There are certain situation, when ophthalmologist is unhappy. He is unhappy when the diagnosis is not obvious. Presentation deals with the situations, when we have completely healthy eye with decreased visual acuity and no signs of pathology.

1. Poor Vision
+
Healthy Eyes
Dr. Anthony
28 Nov, 2013

2. What if?
-cornea clear
-lens transparent
-vitreous intact
-retina intact
-optic nerve healthy
-refraction corrected
- visual functions strongly decreased

3. DDx
-Functional (migraine, hysteria,
amblyopia)
-Blood supply problems (amaurosis fugax,
vertebrobasilar artery insufficiency,
ischemic optic neuropathy)
- CNS damage (cortical blindness,
chiasmal tumor, epilepsy)

4. Migraine

5. Migraine
Classic signs:
Pain
Photophobia, phonophobia
Nausea, vomiting
Presiding visual aura
R (1)

6. Migraine aura

7. Migraine
Types:
without aura (80%)
with aura (10%)
aura without pain
retinal migraine

8. Migraine
Precipitating factors:
birth control pills, pregnancy,
menopause, dietary (thyranine,
phenylalanine, alcohol, nitrates,
nitrites, glutamate), fatigue, emotional
stress, bright lights

9. Migraine
Work-up:
collect proper history
do CT scan in atypical case
check BP and blood sugar

10. Migraine
Basic Treatment:
• avoid precipitating factors
• treat pain (NSAIDs, ergotamines, selective
serotonine receptors agonists – triptans)
• treat prophylactically in severe cases (betablockers, Ca-channel blockers,
antidepressants, antinausea)
• review in 4-6 weeks

11. Hysteria

12. Hysteria
Classic signs:
Visual loss / blindness
no ocular pathology
no neuropathology
normal pupillary reaction

13. Hysteria
Important DDx:
Simulation, Aggravation

14. Hysteria
Exclude simulants:
NLP: torch test
test near visual acuity
test approximate visual field
use a “strong” drops in children

15. Hysteria
Basic Treatment:
no treatment available
psychiatrist referral may be indicated
patient often benefits from promise of
good vision by next visit
review in 1-2 weeks
R (1)

16. Amblyopia
Crucial Signs:
no ocular changes
no neurological changes
decreased visual acuity with refraction
corrected

17. Amblyopia
DDX:
diagnosis of exclusion
collect history

18. Amblyopia
Types:
strabismic
refractive anisometropic
deprivation

19. Amblyopia
Basic Treatment:
correction of refractive error
patching of the best eye
penalization of the best eye
adults can be treated
R (2)

20. Amblyopia

21. Amaurosis Fugax
(Transient Vision Loss)
Classic signs:
no ocular changes
visual loss, scotomas (seconds - hours)
monocular

22. Amaurosis Fugax

23. Amaurosis Fugax
(Transient Vision Loss)
DDx:
migraine w/o pain
Ischemic optic neuropathy
vertebrobasilar artery insufficiency

24. Amaurosis Fugax
(Transient Vision Loss)
Etiology:
embolus
arteriosclerotic disease (hypoperfusion)
hypercoagulable/hyperviscocity state

25. Amaurosis Fugax
(Transient Vision Loss)
Work-Up:
ESR, CRP, platelet count
visual field test
carotid auscultation, ultrasound
CBC, fasting blood sugar, lipid profile
ECG

26. Amaurosis Fugax
(Transient Vision Loss)
Tx:
carotid surgery
BP, sugar control
follow-up with physician
R (1)

27. Vertebrobasilar artery
insufficiency
Classic signs:
no ocular changes
blurred vision (seconds)
bilateral
combined with ataxia, vertigo, dysarthria,
dysphasia, perioral numbness, hemiparesis,
hemisensory loss

28. Cerebral Arterial Circle

29. Vertebrobasilar artery
insufficiency
DDx, Tx
Like in amaurosis fugax
R (1)

30. Cortical blindness
Clinical signs:
severe vision loss
bilateral
normal pupillary reactions

31. Cortical Blindness

32. Cortical blindness
Etiology:
infarction
tumor
infection
toxic

33. Cortical blindness
Work-Up:
exclude functional vision loss
exclude meningitis
BP, ECG
refer

34. Cortical blindness
Tx:
treat underlying cause

35. Ischemic Optic
Neuropathy
Certain types of ischemic optic
neuropathy are “invisible” during
fundoscopy: posterior ischemic
optic neuropathy.

36. Ischemic Optic
Neuropathy
Anterior ischemic optic neuropathy –
occlusion of short posterior ciliary
artery – infarction of optic nerve head
Posterior ischemic optic neuropathy –
infarction of retrolaminar portion of
optic nerve (pial capillary plexus)

37. Ischemic optic neuropathy

38. Ischemic disc appearance
Normal optic neuropathy

39. Ischemic Optic
Neuropathy
Signs
Monocular vision loss
Sudden
Painless
Dischromatopsia
Scotoma

40. Ischemic Optic
Neuropathy
Work-Up
BP
blood glucose
fasting lipid profile
refer

41. References:
(1) The Wills Eye Manual Office and Emergency
Room Diagnosis and Treatment of Eye
Disease (2008)
(2) J. Kanski "Clinical Ophthalmology - A
Systematic Approach" (2011)

42. Cataract extraction
to Csar, blind
elephant in US
Thank you