QuestionSBA
QuestionChoice
This would be appropriate for giant cell arteritis, which would present with pain and tenderness over the temporal arteries, along with systemic upset.
10015727
b
IV methylprednisolone
QuestionChoice
There  is no evidence of a viral infection of the eye.
10015730
e
Valganciclovir
QuestionChoice
This would be the correct treatment for giant cell arteritis with no visual involvement. As the patient has no pain or tenderness over the temporal arteries, giant cell arteritis is unlikely.
10015728
c
PO prednisolone
QuestionChoice
Timolol would be useful in the treatment of acute angle closure glaucoma, which would be painful.
10015729
d
Topical timolol
QuestionChoice
The most likely diagnosis is vitrial haemorrhage, which is treated by a vitrectomy. This is because patients with poorly controlled diabetes often develop proliferative diabetic retinopathy, in which fragile blood vessels which are prone to bleeding form.
10015726
a
Vitrectomy
QuestionComment
Can't believe I misread the question as "which one of the following mx plans is the cause of her condition"...
33073
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DJnR
QuestionComment
Good question
34635
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editor
deleted_user
QuestionComment
so you asking me for management without giving me investigations, say less
52295
QuestionComment
I hate two step questions 
60076
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Humerus H
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Someone doing something 
QuestionComment
you haven't said that there is no tenderness over the temporal artery and temporal arteritis can cause painless loss of vision??
61975
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Positive Whiff Test
Concept
Chapter
# Summary

Sudden painless visual loss is an emergency presentation with a variety of causes including retinal artery or vein occlusions, optic nerve ischaemia, retinal detachment or vitreous haemorrhage. History and ophthalmological examination may be sufficient for diagnosis, with additional investigations including blood tests, imaging such as a B-scan (eye ultrasound) or a temporal artery biopsy in suspected giant cell arteritis. Management varies significantly based on the underlying cause, for example in retinal artery occlusion attempting to dislodge the embolus, aspirin and referral for both stroke and ophthalmology follow up.
 
# Definition

Sudden painless visual loss has a broad differential of causes - we will cover the main ones here. It should be differentiated from visual loss associated with pain (e.g. acute angle closure glaucoma) and transient visual loss (e.g. amaurosis fugax). Retinal examination is usually key to the diagnosis, although there may be specific features in the history that indicate a particular diagnosis.
 
# Differential Diagnosis


## Central retinal vein occlusion

-  Shares risk factors with other forms of venous thromboembolism, including older age, cardiovascular disease, hypercoagulability and the combined oral contraceptive pill
-  History is of sudden unilateral painless visual loss with no other associated symptoms typically
-  Retinal examination shows widespread haemorrhage with dilated tortuous veins - this is described as a "stormy-sunset" appearance
-  Investigations include basic bloods including blood glucose, lipids, serum protein electrophoresis (looking for diabetes, hyperlipidaemia and myeloma respectively as these are all risk factors) and young patients may require a thrombophilia and autoimmune screen
-  There is no specific management other than addressing any underlying conditions found
-  Two important complication is neovascularisation causing glaucoma (which is treated with laser therapy) and macular oedema (treated with anti-VEGF injections)
 
## Central retinal artery occlusion
 
- Also presents with sudden unilateral painless visual loss with no other specific symptoms
- On examination patients have a relative afferent pupillary defect and fundoscopy shows a pale retina with a cherry red spot at the macula
- Risk factors include atrial fibrillation, valvular heart disease, carotid artery stenosis, thrombophilia and atherosclerosis
- Investigations should include an ECG looking for arrhythmias, bloods including a coagulation screen, glucose, ESR and lipid profile to look for risk factors, and a carotid artery doppler to look for carotid stenosis. An echocardiogram may be needed if valvular heart disease or endocarditis is suspected.
- Management involves attempting to dislodge the embolus if the patient has presented within 90 minutes of symptom onset - this may involve ocular massage, IV acetazolamide or anterior chamber paracentesis
- A retinal artery occlusion is a type of ischaemic stroke and so should be treated with 300mg aspirin for 14 days initially with stroke team referral for follow up
- The main complication is neovascularisation due to ischaemia

 [lightgallery1]
 
