SUDDEN VISUAL

LOSS
Dr. dr. Habibah S. Muhiddin, Sp.M(K)

DEPARTEMENT OF OPHTHALMOLOGY
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY
 LOSS OF VISION
WITHOUT RED EYE

NEED EARLY
DIAGNOSIS AND
PROMT
TREATMENT
Some possible patomechanism:
• Changes in anatomy and physiology
• ex: retinal detachment
• Inflamation, demyelination
• ex: optic neuritis
• Vascular disturbance
• ex: central retinal artery occlusion
• Intoxication
• ex: toxic neuropathy
 SOME VITREOUS HAEMORRHAGE

CAUSES OF RETINAL DETACHMENT

SUDDEN RETINAL ARTERY / VEIN OCCLUSION

VISUAL OPTIC NEURITIS

LOSS HYPERTENSIVE RETINOPATHY

VITREOUS HAEMORRHAGE
3 main categories:
1. abnormal vessels that are prone to
bleeding (ex: Neovascularzation in
PDR, CRVO)
2. normal vessels that rupture under
stress (ex: Rhegmatogenous retinal
ablation, blunt or perforating trauma)
3. extension of blood from an
adjacent source (ex: tumors and
choroidal neovascularization from
AMD)

https://www.aao.org/eyenet/article/vitreous-hemorrhage-diagnosis-treatment-
2
VITREOUS HAEMORRHAGE
Symptoms:
• painless unilateral floaters and/or
visual loss
• Mild hemorrhage may be
described as floaters, cobwebs,
haze, shadows or a red hue.
• More significant hemorrhage
limits visual acuity and visual
fields, scotomas.
• Vision is worse in the morning as
blood has settled to the back of
the eye, covering the macula.

• https://www.aao.org/eyenet/article/vitreous-hemorrhage-diagnosis-treatment-2
• https://www.frasereye.com/retina/floaters/
VITREOUS HAEMORRHAGE
VH due to choroidal malignancy

Subhyaloid hemorage

Neovascularization in PDR
VITREOUS HAEMORRHAGE
Treatment
• Looking for evidence of retinal detachment
• YES → immediate surgery (vitrectomy)
• NO → observation (4-8 weeks, check for risk factors (diabetes,
hypertension, etc) → no changes, referred to vitrectomy
• If neovascularization from PDR is the cause, laser panretinal
photocoagulation should be performed

In observation period, maintaine SEMI

FOWLER position when sleeping

Blood will follow gravitation and keep at

the inferior side

• https://www.aao.org/eyenet/article/vitreous-hemorrhage-diagnosis-treatment-2
• Buku ajar oftalmologi FKUI, 2017
VITREOUS HAEMORRHAGE
Vitrectomy procedure

http://www.retinahyderabad.com/treatments-vitrectomy.html
VITREOUS HAEMORRHAGE
Complication:
• Hemosiderosis bulbi 
• Proliferative vitreoretinopathy
• Tractional retinal detachment
• Ghost cell glaucoma. .
• Hemolytic glaucoma. 
Ghost cell glaucoma

Proliferative vitreoretinopathy Tractional retinal detachment

 RETINAL DETACHMENT
Defenition
separation of neurosensory layer of retina from underlying
choroid and retinal pigment epithelium.

Neuro-
sensory

RPE

• http://eyewiki.aao.org/Retinal_Detachment
• http://courses.md.huji.ac.il/histology/senseorgans/XIV-1a.html
RETINAL DETACHMENT
Classification:

Rhegmatogenous
the most common type –when a hole, tear, or break in
the neuronal layer allows fluid from the vitreous to
seep between and separate sensory and RPE layers
• Etiology: Retinal degeneration → severe miopia ;
trauma

Non-Rhegmatogenous
1. Tractional : adhesions between the vitreous gel/fibrovascular
proliferation and neurosensory retina
• Etiology : Hemorage; Diabetic Retinopathy
2. Exudative : exudation of material into the subretinal space from
retinal vessels
• Etiology: hypertension, tumor, wet AMD

