Acute vision impairment

In case of loss of vision in one eye, (whether it is an acute or gradually developing condition), the patient will first visit the oculist. In the case of a sudden, sudden loss of vision on both eyes, the underlying causes are mostly neurological in nature.

[1], [2], [3], [4], [5]

The main causes of acute visual impairment:

I. On both eyes:

1. Ischemic optic neuropathy.
2. Two-way infarct in the vertebral-basilar system.
3. Toxic optical neuropathy.
4. Retrobulbaric neuritis with multiple sclerosis.
5. Benign intracranial hypertension. (Pseudotumor).
6. Artistic (post-angiographic).
7. Increased intracranial pressure.
8. Psychogenic.

II. For one eye:

1. Fracture of base of skull (anterior cranial fossa and orbit).
2. Arterio-sclerotic ischemic optic neuropathy.
3. Temporal arteritis.
4. Amaurosis fugax with stenosis of the internal carotid artery.
5. Attack of amblyopia with edema of the nipple of the optic nerve with increasing intracranial pressure.
6. Retinal migraine (periodic loss of vision)

I. Acute visual impairment in both eyes

Ischemic optic neuropathy. At the same time, retinal ischemia is observed. Sometimes bilateral ischemia of the retina occurs in the syndrome of the aortic arch, with a rapid transition from the inclination forward to the vertical posture.

Vascular bilateral lesion of the visual cortex (bilateral infarction or TIA), there are signs of a violation of basilar blood flow and a sudden onset. Elderly people constitute a special risk group. Disturbance of color vision precedes the appearance of symptoms; pupillary reactions remain normal; it is necessary to differentiate from visual agnosia.

Toxic optical neuropathy. Toxic lesions are characteristic, for example, for intoxication with methyl alcohol; tobacco and ethyl alcohol (tobacco-alcoholic amblyopia progresses for several days or weeks), as well as methanol, disulphuram, cyanides, phenothiazines, isoniazid, antineoplastic drugs, trichlorethylene, etc.

Retrobulbaric neuritis with multiple sclerosis as an initial symptom occurs in 16% of patients with multiple sclerosis and manifests an acute, less frequent subacute decrease in visual acuity. The most significant defect is noted in the central visual field. Retrobulbaric neuritis is not always a manifestation of multiple sclerosis. Inflammatory or infectious processes that can affect the optic nerve can be different: tuberculosis, sarcaidosis, cryptococcosis, toxoplasmosis, syphilis (with the subsequent development of atrophy of the optic nerves), Lyme disease, mycoplasma, brucellosis, etc. Viruses or viral encephalitis (measles, mumps, rubella , chicken pox, infectious mononucleosis, herpes zoster, hepatitis A, CMV, HTLV-1), sometimes accompanied by bilateral optical neuritis.

Benign intracranial hypertension is more common in girls and young full-grown women with menstrual irregularities (not an obligatory symptom). It develops gradually and manifests itself mainly as a headache, which is often occipital localization, but can be generalized and asymmetric. The next most frequent symptom is a visual impairment, which sometimes develops sharply. Less often there is a one-sided or bilateral defeat of the abducent nerve. On the fundus of the optic nerve edema. The pressure of the cerebrospinal fluid is increased to 250-450 mm aq. Post. On CT or MRI, it is sometimes possible to detect a decrease in the size of the ventricles of the brain. Sometimes (with reduced visual acuity and no effect of conservative therapy) decompressive trepanation is indicated.

In most cases, idiopathic cases are observed; sometimes it develops against the background of endocrinopathy, with iron deficiency anemia, during pregnancy.

Artistic (post-angiographic) cortical cramps (Anton's syndrome) on both eyes often develop due to toxic damage to the occipital lobes after angiography. Visual disorders usually occur after 1-2 days.

Attacks of amblyopia (seizures last for a second, in severe cases - several minutes) can be observed against a background of increased intracranial pressure. In the latter case, visual disturbances are more often bilateral. When examining the fields of vision, an expansion of the blind spot and narrowing of the visual fields along the periphery are revealed. On the fundus there are gross stagnant phenomena, sometimes hemorrhages into the area of a yellow spot. In the future, a more persistent drop in vision develops.

