1. Acute Visual Loss
Karl D. Bodendorfer, MD
Assistant Professor of Ophthalmology
University of Florida

2. Acute Visual Loss
Categories
• Ocular
– Media opacities
– Retinal (most are vascular)
– Optic nerve (most are vascular)
• Non-ocular
– Stroke
– Functional
– Acute discovery of chronic visual loss

3. Acute Visual Loss
Ocular
• Media Opacities
– Corneal edema - acute angle closure glaucoma,
keratitis (corneal infections)
– Hyphema
– Cataract
– Vitreous hemorrhage

4. Acute Visual Loss
Acute Angle Closure Glaucoma
• Characterized by a sudden rise in IOP in a
susceptible individual with a dilated pupil,
which decompensates the cornea
• Aqueous humor (produced behind the iris
by the ciliary body) cannot get into anterior
chamber to reach trabecular meshwork
(drain of the eye)

5. Acute Visual Loss
Acute Angle Closure Glaucoma

6. Acute Visual Loss
Acute Angle Closure Glaucoma

7. Acute Visual Loss
Acute Angle Closure Glaucoma
• Symptoms
– Severe ocular pain
– Frontal headache
– Blurred vision with halos around lights
– Nausea and vomiting

8. Acute Visual Loss
Acute Angle Closure Glaucoma
• Signs
– Corneal edema
– Conjunctival hyperemia
– Pupil mid-dilated and fixed
– Iris bowed (bombe’d) forward
– Swollen lids

9. Acute Visual Loss
Acute Angle Closure Glaucoma

10. Acute Visual Loss
Acute Angle Closure Glaucoma

11. Acute Visual Loss
Acute Angle Closure Glaucoma
• Acute glaucoma is the “great masquerader”
of the red eye syndromes
• Recognize it and refer quickly - profound
visual loss can result from a delay in
treatment

12. Acute Visual Loss
Acute Angle Closure Glaucoma
• Initial treatment
– Pilocarpine q 15 min x 2
– Other IOP drops
– Acetazolamide PO or IV
– Oral glycerine or isosorbide
– IV mannitol

13. Acute Visual Loss
Acute Angle Closure Glaucoma
• Definitive treatment
– YAG laser peripheral iridotomy
– Surgical peripheral iridectomy
– Cataract extraction

14. Acute Visual Loss
Acute Angle Closure Glaucoma

15. Acute Visual Loss
Acute Angle Closure Glaucoma

16. Acute Visual Loss
Corneal Ulcer

17. Acute Visual Loss
Hyphema
• Blood in the anterior chamber
• Usually caused by trauma
• Check blacks for sickle cell disease

18. Acute Visual Loss
Hyphema

19. Acute Visual Loss
Hyphema

20. Acute Visual Loss
Hyphema
• Treatment
– Bedrest with head elevated
– Topical atropine
– Topical steroids
– +/- Oral steroids
– Watch the IOP and cornea - evacuate blood, if
necessary
– Generally needs urgent referral to
ophthalmology

21. Acute Visual Loss
Cataract
• Cataract
– Can develop or worsen quickly
– Usually in association with trauma or metabolic
imbalances
– Still, most often this would fall under category
of acute discovery of chronic visual loss

22. Acute Visual Loss
Cataract

23. Acute Visual Loss
Vitreous Hemorrhage
• Vitreous hemorrhage
– Usually in association with trauma or
neovascularization from diabetes or vascular
occlusions
– Most often just wait for blood to clear naturally
– Use laser, if appropriate, as soon as retina
visible
– Evacuate blood if not clear by 3-4 months

24. Acute Visual Loss
Vitreous Hemorrhage

25. Acute Visual Loss
Ocular
• Retinal Causes
– Retinal detachment
– Macular disease - usually neovascular
– Retinal vascular occlusions
• Central retinal artery occlusion (CRAO)
• Branch retinal artery occlusion (BRAO)
• Central retinal vein occlusion (CRVO)
• Branch retinal vein occlusion (BRVO)

26. Acute Visual Loss
Retinal Detachment
• Separation of sensory retina from choroid
• Usually in conjunction with a predisposing
situation
– Vitreous degeneration and detachment
– Lattice degeneration (high myopes)
– Neovascularization of the retina (diabetes)
– Trauma

27. Acute Visual Loss
Retinal Detachment
• Symptoms
– Flashing lights
– Floaters
– Loss of vision

28. Acute Visual Loss
Retinal Detachment

29. Acute Visual Loss
Retinal Detachment

30. Acute Visual Loss
Retinal Detachment

31. Acute Visual Loss
Retinal Detachment

32. Acute Visual Loss
Retinal Detachment

33. Acute Visual Loss
Retinal Detachment

34. Acute Visual Loss
Retinal Detachment
• Exam
– Any patient with risk factors should be dilated
and examined
– A retinal detachment large enough to cause
“window shade” loss of vision is big enough to
see with a direct ophthalmoscope
– Most often, patients with these symptoms
should be referred for exam

