolamide 500mg 4x/daily

- Rever se pupil block

- Topical Pilocarpine 2% (every 15 minutes for 1 hour followed by every hour for 4 hour)

- Prevent recurrence- Laser ir idotomy



Glaucoma eye



Optic Neuritis

Aetiology Classification:- Demyelinating : Nerve fibres lose their myelin layer, most common

cause. E.g Multiple Sclerosis

- Infectious : Sinus related, Cat-scratch fever, Syphilis (1* or 2*

Stage), Lyme disease(spirochete infection), Cryptococcal Meningitis (in

patient with AIDS)

- Parainfectious : Measles, Mumps- Non-infectious : Sarcoid, Autoimmune

Opthalmoscopic Classification:

- Retrobulbar neuritis : optic disc appearance normal, optic nerve head

not involved. Frequent in Multiple Sclerosis

- Papillitis : Optic nerve head affected primarily or secondarily due to

retinal inflammation.

- Neuroretinitis : Characterized by papillitis in association with

inflammation of retinal nerve fibre layer and macular star figure



Presentation:

- in age between 20 and 50 (mean ar ound 30 y/o)- vision wor sens over sever al days recover ar ound 2-4 weeks

Symptoms :- pain in or ar ound eye, exacerbated on eye movement (especially retr obulbar neur itis)- Acute loss of vision, that lasts a f ew days

- Tiny white or coloured flashes/sparkles- Fr ontal headache- Tender ness of the globe

Signs :- Reduce visual acuity- Reduced colour vision

- Other signs of optic disc dysfunction. E.g Impair ment of contr ast sensitivity, aff erent pupillary def ect.- Swollen disc in papillitis , nor mal in retr obulbar neur itis- Centr al scotoma



Investigation :- MRI Identif y additional plaques of demyelination

Treatment :- IV Methylprednisolone sodium succinate 1g daily for 3 days, followed by or alprednisolone 1mg/kg/day for 11 days



Macular star in Optic neur itis



Anter ior Ischaemic Optic Neur opathy ( AION)

- 2 types : Arter itic and Non Arter itic- Arter itic AION can be caused by Giant Cell Arter itis (GCA)

Pathogenesis :- Degener ative vaso-occlusive or vasculitis disease of the arter iolescauses poster ior cilliary vessels become compr omised.

- Leads to sudden decrease in blood supply to the optic nerve head that result in anter ior ischaemic optic neur opathy

Giant Cell Arteritis:- Autoimmune vasculitis occurr ing in patient aged over 60- Aff ect arter ies with inter nal elastic lamina- Presents with sudden loss of vision, tender scalp, pain on chewing,

shoulder pain, malaise



Symptoms :- Sudden, pr ofound unilater al loss of vision or visual field of ten onwaking up- Per iocular pain preceded by tr ansient flashing of light- Jaw claudication*- Headache of recent onset*- Scalp tender ness*

- Weight loss*

Signs :- Tender ness and loss of pulsation of one or both tempor al arter ies- Swollen Optic Disc with haemorrhage and cotton wool spots- Pale 'Chalky white' Disc- Relative Aff erent Pupil Def ect

Symptoms of GCA



Investigations :- ESR and CRP will be r aised- C-reactive pr otein- Tempor al artery biopsy- gr anulomatous inflammation

Treatment :- IV Methylprednisolone sodium succinate - 1g daily for 3 days and or al prednisolone 80mg daily- Or al dose reduced to 60mg af ter 3 days then 50mg for 1 week each



Pale, Oedematous Optic Disc



Non-Arteritic Anterior Ischaemic OpticNeropathy

- presented as sudden painless, monocular visual loss- common in patient ages of 55 to 70 y/o

- predisposing systemic conditions includes diabetes, hypertension, hyper cholester olaemia, antiphospholipid syndr ome- Investigations should be done :- Full blood count Exclude anaemia- Blood pressure check- Blood sugar check- ESR and C-Reactive pr otein to exclude Giant Cell (Tempor al) Arter itis



Trauma

Examples of traumaBlunt and penetrating trauma are both significant causes of visual loss.

1. Blunt trauma more common. E.g eye is struck with a finger, fist,tennis ball,or other solid object.R sudden compression and indentation of the globe that occurs at themoment of impact.Damages- Hyphema : Bleeding may occur in the front of the eye between the clear cornea and colored iris .- Damaged lens may turn cloudy, thus forming a cataract or displaced withinthe eye so that is can no longer focus a clear image.- Retinal damage result reduce of vision. A tear in the retina leads to a largeretinal detachment.- Late effect, becomes evident for months or years after the injury occurs.These late effects, including cataract, retinal detachment, or glaucoma

2. Penetrating trauma i.e eye pierced by a sharp object such as a knife, or by a

high-velocity missile such as BB pellet. Surgery is often needed to repair thedamage.Damages:- Intraocular infection may develop that can rapidly lead to permanent blindness in that eye.

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