Visual Disturbance

Differential Overview

Acute Loss/Scotoma

❑ Ophthalmic migraine

❑ Amaurosis fugax

❑ Retinal detachment

❑ Acute angle closure glaucoma

❑ Optic neuritis

❑ Papilledema

❑ Retinal artery occlusion

❑ Giant cell arteritis

❑ Trauma

❑ Toxic

❑ Occipital stroke

❑ Ischemic optic neuropathy

❑ Retinal hemorrhage

❑ Vitreous hemorrhage

❑ Central retinal vein occlusion

Gradual Loss

❑ Refractive error

❑ Intraocular hypertension

❑ Cataract

❑ Diabetic retinopathy

❑ Macular degeneration

❑ Cytomegalovirus retinitis

❑ Drugs

❑ Keratoconjunctivitis sicca

❑ Optic nerve compression

❑ Pituitary adenoma

❑ Choroidal melanoma

❑ Retinitis pigmentosa

Diagnostic Approach

Homonymous hemianopsia may be perceived as blurring or as trouble finding the start of a line of print. On closer inspection, visual loss in corresponding fields in both eyes will be detected. This usually results from a lesion in the suprageniculate pathway. The macula is usually spared in cortical lesions. Bitemporal hemianopsia is due to a chiasmal lesion such as a pituitary adenoma, anterior communicating artery aneurysm, cerebellar tumor with third ventricle hydrocephalus, or meningitis. Thiamine deficiency, methanol toxicity, or optic neuritis at the chiasm can cause true acute bilateral visual loss

An afferent pupillary defect (Marcus Gunn pupil) is diagnostic for a prechiasmal optic nerve lesion. Have the patient fixate on a far object, and then shine a bright light into his or her eyes. The initial (abnormal) response is dilation instead of brisk contraction.

Tunnel vision causes a patient to turn his or her head to avoid bumping into objects, and it can be outlined by visual field confrontation. Causes include glaucoma, retinitis pigmentosa, and quinine toxicity.

Clinical Findings

Ophthalmic migraine  The transient visual loss may or may not be accompanied by headache, but the patient usually has a history of migraine. Visual phenomena include homonymous hemianopsia, scintillating scotoma, like heat rising off pavement, or zigzag lights, like a prarie fire with a bright periphery and dark center. The lights are present with the eyes open or closed.

Amaurosis fugax  This is a classic sentinel sign for an impending stroke. Vision becomes grayer until no vision remains, and then returns after 1 minute, progressing from gray to clear. It is caused by a transient retinal artery embolism, usually by a platelet thrombus. If seen, this may appear dull white within a vessel. An ipsilateral carotid bruit often is present.

Retinal detachment  There is often a prodrome of flashing lights and a shower of vitreous floaters. Visual loss occurs as if a veil is being placed over the person or a shade is being pulled down. A gray billowing retina can be seen unless obscured by blood.

Acute angle closure glaucoma  The eye is severely painful and red. The pupil is fixed and midposition. The anterior chamber is shallow and does not transmit tangential light well. The cornea becomes cloudy.

Optic neuritis  Visual loss is progressive over hours or days. The optic nerve is hyperemic in the acute stages, having the appearance of papilledema, but spontaneous venous pulsations are present. There is often an afferent pupillary defect and internuclear ophthalmoplegia (weak ipsilateral adduction and contralateral nystagmus on abduction), as well as prominent impairment of macular and red vision. There is pain with eye movement, and the globe is tender. This is a common prologue to multiple sclerosis.

Papilledema  Central vision is normal, but the periphery is constricted. The optic disc margins are blurred, the disc is hyperemic, and venous pulsations are absent.

Retinal artery occlusion  All or part of a monocular visual field is affected. Visual acuity is reduced to light perception only or worse. In central retinal artery occlusion, the retina appears pale and edematous with a prominent “cherry red” macula, and there will be anisocoria. In branch occlusions, a brightly refractile yellow cholesterol embolus may be seen in a retinal artery.

Giant cell arteritis  Visual loss occurs in the context of headache, ropy and tender temporal artery, jaw claudication, or proximal muscle weakness.

Trauma  Vision may be lost through an occipital concussion that produces edema or by a skull fracture into the sphenoid that affects the optic nerve.

Toxic  There is bilateral optic disc swelling with a central scotoma. Agents include ethambutol, methyl alcohol, ethylene glycol, and carbon monoxide.

Occipital stroke  Homonymous hemianopsia is the main manifestation. The patient may not be aware of this, and it may manifest by bumping into unseen objects.

Ischemic optic neuropathy  Visual loss involves the superior visual field and macula. The optic disc appears edematous with flame hemorrhages in one portion. This usually occurs in younger patients with diabetes or hypertension, or in older patients with vascular disease.

Retinal hemorrhage  Easily seen as a red retinal plaque, it occurs in diabetes, glaucoma, and thrombocytopenia.

Vitreous hemorrhage  Hemorrhage occurs with retinal detachment, diabetes, and sickle cell anemia. The media is cloudy.

Central retinal vein occlusion  Visual loss is sudden but less pronounced. The fundus has a “squashed tomato” appearance with engorged tortuous veins and flame (nerve layer) hemorrhages.

Refractive error  Myopia usually stabilizes by the time a patient reaches his or her twenties. By determining the number of diopters needed to focus on the retina one can assess the degree of the problem. With presbyopia, the decreased ability to accommodate reduces acuity with close reading.

Intraocular hypertension  Findings of chronic glaucomatous pressure effects include increased cup-to-disc ratio, nasalization of the vessels, and cribriform striations in a deep disc. Field loss begins with arcuate or sector-shaped scotoma, which enlarge. Central vision remains intact.

Cataract  The patient has difficulty focusing and is visually irritated by oncoming headlights. The retina cannot be brought into sharp focus on fundoscopy, and opacity may be seen when focusing the fundoscope more anteriorly.

Diabetic retinopathy  Neovascularization around the optic disc is the key finding. Diabetes can also cause blurred vision through an edematous lens.

Macular degeneration  Central vision is impaired, but peripheral vision remains intact. Fundoscopy reveals macular drusen (small, yellow lesions clustered at the macula) and atrophy of the retinal pigment epithelium with prominent choroidal vessels, subretinal hemorrhage, and central fibrous scar.

Cytomegalovirus retinitis  Occurring in a patient with HIV infection, retinitis causes a broad crystalline “crumbled cheese” retinal exudate, with hemorrhage at the advancing border.

Drugs  Chloroquine and phenothiazines may affect the vision.

Keratoconjunctivitis sicca  There is a dry, gritty sensation in the eyes with decreased tearing. It often occurs in a patient with a connective tissue disease (Sjogren syndrome).

Optic nerve compression  Compression may be suggested by functional pupillary abnormalities, visual field defects, or pallor/atrophy of the optic disc.

Pituitary adenoma  Loss of central vision occurs along with altered endocrine function, such as lactation in prolactinoma.

Choroidal melanoma  Symptoms include photopsia, an enlarging scotoma, and visual loss. On fundoscopy, a darkly pigmented retinal lesion can be seen.

Retinitis pigmentosa  Night blindness and tunnel vision are typical symptoms. Fundoscopy reveals pigment clumped at the periphery of the retina and constriction of retinal arterioles.  

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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