Acute loss of visual acuity eye diseases msd manual profi edition

Loss of vision is considered acute if it develops within minutes to days. One or both eyes may be affected, as well as only parts of the visual field. Patients with small visual field loss (z. B. by a small retinal detachment Retinal detachment is a separation of the neurosensory retina from the underlying retinal pigment epithelium. The most common cause is a retinal herniation (a tear or, less frequently. Learn more ) sometimes describe their symptoms as blurred vision.

Pathophysiology

There are three main reasons for acute visual loss:

An opacification of the normally transparent structures through which light rays reach the retina (z. B. cornea, vitreous body)

Abnormal conditions of the retina

Affections of the optic nerve or the visual pathway.

Etiology

The most common causes of acute vision loss are:

Occlusion of the A. centralis retinae (central retinal artery occlusion Retinal central artery occlusion and branch artery occlusion Occlusion of the central retinal artery occurs when it becomes blocked, usually due to an embolism. This causes sudden, painless, unilateral and usually. Learn more , central retinal vein occlusion Retinal central vein occlusion and branch retinal vein occlusion A retinal central vein occlusion is a blockage of the retinal central vein by a thrombus. It causes painless, mild to severe loss of vision and usually occurs in pl&#246. Learn More )

Vitreous hemorrhage (caused by diabetic retinopathy Diabetic retinopathy Manifestations of diabetic retinopathy include microaneurysms, intraretinal hemorrhages, exudates, macular edema, macular ischemia, neovascularization, vitreous hemorrhages. Learn more or trauma)

In addition, a "suddenly noticed" vision loss (pseudo-sudden loss of vision) can be confused with an "acute" vision loss vision loss. For example, a patient with long-standing vision loss in one eye (z. B. by a pronounced cataract Cataract A cataract is a congenital or degenerative lens opacity. The main symptom is a gradual, painless deterioration of vision. The diagnosis can be made by a. Learn more ) when covering the healthy eye suddenly first the decreased vision of the other eye.

Most disorders that can cause complete loss of vision are also possible in milder manifestations, such that they affect only part of the eye and result in only partial visual field loss (z. B. Occlusion of a branch of the retinal artery or vein, local retinal detachment Retinal detachment is a separation of the neurosensory retina from the underlying retinal pigment epithelium. The most frequent cause is a retinal break (a tear or, more rarely. Learn More ).

Less common causes of acute vision loss include:

Anterior Uveitis Overview of Uveitis Uveitis is defined as an inflammation of the middle layer of the eye – the iris, ciliary body and choroid. However, the retina. The fluid in the anterior chamber. Learn more (common, but usually more severe eye pain before visual loss, so evaluation is usually still timely)

Certain medications (z. B. Methanol, salicylates, ergot alkaloids, quinine).

Investigation

Medical history

During the present anamnesis questions focus on the onset, duration, progression, and location of visual loss (monocular or binocular, partial or total visual field, determination of exact area of failure). Important visual symptoms include mouches volantes floating particles floating particles are opacities that move across the visual field and are not related to external visual objects. With age, the vitreous body may contract. Learn more , flashes of light, rings around lights, impaired color vision, and jagged or mosaic patterns (flicker scotomas). The patient is asked about eye pain. Whether these are persistent or occur only during eye movements.

The Checking the organ systems serves to look for extraocular symptoms that may be related to the disease: rapid fatigue of the jaw or tongue (claudication), temporal headache, proximal muscle pain and stiffness (giant cell arteritis), and headache (retinal migraine).

The Self-history includes known risk factors for eye diseases (z. B. Contact lens use, severe myopia, previous eye surgery or injury), risk factors for vascular disease (z. B. Diabetes Diabetes mellitus (DM) Diabetes mellitus (DM) is due to impaired insulin secretion and/or peripheral insulin resistance of varying degrees, leading to hyperglycemia f&#252. Learn More , Hypertension Overview of Hypertension Hypertension is the persistent elevation of resting systolic blood prere (≥130 mmHg), diastolic blood prere (≥80 mmHg), or both. 228. Learn more ). Hematological diseases (e.g. Learn more ) and hematological diseases (z. B. Sickle cell anemia Sickle cell anemia (a hemoglobinopathy) is a chronic hemolytic anemia that occurs almost exclusively in dark-skinned individuals. It is caused by homozygous. Learn more or diseases associated with increased blood viscosity, such as Waldenstrom's disease Macroglobulinemia Macroglobulinemia is a malignant plasma cell disease in which B cells produce excessive amounts of IgM paraprotein. The manifestations can be hyperviscosity&#228. Learn more or multiple myeloma Multiple myeloma is a malignant tumor disease of plasma cells that produce monoclonal immunoglobulins, invade and destroy adjacent bone tie. H&#228. Learn more ).

Physical examination

Vital signs including body temperature are determined.

If a transient ischemic attack is suspected, a complete neurologic examination is performed. The temples are palpated for pulsations, tenderness, or nodularity over the course of the temporal artery. However, most of the testing involves the eye itself.

Determination of peripheral visual field by finger perimetry

examination of the central visual field using the Amsler grid

Direct and consensual light response with the swinging flashlight test

Ocular motility testing

Testing of color vision with appropriate color charts

Eyelids, sclera and conjunctiva are examined with slit lamp if possible.

