Sudden loss of vision

SUDDEN LOSS OF  VISION

 

AUTHORS:

 

Dr.Ramkumar S.[ MEM-PGY-1]

Dr.Abdul Jaleel P.M.[MEM-PGY-3]

Dr.Venugopalan P.P. [Chief-ED]

A 62 year old male presented to Emergency Department with

Symptoms:  Sudden loss of vision both the eyes since morning

           Vomiting 2 episodes

           No pain on eye, No limb weakness or numbness

Allergies: None

Medications: None

Previous medical/surgical history: No significant co morbidities like hypertension, diabetes and convulsion.

O/E:

Airway : Patent

Breathing : Air entry bilaterally equal

            respiratory rate-20/min

Circulation :Pulse-80/min,regular

             BP-150/100 mmhg

             Capillary refill-normal

Disability :Conscious, alert

            Bilateral vision loss +

            Bilateral pupils PEARL

            Moving all four limbs

Exposure :No rashes or injuries

Vitals : Temp- 98.6 F

           Pulse- 80/min

           BP-150/100 mm hg

           Respiratory rate- 20/min

           GRBS- 101 mg/dl

Head to Toe Examination :

 HEENT   - Visual Acuity : Bilateral Eye no Perception of Light

         - Occular Movements : Normal Bilateral

         - Pupils : Normal Bilateral Eyes

         - Funduscopy : Retina Normal Bilateral Eyes

         -Disc & Vessels Normal Bilateral Eyes

           No Pallor

           No icterus        

 Neck : Trachea midline, no JVD

 Chest : Air entry bilateral Equal,NVBS+

 CVS : S1S2 +, No S3, No murmurs, No pericardial rub

 P/A : Soft,no organomegaly

 Extremities :Warm,No edema,pulses Normal

 Spine & Back :Normal

 Neurology : Conscious,Oriented, Normal speech

             All cranial nerves normal

             Motor, sensory all limbs normal

             DTR, Plantar bilateral normal

              No sign of meningeal irritation or cerebellar dysfunction

Differential Diagnosis :

    Intra-cranial hemorrhage

    Central Retinal Artery Occlusion

    Central Retinal Vein Occlusion

    Retinal detachment

   Labs :

     Hb- 13.4 mg/dl

     WBC- 9700 /mm. cu.

     Platelet-1.53 lakhs/mm. cu.

     PT- 12.0

     INR-1.0

     RBC-4.27

     ESR-15 mm/min

     Na-133 mmol

     K-3.2 mmol

     ECG - Within Normal Limits 

     CT Brain(P): - Intracerebral bleed size 4.2cm * 2.8cm in the Rt. temporo-occipital lobe with     

                    extension into Rt. lateral ventricle

                  - Mass effect with compression of occipital horn of Rt. lateral ventricle

                  - Hydrocephalus +

                  - Gliosis of Lt. occipital region with dialatation of Lt. lateral ventricle

                  - Bilateral ventricles are dialated

 

 Neurology Consult-    

                  IC bleed, de-edema measures, Neuro- ICU admission                    

Ophthalmologist Consultation :

                - Visual Acuity : Bilateral Eye no Perception of Light

                - Occular Movements : Normal Bilateral

                - IOP : 17.3 Bilateral Eyes

                - Pupils : Normal Bilateral Eyes

                - Funduscopy : Retina Normal Bilateral Eyes

                - Disc & Vessels Normal Bilateral Eyes

DIAGNOSIS: Intra-cerebral bleed Rt. temporo-occipital lobe with extension into Rt. lateral ventricles.

Patient admitted under Neurology in Medical ICU.

Treatment :

                 Anti hypertensives

                 Anti edema  measures

                 Anti epileptics

                 Antibiotics

                 RT feeds

 

DISCUSSION:

Sudden loss of vision is classified as follows:

1. Painful & Painless

2. Unilateral & Bilateral

3. Acute & Progressive(Chronic)

Our Patient discussed above has a sudden loss of vision, the cause is intra-cerebral bleed. This not being a commonest cause. Acute vision loss usually occurs over a period ranging from a few seconds to a day or two. Most of these patients need Ophthalmic or Neurological referral for a complete workup.

