Blurred Vision Part II

..

Blurred vision

Scope

Review approach

Common blurred vision in ambulatory care

Initial treatment

Approach to blurred vision

By cause

By symptom

By ocular signs

Approach to blurred vision

by causes

Visual pathway

Refractive error

Opaque optical media

( cornea vitreous)

Abnormal sensory pathway

(retina occipital cortex)

Malingering

Visual loss

Pin hole

Hyperopia / myopia /astigmatism

improve

Approach blurred vision

by ocular signs
not improve

Refractive error
Pen light
normal

Cornea abrasion/ulcer/scar , hyphema, cataract

abnormal
Opacity of cornea, Anterior chamber, Lens

Red reflex
VH, vitritis, RD

abnormal
Cataract, vitreous
opacity, retinal
disease

normal

RAPD
negative

CRVO, CRAO, TON, ION, optic neuritis

positive
Macula to prechiasmatic optic nerve lesion

BRAO,BRVO / DR

Fundus examination
normal
Visual field

abnormal

Retinal disease

normal
Amblyopia, malingering

Pituitary or brain tumor, stroke

abnormal
Chiasmatic to occipital lobe lesion, malingering

Approach to blur vision

by ocular symptoms

Painful visual loss

Painless visual loss

Acute
Chronic

Approach to blur vision

by ocular symptom

Painful visual loss ex.

Acute attack angle closure glaucoma

Optic neuritis
Uveitis
Endophthalmitis
Corneal hydrop (keratoconus)
Related with trauma

Chemical burn
Rupture globe
A/C: Hyphema

Approach to blur vision

by ocular symptom

Acute painless visual

loss ex.

Central retinal artery

obstruction (CRAO)
Vitreous hemorrhage
Retinal detachment
Ischemic optic
neuropathy

Chronic painless visual

loss ex.

Refractive error, dry eye

Cataract
Open angle glaucoma
Chronic retinal disease
Ex. Diabetic retinopathy,
age-related macular
degeneration
Chronic corneal disease
Ex. Corneal dystrophy
Optic neuropathy: tumor
compression

I. Painful visual loss

Acute angle closure glaucoma

Normal aqueous
drainage

Symptoms

Pain, headache ,N/V -> IOP

blurred vision, colored halos
around light -> Cornea
edema

Signs

Closed angle iris bombe

Acute increase IOP
Corneal edema
Conjunctival injection, mid
dilated pupil

Acute angle closure glaucoma

Etiology
Pupillary block

Pupillary block apposition of

lens and posterior iris in
predisposing eyes (narrow
A/C angle

Acute attack angle closure glaucoma

Treatment
Medication reduced
IOP

laser preripheral
iridotomy (laser PI)

CAI (Acetazolamide)
Osmotic agent (glycerine)
Topical beta-blocker
(timolol)
Pilocarpine -> give after
attack

Prevent pupillary block and

subsequently attack

Surgical

If uncontrolled IOP

Iris bombe

Corneal ulcer

Symptoms

Signs

Pain, red eye, photophobia,

decrease vision, dischage
Focal white opacity (infiltrate)
in cornea
A/C reaction with or without
hypopyon

Treatment

Refer to ophthalmologist

Corneal scraping and C/S

Frequent Topical antibiotic
(board spectrum)
Cycloplegic (1%atropine)
Pain control
Do not use topical steroid in
the initial

hypopyon

Related with trauma

Chemical burn
Corneal abrasion
Hyphema
Ruptured globe

Chemical burn

History of acid or alkali burn

Treatment

*** emergency treatment***

Copious irrigation using saline or Ringer lactate solution for at

least 30 mins
Conjunctival fornic should be swept with moistened cottontipped
Wait 5-10mins after irrigation -> litmus paper check PH at
inferior fornix irrigation until neutral PH achieve

Chemical burn
Epithelial defect

Corneal haze

Limbal ischemia

Chemical burn

Refer to
ophthalmologist

Evaluate severity and

follow

Long term complications

Perforation,Scarring ,
Neovascularization of the
cornea

Adhesions of the lids to the

globe (symblepharon)

Glaucoma

Cataracts

Retinal damage

Corneal abrasion

Symptoms

Signs

Sharp pain, photophobia, FB

sensation, tearing
History of scratching or hitting
Epithelium defect stain with
fluorescein

Treatment

Patching > promote wound

healing (but if longer

chance of infection) F/U
24 hr for reevaluation

Topical antibiotic drop and

ointment

Corneal abrasion

Hyphema

Symptoms

Signs

Pain, blurred vision

History blunt trauma

Blood or clot or both in

A/C

Treatment

Refer to ophthalmologist
/ evaluation or admit

Check IOP
Bed rest head elevate ->
prevent re-bleeding and
allow blood settle

Rupture globe

Symptoms

Iris prolapse / flat A/C

Pain, decrease vision, loss

of fluid from eye
History trauma, fall , sharp
object entering globe

Signs

Full thickness sclera or

corneal laceration
Deep or shallow A/C
compare fellow eye
Intraocular content (uveal
,vitreous) outside the globe
Peak or irregular pupil
Intraocular Foreign body