• http://eyewiki.aao.org/Retinal_Detachment
• Buku ajar oftalmologi FKUI, 2017
RETINAL DETACHMENT
Risk factors
• Increasing age
• History of posterior vitreous detachment
• Myopia (nearsightedness)
• Trauma
• Diabetic retinopathy
• Complicated cataract surgery.
Lattice degeneration

posterior vitreous detachment posterior capsule rupture in cataract surgery

• http://eyewiki.aao.org/Retinal_Detachment
• https://www.optometrystudents.com/clinical-review-lattice-degeneration/
• Buku ajar Ilmu Kesehatan Mata, 2013
RETINAL DETACHMENT
Signs and symptoms
• “black curtain coming down over visual field”
• bright flashes of light (photopsia)
• increasing floaters
• decreased visual acuity
• distortion of objects (metamorphopsia)

“black curtain” and floaters photopsia

• http://eyewiki.aao.org/Retinal_Detachment
• Buku ajar oftalmologi FKUI, 2017
RETINAL DETACHMENT
Diagnosis
• Direct ophtalmoscopy
• Inconclusive → refer to
ophthalmologist for dilated
fundus exam with indirect
ophthalmoscope
• USG

Fundus examination

USG
RETINAL DETACHMENT
KEY MANAGEMENT POINT
know “classic” presentation so you
can refer to
an ophthalmologist soon

Start from peripheral: RD with Macular on

- Visual field defect (developing
over time; may help localize
detachment)
- Floaters
- Photopsia (common initially)
- If including macula → vision ↓
RD with Macular off
RETINAL DETACHMENT
Treatment
1. For rhegmatogenous detachments
• all retinal breaks should be identified, treated and closed.
• techniques include pneumatic retinopexy, scleral buckle or vitrectomy, or
combinations of these techiques.
2. For tractional detachments, tractional elements must be relieved.
3. For serous detachments, management is nonsurgical. Any inflammatory disease
or underlying mass should be identified and treated if possible.

Pneumatic retinopexy Scleral buckle Vitrectomy

• http://eyewiki.aao.org/Retinal_Detachment
• Buku ajar oftalmologi FKUI, 2017
RETINAL DETACHMENT
Complications
• Proliferative retinopathy (PVR) is
the most common cause of repair
failure and occurs in about 8–10%
of patients undergoing primary
retinal detachment repair. 

Risk factors for PVR include:

• Age
• Giant retinal tears
• Retinal detachments involving more than 2 quadrants
• Previous retinal detachment repair
• Use of cryotherapy
• Vitreous hemorrhage
• Choroidal detachment.

http://eyewiki.aao.org/Retinal_Detachment
RETINAL ARTERY /VEIN OCCLUSION
Central retina artery occlusion (CRAO)

Artery

Branch retina artery occlusion (BRAO)

Occulsion

Central retina vein occlusion (CRVO)

Vein

Branch retina vein occlusion (BRVO)

https://www.semanticscholar.org/paper/Abnormalities-of-the-optic-disc.-Sadun-Wang/9c11923c592c20d327c1783ed566cd79183e9e29/figure/10
CENTRAL RETINAL ARTERY OCCLUSION
Symptoms:
• Unilateral sudden visual loss
• Painless, sometimes can be painfull (ex: Giant arteritis)
• Transient visual loss (amaurosis fugax)
• History of DM, hypertension, smoking, drugs, heart disease,
stroke, etc

Ophthalmology examinations:
• Visual acuity : 1/300 – 1/~
• Pupillary reflex negatif
• RAPD positif
• Fundus exam: pale retina and “cherry
red spot”
Cherry red spot
CENTRAL RETINAL ARTERY OCCLUSION
Management:
1. Ocular massage: firm pressure for 10-15 sec
then sudden release
• Theoretically: cause emboli to travel
more distally to reduce the area of
ischemia.
2. Anterior chamber paracentesis
• Theoretically: paracentesis lowers the
intraocular pressure and may allow the
embolus (if any) to move further down Massage
the vessel and away from the central
retina.
3. Increasing carbon dioxide concentration
• induce vasodilation : patient is instructed
to breathe into a bag in order to increase
Paracentesis
carbon dioxide concentration
• http://eyewiki.aao.org/Retinal_Artery_Occlusion
• https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343805
• https://www.slideshare.net/munkhtsatsralchacha/crao-and-brao
BRANCH RETINAL ARTERY OCCLUSION
Symptoms:
• Unilateral sudden visual loss or visual field defect
• Painless, sometimes can be painfull (ex: Giant arteritis)
• History of DM, hypertension, smoking, drugs, heart disease,
stroke, etc