Causes: Acute vision loss related to non- trauma is mainly due to

              1. Vascular occlusion

              2. Macular disorders

              3. Neuro-ophthalomologic disease

              4. Hysteria (Functional)

 

Central Retinal Artery Occlusion(CRAO) :

   - Vision loss is painless

   - CRAO causes an ischemic stroke of the retina 

   - Retina becomes pale, less transparent & edematous

   - Funduscopy- "CHERRY RED SPOT"

   

 

Treatment:

    - Digital orbital massage

    - IOP reduced by Timolol Maleate 0.5%, Acetazolamide 500mg PO or IV

    - Vasodialatation technique: Breathing into a paper bag for 5 - 10 min for increase in PaCO2

    - Immediate Ophthalmic Consultation

    - Complete medical evaluation (CRAO being an embolic event)

 

Central Retinal Vein Occlusion(CRVO):

    - Vision loss is rapid & painless

    - Thrombosis of central retinal vein

    - Funduscopy: optic disc edema & retinal hemorrhages (blood & thunder fundus)

Treatment:

      Tab. Aspirin 60-325 mg daily

Retinal breaks & detachments:

   A retinal break is a tear in the retinal membranes may or may not lead to retinal detachments.

       3 mechanisms

     - Rhegmatogenous

     - Exudative

     - Traction

Ophthalmoscopy - Retinal detachment is seen (Out of focus at site of detachment)

Immediate Ophthalomology Consultation

 

Posterior Vitreous detachment:

      - Seen in elderly

      -With ageing vitreous gel pulls away from the retina

      - Symptoms similar to Retinal detachment

       Immediate Ophthalmic Consultation.

 

Vitreous Hemorrhage:

       - Bleeding into the pre-retinal space or into the vitreous cavity

Causes:

       - Diabetic retinopathy

       - Retinal detachment

       - Sickle cell disease

       - Retinal artery micro aneurysms

       - Trauma

Direct Ophthalmoscopy :

       - Reddish haze in mild cases

       - Black reflex in severe cases

Treatment :

      - Treat underlying cause

 

Macular disorders :

     - Loss of central vision & preservation of peripheral vision

     - Most common degenerative maculopathy is Senile

Funduscopy :

    - Scattered Drusens

 

 

 

fig: Drusens are small sharply defined yellow-white masses

 

Treatment :

      Photocoagulation as soon as possible.

 

Neuro-ophthalmologic visual loss :

      No obvious abnormalities on physical examinations.

      3 types:  1. Prechiasmal

                     2. Chiasmal

                     3. Postchiasmal

    1. Prechiasmal:

             - Decreased visual acuity or visual field loss unilateral or bilateral.

             - Causes:  a) Optic neuritis

                              b) Compressive optic neuritis

                              c) Ischemic optic Neuritis

                              d) Toxic optic neuritis

                              e) Metabolic optic neuritis

     2. Chiasmal Visual loss:

            - Chiasmal compression by Pituitary tumors, Craniopharingiomas, Meningiomas.

            - Classical defect is bitemporal hemianopsia.

                  

3. Post chiasmal visual loss:

             - Causes are infarction, AV malformations, tumors & migraine.

             - Visual defect is Homonymous hemianopia.

 

Fucntional (Hysterical) : 

- Examinations to rule out possible neuro-ophthalmic deficits.

Conclusion

Bilateral sudden loss of vision , intracranial bleed should also be considered as a cause during the workup ,even if it is not so common.

References :

1. Rosen's Textbook of Emergency Medicine 6th edition.

2.Tinttinalli Emergency Medicine 6th edition.

3. Davidson’s Principles and practice of medicine 20th edition.

4.Parson's Disease of eye.

5.Medscape online reference.