Visual Loss Differential Diagnosis PDF

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Summary

Differential diagnosis summary that will come in handy for clinical exam ISCE in fourth year....

Description

Visual Loss

Chronic

Acute

Bilateral

Unilateral

Painless

Painful

Painless

Painless

● Refractive error ● Chronic open angle glaucoma ● Cataract

● Age related macular degeneration ● Diabetic maculopathy ● Trauma (foreign body) ● Orbital cellulitis ● Endophthalmitis ● Anterior uveitis ● Acute angle-closure glaucoma ● Keratitis ● Giant cell arteritis ● Optic neuritis ● Migraine with aura

● Drug toxicity (hydroxychloroquine)

● Vitereous haemorrhage

● Chronic eye strain

● Central retinal artery occlusion ● Central retinal vein occlusion

● Papilloedema

● Age related macular degenration

● Cerebrovascular event/ Stroke

● Retinal detachment

● Anticholinergic drugs

● Amaurosis fugax

● Antipsychotic drugs

● Giant cell arteritis ● Papilloedema

UNILATERAL, SUDDEN, PAINFUL VISUAL LOSS DIFFERENTIAL DIAGNOSIS Condition Trauma (foreign body/ corneal abrasion)

Symptoms • • • • •

Redness, pain, watering FB sensation Blurred vision Photophobia Pain on eye movement

Signs • •

Lacerations or injuries around eye Conjunctival injection (redness) or ciliary injection

Investigations •

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Orbital cellulitis (infection develops in the postseptal orbit)

Endophthalmitis (severe inflammation of the anterior and/or posterior chambers of the eye)

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Acute onset of unilateral swelling of conjunctiva and lids Oedema, erythema, pain Blurred vision Fever and malaise May have discharge Acute eye pain and decreased vision Swollen eye lid May have discharge Post eye surgery (1-2 weeks)

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Acute anterior uveitis (inflammation of the iris)

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Pain, redness and photophobia Eye pain is often worse when trying to read Blurred vision Excess tear production

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External eye muscle ophthalmoplegia Proptosis Pain on eye movement RAPD

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Intense conjunctival injection Hypopyon (pus in the anterior chamber Reduced red reflex Decreased visual acuity

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Decreased visual acuity Photophobia (pain when shining light into eye) Circumlimbal injection

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Acute angle-closure glaucoma

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Severe and rapidly progressive pain in eye and around orbit

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Ciliary flush: redness is more marked around the

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Detailed history of the event (?ruptured globe) Visual acuity Slit lamp examination with fluorescein staining (shows green in cobalt blue light) Hyphaema (a fluid level of blood in an upright patient Swab discharge for microbiology FBC, CRP, blood culture CT of the sinuses and orbit ± brain (intracranial abscess)

Slit lamp examination USS of globe Diagnostic surgical vitrectomy full infection screen (FBC, blood cultures and culture of all indwelling lines and catheters) PCR if fungal infection Slit lamp examination (hazy anterior chamber due to leaked protein, white or red blood cells may be observed) Hypopyon may be present IOP may be raised Slit lamp examination (shallow anterior

Management Conservative • If open globe (penetrating) injury is suspected, stop the examination and refer immediately. DO NOT apply any pressure to the eye • If chemical injury, start copious irrigation immediately • Avoid use of contact lenses until the cornea has completely healed • Tetanus prophylaxis as for any superficial wound • Only remove FB if confident and experienced, otherwise refer! • Patching of eyes and advice not to drive Medical • Pain relief may be achieved with topical NSAIDs or oral analgesics • Topical antibiotics (Chloramphrenicol/ Fusidic acid) are commonly prescribed to prevent bacterial superinfection Conservative • Refer immediately to ophthalmologist Medical • IV antibiotics (cefotaxime and flucloxacillin) with addition of metronidazole if chronic sinonasal disease Surgical • Surgical drainage if no response to medication Conservative • Refer immediately to ophthalmologist Medical • Intravitreal injections of antibiotics • Systemic antibiotics if endogenous bacterial infection • Topical cyclopegics Surgical • If severe, vitrectomy (vitreous is entirely removed to reduce the infectious load)

Conservative • Ophthalmology referral within 24hrs Medical • Cycloplegic-mydriatic drugs (eg, cyclopentolate 1%) are used to paralyse the ciliary body. This relieves pain and prevents adhesions between the iris and lens • Corticosteroid (Top/ PO) to reduce inflammation • Antimicrobial if infectious uveitis is suspected Surgical • Treat complications such as cataract, glaucoma and vitreoretinal problems Conservative • Urgent referral to ophthalmologist • Patients are lain supine