Peak
pupil

Rupture globe

Rupture globe

Initial treatment

Protect eye with shield at all times

Film orbit / CT route out IOFB
NPO
Systemic antibiotic
TT prophylaxis
Pain control
Refer to ophthalmologist -> surgical repaired

II. Painless visual loss

Acute painless visual loss

Central retinal arterial occlusion (CRAO)

Sudden painless visual loss

Etiology : embolus or
thrombosis to central retinal
artery
Signs

VA FC-PL in 94% of eyes

RAPD +
Whitening of retina
Cherry red spot appearance
to fovea

Central retinal arterial occlusion (CRAO)

Treatment

* ophthalmic emergency*

Digital ocular massage

IOP reduction

Medication

Acetazolamide 250mg 2 tab oral stat

Topical beta-blocker ( 0.5% timolol bid)

A/C paracentesis

Inhalation therapy with 95%O2 + 5%CO2 q 10min every 2 hour in

48 hr ( vasodilatation)

Refer to ophthalmologist

Systemic work up risk factors and cause of emboli

Follow complication ( NVI/NVD/NVA)

II. Painless visual loss

Chronic painless visual loss

Refractive error

Hyperopia

Myopia

Astigmatism

Focus difference piont in 2

meridians

Presbyopia

Physiologic condition
age>40
Blurred at near
Decrease amplitude of
accomodation

Refractive error

Treatment

Glasses, contact lens

correction

Myopia -> concave

Hyperopia -> convex
Astigmatism -> cylinder

Refractive surgery
( LASIK/ PRK )

Glaucoma

Progressive GG cell death

and nerve fiber layer loss
Symptoms

Signs

Asymptomatic until late

stage ( VF defect, tunnel
vision)
Increase IOP
Glaucomatous optic
neuropathy
Glaucomatous visual field
defect

Treatment IOP reduction

Medication
Surgical

Senile cataract

Symptom

Signs

Chronic progressive
visual loss

Opacification of normally
clear crystalline lens

Treatment

* surgical*

PE
ECCE
ICCE

ICCE

. Lens

Lens

ECCE with IOL

PE with IOL

(
)

Diabetic retinopathy

Diabetic microangiopathy

Cause basement membrane

thickening, endothelium cell
damage and loss of pericytes

Classifications

No DR
Non proliferative DR (NPDR)
Proliferative DR (PDR)

Non-proliferative diabetic retinopathy

(NPDR)
Dot/blot hge
Flame shape
hge

exudate

Non-proliferative diabetic retinopathy

(NPDR)

Non-proliferative diabetic retinopathy

(NPDR)

Non-proliferative diabetic retinopathy

(NPDR)

Proliferative diabetic retinopathy

(PDR)

NVD

Proliferative diabetic retinopathy

(PDR)

NVD

Proliferative diabetic retinopathy

(PDR)
NVE

Proliferative diabetic retinopathy (PDR)

neovascularization

NVD
Pre-retinal
hge

TRD

NVI/NVG

Recommended eye examination

schedule
Age of onset of
DM

First time exam

Routine minimal
F/U

0-30

5 yrs after onset

Yearly

31 and older

At time of diagnosis

Yearly

Pregnancy
(Gestational DM)

Early in the first

trimester

3 months

Clinical practice guideline in

ophthalmology 2004. RCOPT

Branch or Central retinal vein occlusion

Retinal hemorrhage in a
sector of retina along retinal
vein (BRVO)
Diffuse retinal hemorrhage
in all four quadrants dilate
and tortuous retinal veins
(CRVO)

Treatment

Refer to ophthalmologist for

Work up / advice control

underlying disease
Follow and observe
complication
(NVD/NVE/NVI)
Detect macular edema

Post- test

1 Which one is not acquired emergency

treatment?

A
B
C
D

acute attack angle closure glaucoma

CRAO
chemical burn
vitreous hemorrhage

2 Which one is use to prophylaxis treatment in

patient with previous attack acute angle
closure glaucoma (AACG) ?

A anti-glaucoma drug
B laser pupillary iridotomy
C Topical steroid
D Topical atropine

What staging of DR?

Diagnosis and treatment

Diagnosis and treatment

Thank you

Proliferative diabetic retinopathy

(PDR)

Rhegmatogenous Retinal Detachment

(RRD)

Symptoms

Risk factors

Peripheral or central visual

loss
Flashing, floater

Myopia
Trauma
Aging

Signs

Elevate of neurosensory
retina from RPE by
subretinal fluid
Retinal break

Rhegmatogenous Retinal Detachment

(RRD)

Rhegmatogenous RD
Rhegma ( Gr. ) = tear
Retinal break

vitreous fluid

subretinal space
Treatment

Refer to ophthalmologist for

surgical treatment