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Sudden loss of vision ( GCA and fundoscopy)

You are the FY 2 doctor in the Medical department.
59 year old Mrs Jane Anderson presented to the hospital sudden loss of vision.
Take a detailed history from her and do the necessary examination and talk to her about
the further management.

Causes of Sudden Loss ofVision

Questions
1) When happened?
2) One eye or both eye? – whicheye
3) Can you still see something with that eye or you can’t see anything at all?
4) Has it lasted only for short time or you still have the problem?
5) Painful – Glaucoma, Opticneuritis
6) Headache – GCA ( combing hair, jaw claudication), Ocular migraine
( wavyvision)
7) Medications ? Cialis, Viagra, andLevitra.
8) Loss of speech and loss of feeling one side of body for short time
( Amaurosisfugax)
9) Curtain coming in front of the eye ( Retinaldetachment)
10) Blurry vision or the presence of spots in your visual field (VitreousHeamorrhage)
11) Brain tumour, Stroke ( rarecauses)

Take brief history as above.

Patient gives history of pain on head while combing hair and pain in jaw while chewing.
Sudden loss of vision left eye only
Candidates should say I need to examine your eyes
Do red reflex and fundoscopy on mannikin
Fundoscopy slides were normal both the eyes.

Talk to the patient

You have condition called GCA – explain the diagnosis. This condition has affected the
eyes that is why you are having blindness.
Treat with high dose steroid to prevent blindness of other eye. Then investigation to
confirm. Then long term treatment with low dose steroid.
Is the blindness permanent ? – unfortunately yes.
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Fundoscopy
Explain Procedure : I need to examine the back of your eye with a special instrument called
opthalmoscope . For that I will be shining a bright light on your eyes . During the
examination I will be coming very close to you and will be touching your cheek and face. I
will be using some dilating drops which might dim or blur your vision; therefore you are
advised not to drive home alone or to sign any important legal documents during theday.

Exposure / Position : You can blink normally during the procedure but don't move your head
and sit comfortably . I will be dimming the lights of the room and you should fix your vision
at a distant object .

Check Instruments
Check power of lens.
Check light – BIG FULL MOON

Inspection – coming at eye level

Both Eyes are at same level
No Ptosis
No signs of inflammation
Orbit and appendages are normal

Do a Red Reflex – same level as the eye. Look through the fundoscope for Red Reflex
( seen in normal eye and it means media is clear)
Media is clear therefore I proceed to Fundoscopy.

In real patient I would have examined with Fundoscope light on but in exam since there is a
bright light shining from back I may have reflection or glare so I would like to examine now
with Fundoscope light switched off .

Right eyeofpatient Left eye ofpatient

Right eyeof examiner Left eye ofexaminer
Right handofexaminer Left hand ofexaminer

Do the procedure , approach at an angle of 30-450., and follow the red reflex .
Ask to follow into the instrument visualize macula .
Expalin findings to the examiner.

Description of Slide
Comment on

Optic disc :(1) Colour (2) Margins (3) Contour (4) Cup disc ration {CD Ratio }
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Origin ofBlood Vessels: shape of vessel and calibre ofvessels.

Periphery and Rest of Retina

Macula

NORMAL FUNDUS

A. Optic disc – Alwaysnasal

• Colour – Pinkish pale or pinkishyellow
• Margins – Welldefined
• Circular or Rounded inContour
• Cup disc Ratio – 0.3 –0.5

B. Blood Vessels -Originating from Optic disc, straight not tortuous normal callibre of
vessels-A :V2:3
C. Periphery and rest of retina – Healthy and Normal – no exudates, nohaemorrhage
D. Macula – Healthy andNormal
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SLIDE OF NORMAL FUNDUS: SLIDE 9

I can see the OD, pinkish pale or pink yellow in colour, well defined margins, circular in
contour CD ratio is normal.
Vessels are originating from the OD, Straight not tortuous, normal in calibre.
Periphery and rest of retina and macula appears healthy and normal.
Therefore my diagnosis is NORMAL FUNDUS.

SLIDE OF OPTIC ATROPHY

I can see the OD, pale or chalky white in colour, margin well define, and circular in contour
.Cup cannot be appreciated.
Origin of vessels not clear, they are straight and normal in calibre.
Macula and periphery and rest of retina appear healthy and normal.
Therefore my diagnosis is Optic Atrophy.

SLIDE OF DISC CUPPING: SLIDE 10

I can see the OD, pinkish pale in colour, circular in contour, margins ill defined. CD ratio is
increased in size indicating cupping of the optic disc.
Origins of vessels not clear, they are straight not tortuous, normal in calibre .
Macula and periphery and rest of retina appear healthy and normal.
Therefore my diagnosis is Disc Cupping most probably due to glaucoma.
Treatment: Urgent reduction of intra ocular pressure e.g. mannitol oracetazolamide.

