Eye Movements

Superior Rectus: Abduction and elevation Lateral Rectus: Abduction Inferior Rectus Abduction and depression Inferior Oblique: Adduction and elevation Medial Rectus: Adduction Superior Oblique: Adduction and depression

Sudden Painless Loss of Vision

Causes 1. 2. 3. 4. 5. 6. 7. 8. Retinal detachment Vitreous haemorrhage Retinal vein occlusion Retinal artery occlusion Wet age related macular degeneration Anterior ischemic optic neuropathy Optic neuritis Cerebrovascular accident

Retinal detachment

sudden painless loss of vision preceded by flashing lights (photopia), floaters, visual field defects macula involved = Central vision loss macula NOT involved = peripheral field loss and visual acuity maybe normal Relative Afferent Pupillary Defect (affected eye pupil dilates in response to light)

Ophthalmoscope

abnormal red reflex detached retina grey and wrinkled normal examination does not exclude diagnosis

Management

laser to retinal hole/ retinal surgery +/- vitrectomy

Vitreous haemorrhage

sudden painless loss of vision (extent of loss depends on degree of haemorrhage) o large haemorrhage = TOTAL visual loss o small haemorrhage = presents as floaters and normal/slight reduced visual acuity sudden appearance of black spots/ cobwebs/ haze in vision

Ophthalmoscope

decreased red reflex RBC in anterior vitreous

Causes

Proliferative diabetic retinopathy Retinal detachment Trauma Age related macular detachment

Management

Refer to ophthalmologist and determine cause Mange complications e.g. glaucoma due to RBC occluding trabecular meshwork

Vascular occlusion Central Vein Occlusion

sudden painless loss of vision if severe = RAPD

Ophthalmoscope

hyperaemic retina with engorged vines multiple haemorrhages

cotton wool spots stormy sunset

Causes

Raised intraocular pressure (chronic glaucoma, hypertension) Hyperviscosity syndromes (polycythemia) Vessel wall disease (e.g. diabetes, sarcoidosis)

Management

CRVO associated with arteriosclerosis check BP

Central retinal artery occlusion

sudden painless loss of vision Unilateral RAPD Visual acuity markedly reduced

Ophthalmoscope

Pale retina with cherry red spot (macula is spared as receives branches from posterior ciliary artery)

Cause

very high intraocular pressure Arterial embolus from diseased carotid, valvular heart disease, AF Temporal Arteritis high ESR! Vasculitis (polyarteritis nodosa) Artherosclerotic process (diabetes, HT)

Management

Check - BP, Pulse AF?, Carotids bruits? , Heart murmur?

Wet Age-related macular degeneration

occurs in the elderly sudden distortion straight lines seem curved and central blank patch of vision or, sudden blurring of vision decrease visual acuity with CENTRAL SCOTOMA

Ophthalmoscope

drusen subretinal haemorrhages hard exudates macular oedema All occur at macula as new abnormal vessels under it leak fluid and bleed.

Acute optic neuropathy

rapid progressive loss of vision maybe decreased colour vision decreased visual acuity RAPD symptoms of underlying disease (MS, nerve ischemia, artherosclerosis)

Ophthalmoscope

normal/ swollen optic disc

Before the Optic chiasm - The visual field loss is seen on the same (ipsilateral) side as the lesion. Fig 1 lesion of right optic nerve gives a Right Monocular loss - Can be caused by trauma, Multiple sclerosis Fig 2 lesion at optic chiasm Can be caused by a pituitary tumour, craniopharyngioma, suprasellar meningioma After the optic chiasm - The visual loss is seen on the opposite (contralateral) side of the lesion because the optic nerves have already crossed over at the optic chiasm. Fig 3 - lesion at the right optic tract gives a left homonymous hemianopia. Can be caused by vascular disease, head injury, cerebral tumour.

Each eye has a left and a right visual field. In a left homonymous hemianopia the left visual field of both the right eye and left eye is lost but the lesion is of the right optic tract. Fig 4 - lesion at the left optic radiation gives a right upper homonymous quadrantanopia. Can be caused by stroke, Space occupying lesions Each eye has a left and right visual field. In a right upper homonymous quadrantanopia the right visual field of both the right eye and left eye is lost. The lesion is of the left temporal radiation (remember that Temporal produces a Top quadrantanopia). Fig 5 - lesion of the parietal radiation will result in a lower homonymous quadrantanopia. Fig 6 Lesion at the right occipital lobe/pole. Gives a left homonymous hemianopia with macular/ central vision sparring. Can be caused by stroke in posterior circulation

Quick Summary Table

Defect Loss of vision in one eye Bitemporal Hemianopia Binasal hemianopia Left homonymous hemianopia Right homonymous hemianopia Homonymous quadrantopia Location Ipsilateral Optic Nerve Optic chiasm Optic chiasm Right optic tract / radiation Left optic tract / radiation Contralateral optic radiation

Upper temporal region Lower parietal region

Scotoma

Occipital region