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• •

Blurred vision rapidly progressing to visual loss Coloured haloes around lights Nausea and vomiting

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Keratitis (bacterial, viral, fungal)

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Redness and pain in eye Photophobia Blurred vision Foreign body sensation May have discharge

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periphery of the cornea Hazy cornea and a non-reactive (or minimally reactive) mid-dilated pupil Palpation of the globe will reveal it to be hard

Circumlimbic injection (redness around limbus)

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Giant cell arteritis

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Acute demyelinating optic neuritis (demyelination and axonal loss due to an inflammatory process)

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Temporal headache Fever, malaise, myalgia Scalp tenderness eg combing hair Jaw claudication (pain comes on gradually during chewing) Blurred vision (inflammation of the branches of the ophthalmic artery) Diplopia Visual impairment Loss of colour vision Pain worse on eye movement Light flashes Fading of vision (fatigue)

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Temporal arteries may be prominent, tender and pulseless

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Uhthoff's phenomenon Pulfrich's phenomenon (altered perception of the direction of movement) RAPD

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chamber, closed iridocorneal angles) Intraocular pressure using Goldmann tonometry (high IOP, normal is 10-21mmHg)

Slit lamp examination (epithelial defect ± the presence of white cell infiltrate ± oedema) Hypopyon (inflammatory cells) in anterior chamber Corneal defect on fluorescein staining

ESR, CRP Temporal artery biopsy (may be normal due to skip lesion) Colour duplex ultrasonography

Full neuro exam MRI of the brain NMO-IgG (rule out Devic’s disease)

Medical • Analgesia and antiemetic • Acetazolamide IV 500mg over 10mins • Beta-blockers – eg. timolol, cautioned in asthma • Pilocarpine 1-2% (in patients with their natural lens) • Phenylephrine 2.5% (in patients who do not have their own lens) • Steroids - prednisolone 15 every 15 minutes for an hour, then hourly • If there is no response, systemic hyperosmotics (eg. mannitol) Surgical • Peripheral iridotomy: usually two holes made in each iris with a laser to provide a free-flow transit passage for the aqueous. Both eyes are treated, as the fellow eye will be predisposed to an AAC attack • Surgical iridectomy Conservative • Discontinue any contact lens wear • Replace contaminated contact lenses and contact lens cases • Bring their contact lens equipment for microbiological assessment • Ophthalmology referral Medical • Topical antibiotics: Ciprofloxacin/ levofloxacin • Topical antiviral: Aciclovir • Cycloplegic eye drops (eg. tropicamide) to reduce photophobia from ciliary spasm Surgical • Corneal surgery if severe Conservative • Adequate dietary calcium and vitamin D intake to prevent osteoporosis Medical • If visual symptoms: Admit and IV methylprednisolone • If jaw claudication: Prednisolone 60mg PO • If none of the above: Prednisolone 40mg PO • Steroids slowly tapered down over year. Tocilizumab/ methotrexate can be used as steroid sparing agents • Aspirin 75mg as prophylaxis unless CI (eg. peptic ulcer/ bleeding disorder) • PPI due to steroids and aspirin.

Conservative • Ophthalmology and neurology referral • Discuss risk of developing MS • Uhthoff’s: Avoid hot environments and take cool drinks; reassure patients that this symptom is reversible and does not further damage vision • Pulfrich’s: Using spectacles with a tinted lens over the unaffected eye, to balance the delay in conduction from the other side • Visual will usually return to normal Medical • Methylprednisolone 1g IV for 3 days

Migraine with aura

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Visual disturbance starts in one eye and may spread May have unilateral numbness in limbs Unilateral pulsating severe headache Nausea and vomiting Difficulty concentrating Photophobia Neck stiffness

DDx of unilateral sudden painful visual loss • • • • • • • • •

Trauma (FB/ corneal abrasion) Orbital cellulitis Endophthalmitis Anterior uveitis Acute angle- closure glaucoma Keratitis Giant cell arteritis Optic neuritis Migraine

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Examination during an attack may reveal localised oedema of the scalp, face, or under the eyes

