Approach
• Complete eye exam: Visual acuity (corrected), visual fields, external inspection, periorbital soft tissue & bones, extraocular movement, pupils (including swinging light test for afferent pupillary defect), pressure (tonometry), slit lamp (lids, conjunctiva, sclera, cornea w/ fluorescein, anterior chamber, iris, lens), funduscopy, & full neurologic exam
Central Retinal Artery Occlusion
Definition: Retinal artery occlusion, most commonly embolic
History
• Sudden painless, monocular vision loss (or visual field cut if branch of retinal artery), may have transient loss prior to complete loss (amaurosis fugax)
• RFs: HTN, DM, CVA, AF, carotid dz, hypercoagulable, vasculitis, endocarditis, sickle cell anemia
Physical Findings
• Afferent pupillary defect, funduscopic exam shows cherry-red spot at fovea (spared)
• May have carotid bruit, irregular HR, murmur; r/o temporal arteritis
Evaluation
• CBC, ESR
• For embolic w/u: Neuroimaging (CT/CTA or MRI/MRA), carotid imaging, echo, EKG
Treatment
• Initiate immediately (>2 h = irreversible vision loss)
• Immediate ophthalmologic consult
• Intermittent globe massage (to try to dislodge embolus & move it further downstream)
• Reduce IOP as in glaucoma (eg, acetazolamide, mannitol, timolol)
• Anterior chamber paracentesis
• Surgical decompression, anticoagulation, intra-arterial thrombolysis, hyperbaric oxygen
Disposition: Admit
Pearl: Cardiac embolus most common in >40 y/o, coagulopathies most common in <30 y/o
Central Retinal Vein Occlusion
Definition: Retinal vein occlusion, usually thrombotic
History
• Sudden painless monocular vision loss (may be gradual onset)
• RFs: CAD, HTN, glaucoma, venous stasis, hypercoagulable, DM, vascular dz
Physical Findings: Afferent pupillary defect, funduscopic exam w/ retinal hemorrhages/disk edema (“blood & thunder”)
Management: Immediate optho consult. Start ASA, outpt hypercoagulability w/u.
Disposition: Home
Temporal Arteritis (Giant Cell Arteritis)
Definition: Granulomatous inflammatory vasculitis of medium/large arteries
History
• Unilateral HA, jaw/tongue claudication, malaise, low-grade fevers, visual impairment
• Usually >50 y/o (90% >60 y/o), F > M, h/o PMR (50% of pts)
Physical Findings: Tenderness over temporal artery, decreased visual acuity
Evaluation: ↑ ESR, ↑ CRP, temporal artery biopsy
Management
• Prednisone 80 mg/d (if visions threatened do not await biopsy results)
• If no visual sxs, biopsy w/i 2 wk. Consult rheumatology, ophthalmology.
Disposition: Admit only for visual deficits
Pearls
• Failure to diagnose & treat may result in permanent blindness
• 75% of pt w/ visual deficits in one eye will develop contralateral deficits w/i 3 wk
• 20× higher risk of thoracic aortic aneurysm
Optic Neuritis
Definition
• Inflammation of the optic nerve usually due to focal demyelination
• A/w MS (¹⁄³ pts will be diagnosed w/ MS), but also sarcoidosis, SLE, leukemia, alcoholism, syphilis, idiopathic, postviral
History: Vision loss (minimal → complete), ↓ color perception, pain w/ eye movement
Physical Findings
• ↓ Visual acuity, afferent pupillary defect, central scotoma, funduscopic exam
• Disk swelling/pallor
Evaluation: MRI shows inflammation of optic nerve, 20% have other demyelinating lesions
Treatment: Immediate ophthalmology/neurology consult, steroids
Disposition: Admit
Retinal Detachment
History
• Painless, classically “curtain-like” visual field deficit, floaters, photopsia (scintilla)
• RFs include myopia, trauma, surgical hx (cataract removal), DM, HTN, malignancy (breast CA, melanoma, leukemia), SCD, eclampsia, prematurity
Physical Findings: Visual field cut, “billowing” retina, may see pigmented vitreous or visible line demarcating detachment (usually by indirect ophthalmoscopy)
Evaluation: Bedside ED ocular U/S highly sens for detachment
Management
• Immediate optho consult if suspected
• Most inflammatory retinal detachments are treated medically (NSAIDs, steroids), but sometimes require emergent surgery depending on etiology, size, location
Disposition: Admit if acute