Almobarak Associate Professor and Consultant Department of Ophthalmology College of Medicine King Saud University Chronic Visual Loss Vision 1 Quantity VA 2 Quality VF clarity of vision color ID: 1034891
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1. Chronic Visual LossDr. Faisal AlmobarakAssociate Professor and ConsultantDepartment of OphthalmologyCollege of MedicineKing Saud University
2. Chronic Visual LossVision: 1- Quantity: VA2- Quality: VF, clarity of vision, color vision
3. Chronic Visual LossCauses:RefractiveCorneaLensVitreousRetinaOptic NerveNeurologic
4. Chronic Visual LossRefractiveMostly in young patientsMyopia, hyperopia or astigmatismAmblyopia !!Signs: Normal exam. Refraction needed to show errorsRx: Glasses, CL, Refractive surgeryNB: lenticular causes needs cataract surgery
5. Chronic Visual LossCorneaScar: trauma, infectionHereditary: corneal dystrophies, keratoconusSigns: corneal scar, bulging corneal, stromal opacities. Might have some conjunctival injection with chronicity
6. Chronic Visual LossCorneaRx: Refraction, CL (soft or hard), corneal cross linking, keratoplasty
7. Chronic Visual LossLensDisorganization of lens proteins Opacification
8. Chronic Visual LossLensCauses:Age relatedMetabolicTraumaticCongenitalDrugsInflammationOcular
9. Chronic Visual LossLensClinical Classification:Maturity: immature, mature, hypermatureAnatomic: nuclear, subcapsular, corticalAge: congenital, infantile, pre-senile, senile
10. Chronic Visual LossLensGradual onsetVA: worsening of existing myopia, correction of hyperopia Loss of contrast sensitivity in low lightGlare in bright light (scatter of light)
11. Chronic Visual LossLensManagement:Congenital: lens aspitation ± IOLAcquired: ECCE + PCIOL / Phaco + PCIOL
12. Chronic Visual LossVitreousVitreous Hge: trauma, PDR, uveitis, PRVitreous condensation, opacificationVitritis: uveitis
13. Chronic Visual LossVitreousRx: underlying cause
14. Chronic Visual LossGlaucomaSecond leading cause of blindnessEarly diagnosis is crucial to prevent loss of visionHigh IOP + Characteristic optic nerve head changes + visual field loss secondary to nerve fiber layer lossIOP is the single factor to be controlled
15. Chronic Visual LossGlaucomaAqueous HumorActive secretion:Na/K ATPaseCl secretionCarbonic anhydrasePassive secretionUltrafiltrationDiffusion
16. Chronic Visual LossGlaucomaGonioscopy
17. Chronic Visual LossGlaucomaIs the irisCovering TMNot covering TMCLOSEDOPEN
18. Chronic Visual LossGlaucomaONH complex evaluationDisc margin and disc diameterNeuroretinal rimCup/disc ratioDisc sizePPANFL defectOptic disc haemorrhage
19. Chronic Visual LossGlaucomaPrimaryNo detectable reasonOften bilateralSecondaryPredisposing factorOften unilateralAetiologyAngleOpenClosedCombined Mechanism
20. Chronic Visual LossGlaucomaStart with peripheral (navigational) vision involvement
21. Chronic Visual LossGlaucomaInitially asymptomaticUsually detected on routine examinationRisk factors: IOP age Family history DMmyopia
22. Chronic Visual LossGlaucomaSigns:High IOPGonioscopy: open or closedOptic nerve head damageVisual field loss
23. Chronic Visual LossRx: Antiglaucoma medicationsLasers: SLT, PIGlaucoma surgeryGlaucoma
24. Chronic Visual LossMacular DegenerationImpaired central visionPeripheral vision preservedLeading cause of legal blindness in developed worldMultifactorialAgeSmoking, vascular disease, UV light, diet, FHx
25. Chronic Visual LossMacular DegenerationComplaints:Metamorphopsia: distorted vision Micropsia: reduction of size of objectsMacropsia: enlargement of size of objects Scotoma: VF loss
26. Chronic Visual LossMacular DegenerationMacular involvement:Outer retinal layerRetinal pigment epitheliumBruch’s membrane choriocapillaris
27. Chronic Visual LossMacular DegenerationDrusens: lipid products from photoreceptor outer segments, found under retina new vessels from choroid grow into the sub-retinal space forming subretinal neovascular membraneHemorrhage into subretinal space or even through the retina into the vitreous (significant loss of vision)