35. Acute Visual Loss
Retinal Detachment
• Treatment
– A number of treatments depending on size and
location
• Scleral buckle
• Laser
• Cryo
• Intraocular surgery
– Key point is that the sooner the repair, the
better the outcome

36. Acute Visual Loss
Macular Disease
• Macula is area of sharp acuity
• Small anomaly can cause profound visual
loss
• Most common cause is subretinal
hemorrhage from neovascularization
seen in macular degeneration

37. Acute Visual Loss
Sub-Macular Neovascularization

38. Acute Visual Loss
Sub-Macular Neovascularization

39. Acute Visual Loss
Macular Hole

40. Acute Visual Loss
Macular Disease
• Symptoms
– Sudden loss of vision
– Wavy lines (metamorphopsias)
– Gray areas

41. Acute Visual Loss
Macular Disease
• Exam
– Amsler grid (graph paper) - very sensitive
– Use direct ophthalmoscope - often see elevated
areas of retina, hemorrhage
– Fluorescein angiogram

42. Acute Visual Loss
Macular Disease
• Treatment
– Often amenable to laser treatment
– Occasionally, intraocular surgery to evacuate
the hemorrhage is helpful
– Again, the sooner treatment is initiated, the
better the outcome - refer quickly

43. Acute Visual Loss
Retinal Vascular Occlusions
• Central retinal artery occlusion (CRAO)
– Acute painless loss of vision
– Usually embolic or thrombotic
• Check heart - atrial fibrillation, MI, valvular disease
• Check carotids - cholesterol plaques
• * * Check ESR for giant cell arteritis in patients
over 60

44. Acute Visual Loss
Central Retinal Artery Occlusion
• Profound visual loss will become permanent
within hours
• Diagnosis made based on appearance
– Acute - vascular stasis and very narrow
arterioles
– Hours later - inner retina becomes opaque
except for macula - “cherry red spot”
appearance

45. Acute Visual Loss
Central Retinal Artery Occlusion

46. Acute Visual Loss
Central Retinal Artery Occlusion

47. Acute Visual Loss
Central Retinal Artery Occlusion
• Treatment
– Little to lose in initiating treatment
• Press firmly on eye for 10 seconds
• Release for 10 seconds
• Repeat - try to dislodge embolus/thrombus
– Ophthalmologist may tap anterior chamber to
lower IOP to zero - trying to dislodge embolus
– Also, rebreathing CO2, hyperbaric O2, Ca
channel blockers - none work well

48. Acute Visual Loss
Branch Retinal Artery Occlusion
• Sudden painless loss of vision - severity
depends on location of occlusion
• Usually embolic
• Look for cholesterol plaques on exam

49. Acute Visual Loss
Branch Retinal Artery Occlusion

50. Acute Visual Loss
Branch Retinal Artery Occlusion

51. Acute Visual Loss
Branch Retinal Artery Occlusion
• Treatment
– Little can be done
– Try to prevent another plaque-related insult
(stroke)
• Check carotids
• Lower cholesterol
• +/- Aspirin

52. Acute Visual Loss
Central Retinal Vein Occlusion
• Less sudden painless loss of vision
– Rarely complete, but often severe
• Usually elderly patients
• Often becomes bilateral (10%)

53. Acute Visual Loss
Central Retinal Vein Occlusion
• Associations
– Hypertension
– Atherosclerotic vascular disease
– Glaucoma
– Hyperviscosity syndromes

54. Acute Visual Loss
Central Retinal Vein Occlusion
• Examination
– Use direct ophthalmoscope
– “Blood and thunder” appearance
• Many diffuse flame and blot hemorrhages
• Cotton wool spots (white patches of retina)
• Engorged veins
– Optic nerve head edema

55. Acute Visual Loss
Central Retinal Vein Occlusion

56. Acute Visual Loss
Central Retinal Vein Occlusion
• Treatment
– Hemorrhages and cotton wool spots resolve
with time
– Vision may improve a little bit
– Retina may become ischemic
• Watch for neovascularization - 90 day glaucoma
• Needs close followup - may need laser

57. Acute Visual Loss
Branch Retinal Vein Occlusion
• Semi-sudden, painless loss of vision -
severity depends on location of occlusion
• Same associations as CRVO
• Looks like CRVO except for is sectoral
• Treat the same way
– Watch for neovascularization
– Laser for neovasc or non-resolving macular
edema

58. Acute Visual Loss
Branch Retinal Vein Occlusion

59. Acute Visual Loss
Ocular
• Optic nerve disorders
– Optic neuritis
– Optic nerve edema
– Ischemic optic neuropathy (ION)
– Giant cell arteritis

60. Acute Visual Loss
Normal Nerve

61. Acute Visual Loss
Optic Neuritis
• Inflammation of the optic nerve
– Idiopathic - often associated with multiple
sclerosis
– Signs and symptoms - decreased vision,
decreased color vision, afferent pupillary defect
(APD), pain with eye movements, and visual
field cuts (central scotomas)

62. Acute Visual Loss
Optic Neuritis
• Examination - optic nerve usually normal;
sometimes hyperemic and edematous
• Usually resolves with time
• Treatment controversial
• Prognosis of a single attack is usually good