Psychogenic blindness develops sharply and more often in women prone to other psychogenic disorders (in anamnesis or at the time of the examination). Usually, other functional-neurological stigmas ("lump in the throat", pseudo-ataxia, pseudoparesis, etc.) are revealed. In this case, pupillary reactions and the fundus remain normal; such patients do not behave like suddenly blinded (good tolerance to the symptom, "perfect indifference"); there are no reasons for blindness in the examination; optokinetic nystagmus is preserved, the indices of visual evoked potentials and EEG are not changed.

II. Acute vision impairment in one eye (amblyopia and amaurosis)

Fracture of the base of the skull in the visual channel area. Confirmation of this diagnosis are: anamnesis and signs of head trauma, anosmia or visible external damage, pallor of the optic nerve disk 3 weeks after injury, corresponding to radiographic findings.

Arteriosclerotic ischemic optic neuropathy. A sudden drop in vision is observed in one eye, not accompanied by pain in the eyeball. Sometimes there are harbingers in the form of short-term episodes of visual impairment. Pseudoarthrosis of the optic nerve disk, later retinal pallor, pallor of the optic nerve disk, there is never complete blindness. Reason: arteriosclerosis, often developing against hypertension and diabetes mellitus.

Temporal arteritis often leads to complete blindness, observed in the elderly, more often in women. Almost all patients complain of a headache, a tense, painful temporal artery is palpable. Usually there is an acceleration of the ESR. Most often, the temporal artery is involved in the pathological process, but it is a systemic disease.

Amaurosis fugax

In the elderly, with stenosis of the internal carotid artery (there is a noise on the arteries, contralateral hemisymptoms), the most common cause of sudden and transient monocular vision loss is amavrosis fugax (transitory violation of the retinal circulation). Blindness to one eye or some blurred vision occurs in the patient suddenly or develops in a few minutes or hours. At the same time, sensitivity disorders and transient weakness in contralateral limbs are possible. The duration of the episode is from a few minutes to several hours. A routine ophthalmological examination reveals a pronounced degree of development of atherosclerosis of the retinal vessels, which is usually for people of this age.

In more than 90% of cases, amavrosis fugax develops as a result of the embolus into the retinal artery resulting from the damaged atherosclerosis wall of the ipsilateral internal carotid artery on the neck, and brought by the blood flow into the ophthalmic artery. As a result of retinal ischemia, a decrease in vision develops. Usually, the emboli is transferred by the bloodstream further into the peripheral branches of the retinal artery; usually there is spontaneous thrombolysis, and as a result, a rapid regression of symptoms.

In the acute stage, a collapsoidal state of the retinal artery is observed, or fluorescent angiography allows visualization of the embolus directed toward the periphery of the retina. Rarely, however, this examination is available.

Since the seizure of amavrosis fugax during the following year, 30% of cases develop a disorder of cerebral circulation. Doppler ultrasonography is the diagnostic method of choice in these cases and if suspicion of carotid artery stenosis should be carried out immediately.

Retrobulbaric neuritis develops sharply, but reaches its highest expression in the first 4 days, and then within a few days or weeks there is an improvement. Sometimes it is accompanied by pain in the eyes and "flickering" with the movements of the eyes. It is observed mainly in young people; never leads to complete blindness. The loss of vision is usually one-sided, but there is also a bilateral retrobulbar neuritis. In the beginning, the fundus is not changed. The most significant defect is noted in the central field of vision (central scotoma). In many cases (from 17 to 85%) in the future, these patients develop multiple sclerosis.

The cause may be other (in addition to multiple sclerosis) demyelinating diseases (acute disseminated encephalomyelitis), syphilis (acute neuritis of the optic nerve, but it can be bilateral).

Eye disease. Intraocular inflammation; retinal disinsertion; Eles syndrome - vitreous hemorrhage and retina of different etiology (tuberculosis, syphilis, other infections, blood diseases) with a picture of retinal perivasculitis.

Retinal migraine (retinal migraine) is manifested by attacks of blindness on one eye or monocular scotoma as a result of discirculation in the central retinal artery. This form of migraine can alternate or combine with migraine attacks without an aura or with an ophthalmic migraine.

Ophthalmic migraine is characterized by migraine attacks with homonymous visual disturbances (zigzags, sparks, flashes, etc., as well as absolute or relative scotomas). There is no true loss of vision.