## Ischaemic optic neuropathy
 
- This is a broad term that describes optic nerve damage due to a lack of blood supply
- It can be classified as anterior or posterior, with visible optic disc swelling characterising anterior ischaemic optic neuropathy (AION)
- AION can be further divided into arteritic and non-arteritic AION, with the usual cause of arteritic AION being giant cell arteritis (GCA)
- History may reveal other symptoms of GCA e.g. temporal headache, scalp tenderness and jaw claudication and there may also be systemic symptoms or features of polymyalgia rheumatica such as proximal weakness, fatigue and weight loss
- Fundoscopy shows a swollen optic disc acutely, which becomes pale due to optic atrophy
- Investigations include basic bloods including an ESR for GCA, and a HbA1c and lipid profile for non-arteritic anterior ischaemic optic neuropathy (NAION)
- For GCA, a duplex ultrasound of the temporal artery should be done +/- a temporal artery biopsy
- Management of GCA is with high-dose steroids and rheumatological referral
- NAION management is upportive and involves optimisation of risk factors e.g. hypertension

## Retinal detachment
 
- This may be secondary to traction where the retinal is pulled away (e.g. in proliferative diabetic retinopathy or trauma) or exudative causes where subretinal fluid causes the detachment (e.g. due to inflammation or malignancy)
- Patients present with floaters and peripheral flashes followed by a "curtain" or "shadow" falling over their vision
- Fundoscopy shows a pale grey area of retina ballooning forward and a retinal tear may be seen
- Diagnosis is usually clinical, however if the diagnosis is unclear is can be confirmed with a B-scan (ultrasound of the eye) to look for detachment of the retina
- Management is usually surgical in cases of tractional retinal detachment, with either a pars plana vitrectomy or a scleral buckle
 
## Vitreous haemorrhage

- This occurs due to bleeding of the retinal vessels
- These are often vessels that are new and fragile due to neovascularisation, most commonly due to proliferative diabetic retinopathy
- Trauma and retinal detachment can also cause vitreous haemorrhage
- Symptoms include sudden floaters and blurred vision or visual loss
 - When the bleed is large enough to cause visual loss, the retina is difficult to view on fundoscopy and the red reflex is absent
- Management may be conservative with follow up to look for retinal detachment
- Patients should avoid heavy lifting in case they dislodge a clot leading to further bleeding
- Laser therapy should be considered for patients with neovascularisation to prevent further bleeding
- Vitrectomy surgery may be required in some cases to remove the blood

[lightgallery]

# NICE Guidelines

[NICE CKS - Retinal Detachment](https://cks.nice.org.uk/topics/retinal-detachment/)

[NICE CKS - Giant Cell Arteritis](https://cks.nice.org.uk/topics/giant-cell-arteritis/)

# References

[Royal College of Ophthalmologists - Retinal Vein Occlusion Guidelines](https://www.rcophth.ac.uk/wp-content/uploads/2015/07/Retinal-Vein-Occlusion-Guidelines-2022.pdf)

[Patient UK - Retinal Artery Occlusion](https://patient.info/doctor/retinal-artery-occlusions)

[Patient UK - Vitreous Haemorrhage](https://patient.info/doctor/vitreous-haemorrhage-pro)
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Fundoscopy showing a pale optic disc in a patient with optic neuritis.
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Fundoscopy showing the classic 'cherry red spot' seen in central retinal artery occlusion.
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Sudden painless visual loss
Topic
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Ophthalmology
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In patients with poorly controlled diabetes, bleeding from fragile retinal vessels due to proliferative diabetic retinopathy can cause sudden painless visual loss, requiring urgent intervention such as vitrectomy.
Presentation
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Acute change in or loss of vision
UkmlaTopic
1
Acute and emergency
Presentation
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Acute change in or loss of vision
UkmlaTopic
4
Cardiovascular
Presentation
38
Acute change in or loss of vision
UkmlaTopic
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Neurosciences
Presentation
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Acute change in or loss of vision
UkmlaTopic
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Ophthalmology
A 43-year old woman experiences sudden-onset painless visual loss. She has a history of rheumatoid arthritis and poorly controlled type 2 diabetes mellitus.

Which of the following management plans is likely to treat the cause of her condition?
a