ocular diff diaganosis 1
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Clinical Optometry 2(i)
Differential Diagnosis 2
“A matter of life and death…?!”
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Turn off comments! Chris BagotChris Bagot
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• loss of transparency of media
• loss of function in neural pathway i.e. retina to cortex
mostly evident from examination!
Sudden Visual Loss
Main Causes
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• Onset!sudden onset or suddenly noticed?Constant or Intermittent
• Laterality• Type of visual loss
blank field, blur, distortion, colour
• Pain?
...again - think horses before zebras
Sudden Visual Loss
HistoryAge of Patient:SVL pts with serious concern have pathology. Diff pathology often related to age & GENERAL HEALTH
Age of Patient:SVL pts with serious concern have pathology. Diff pathology often related to age & GENERAL HEALTH
which hemianopia/altitudinal?which hemianopia/altitudinal?
relation to CHIASM, LE or L hemifield?
relation to CHIASM, LE or L hemifield?
secs/rapid on&off/10-30minsecs/rapid on&off/10-30min
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• VA
• Pupil Examination
• Visual Field
• Anterior Segment
• Fundus examination
again what follows are not exhaustive lists
Sudden Visual Loss
Examination
Both eye’s, habitual correction & pinholeBoth eye’s, habitual correction & pinhole
espec RAPDespec RAPD
confrontationconfrontation
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visual loss can appear like a curtain
cholesterol/calcium
plaque
• Vitreous floaters
Sudden Visual Loss
Temporary Visual Loss (durn < few hours?)
• Postural hypotension• Sub-acute Angle Closure Glaucoma• Papilloedema
• Poor tear film• Migraine• Amaurosis fugax
Transient Ischaemic Attack (TIA)
in order of appearance!
in order of appearance!
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• Trauma• Iritis• Recurrent corneal erosion• Angle closure glaucoma• Radiation damage
Sudden Visual Loss
>24 hours with PAIN
• Optic NeuropathyInflammatory vs De-myelinatingUhthoff’s sign
Generally incomplete healing of wound. Sx worse on waking.Seen with slit lamp
eg: welder’s flash
in order of appearance!
in order of appearance!
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Sudden Visual Loss
>24 hours and PAINLESS• Any age
malingering
• Age 20-40 yearsCentral Serous Chorioretinopathy (CSCR)
Optic neuritis
Macular hole
Retinal Detachment
HIV related infection
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Central Serous Chorioretinopathy
Sx: blurred DV & NV; micropsia; metamorphopsia; central scotoma; poor colour vision
Signs: Rx can show increased hyperopia (due to sub-retinal fluid accumulation); stereo fundoscopy
Manage: refer (often self-limiting, 3-6/52), laser may help
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Macular Hole
Again dramatic sudden loss of VA; associated with metamorphopsia/scotoma
Seen with direct/indirect as full thickness depression in retina
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Retinal Detachment
Sx: curtain falling over vision or localised & persistent flashing lights or increased number of floaters
Schaefer’s sign: ‘Tobacco dust’ in anterior vitreous means retinal tear is present
More in pathology lectures...
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Sudden Visual Loss
>24 hours and PAINLESS• Age 40-60 years
Vitreous Haemorrhage
Retinal Vascular Disease
Diabetic retinopathy
Vein/artery occlusion
Hypertensive retinopathy
Non-Arteritic Ischaemic Optic Neuropathy
Myopic Degenerationrugby player storyrugby player story
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Vitreous Haemorrhage
Common cause of loss of transparency
Found in situations where retina lacks O2 and ‘new’ blood vessels develop
New vessels are thin and weak so easily leak blood into space between retina and vitreous
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Retinal Vein Occlusion
Visual loss depends on site of occlusion (central v branch)
Can have residual vision
?RAPD if central
Ophthalmoscopy: retinal haem’s, oedema, exudates
More in pathology lectures..!new piccy?new piccy?
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Retinal Artery Occlusion
Visual loss depends on site of occlusion (central v branch)
Often total visual loss in affected region
RAPD
Ophthalmoscopy: ‘cherry red’ spot at macula
?Preceded by Amaurosis Fugax
More in pathology lectures..!
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Sudden Visual Loss
>24 hours and PAINLESS
• Age 60+ years
Retinal Vascular Disease
Retinal Detachment
Subretinal neovascular membrane
‘wet ARMD’, Sx: similar to CSCR
Cerebral Vascular accident, (CVA)
Arteritic Ischaemic Optic Neuropathy
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Ischaemic Optic Neuropathy
Infarction of the anterior optic nerve due to blockage of the short posterior ciliary arteries
Two main types:
Non-arteritic: variable reduction in vision, altitudinal hemianopia, swollen optic disc
Arteritic: sudden, profound(HM), permanent visual loss, swollen pale optic disc, RAPD. Preceded by Amaurosis fugax.
2nd can be linked to CVAs
More in pathology lectures..!
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A Case Study
Optometry Today, Oct 22, 1999
• 56 year old male ‘disturbed’ RE vision• VA R:6/9 L:6/5, Ocular exam normal
referred to GP
• Vision drops over 3 daysPt self reports to casualty
• VA R:CF L:6/5, • Exam:
right RAPD,
VF: R dense central scotoma, L normal
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• backed by RAPD, colour perception• Central VF defect - most GC fibres from
macula• Differential diagnosis
in: inflammation, disturbed blood supply, glioma
on: retrobulbar neuritis, or as in this case...
A Case Study
• Normal R fundus & full L visual field
implies R optic nerve problem
Optometry Today, Oct 22, 1999
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A Case Study
Optometry Today, Oct 22, 1999
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History• Onset• Age• Monocular vs Binocular
are there more than two images?
• TypeHoriz, vertical, oblique
• Frank diplopia or ghosting?• Constant?
Associated with specific task / eye position?
Diplopia
Q: What proportion of us have diplopia?