AcuLe vlsual loss ln a quleL eye

eLlna deLachmenL
W eLlnal deLachmenL refers Lo Lhe separaLlon of
Lhe neurosensory reLlna from Lhe underlylng
reLlnal plgmenL eplLhellum Lo whlch normally
lL ls loosely aLLached
Lhe lmage shows a Lyplcal reddlsh horseshoe
Lear ln Lhe reLlna (arrow) wlLh bullous reLlnal
deLachmenL
classlfled lnLo four Lypes
khegmatogenous ret|na| detachment resulLs from
a Lear le a break ln Lhe reLlna
1ract|ona| ret|na| detachment resulLs from LracLlon
le from vlLreous sLrands LhaL exerL Lenslle forces
on Lhe reLlna
Lxudat|ve ret|na| detachment ls caused by fluld
8lood llplds or serous fluld accumulaLes
beLween Lhe neurosensory reLlna and Lhe reLlnal
plgmenL eplLhellum
1umorre|ated reLlnal deLachmenL
Llology
W khegmatogenous ret|na| detachment @hls dlsorder
develops from an exlstloq bteok lo tbe tetloo
W 1ract|ona| ret|na| detachment @hls develops from Lhe
Lenslle forces exerLed on Lhe reLlna by prereLlnal
flbrovascular sLrands especlally ln prollferaLlve reLlnal
dlseases such as dlabeLlc reLlnopaLhy
W Lxudat|ve ret|na| detachment @he prlmary cause of Lhls
Lype ls Lhe breakdown of Lhe lnner or ouLer blood reLlna
barrler usually as a resulL of a vascular dlsorder such as
CoaLs' dlsease
W 1umorre|ated ret|na| detachment lLher Lhe LransudaLe
from Lhe Lumor vasculaLure or Lhe mass of Lhe Lumor
separaLes Lhe reLlna fromlLs underlylng Llssue
ympLoms
etlool Jetocbmeot
W lootets
W losbloq llqbts
W 5boJow
pLlc neurlLls
W pLlc neurlLls ls an lnflammaLlon of Lhe opLlc
nerve LhaL may occur wlLhln Lhe globe
papllllLls) or posLerlor Lo lL (reLrobulbar opLlc
neurlLls)
9ap||||t|s
oflommototy ptocesses 1bese locloJe lofectloos Jlseoses
socb os lyme dlsease malarla and syphllls and
manlfesLaLlons ln Lhe opLlc nerve of lnflammaLlon of Lhe
orblL paranasal slnuses or base of Lhe skull
otolmmooe JlsotJets 1bese locloJe lopos etytbemotosos
polycbooJtltls reglonal enLerlLls (Crohn's dlsease)
ulceraLlve collLls nodular panarLerlLls andWegener's
granulomaLosls
1oxlc Jomoqe Joe to oqeots socb osmetboool leoJ
Myombotol (etbombotol hydrochlorlde) and
chloramphenlcol ln 70 of Lhese cases Lhe coose ls oot
JetetmloeJ
ketrobu|bar opt|c neur|t|s @he prlmary causes
of Lhls dlsorder are Jemyellootloq Jlseoses of
tbe ceottol oetvoos system socb os Jlffose
eocepbolltls o 0 of all cases reLrobulbar
opLlc neurlLls ls an lsolaLed early sympLom of
dlffuse encephallLls Powever a dlfferenLlal
dlagnosls should always also conslder Lhe
otbet cooses of poplllltls meotlooeJ obove
pap|||t|s
@he dlsc ls swollen wlLh
blurred dlsc marglns ln
papllllLls Lhe dlsc ls
hyperemlc raLher Lhan pale as
ln lschemlc opLlc neuropaLhy
apllllLls ls
usually unllaLeral 8llaLeral
papllllLls can be dlfferenLlaLed
from papllledema based on
decreased vlsual aculLy ln
papllllLls
@he opLlc dlsc ls elevaLed and Lhe marglns are
lndlsLlncL @here ls mlcro vascular congesLlon
on Lhe dlsc Lhe reLlnal velns are dllaLed and
flame shaped hemorrhages are presenL @he
appearance ln Lhe oLher eye should
be slmllar
eLlnal vascular ccluslon
W entra| ket|na| Artery Ccc|us|on rolonged
lnLerrupLlon of reLlnal arLerlal blood flow
causes permanenL damage Lo Lhe gangllon
cells and oLher Llssue elemenLs
ArLerlal occluslon
W lstoty1be potleot complolos of o soJJeo