63. Acute Visual Loss
Optic Neuritis

64. Acute Visual Loss
Optic Neuritis

65. Acute Visual Loss
Optic Nerve Edema
• Many possible causes - including:
– Malignant hypertension
– Tumors
– Elevated intracranial pressure
– Meningitis
• Often need CT/MRI and lumbar puncture
• Possibly an ophthalmologic or life
emergency - react quickly

66. Acute Visual Loss
Unilateral Optic Nerve Edema
• A - AION (acute ischemic optic neuropathy)
• T - Tumor
• O - Optic neuritis, orbital pseudotumor
• U - Uveitis
• C - CRVO
• H - Hypotony

67. Acute Visual Loss
Bilateral Optic Nerve Edema
• M - Mass
• M - Malignant Hypertension
• M - Meat (pseudotumor cerebri)
• M - Mucked up drainage (hydrocephalus, DVO)
• M - Meningitis
• M - Medicines (vitamin A, tetracyclines)

68. Acute Visual Loss
Optic Nerve Edema

69. Acute Visual Loss
Optic Nerve Edema

70. Acute Visual Loss
Optic Nerve Edema

71. Acute Visual Loss
Bilateral Optic Nerve Edema

72. Acute Visual Loss
Optic Nerve Edema
• Papilledema is a term reserved for optic
nerve edema, usually bilateral, caused by
elevated intracranial pressure
• A definite ophthalmologic or life
emergency

73. Acute Visual Loss
Ischemic Optic Neuropathy
• Ischemic optic neuropathy (ION)
– Usually painless
– Vascular - embolic or thrombotic
– Symptoms
• Decreased visual acuity
• Decreased color vision
• Visual field cut - often altitudinal

74. Acute Visual Loss
Ischemic Optic Neuropathy
• Signs
– Acutely - hyperemic, swollen nerve -
sometimes sectoral
– Later - pallid nerve
• Important:
– Check ESR for giant cell arteritis in patients
over 60

75. Acute Visual Loss
Ischemic Optic Neuropathy

76. Acute Visual Loss
Ischemic Optic Neuropathy

77. Acute Visual Loss
Ischemic Optic Neuropathy
• Treatment
– Little can be done
– Consider:
• Checking carotids
• Checking heart
• +/- Aspirin

78. Acute Visual Loss
Giant Cell Arteritis
• A true ocular and sometimes life
threatening emergency
• Generalized inflammatory disease of large
and medium sized arteries
– Nearly all patients over 50 years old
– Most at least 60

79. Acute Visual Loss
Giant Cell Arteritis
• Symptoms
– Jaw claudication
– Headache
– Scalp tenderness
– Myalgias
– Fever
– Acute visual loss***

80. Acute Visual Loss
Giant Cell Arteritis
• Ischemic optic neuropathy is most common
ocular manifestation
• Central retinal artery occlusion (CRAO) is
also common
• Motor nerve palsies can occur
• Profound visual loss
• Other eye can become involved within
hours or days

81. Giant Cell Arteritis:
Ischemic Optic Neuropathy

82. Giant Cell Arteritis:
Central Retinal Artery Occlusion

83. Giant Cell Arteritis:
Third Nerve Palsy

84. Giant Cell Arteritis
Pathology

85. Acute Visual Loss
Giant Cell Arteritis
• Diagnosis - prompt diagnosis and treatment
are critical
– History
– Stat ESR
– +/- Fluorescein angiogram
– Temporal artery biopsy

86. Acute Visual Loss
Giant Cell Arteritis
• If GCA suspected, start steroids
immediately
• Don’t wait for biopsy
• Sometimes immunosuppressive therapy is
needed

87. Acute Visual Loss
Non-Ocular Causes
• Stroke, cerebral mass, or bleed
– Usually painless
– Vision loss is bilateral unless insult is anterior
to chiasm
– Often, there are associated symptoms
• Numbness
• Weakness
• Paresthesias
• Impaired thinking or talking

88. Acute Visual Loss
Stroke, Mass, or Bleed
• Most common manifestation is a
homonymous visual field defect
• Workup and treatment are urgent or semi-
urgent
– CT scan
– Send patient to ER or primary care physician
– DO NOT send patient to ophthalmology - at
least not at first

89. Acute Visual Loss
Right Homonymous Hemianopia

90. Acute Visual Loss
Right Homonymous Hemianopia

91. Acute Visual Loss
Non-Ocular
• Functional visual loss
– Hysteria - implies patient truly believes he has
visual loss even though he doesn’t
– Malingering - implies patient is aware he has no
visual loss, but is faking it for secondary gain
• Money
• Enjoy the sick role

92. Acute Visual Loss
Non-Ocular
• Acute discovery of chronic visual loss
– More common than you’d think
– Scenarios
• One day patient decides to cover one eye and
discovers other eye has decreased vision
• One day patient decides that lack of new glasses has
caused his vision to acutely drop
• One day 80 year old patient decides his dense
cataracts that have been building up for 20 years are
suddenly causing visual loss

93. The End