Examination of the cornea with a fluorescein stain

Examination of the anterior chamber in patients with ocular pain or conjunctival injection for cells and positive Tyndall (flare).

Examination of the lens using direct ophthalmoscopy, slit lamp, or both for possible cataract

Determination of intraocular prere

Ophthalmoscopy (preferably after pupil dilation with a drop of aSympathomimetic, z. B. Phenylephrine 2.5%, or a cycloplegic (z. B. Cyclopentolate 1% or Tropicamide 1%) or both; maximal dilatation after about 20 minutes). The entire fundus is assessed, including the retina, macula, fovea, the vessels, the optic disc, and its margins.

If pupillary light responses are normal and functional visual loss is suspected (rare), optokinetic nystagmus is checked. If an optokinetic drum is not available, a mirror can be moved slowly near the patient's eye. If the patient can see, the eyes usually follow the movement of the mirror (which is evaluated as the presence of optokinetic nystagmus).

Warning sign

Acute loss of vision itself is a warning sign, the cause is usually severe.

Interpretation of the findings

Difficulty in adjusting the fundus reflex during ophthalmoscopy is suggestive of opacification of the transparent structures (z. B. Caused by corneal ulcer A corneal ulcer is a corneal epithelial defect with underlying inflammation (rapidly resulting in necrosis of corneal tie) due to invasion by bacteria, fungi. Learn more , vitreous hemorrhage or severe endophthalmitis Endophthalmitis Endophthalmitis is an acute panuveitis usually due to a bacterial infection. Most cases of endophthalmitis are caused by gram-positive bacteria. Learn more ).

Retinal abnormalities severe enough to cause acute visual loss can be detected ophthalmoscopically, especially if the pupils are dilated. Retinal detachment may be manifested by retinal folds; retinal vein occlusion is manifested by circumscribed retinal detachment Retinal detachment is a separation of the neurosensory retina from the underlying retinal pigment epithelium. The most common cause is a retinal break (a tear or, less commonly. Learn more Retinal hemorrhage and retinal artery occlusion is noticeable as a pale retina with a cherry red spot of the fovea.

An afferent pupillary defect (absence of direct light response with normal consensual pupillary response) with otherwise normal examination findings (except sometimes an abnormal optic disc) suggests an abnormality of optic nerve or retina (d. h. praechiasmal).

In addition, the following clues are useful:

Monocular symptomatology suggests a lesion anterior to the chiasm.

Bilateral, symmetrical (homonymous) visual field defects are suggestive of a postchiasmal lesion

Persistent eye pain is indicative of a corneal lesion (ulcer or abrasion), inflammation of the anterior chamber of the eye, or elevated intraocular prere, while motion-related eye pain is characteristic of optic neuritis.

Temporal headaches suggest giant cell arteritis or migraine.

Tests

Erythrocyte sedimentation rate (ESR), C-reactive protein, and platelet count are performed in all patients whose symptoms (z. B. temporal headache, jaw claudication proximal muscle pain, stiffness) or symptoms (z. B. prere painful or hardened A. temporalis, retinal detachment, papilledema) suggest optic nerve or retinal ischemia to giant cell arteritis Giant cell arteritis predominantly affects the aorta, large arteries leading from the aorta into the neck, and extracranial branches of the carotids. Symptoms of Polymyalgia rheumatica. Learn more.

The retina is examined sonographically when it could not be clearly assessed by an ophthalmologist under indirect ophthalmoscopy with pupil dilation.

Gadolinium MRI is useful in patients with motion-dependent eye pain or an afferent pupillary defect to rule out multiple sclerosis Multiple sclerosis (MS) Multiple sclerosis (MS) is characterized by scattered, patchy demyelination in the brain and spinal cord. Common symptoms may include visual and oculomotor. Learn more indicated, especially if optic swelling was noted ophthalmoscopically.

Therapy

The underlying disorders are treated. Treatment should usually begin immediately if the cause is treatable. In many cases (z. B. with circulatory disturbances), treatment is unlikely to help the affected eye, but may reduce the risk for a similar process in the contralateral eye or a complication of the same cause (z. B. stroke).

Important points

Diagnosis and treatment should be made as soon as possible.

Acute monocular vision loss with afferent pupillary dysfunction is suggestive of a lesion of the eye or optic nerve anterior to the optic chiasm. (praechiasmal)

In patients with acute monocular visual loss or afferent pupillary dysfunction and in patients with or without ophthalmoscopic optic nerve abnormalities but without other abnormalities on eye examination, optic nerve damage must be amed (often ischemic).

Patients with acute monocular visual loss, eye pain, and conjunctival injection probably have a corneal ulcer, acute narrow-angle glaucoma Angle-closure glaucoma Angle-closure glaucoma is glaucoma associated with chronic or, less commonly, acute physical chamber angle closure. Symptoms of acute chamber angle closure are severe. Learn more , an endophthalmitis Endophthalmitis Endophthalmitis is an acute panuveitis usually due to a bacterial infection. Most cases of endophthalmitis are caused by gram-positive bacteria. Learn more or severe anterior uveitis Overview of uveitis Uveitis is defined as an inflammation of the middle skin of the eye – the iris, ciliary body, and choroid. However, the retina. Fluid in the anterior chamber. Learn more underlying.

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