C3 - Vision Loss

C3 - Vision Loss - Painful Vision Loss

Jessica Mason MD, Stuart Swadron MD, Mel Herbert MD

Peer Reviewer Nicholas Testa, MD

* Drug doses are a guide only, always check a second source and follow local practice guideline

OPTIC NEURITIS

• Background
  • Optic neuritis is a demyelinating process of the optic nerve
  • It is commonly associated with multiple sclerosis (⅓ of patients with optic neuritis will develop MS)
  • Other causes – idiopathic, infectious (syphilis, measles, TB, crypto, etc), and autoimmune diseases
• History
  • Painful monocular vision loss
  • Painful behind eye and with eye movements
• Examination
  • Loss of central vision, while the peripheral vision is preserved
  • Afferent pupillary defect (APD)
    • Anything that affects the optic nerve will cause an APD (this is not specific to optic neuritis, it also may occur in any condition where light cannot reach the retina)
  • Fundoscopic exam usually normal but may see optic disc pallor
  • Red desaturation test
    • Take a dark red item and have the patient look at it covering one eye and then the other. The affected eye will see it as lighter red or pink.
  • Don’t forget to complete a neurological examination
• Management
  • Consultation with ophthalmology and neurology are both appropriate
  • MR imaging of brain looking for plaques of MS
  • Admit for IV steroids (methylprednisolone); very high doses are used, confer with specialist colleagues on plan
  • Patients may make a full recovery, but it may recur

GIANT CELL ARTERITIS

• Background
  • Formerly known as temporal arteritis
  • It is a vasculitis of medium sized arteries
  • There is a strong association with polymyalgia rheumatica, a painful chronic condition in older patients causing fatigue and muscle pain
  • Typically occurs in patients over 60 years old
• History
  • Painful monocular vision loss
  • May have profound pain, headache, especially over the temporal areas
  • Jaw claudication (aching pain with eating) is an important clue
• Examination
  • Palpate and inspect over area of temporal arteries for tenderness and nodularity
• Management
  • If the diagnosis is suspected, empiric therapy should be started in the ED because of the potential for progression
    • Patients with any visual loss should be admitted for IV steroids, 500-1,000 mg of methylprednisolone daily for 3 days (similar to optic neuritis or MS)
    • If there’s no vision loss then you can start 1 mg/kg PO of prednisone (UptoDate)
  • An ESR should be drawn
  • A biopsy should then be performed in the next week to confirm the diagnosis (this can be tricky to arrange and may be performed by various surgical specialists)

ACUTE ANGLE CLOSURE GLAUCOMA

• Acute angle closure glaucoma (AACG) may present with painful vision loss but usually the eye is acutely red and abnormal on gross inspection
• We covered AACG (including an excellent description by the patient) in C3 Painful Red Eye (Dec 2017)
• It may be associated with medications, especially eye drops that dilate the eye in susceptible patients (with pre-existent narrow angles)
• The presentation of AACG is usually extremely painful (a deep, boring pain) and frequently associated with vomiting
• Important examination findings:
  • A red, angry appearing eye, firm to touch
  • Cloudy “steamy” cornea
  • Decreased visual acuity, may be profound
  • Markedly elevated IOP (generally >40 mm Hg)
• Management
  • Treat pain and give antiemetic
  • Consult ophthalmologist emergently
  • Carbonic anhydrase inhibitors - acetazolamide
  • Topical beta blockers - timolol
  • IV mannitol or glycerol
  • Alpha agonist drops - apraclonidine
  • Definitive therapy is surgical; involves laser iridectomy