Gradual Loss of Vision

GRADUAL LOSS OF
VISION
LAVEEZA H. SYEDA (93)
MALIKAH TUZ ZUHRA (100)
LEARNING OBJECTIVES
Differentiate among the diseases that cause gradual loss
of vision.
Describe different investigations to carry out in a case

with gradual loss of vision.
Formulae treatment plan for a case of gradual loss of

vision on basis of etiology.
Classification
Gradual loss of vision
Painless Painful
• Keratitis
Reversible Irreversible • Chronic Iridocyclitis
• Scleritis
• Cataract • Keratoconus
• Diabetic Retinopathy • Chronic Open Angle Glaucoma
• Progressive pterygium • ARMD
involving the pupil • Retinitis Pigmentosa
• Corneal • Optic Neuropathy
Degenerations
• Corneal Dystrophy
• Refractive Errors
Painful Gradual Vision Loss
Presenting complaints:
• Common presenting complaints: Eye pain (sharp or deep),
redness, blurred vision, photophobia, and sometimes tearing or
discharge.
• Keratitis: Sharp pain, redness, foreign body sensation, photophobia
• Chronic Iridocyclitis: painful eye
• Scleritis: mild to severe pain, redness, nodules, proptosis, and
ophthalmoplegia
Signs:
Keratitis:
Corneal opacities or ulcers visible on examination.
In severe cases, corneal perforation or scarring.
Chronic Iridocyclitis (Anterior Uveitis):

Presence of cells and flare in the anterior chamber on slit-lamp
Posterior synechiae (adhesions between the iris and lens).
Large greasy mutton fat KPs, koeppe nodules and busacca nodules.
Scleritis:
Thickened, inflamed sclera with a characteristic bluish or violet hue.
Scleral thinning(uvea expose) or yellow necrosis in severe cases..
Diffuse scleritis
Nodular scleritis
Necrotizing scleritis
Fungal keratitis Anterior uveitis

Keratitis
Investigations:
• General Ophthalmic Investigations
• Specific Investigations for Suspected Condition

o Keratitis
- Corneal Scrapings and Culture(bacterial, fungal, yeast, protozoal)
- Polymerase Chain Reaction (PCR)
o Chronic Iridocyclitis (Anterior Uveitis)

- Anterior Chamber Tap
- Complete Blood Count (CBC)
- Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP)
- Antinuclear Antibody (ANA) and Rheumatoid Factor (RF)
- HLA-B27 Testing
- Chest X-ray or CT Scan
- Syphilis Serology
o Scleritis
- T-sign on ultrasound
- ESR and CRP
- Antineutrophil Cytoplasmic Antibodies (ANCA)
- Rheumatoid Factor (RF) and Anti-Cyclic Citrullinated Peptide (Anti-CCP)
- Orbital Ultrasound
- MRI or CT Scan of the Orbits
- Chest X-ray or CT
TREATMENT
•Keratitis
• Bacterial Keratitis: Topical antibiotics, cycloplegics(relieve pain and synechiae formation).
• Viral Keratitis: Topical or oral antivirals (e.g., acyclovir, ganciclovir), corticosteroids (in select cases).
• Fungal Keratitis: Topical antifungals (e.g., natamycin, voriconazole), possible surgical intervention for
severe cases.
• Acanthamoeba Keratitis: Topical anti-amoebic agents (e.g., chlorhexidine, polyhexamethylene biguanide),
corneal transplantation in severe cases.
•Chronic Iridocyclitis (Anterior Uveitis)
• Corticosteroids: Topical, oral, or injectable depending on severity.
• Immunosuppressive Agents: For refractory or severe cases (e.g., methotrexate, azathioprine,
cyclosporine).
• Cycloplegics/Mydriatics: To reduce pain and prevent synechiae (e.g., atropine, cyclopentolate).
• Treat Underlying Systemic Conditions: Addressing autoimmune or infectious causes.
•Scleritis
• NSAIDs: For mild cases (e.g., ibuprofen, indomethacin).
• Corticosteroids: Oral or systemic(necessary for ant necrotizing and posterior) for moderate to severe
cases.
• Immunosuppressive Agents: For steroid-resistant, severe, necrotizing, or refractory scleritis (e.g.,
methotrexate, cyclophosphamide).
• Treat Underlying Systemic Conditions: Particularly for autoimmune-associated scleritis.
Gradual painless reversible vision loss
PRESENTING COMPLAINTS
• Cataract: Blurry or Cloudy Vision, Increased Sensitivity to Glare,
Halos Around Lights, Frequent Prescription Changes, Dull Colors.
• Diabetic Retinopathy: Blurry Vision, Floaters, Difficulty Seeing at
Night, Dark or Empty Areas in Vision, Impaired Color Vision.
• Progressive Pterygium Involving the Pupil: Blurry Vision, Visual
Distortion, Redness and Irritation, Foreign Body Sensation.
• Corneal Degenerations: Blurry Vision, Distorted Vision, Halos
Around Lights, Increased Sensitivity to Glare, Fluctuating Vision
• Corneal Dystrophy: Blurry Vision, Glare and Halos, Difficulty with
Night Vision, Recurrent Corneal Erosions, Decreased Contrast
Sensitivity
• Refractive Errors: Blurry Vision, Eyestrain, Headaches, Double
Vision, Squinting
Corneal Degenerations, Corneal Opacities(lipid
infiltrates), Corneal Thinning
Corneal Dystrophy, Corneal Deposits, Recurrent
Epithelial Erosions, Corneal Edema
Cataract, Opacity of the Lens, Reduced Red Reflex
Refractive Errors, Uncorrected Vision Deficits,

