Sudden Vision Loss. Brendan Girschek, MD, FRCSC, FACS Vitreoretinal Surgery Cedar Valley Medical Specialists

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1 Sudden Vision Loss Brendan Girschek, MD, FRCSC, FACS Vitreoretinal Surgery Cedar Valley Medical Specialists

2 My Credentials -Residency in Ophthalmology at the LSU Eye Center in New Orleans, LA -Fellowship in Retinal Surgery at the Hamilton Eye Institute/Univ of Tennessee in Memphis, TN -Board Certified in the US & Canada -Fellow of the American College of Surgeons

3 What is a Retinal Surgeon? -Uniquely-trained ophthalmologist who works behind the lens -Typically manage cases of sudden vision loss which often involve the retina and/or optic nerve -Requires additional 2-year fellowship

4 Initial Concerns -Unilateral vs. Bilateral -Altitudinal vs. Hemispheric vs. Central -Sudden vs. Progressive -Pain? Recent surgical procedure? PMHx?

5 What Are We Worried About -Things that a retinal surgeon can repair -retinal detachment surgery -Things that cannot afford to wait -giant cell/temporal arteritis -Things that don t require expensive imaging procedures (ie. when to not order a CT/MRI) -no need for CT/MRI with unilateral vision loss

6 The Role of the Pupil -Insults posterior to the chiasm will NOT cause an afferent or efferent pupillary defect -Evaluate reaction to pupil(s) with strong light -Assess for speed and briskness of contraction to light (may have up to 1mm anisocoria) -Ask about subjective light intensity

8 Retinal Detachment -Requires surgery in nearly all circumstances -Macula on vs Macula off -Timing of surgery depends on macular status -If macula on - repair immediately (<24h), often within 6 hours; these are the eyes with 20/20 vision and peripheral vision loss! -If macula off - repair within one week

9 Retinal Detachment -Visual loss does not adhere to any specific quadrant/altitudinal defect -May or may not be associated with flashes +/floaters -Be concerned if post-surgical (cataract surgery)

10 Retinal Detachment -Progressive visual field loss over hours to days -Majority of RDs begin supero-temporal causing infero-nasal visual loss (where one s nose is); insidious onset -Describe a dark curtain starting peripherally moving centripetally

11 Retinal Detachment -Repair with Pars Plana Vitrectomy (PPV) -25g (0.5mm) sutureless incisions; soon 27g -Surgical time < 60 minutes; often < 45 minutes -Internal tamponade with gas vs oil -90+% success rate with initial repair -Local anesthesia only

15 Vitreous Hemorrhage -Sudden-onset cloud of haze or floaters in vision to one eye -Often begins centrally, diffuses within the vitreous -Rule out retinal tear and/or detachment -May be due to proliferative retinopathy (diabetes, sickle cell disease, hypertension)

18 Endophthalmitis -Intraocular inflammation commonly due to infection -Be concerned with red/painful/light sensitive eye with vision loss within one week of intraocular surgery -Requires immediate treatment with intravitreal injection of antibiotics/steroids vs vitrectomy

19 Endophthalmitis -Uncommon presentation with sepsis -Bacteria and fungi can seed the vitreous and cause floaters and retinal necrosis -Due to significant vascularity to the choroid (vascular bed underlying the retina) -Can present uni- or bi-laterally -Be concerned in patients with hardware

21 Giant Cell/Temporal Arteritis -Natural history leads to bilateral irreversible blindness and possible death due to aortic aneurysm or stroke -Vague history of amaurosis fugax, temporallylocated pain, recent weight loss, proximal muscle weakness/pain, fevers, etc. -Rule out with ESR/CRP/platelet screen (check CXR, UA, UCx if elevated white count noted)

22 Giant Cell/Temporal Arteritis -Requires temporal artery biopsy if clinical suspicion is high (regardless of labs) -Nodular granulomatous inflammation of medium-to-large sized arteries -Fragmentation of internal elastic lamina with transmural cellular infiltration

23 Giant Cell/Temporal Arteritis -Most commonly involved vessels are superficial temporal artery, ophthalmic artery, posterior ciliary artery and vertebral arteries -Start systemic corticosteroids immediately if clinical suspicion is high and biopsy within 1 wk -Taper slowly and follow symptoms +/- labs

24 Cortical Stroke -Does NOT cause unilateral altitudinal defects -Visual field loss is hemispheric (left/right) and often with obvious bilateral involvement -Homonymous loss indicates posterior infarct -Often will have macular sparing (ie. reading vision intact) -Will NOT cause an afferent pupillary defect!

25 Retinal Artery Occlusion -May be either branch or central depending on where the occlusion occurred -If occlusion is proximal to retinal artery bifurcation then CRAO, distal then BRAO -Sudden onset of altitudinal defect with BRAO, near complete loss of total visual field with CRAO (may have macular sparing)

29 Retinal Artery Occlusion -Evaluate the pupil! -The greater the area of infarction, the greater the pupillary defect -Evaluate with carotid doppler (MRA if clinical suspicion warrants) and transthoracic echocardiogram (transesophogeal if clinical suspicion warrants)

30 Retinal Artery Occlusion -Do not forget about giant cell/temporal arteritis! -No effective treatment available to restore visual function -Find the source of the emboli and anticoagulate if warranted

31 Central/Macular Vision Loss -Various retinal conditions such as macular degeneration, diabetic macular edema, macular hole -These conditions will not present in a simultaneous bilateral manner -Non-urgent follow-up with retinal specialist or general ophthalmologist recommended

33 Macular Degeneration -No longer a blinding problem for most -Regular intravitreal injections of anti-vegf medications stabilizes vision loss in most and may improve vision in many -Various imaging modalities and treatment options including medication, laser and vitrectomy surgery available

37 Diabetic Macular Edema -Most common cause of vision loss in diabetes is due to macular edema -Treated with regular intravitreal anti-vegf medications, laser surgery and/or vitrectomy surgery -Often occur concurrently with nephropathy and peripheral neuropathy

40 Diabetic Retinopathy -I ask about the patient s hemoglobin A1C at every visit -A1C extremely important in determining followup interval in those with retinopathy -Encourage patient to know the A1C value (not just good or ok )

41 Macular Hole -Present as a relative sudden-onset loss of central/reading vision in one eye without associated symptoms -No pupillary abnormality noted -Due to persistent vitreo-retinal traction at the fovea -Requires vitrectomy surgery to repair

43 Pars Plana Vitrectomy -Pars plana is mm posterior to the limbus -Behind the ciliary muscle, ahead of the retina -Safe point for entry into the posterior segment -3 ports: 1) infusion, 2) light source, 3) cutter/forceps/aspiration

44 Vitreoretinal Surgery

45 Retinal Detachment Repair

46 Macular Hole Repair

47 Q&A

A Patient s Guide to Diabetic Retinopathy

Diabetic Retinopathy A Patient s Guide to Diabetic Retinopathy 840 Walnut Street, Philadelphia PA 19107 www.willseye.org Diabetic Retinopathy 1. Definition Diabetic retinopathy is a complication of diabetes