Warning

Audience

  • Highland Health and Social Care Partnership
  • Primary and Secondary Care

Central retinal artery occlusion (CRAO)

Causes of CRAO:

  1. Thromboembolic (common)
  2. Giant Cell Arteritis (rare)

Symptoms:

  • Sudden profound loss of vision in one eye
  • May have had amaurosis fugax in preceding days/weeks
  • May have history of cardiovascular risk factors.
  • Painless, white eye

Signs:

  • Visual acuity: usually only counting fingers or worse.
  • Relative afferent pupillary defect present
  • Pale retina (subtle) with cherry red spot at fovea may be visible on fundoscopy

Management:

Must exclude Giant cell arteritis (GCA)  if over 50 years old-

  • History of GCA symptoms/ polymyalgia (jaw claudication, etc)
  • Raised inflammatory markers PV/ESR, CRP
  • Can have raised acute phase proteins, alk phos, Platelets, Gamma-glutamyl transferase
  • Can have a normocytic anaemia
  1. Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose
  2. If no suspicion of GCA arrange for follow up with Ophthalmology that day or, if out of hours, the following day
  3. If GCA is clinically suspected:
    • Admit to Physicians
    • 1g IV Methyl Prednisolone as soon as possible
    • Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Central retinal vein occlusion (CRVO)

Symptoms:

  • Sudden loss of vision in one eye (can be mild - severe)
  • May have history of cardiovascular risk factors
  • Painless, white eye

Signs:

  • May have relative afferent pupillary defect
  • Retinal flame shaped haemorrhages may be visible on fundoscopy

Management:

  1. Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose, TFTs
  2. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day.

Anterior ischaemic optic neuropathy (AION)

Symptoms:

  • Sudden loss of vision or visual field in one eye
  • Visual field defect
  • May have had amaurosis fugax in preceding days/weeks
  • Check for symptoms of GCA (jaw claudication, etc)
  • White eye

Signs:

  • May have altitudinal visual field defect (loss of either top half or bottom half of visual field)
  • Will have afferent pupillary defect
  • Swollen pale disc + disc haemorrhages on fundoscopy

Management:

Check BP, FBC, PV, U+E, LFTs, CRP, Lipids, glucose
Must exclude Giant cell arteries if over 50 years old

  • If history of GCA symptoms/ polymyalgia
  • Raised inflammatory markers PV/ESR CRP
  • Can have raised acute phase proteins alk phos, Platelets, Gamma-glutamyl transferase
  • Can have a normocytic anaemia

If GCA is clinically suspected:

  1. Admit to Physicians
  2. 1g IV Methyl Prednisolone as soon as possible
  3. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Amaurosis fugax

Symptoms:

  • Sudden transient unilateral loss of vision – usually lasts secs-mins
  • May have a history of cardiovascular disease or known risk factors
  • Painless, white eye

Signs:

  • Normal vision and visual field
  • No afferent pupillary defect

Management:

  • Follow up to dateTIA protocol
  • Refer to Neurovascular Clinic by email
  • NB GCA can occasionally present as amaurosis fugax – check for consistent history
  • Must exclude Giant cell arteries if over 50 years old
    • If history of GCA symptoms/ polymyalgia
    • Raised inflammatory markers PV/ESR CRP
    • also can have raised acute phase proteins alk phos, Platlets, Gamma-glutamyl transferase
    • can have a normocytic anaemia

If GCA is clinically suspected

  1. Admit to Physicians
  2. 1g IV Methyl Prednisolone as soon as possible
  3. Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Macular Haemorrhage

Symptoms:

  • Sudden unilateral central loss of vision (but with preserved peripheral visual field)
  • Painless, white eye
  • May have recent preceding history of distortion of central vision
  • May have a history of macular degeneration

Signs:

  • Reduced visual acuity
  • No afferent pupillary defect
  • Haemorrhage seen at macula (central retina) on fundoscopy

Management:

Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Vitreous haemorrhage

Symptoms:

  • Progressive loss of vision or shadow in one eye
  • Floaters may be present
  • Painless, white eye
  • Often have a history of diabetic retinopathy or previous retinal vein occlusion

Signs:

  • Reduced vision (variable degree)
  • No afferent pupillary defect
  • No red reflex on ophthalmoscopy
  • No view of retina on ophthalmoscopy

Management:

Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Retinal detachment

Symptoms:

  • Progressive loss of vision or shadow in one eye
  • Flashing lights and floaters.
  • Painless, white eye
  • May have a history short sightedness, or blunt trauma
  • May have a family history of retinal detachment

Signs:

  • Vision may be reduced (variable)
  • Visual field defect may be present
  • Afferent pupillary defect may be present
  • May see detached retina on ophthalmoscopy

Management:

Position on back
Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

NB. If flashes and floaters but no loss of vision or visual field then refer non-urgently by email

Patient information leaflet: Understanding retinal detachment.  

Optic Neuritis

Symptoms:

  • Gradual reduced vision in one eye
  • Pain behind eye on eye movement
  • May have history of MS or other neurological symptoms

Signs:

  • Reduced visual acuity in affected eye (variable)
  • Desensitivity to colour red on comparison with fellow eye
  • Relative afferent pupillary defect
  • Optic nerve may be swollen or normal on ophthalmoscopy

Management:

Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Functional visual loss

  • Diagnosis of exclusion
  • Common in children
  • Suspect when poor vision is reported but visual behaviour doesn’t support this
  • Ensure there is no relative afferent pupillary defect

Management:

Arrange for follow up with Ophthalmology that day or, if out of hours, the following day

Migraine

Symptoms:

  • Transient visual disturbance then returns to normal
  • Unilateral or bilateral
  • Typically lasts 15 to 20 minutes
  • May describe strobing, zig-zags or kaleidoscope effects
  • May be followed by headache
  • May have previous migraine history 

Signs:

  • Normal examination once settled

Management:

Reassurance
No follow up normally required

ABBREVIATIONS

  • BP: Blood pressure
  • CRP: C-reactive protein
  • ESR: Erythrocyte sedimentation rate
  • FBC: Full blood count
  • GCA: Giant cell arteritis
  • IV: Intravenous
  • LFTs: Liver function tests
  • MS: Multiple sclerosis
  • PV: Plasma viscosity
  • TFTs: Thyroid function tests
  • TIA: Transient ischaemic attack
  • U&E: Urea and electrolytes

Last reviewed: 14/02/2023

Next review date: 28/02/2026

Author(s): Ophthalmology Review Group.

Version: 1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr T Leslie, Consultant Ophthalmologist.

Document Id: TAM557

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