ooset of vlsool dlsLurbance ofLen descrlbed as
a greyouL" of Lhe vlslon or as a curLaln"
descendlng over Lhe vlslon ln one or boLh
eyes
W @hls may be Lemporary (amaurosls fugax) lf
Lhe obsLrucLlon dlslodges or permanenL lf
Llssue lnfarcLlon occurs
xomlootloo
W o tetlool ottety occlosloo tbe vlsool ocolty depends on
wheLher Lhe macula or lLs flbres are affecLed
W @here may be no dlrecL puplllary reacLlon
W @he arLerles may be blocked by aLherosclerosls Lhrombosls
or emboll and Lhe aLLacks may be assoclaLed wlLh a hlsLory
of LranslenL lschaemlc aLLacks lf Lhe aeLlology ls embollc
When Lhe reLlna lnfarcLs lL becomes oedemaLous and pale
and masks Lhe choroldal clrculaLlon excepL aL Lhe macula
whlch ls exLremely Lhlnhence Lhe cherry red spoL"
appearance phLhalmoscopy may be normal lnlLlally
before oedema ls esLabllshed and lndeed Lhe reLlnal
appearance may reLurn Lo normal afLer Lhe oedema
resolves
W laques of cholesLerol or calclum occaslonally
may be seen ln Lhe vessels ln posLerlor clllary
arLery occluslon Lhere ls lnfarcLlon of Lhe opLlc
nerve head whlch has a pale swollen appearance
wlLh perlpaplllary haemorrhage @hls appearance
may be mlsLaken for papllloedema
W apllloedema however ls usually bllaLeral
andLhe vlsual aculLy ls noL affecLed unLll laLe ln lLs
developmenL
ArLerlal occluslonlnfarcLlon of
lower half of reLlna
ArLerlal occluslonembolus
ArLerlal occluslonlschaemlc opLlc nerve
head pale and swollen
CenLral reLlnal arLery occluslon
(CA) and
cherry red spoL aL Lhe macula
W entra| ket|na| Ve|n Ccc|us|on @he
ophLhalmoscoplc plcLure of dlsc swelllng
venous engorgemenL coLLonwool spoLs
(whlch appear as small whlLe paLches on Lhe
reLlna) and dlffuse reLlnal hemorrhages
lndlcaLes a cenLral reLlnal veln occluslon
pldemlology
W eLlnal veln occluslon ls Lhe second mosL
frequenL voscolot reLlnal dlsorder afLer
dlabeLlc reLlnopaLhy
W @he mosL frequenL underlylng sysLemlc
dlsorders are arLerlal hyperLenslon and
dlabeLes melllLus Lhe mosL frequenL
underlylng ocular dlsorder ls glaucoma
Llology
W ccluslon of Lhe cenLral veln of Lhe reLlna or
lLs branches ls frequenLly due Lo local
Lhrombosls aL slLes where scleroLlc arLerles
compress Lhe velns
ympLoms aLlenLs only noLlce a loss of vlsual
aculLy lf Lhe macula or opLlc dlsk are lnvolved
lagnosLlc conslderaLlons and flndlngs
W CenLral reLlnal veln occluslon can be dlagnosed
where llnear or puncLlform hemorrhages are
seen Lo occur ln all four quadranLs of Lhe reLlna
W CoLLonwool spoLs and reLlnal or opLlcdlsk
edema may also be presenL
W Chronlc occluslons may also be accompanled by
llpld deposlLs
W lschemlc occluslon ls dlagnosed wlLh Lhe ald of
fluoresceln anglography
lfferenLlal dlagnosls
W dlabeLlc reLlnopaLhy An lnLernlsL should be
consulLed Lo verlfy or exclude Lhe posslble
presence of an underlylng dlsorder
@reaLmenL
W ln Lhe acute stage of ve|n occ|us|on hematocr|t
shou|d be reduced Lo 3338 by hemodlluLlon
W aser LreaLmenL ls performed ln lschemlc
occluslon LhaL progresses Lo neovascularlzaLlon
or rubeosls lrldls
W local laser LreaLmenL ls performed ln branch
ret|na| ve|n occ|us|on w|th macu|ar edema when
v|sua| acu|ty |s reduced to 20]40 or |ess w|th|n
three monLhs of occluslon
Cllnlcal course and prognosls
