PAINLESS VISION LOSS:

 

Damage can be attributed to any of the following:

  1. Optic nerve -
     
    • Acute: trauma, ischemia, bleeding, acute attack of glaucoma.
       
    • Chronic: glaucoma, papilledema, optic atrophy. These entities are beyond the scope
       
  2. Chiasm - Tumor, hemorrhage or infarcts to pituitary gland inflammation, ischemia. These entities are beyond the scope of  this study guide.
     
  3. Temporal Arteritis - see in the Neurology/Headache section of this manual
     
  4. Vitreous  hemorrhage -due to tearing of retinal vessels (trauma, retinal detachment), DM, sickle cell and other coagulopathies. Patients c/o floaters and dark  lines that move with ocular motion (it is a blood that moves in vitrous humor). Other symptoms such as blurry vision and  visual acuity are also present. Diagnosis is suspected by not visualizing fundi on ophtalmoscopy. Head elevation and Ophthalmology consult is required.
     
  5. Retina detachment - occurs between the layers of retina. Pt c/o spectrum of symptoms that varies from mild  in visual field to blurry vision, floaters, falling curtain. Fundus exam reveals detached gray retina. STAT ophthalmology  consult is mandated.
     
  6. CMV retinitis - it is very common  manifestation of  systemic CMV and considered emergency since visual loss is inevitable if left untreated. Pts c/o sudden or gradual loss of vision and floats. On exam patches of white "cotton" granulation and retinal hemorrhages are seen. Ganciclovir  and ophthalmology consult are needed.
     
  7. Central Retinal Vein Occlusion (CRVO) - patients predisposed to CRVO are: DM, HTN, hypercoagulability. Pts report mild central visual loss and blurring that improves as day progresses. On fundoscopic exam diffuse retinal hemorrhage and engorged, dilated veins are seen. For management ophthalmologist is consulted.
     
  8. Central Retinal Artery Occlusion - Common causes are embolic events from a. fib, valvular disease, HTN, DM, hypercoagulability andTA (send ESR).  Patient c/o sudden and painless visual loss. This, occasionally can improve if embolus moves or reabsorbs. On exam   pale retina and a "tomato-red" macula are seen. Pts commonly c/o symptoms at night or early morning. The CRAO is an ocular  emergency. While waiting for ophthalmologist digital massage of ocular globe is performed on-and-off  for few seconds in order to displace the embolus. Also breathing into the paper bag for 10-15 min and  pCO2 to dilate the artery. Heparin is considered in consultation with ophthalmologist. All the above treatment modalities are  futile  if symptoms are more than 2-3 hours long since the damage is irreversible

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