This is a continuation of our discussion of Eye Emergencies in the elderly with ophthalmologist and retina specialist, Dr. Bryan Hong. Many thanks to the Life in the Fast Lane blog for including eye emergencies part 1 in their LITFL Weekly Review!
See below the audio player for more notes!
Sudden painless vision loss
- Case: A 55yo M with sudden, painless, monocular vision loss typically has a vascular cause.
- CRAO – Typically occurs from an embolus from the carotids or cardiac valves. It is often very rapid onset with marked visual impairment (counting fingers to light perception). May have APD. Patients may have had previous episodes of transient vision loss (amaurosis fugax). On funduscopic exam the retina is pale, with a cherry red macula. These patients require workup to identify the source of the embolus (eg cardiac echo, carotid dopplers). Unfortunately vision often does not improve or return. The workup is to prevent further emboli and CVA. There is also overlap in the presentation with giant cell arteritis (discussed in part 1). Other causes may include sickle cell disease, Behcet’s, syphilis or collagen vascular disease. Ocular massage and anterior chamber paracentesis can be attempted but low likelihood of success.
- CRVO – Vision typically not as severe as with CRAO though can be, and patients can have an APD. The funduscopic exam has a “blood and thunder” appearance with intra-retinal hemorrhages. Can be due to hypercoagulable disorders, or syphilis. The main prognostic factor is their vision at the time of presentation.
- Case: Gradual painless loss of vision in 70 year old man who has difficulty with reading and driving (particularly at night). However, sometimes the patients will think the changes are more acute, as they compensate until the vision impairment is severe enough that it interferes with their reading or other activities.
- Evaluation: Vision, pupils, pressure. Thorough history of nature of vision loss. Typically describes colors as being dull, colors are not as vibrant, see starbursts when bright light is shone into eyes, things look hazy. The progression is often symmetrical, but you can check with the direct ophthalmoscope from 2-3 feet away for any decreased red reflex in one eye. You can use a pinhole occlude to get a better measure of their visual acuity through the cataract.
- Management: Non urgent referral to comprehensive ophthalmologist.
- Case: 40 year old janitorial worker splashes oven cleaner in her eye and arrives with tearing/red eye and decreased vision.
- Evaluation: Gross measure of vision, followed by generous irrigation with Saline/LR/tap water. Topical anesthetic may be applied prior to irrigation. Upper and lower fornices should be swept with Q tip and everted prior to irrigation. All particulate matter should be removed. Time of injury? Time to irrigation? Type of chemical? Slit lamp exam with fluorescein staining looking for corneal epithelial defects or signs of corneal perforation.
- Management: Copious irrigation, checking for normalization of pH with Litmus paper. Consider cycloplegia if significant photophobia or pain, such as cyclopentylate 1% or homatropine 5%. Frequent artificial tears. Avoid phenylephrine use, which constricts blood vessels and can impair healing. Typically there will be an epithelial defect, in which case prescribe topical antibiotic drops. Avoid ciprofloxacin drops in large epithelial defects as it can precipitate out. Next morning consult with ophthalmologist—needs to be followed daily until stable. Alkali burns tend to penetrate more deeply into the ocular tissue and cause more permanent damage.
Image credit . This podcast uses sounds from freesound.org by Jobro and HerbertBoland
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Great stuff. This podcast series has been such a help.