Squinting, Astigmatism
Diabetic Retinopathy, Microaneurysms, Retinal
Hemorrhages, Macular Edema, Cotton Wool Spots
Progressive Pterygium Involving the Pupil, Fleshy,
Wing-Shaped Growth, Induced Astigmatism
Arcus senilis Lipid keratopathy Band keratopathy Spheroidal Salzman nodular
degeneration degeneration
Reis buckler’s Meesman’s Granular dystrophy Lattice dystrophy Macular dystrophy

dystrophy dystrophy
INVESTIGATIONS
i. Cataract iv. Corneal Degenerations
• Slit-Lamp Examination • Slit-Lamp Examination
• Visual Acuity Testing • Corneal Topography
• Retinal Examination (Fundoscopy) • Confocal Microscopy
ii. Diabetic Retinopathy v. Corneal Dystrophy
• Fundus examination • Slit-Lamp Examination
• Fluorescein Angiography • Genetic Testing (if indicated)
iii. Progressive Pterygium Involving • Specular Microscopy
the Pupil vi. Refractive Errors
• Slit-Lamp Examination • Refraction Test
• Optical Coherence Tomography • Corneal Topography
(OCT) • Autorefractor and Keratometer
• Corneal Topography Measurement
Treatment
1. Cataract 4. Corneal Degenerations
• Cataract Surgery • Chelation with EDTA
(Phacoemulsification with Intraocular • Lamellar keratoplasty
Lens Implantation) • Excimer keratectomy
2. Diabetic Retinopathy 5. Corneal Dystrophy
• Intravitreal Injections (e.g., Anti- • Sodium chloride ointment or solution
VEGF, Corticosteroids) • Hydrated soft contact lens
• Laser Photocoagulation • Endothelial replacement surgery
• Vitrectomy (for advanced cases) 6. Refractive Errors
3. Progressive Pterygium Involving • Prescription Glasses or Contact
the Pupil Lenses
• Surgical Excision (Pterygium • Refractive Surgery (e.g., LASIK,
Removal) PRK)
• Topical Steroids (for inflammation)
Handing it
over to
Malikah
Now!
Gradual painless Irreversible vision loss
Presenting complaints
• Keratoconus: Blurry or distorted vision, Light sensitivity, Frequent prescription
changes
• Chronic Open Angle Glaucoma: Gradual peripheral vision loss, Difficulty in low
light, Silent progression
• Age-related macular Degeneration (ARMD): Central vision loss, Difficulty
reading or recognizing faces, Distorted vision
• Retinitis Pigmentosa: Night blindness, Peripheral vision loss, Difficulty adapting
to light changes.
• Optic Neuropathy: Gradual vision loss, Decreased color vision, Blurred vision
Keratoconus: Irregular astigmatism, Corneal thinning, Cone-
shaped cornea
Chronic Open Angle Glaucoma: Elevated intraocular pressure

(IOP), Optic nerve cupping, Visual field defects
Age-Related Macular Degeneration (ARMD): Drusen deposits

in the macula, Retinal pigment epithelial changes, Central scotoma
Retinitis Pigmentosa: Bone spicule pigmentation in the retina,

Attenuated retinal vessels, Pale optic disc.
Optic Neuropathy: Optic disc pallor, Visual field defects

INVESTIGATIONS
•Keratoconus •Retinitis Pigmentosa
• Distant direct ophthalmoscopy(oil-droplet • Fundoscopy
reflex) • Electroretinography (ERG)
• Slit-Lamp Examination(vogt’s line vertical, • Perimetry
Fleisher’s ring) •Optic Neuropathy
• Retinoscopy (irregular scissors reflex) • Visual Field Testing (Perimetry)
•Chronic Open Angle Glaucoma • Optical Coherence Tomography (OCT
• Slit lamp the Optic Nerve
• Intraocular Pressure Measurement • Magnetic Resonance Imaging (MRI) o
(Tonometry) Brain and Orbit
• Visual Field Testing (Perimetry)
• Optical Coherence Tomography (OCT) of
the Optic Nerve
•Age-Related Macular Degeneration (ARMD)
• Fundoscopy
• Fundus fluorescein angiography
Treatment
•Keratoconus
• Corneal Cross-Linking
• Rigid Contact Lenses •Retinitis Pigmentosa
• Hydrops treated with hypertonic saline. • Vitamin A Supplementation (in some
•Chronic Open Angle Glaucoma cases)
• Topical Medications (e.g. prostaglandin • Low Vision Aids
analogs, beta-blockers) •Optic Neuropathy
• Laser Trabeculoplasty • Treatment of Underlying Cause (e.g.,
• Glaucoma Surgery (e.g., steroids for inflammatory causes)
trabeculectomy) • Neuroprotective Strategies
•Age-Related Macular Degeneration • Low Vision Rehabilitation
(ARMD)
• Amsler grid testing
• Anti-VEGF Injections (for wet AMD)
• Dietary Supplements (AREDS formula
for dry AMD)

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GRADUAL LOSS OF

Describe different investigations to carry out in a case

Formulae treatment plan for a case of gradual loss of

Gradual loss of vision

Chronic Iridocyclitis (Anterior Uveitis):

Fungal keratitis Anterior uveitis

• Specific Investigations for Suspected Condition

o Chronic Iridocyclitis (Anterior Uveitis)

Cataract, Opacity of the Lens, Reduced Red Reflex

Refractive Errors, Uncorrected Vision Deficits,

Reis buckler’s Meesman’s Granular dystrophy Lattice dystrophy Macular dystrophy

Chronic Open Angle Glaucoma: Elevated intraocular pressure

Age-Related Macular Degeneration (ARMD): Drusen deposits

Retinitis Pigmentosa: Bone spicule pigmentation in the retina,

Optic Neuropathy: Optic disc pallor, Visual field defects

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