SLIDE OF PAPILLOEDEMA: SLIDE 11

I can see the OD which is swollen, oedematous, hyperaemic and bulging, margins are blurred
or ill defined and cup cannot be appreciated.
Origin of vessels are not clear but vessels are engorged, tortuous and congested.
Periphery and rest of retina appears hyperaemic.
Therefore my diagnosis is Papiloedema.
Urgent MRI to rule out inracranial mass.

SLIDE OF CENTRAL RETINAL VEIN OCCLUSION: SLIDE 15

I cannot appreciate the OD. Origin of vessels is not clear, but veins are engorged, tortuous
andcongested.
I can appreciate flame shape, dot and blot haemorrhages in all quadrants, hard exudates and
cotton wool spots.
Periphery and rest of retina appears hyperaemic and seems to be a stormy sunset or tomato
splash appearance. Therefore most probable diagnosis is CRVO.

SLIDE OF SENILE MACULAR DEGENARATION

I can see the OD which is pale towards temporal side, margins well defined, circular
in contour cup cannot be appreciated.
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Origin of vessels not clear but they are straight and not tortuous, normal in calibre.
I can appreciate macula, there are few unusual pigmentation around it and also
scattered around periphery of retina.
Therefore my most probable diagnosis is senile macular or age related macular
degeneration.

SLIDE OF BACKGROUND DIABETIC RETINOPATH: SLIDE 1

Optic disc is not so clear.
Origin of vessels not so clear but they are straight and not tortuous.
Can appreciate hard exudates along the inferior temporal arcade, discrete, having
irregular surface, margins are ill defined.
Can also appreciate dot and blot haemorrhages in the nasal macular area and
superior temporal arcade, micro aneurysms in the macular area.
Therefore my most probable diagnosis is background diabetic retinopathy.

SLIDE OF PRE-PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE 3

Pre-proliferative diabetic retinopathy is characterised by retinal ischaemia. Cotton wool spots
represents area of focal retinal ischaemia. Initial description of background + Can also
appreciate hard exudates, dot and blot haemorrhages, micro aneurysms and cotton wool
spots. Therefore my most probably diagnosis is Pre Proliferative Diabetic Retinopathy.

SLIDE OF PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE 4

Can appreciate neo vascularization around OD and elsewhere along the vascular arcade.
Can also appreciate hard exudates, micro aneurysms and dot and blot haemorrhages, pre
retinal fibrosis. The new vessels grow into the vitreous and are fragile leading to
haemorrhage. As the haemorrhage organises, fibrous tissue reaction occurs.
Therefore my most probably diagnosis is Proliferative Diabetic Retinopathy.
Management:
The most important part of treatment is to keep diabetes under control.
In the early stages of diabetic retinopathy, controlling diabetes can help prevent vision
problems developing.
In the more advanced stages, when vision is affected or at risk, keeping diabetes under
control can help stop the condition getting worse.
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.
Treatment for advance diabetic retinopathies:
1. Laser treatment: To treat the growth of new blood vessels at the retina in case of
proliferative diabeticretinopathy.
2. Eye injections: AntiVEGF
3. Eye surgery: To remove blood or scar tissue from the eye if laser treatment is not
possible.

SLIDE OF SUB HYALOID HAEMORRHAGE:SLIDE 22

Can appreciate massive boat shaped haemorrhage in , which is most probably a sub hyaloids
haemorrhage .
Can also appreciate a few, micro aneurysms, dot and blot haemorrhages.
Therefore my most probably diagnosis is Pre Proliferative Diabetic Retinopathy with pre
retinal haemorrhage.
SLIDE OF LASER COAGULATION :SLIDE 7
Can appreciate a few scar marks at the periphery of the retina, which are homogeneously
distributed throughout periphery and are most probable due to laser burns .
Therefore most probably diagnosis is diabetic retinopathy treated with laser photo
coagulation

SLIDE OF HYPERTENSIVE RETINOPATHY: SLIDE 14

Can see diffusive narrowing and tortuosity of arterioles.
Can also appreciate changes at arterio venous crossings along infero temporal arcade (A-V
nipping)
Absence of haemorrhages (flame shaped) and disc swelling suggest early changes or chronic
hypertension.
Grade 1: Arteriolar narrowing
Grade 2: A-V nipping
Grade 3: Exudates, haemorrhages, cotton wool spots
Grade 4: Papilloedema

Hypertensive retinopathy is managed primarily by controlling hypertension. If vision loss

occurs, treatment of the retinal edema with laser or with intravitreal injection of
corticosteroids or anti VEGF drugs may be useful.