Ophthalmology examinations:
• Visual acuity variated
• Pupillary reflex usually positif
• RAPD +/-
• Fundus exam: incomplete pale
retina and emboli/trombus in
artery

• https://emedicine.medscape.com/article/1223362-overview
• American Academy of Ophthalmology. Retina/Vitreous: Branch retinal artery occlusion Practicing
Ophthalmologists Learning System, 2017 - 2019 San Francisco: American Academy of Ophthalmology, 2017.
BRANCH RETINAL ARTERY OCCLUSION
CENTRAL RETINAL VEIN OCCLUSION
Symptoms:
• Unilateral sudden visual loss
• Painless
• History of glaucoma, DM,
hypertension, smoking, drugs,
heart disease, etc

Ophthalmology examinations:
• Fundus exam: tortous and
dilated vein, blot dot
hemorage, flame shaped
hemorage, macula edema,
edema of optic nerve, cotton
wool spot
CENTRAL RETINAL VEIN OCCLUSION
Futher examination:
- Fluorescein Angiography
- Optical Coherence Tomography
- Fundus Autofluorescence

Complications
The hypoxic retinal tissue in CRVO may release
vascular endothelial growth factor (VEGF) and
inflammatory mediators → inducing
complications of macular edema, vitreous Neovascular glaucoma
hemorrhage and neovascular glaucoma.

Management:
• Goal : maintain visual acuity and prevent
complication (ex: neovascular glaucoma)
• Treat macular edema
• Intravitreal Anti VEGF injection
• Laser photocoagulation
• Intravitreal steroid
Macular edema
http://eyewiki.aao.org/Central_Retinal_Vein_Occlusion
BRANCH RETINAL VEIN OCCLUSION
OPTIC NEURITIS
Defenition
Acute Inflammatory demyelination of the
optic nerve, including:
• Anterior optic neuritis (papilitis)
• Posterior optic neuritis (retrobulbar optic
neuritis)

Mostly related to multiple sclerosis (MS)

Also related to others autoimun (ex: SLE)
or infection causes (ex: toxoplasmosis,
syphilis)

• https://www.aao.org/clinical-statement/optic-neuritis
• Buku ajar oftalmologi FKUI, 2017
OPTIC NEURITIS
Symptoms:
• Sudden visual loss, usually unilateral
• Pain in eye movement
• Visual field defect
• Impaired color vision
Impaired color
• Impaired contrass sensitivity normal vision

• RAPD (+)

NEED FURTHER INVESTIGATION,

such as:
• MRI brain
• Laboratorium : count blood cells,
toxoplasma, syphilis, autoimun
investigation

• https://radiopaedia.org/cases/optic-neuritis-in-multiple-sclerosis-3
• Buku ajar oftalmologi FKUI, 2017 MRI in MS
OPTIC NEURITIS
Differential Diagnosis
• papilloedema (increase intracranial pressure : brain tumor ext)
• pseudo-papilloedema
• malingering, hysterical blindness,
• cortical blindness

Management
• Optic Neuritis Treatment Trial protocol:
High dose intravena steroid: 1 gram / hours for 3 days, continue with oral
1 mg/kgBW for 11 days
• Infection causes → treatment for causal microorganism
HYPERTENSIVE RETINOPATHY

• Acute hypertension: such as :

preeclampsia ; acute renal failure

• Important for indication to make

decision for background diseases

• Malignant hypertension →
warning for more severe
complications of hypertension,
considertaion for management
 THANK YOU..

ANY QUESTIONS??