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The management of acute visual failure
1Harvard Medical School, Department of Neurology, Massachusetts General Hospital, Boston 02114.
Insights
This review details diagnosing and managing acute visual failure from ocular strokes like central retinal artery (CRA) occlusion and anterior ischemic optic neuropathy (AION). Prompt diagnosis and risk factor management are key to preventing vision loss.
Area of Science:
- Ophthalmology
- Neurology
- Vascular Medicine
Background:
- Acute visual failure can result from ocular strokes, including central retinal artery (CRA) occlusion, branch retinal artery (BRA) occlusion, and anterior ischemic optic neuropathy (AION).
- Timely diagnosis and management are crucial for preserving vision and preventing contralateral eye involvement.
Purpose of the Study:
- To review the clinical manifestations and management strategies for ocular strokes.
- To outline a comprehensive diagnostic approach for patients presenting with acute visual failure.
Main Methods:
- Systematic review of literature on ocular strokes and acute visual failure.
- Detailed examination including vital signs, funduscopy, and laboratory tests (CBC, coagulation profile, ESR, lipids, antiphospholipid antibodies).
- Non-invasive investigations such as carotid Doppler ultrasonography, oculoplethysmography, phonoangiography, B-Scan ultrasonography, and echocardiogram.
- Invasive investigations including temporal artery biopsy and carotid arteriogram, with MRA as a screening tool.
- Fluorescein angiography (FFA) for specific indications like suspected ophthalmic artery occlusion or embolic AION.
Main Results:
- Diagnostic process emphasizes meticulous attention to systemic and ocular findings.
- A combination of non-invasive and, in selected cases, invasive tests aids in diagnosis.
- Treatment strategies vary based on the specific condition, including emergency measures for CRA occlusion and systemic corticosteroids for arteritis-related cases.
Conclusions:
- Effective management of acute visual failure requires a thorough diagnostic workup to identify the underlying cause of ocular stroke.
- Treatment focuses on immediate interventions to restore blood flow, manage inflammation, and address underlying risk factors to prevent recurrence and protect vision.
Abstract:
This review of acute visual failure covers the clinical manifestations and management of ocular strokes CRA occlusion, BRA occlusion and AION. The diagnostic process for each patient requires meticulous attention to: 1. Blood pressure, heart rate and rhythm, palpation of the temporal arteries, and auscultation of the heart, neck, eyes and head. 2. Dilated funduscopic examination. 3. Immediate blood tests: complete blood count, PT, PTT, platelet count, ESR, fibrinogen level, fasting blood sugar, cholesterol, triglyceride and blood lipids. A test for antiphospholipid antibodies (ACLA and LA) is recommended in unexplained cases of CRA occlusion. Non-invasive investigations should utilise a battery of tests: 1. Carotid non-invasive studies; the useful tests give information about the presence of a haemodynamic lesion (Dopper ultrasonography and oculoplethysmography), analyse the bruit to determine the residual lumen diameter (phonoangiography), or image the artery with ultrasound (B-Scan ultrasonography). 2. Two-dimensional echocardiogram Invasive investigations are required in selected patients: 1. A temporal artery biopsy 2. A carotid arteriogram if the patient is a candidate for endarterectomy. The patient can be screened first with a non-invasive MRA of the neck and brain. 3. A timed FFA, particularly in cases of CRA occlusion when occlusion of the ophthalmic artery is suspected, in cases of AION of possible embolic origin or in AION to document the position of the watershed zone of the choroidal circulation and its relation to the optic nerve head. Emergency treatment in CRA occlusion is designed to lower intra-ocular pressure and dislodge the embolus. In impending CRA occlusion heparin is useful. Urgent systemic corticosteroids are needed when CRA occlusion, or AION are due to arteritis. In other situations treatment is directed towards preventing recurrence or involvement of the other eye by reducing or eliminating identified risk factors.