• •

Fundoscopy to exclude raised ICP CT head to rule out SOL

Conservative • Keeping a diary on triggers and attacks to identify the triggering factor • Avoid triggers: stress, chocolate, alcohol, sleep deprivation, contraceptive pills • Stop COCP and switch to other forms • CBT Medical • 1st line: Aspirin/ ibuprofen +/- antiemetic (prochlorperazine, metoclopramide) • 2nd line: Diclofenac + domperidone PR • 3rd line: Rizatriptan/ eletriptan PO • 4th line: Ergotamine • Prophylaxis if >1 episode/ month • 1st line: B-blocker (atenolol/ propranolol/ bisoprolol). Amitriptyline if CI • 2nd line: Topiramate/ sodium valproate • 3rd line: Pizotifen

UNILATERAL, SUDDEN, PAINLESS VISUAL LOSS DIFFERENTIAL DIAGNOSIS Condition Vitreous haemorrhage

Symptoms • • • •

Sudden, painless visual loss or haze May have red hue New onset floaters Symptoms which may be worse in the morning if blood settles on the macula during sleep

Signs •

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Variable visual acuity, depending on the size of the haemorrhage A history of diabetes, hypertension, sickle cell disease, ocular surgery or trauma

Investigations • • • •

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Central retinal artery occlusion

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Sudden (over a few seconds), unilateral painless visual loss

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RAPD Pale retina The centre of the macula (supplied by the intact underlying choroid) stands out as a cherry-red spot

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Central retinal vein occlusion

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Sudden unilateral painless loss of vision or blurred vision, often starting on waking

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Age-related macular degeneration

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Painless deterioration of central vision (scotoma), particularly near vision Flashing lights

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Widespread dotblot and flame haemorrhages (non-ischaemic) Blood storm haemorrhage with cotton wool spots (ischaemic – lead to neovascularisation) May be detected incidentally during a routine eye test Decreased visual acuity not

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Fundoscopy Slit lamp examination Measure IOP USS (detect blood, PVD, retinal detachment, tractional membranes, intraocular tumours and foreign bodies) Fluorescein angiography identify neovascularisation ESR, CRP to rule out GCA Fundoscopy Fluorescein angiography FBC, coag and vasculitic screen if young patient Cardiovascular assessment (lipids, BP, BM) ECG

FBC, ESR, lipids, BM BP Fluorescein angiography Optical coherence tomography (OCT) to detect macular oedema ECG Thrombophilia screen Slit lamp examination (drusen, haemorrhage, atrophy) Colour fundus photography is used to

Management Conservative • Rest with the head elevated and revaluate after 3-7 days • Avoid strenuous activity, as an increase in blood pressure may disrupt a clot and cause new active bleeding • Bilateral patching and bedrest may facilitate settling of blood Surgical • Laser photocoagulation in proliferative vasculopathies • Anterior retinal cryotherapy (ARC) help with clearance of liquefied blood • Intravitreal anti-VEGF agents

Conservative • Immediate referral to ophthalmologist • If presented within 90-100 mins, firm ocular massage (repeatedly massaging the globe over the closed lid for ten seconds with five-second interludes) may dislodge the obstruction • Notify DVLA about condition Medical • Sublingual isosorbide dinitrate to dilate vessels • Reduce risk of atherosclerosis (eg statins) • Treat HTN Surgical • Lowering intraocular pressure with anterior chamber paracentesis (withdrawal of a little fluid from the anterior chamber under local anaesthetic) then acetazolamide • Carotid endartectomy if stenosis Conservative • Refer within 24 hours to the on-call ophthalmologist Medical • Treat HTN • Treat underlying cause if found Surgical • Reduction of intraocular pressure is needed if this is elevated • Intravitreal anti-VEGF agents with use of laser panretinal photocoagulation (PRP)

Conservative • Referral to ophthalmologist 1 week if dry AMD, urgent referral if wet AMD • Advise to attend eye casualty if symptoms worsen while waiting • Stop smoking • Visual rehabilitation • Help in registering as sight-impaired

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New onset floaters and flashes Progressive painless visual loss, described as a dark curtain starts in the periphery and progresses towards the centre

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corrected by pinhole occluder Distortion on the Amsler grid Fundus examination reveals drusen (discrete yellow deposits) in the macular area Haemorrhage in wet AMD RAPD Poor visual acuity suggests that the macula has already become detached Gross visual defects

Transient unilateral painless visual loss and resolved within seconds/ minutes Described as a curtain coming down across the vision

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May be all normal

Temporal headache Fever, malaise, myalgia Scalp tenderness eg combing hair Jaw claudication (pain comes on gradually during chewing) Blurred vision (inflammation of the branches of the ophthalmic artery) Diplopia

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Abnormal dark adaptation (central dark patch in the visual field noticed at night, which clears within a few minutes as the eyes adapt) Straight lines appear crooked or wavy (Wet AMD)