W vlsual aculLy lmproves ln approxlmaLely
oneLhlrd of all paLlenLs remalns unchanged ln
oneLhlrd and worsens ln oneLhlrd desplLe
Lherapy
W CompllcaLlons lnclude prereLlnal
neovascularlzaLlonreLlnal deLachmenL and
rubeosls lrldls wlLh angle closure glaucoma
ket|na| ve|n occ|us|on
CenLral reLlnal
veln occluslon lnLrareLlnal
Pemorrhages are vlslble
ln every reLlnalquadranL
ccluslon of Lhe Lwo
maln lnferlor
branches8leedlng
occurs only ln Lhe
affecLed areas of
Lhe reLlna ln branch
reLlnal veln occluslon
vlLreous Pemorrhage
vlLreous Pemorrhage
eflnlLlon
8leedlng lnLo Lhe vlLreous chamber or a space
creaLed by vlLreous deLachmenL
Llology
A vlLreous hemorrhage may lnvolve one of Lhree
posslble pathogenet|c mechan|sms
1 8leedlng from ootmol tetlool vessels
8leedlng from tetlool vessels wltb obootmol
cbooqes
3 oflox of blooJ ftom tbe tetloo ot otbet
sootces
,ore frequent causes of v|treous hemorrhage
|nc|ude
W osLerlor vlLreous deLachmenL wlLh or wlLhouL
reLlnal Lears (38)
W rollferaLlve dlabeLlc reLlnopaLhy (3)
W 8ranch reLlnal veln occluslon (11)
W AgerelaLed macular degeneraLlon ()
W eLlnal macroaneurysm ()
ess frequent causes of v|treous hemorrhage
|nc|ude
W ArLerlosclerosls
W eLlnal perlphleblLls
W @erson's syndrome
W eneLraLlng Lrauma
W eLlnal vascular Lumors
ympLoms
W ecreased vlslon
W ensaLlon of looklng Lhrough haze or smoke
W MulLlple new floaLers
W Cobweb shapes dark sLreaks
W llashes of llghL
orms of v|treous hemorrhage
a D|ffuse v|treous hemorrhage
@he vlew of Lhe fundus ls
obscured by Lhe vlLreous
hemorrhage deLalls are
clouded or compleLely
obscured
@he sLar lndlcaLes Lhe cenLer of
Lhe vlLreous hemorrhage Lhe
arrow lndlcaLes Lhe opLlc
dlsk
bketrohya|o|dbleedlng wlLh
formaLlon of a fluld
menlscus @he
lmage shows bleedlng lnLo a
space creaLed by a clrcular
vlLreous deLachmenL
lagnosLlc conslderaLlons
W emottboqes loto tbe vltteoos boJy ltself Jo oot
exhlblL any characLerlsLlc llmlLaLlons buL spread
Jlffosely
W vlLreous hemorrhages requlre examlnaLlon wlLh an
ophLhalmoscope or conLacL lens
W ulLrasound sLudles are lndlcaLed where severe
bleedlng slgnlflcanLly obscures Lhe fundus examlnaLlon
W leeJloq lo tbe tlssoes oJjoceot to tbe vltteoos boJy
le lo tbe tettobyololJ space 8erger's space or eLlL's
space can produce a cbotoctetlstlc flolJ meolscos 1bls
meolscos wlll be vlslble ooJet slltlomp exomlootloo
@reaLmenL
W aLlenLs wlLh acuLe vlLreous hemorrhage
should be placed ln an optlqbt testloq
posltloo
W vlLrecLomy wlll be requlred Lo draln any
vlLreous hemorrhage LhaL ls noL absorbed
Cllnlcal course and prognosls
W AbsorpLlon of a vlLreous hemorrhage ls a long
process
W @he cllnlcal course wlll depend on Lhe
locaLlon cause and severlLy of Lhe bleedlng
W 8leedlng ln Lhe vlLreous body lLself ls
absorbed parLlcularly slowly
Moooqemeot
W 6iont ce// orteritis must be exc/uded by the
hlsLory and examlnaLlon and by checklng Lhe
eryLhrocyLe sedlmenLaLlon raLe lmmedlaLe hlgh
dose lnLravenous sLerold Lherapy ls lndlcaLed
W mboll from Lhe caroLld arLerles and hearL should
be excluded ALLempLs may be made Lo open up
Lhe arLerlal clrculaLlon ln acuLe cases by ocular
massagerapld reducLlon ln lnLraocular pressure
medlcally anLerlor chamber paracenLesls or by
carbon dloxlde rebreaLhlng Lo cause arLerlal
dllaLaLlon