28. Chronic Visual LossMacular DegenerationAtrophic Often asymptomaticGradual over yearsSigns: DrusenGeographic atrophyPhotoreceptor degenerationscotoma when light adaptingExudative Rapidly progressive (weeks)Signs:Choroidal (sub-retinal) neovascularisationPre-retinal hemorrhageElevation of retinaSubretinal fibrosis MetamorphopsiaCentral scotoma
29. Chronic Visual LossMacular DegenerationDiagnosis:Visual acuityAmsler grid OphthalmoscopyFluorescein angiographyICGOCT
30. Chronic Visual LossMacular DegenerationRx Dry Macular DegenerationLifestyleStop smoking, reduce UV exposure, Zinc & antioxidantsLow vision aidsMonitoring with Amsler chart
31. Chronic Visual LossMacular DegenerationObservationLaser photocoagulationAnti-VEGFVerteporfin photodynamic therapy (PDT): injection of photosensitizer into systemic circulation followed immediately by laser targeting new vessels in macular area
32. Chronic Visual LossDiabetic RetinopathyMicroangiopathy which involves pre-capillary arterioles, capillaries and post-capillary venulesMicrovascular occlusionMicrovascular leakage
33. Chronic Visual LossDiabetic RetinopathyMicrovascular OcclusionThick capillary basement membraneCapillary endothelial cell damageChanges in red blood cellsRetinal ischemiaAV shunts and NVs
34. Chronic Visual LossDiabetic RetinopathyMicrovascular LeakageLoss of pericytes between endothelial cellsLeakage into retinaExudates and edema
35. Chronic Visual LossDiabetic RetinopathyRisk FactorsDuration poor metabolic controlPregnancyHTNNephropathySmokingObesityhyperlipidemia
36. Chronic Visual LossDiabetic RetinopathyClassified clinically to two types:NPDRMildModerateSeverPDREarlyAdvance
37. Chronic Visual LossDiabetic RetinopathyNPDRAsymptomaticDecreased visual acuity:CSMEmacular ischemia
38. Chronic Visual LossDiabetic RetinopathyPDRSymptomaticCan also cause macular ischemia and/or edema
39. Chronic Visual LossDiabetic RetinopathyPDRNeovascularizationNVD: neovascularization of the discNVE: neovascularization elsewhereFragile (intra-retinal or vitreous hemorrhage)Associated with fibrous proliferation TRD
40. Chronic Visual LossDiabetic RetinopathyDiabetic Macular EdemaRetinal edema threatening or involving the maculaEvaluate: location of retinal thickening relative to the fovea and the presence and location of exudates
41. Chronic Visual LossDiabetic RetinopathyRx:Laserintravitreal steroid injectionintravitreal anti-VEGF injectionpars plana vitrectomy
42. Chronic Visual LossRetinitis PigmentosaGroup of genetic disorders affect the retina ability to respond to lightSlow loss of vision: nyctalopia, loss of peripheral vision, blindnessMost are legally bling by 40sCentral visual field of less than 20 degreesXR: males: more often and more severe females: carry the genes and experience vision loss less frequently
43. Chronic Visual LossRetinitis PigmentosaTarget photoreceptorsAssociated with pigmentary changes in the RPE, which may be primary or secondary to the photoreceptor loss
44. Chronic Visual LossRetinitis PigmentosaSymptomsNyctalopia (loss of night vision)Tunnel vision (loss of peripheral vision)
45. Chronic Visual LossRetinitis PigmentosaSignsVA: 20/20 - NLP+- APDPSCCRPE hyperpigmentation (bone spicules) alternate with atrophic regions Attenuation of the arteriolesWaxy pallor of the optic nerve headCME ( severe cases of RP)
46. Chronic Visual LossRetinitis Pigmentosa
47. Chronic Visual LossRetinitis PigmentosaInvestigationsVF testColor testing (mild blue-yellow axis color defects) Dark adaptation study (reduced contrast sensitivity relative to VA)Genetic subtyping
48. Chronic Visual LossRetinitis PigmentosaInvestigationsOCT (CME)FFAERGEOG
49. Chronic Visual LossRetinitis PigmentosaSystemic Associationshearing loss and RP Usher syndrome Alport syndromeRefsum disease • Kearns-Sayre syndromeExternal ophthalmoplegiaLid ptosisHeart blockPigmentary retinopathy
50. Chronic Visual LossRetinitis PigmentosaSystemic AssociationsAbetalipoproteinemiaMucopolysaccharidoses Bardet-Biedl syndrome Neuronal ceroid lipofuscinosis
51. Chronic Visual LossRetinitis PigmentosaTreatmentCAI: CMEVitamins ?? Cataract: surgeryLow vision aidsGene therapy !!