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• Retinal detachment (retina separating off from the underlying retinal pigment epithelium)

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Amaurosis fugax

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Giant cell arteritis

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Temporal arteries may be prominent, tender and pulseless

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record the appearance of the retina Fluorescein angiography is used if neovascular AMD is suspected Ocular coherence tomography produces three-dimensional images of the retina

• Able to drive if visual acuity meets requirement of DVLA (6/12) • Healthy, balanced diet rich in leafy green vegetables and fresh fruit • Vitamin supplements Surgical • Intravitreal anti-VEGF agents (ranibizumab, aflibercept) • Laser photocoagulation

Fundoscopy Slit lamp examination Optical coherence tomography USS

Conservative • Same day referral to ophthalmologist • Protective eyewear is recommended when participating in contact sports, especially for patients with moderate or severe myopia Surgical • Cryotherapy or laser photocoagulation achieves permanent adhesion between the retina and RPE • Vitrectomy (Air or gas is injected into the vitreous space to help flatten the retina) • Scleral buckling (indents the wall of the eye, pushing it closer to the detached retina) Conservative • Refer to TIA/ stroke clinic • No need to inform DVLA if 1st episode of TIA but refrain from driving for 1/52 • Stop smoking, weight loss, balanced diet, cut down alcohol, regular exercise Medical • Immediate aspirin 300mg if presented with neurological signs and wait for review in clinic • Clopidogrel 300 mg loading dose followed by 75 mg daily in confirmed TIA • Treat underlying cause eg. AF (anticoagulate) • Statin, antihypertensive drugs and treat DM Surgical • Carotid endarterectomy if stenosis Conservative • Adequate dietary calcium and vitamin D intake to prevent osteoporosis Medical • If visual symptoms: Admit and IV methylprednisolone • If jaw claudication: Prednisolone 60mg PO • If none of the above: Prednisolone 40mg PO • Steroids slowly tapered down over year. Tocilizumab/ methotrexate can be used as steroid sparing agents • Aspirin 75mg as prophylaxis unless CI (eg. peptic ulcer/ bleeding disorder) • PPI due to steroids and aspirin.

Fundoscopy/ slit lamp examination to rule out other causes ECG USS doppler of carotid ECHO Fluorescein angiography

ESR, CRP Temporal artery biopsy (may be normal due to skip lesion) Colour duplex ultrasonography

DDx of unilateral sudden painless visual loss • • • • • • • •

Vitreous haemorrhage Central retinal artery occlusion Central retinal vein occlusion Age-related macular degeneration Retinal detachment Papilloedema Amaurosis fugax Giant cell arteritis

BILATERAL, SUDDEN, PAINLESS VISUAL LOSS DIFFERENTIAL DIAGNOSIS Condition Papilloedema

Symptoms •

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Headache worse in the morning or when coughing/ sneezing Nausea and vomiting Pulsatile tinnitus Blurring of vision Diplopia (6th nerve palsy)

Signs • • • •

• Cerebrovascular accidents

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Sudden onset hemiparesis (initially flaccid then spastic) Hemisensory loss Facial droop

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Investigations

RAPD Swollen optic discs Blurring of optic margins Venous engorgement (typically the first sign) Enlarged blind spot

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Homonymous hemianopia Dysphagia Dysphasia

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Fundoscopy Urgent neuro-imaging; MRI with gadolinium MR venogram for venous thrombosis LP to measure opening pressure and CSF analysis Fluorescein angiography ROSIER score FBC, U+E, LFT, ESR, glucose, coag, lipids Urgent CT Head ECG US doppler of carotid Vasculitic/ prothrombotic screen in young patients Echo to look for mural thrombus/ valvular lesion

Management Medical • Resus if coma (Head elevation, hyperventilation to lower PaCO2, IV mannitol) • IV Furosemide • Barbiturate to induce coma in severe cases Surgical • Treat underlying cause (eg. tumour, venous thrombosis, haematoma, hydrocephalus) • Decompressive craniectomy/ VP shunt/ therapeutic LP to remove CSF

Conservative • Nil by mouth until swallow screen. Keep hydrated with IVI • Oxygen if sats 0.7)

Slit lamp examination to exclude other causes

Management Conservative • Spectacles with power • Contact lens Surgical • LASIK - reshaping of the cornea allows the refraction of the eye to be corrected • Intraocular lens implant Conservative • Referral to ophthalmologist • Regular monitoring to assess IOP, the optic disc and the visual fields • Patient education • Inform DVLA if glaucoma af...