Top 12 Vision-Threatening Diagnoses - American Academy of Ophthalmology

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JUN 12, 2019

Top 12 Vision-Threatening Diagnoses

By Natasha Nayak Kolomeyer, MD

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Here’s a quick refresher of diagnoses that you shouldn’t miss … and vital tips for handling these eye emergencies.

* * *

About the author: Natasha Nayak Kolomeyer, MD, is a glaucoma specialist at Wills Eye Hospital in Philadelphia and joined the YO Info Editorial Board in 2019.

1. Ischemic Optic Neuropathy

Symptoms: Fundus photo shows a chalky white pallor of the optic nerve from arteritic anterior ischemic optic neuropathy.
Tip: If there is vision loss, but no pain in a patient age 50 or over, consider tests to rule out giant cell arteritis (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP] and complete blood count [CBC]).

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2. Retrobulbar Hemorrhage

Symptoms: External photo demonstrates periorbital ecchymosis, proptosis and decreased motility.
Tip: Do canthotomy and cantholysis immediately.

3. Central Retinal Artery Occlusion

Symptoms: Fundus photo shows diffuse retinal whitening with a foveal cherry red spot.
Tip: Do a time-sensitive workup for giant cell arteritis as well as an embolus/thrombus workup, given the increased risk of a cardiovascular event.

4. Endophthalmitis

Symptoms: Slit-lamp photo shows conjunctival injection, corneal edema and hypopyon.
Tip: Get a tap and injection of intravitreal antibiotics immediately, with or without vitrectomy.

5. Macula-On Rhegmatogenous Retinal Detachment

Symptoms: Fundus photo montage demonstrates a superior macula-on retinal detachment.
Tip: Do surgery/procedure immediately. Don’t forget to dilate and evaluate the contralateral eye carefully.

6. Carotid Cavernous Fistula

Symptoms: External photo highlights dilated episcleral vessels and chemosis in the right eye.
Tip: Supportive findings can include blood in Schlemm’s canal on gonioscopy and presence of an orbital bruit. Urgent imaging is warranted.

7. Orbital Cellulitis

Symptoms: External photo shows lid swelling, proptosis and limited extraocular motility of the left eye.
Tip: Get a CT scan and a clinical diagnosis.

8. Open Globe

Symptoms: Slit-lamp photo shows uvea protruding through a corneal laceration and a peaked pupil.
Tip: Get a CT scan to rule out an intraocular foreign body. Place a shield over the eye immediately and examine the eye gently.

9. Acute Angle-Closure Glaucoma

Symptoms: Slit-lamp photo shows corneal edema and shallow anterior chamber. The ultrasound biomicroscopy shows the narrow angle.
Tip: Treat immediately and order laser peripheral iridotomy (LPI). The contralateral eye also may need an LPI.

10. Microbial Keratitis

Symptoms: Slit-lamp photo shows conjunctival infection, a central corneal infiltrate and hypopyon.
Tip: It’s crucial to obtain cultures before the start of treatment.

11. Acute Retinal Necrosis

Symptoms: Color fundus photo montage shows peripheral areas of retinal whitening and vasculitis.
Tip: This condition is most commonly associated with herpes simplex virus or varicella-zoster virus infection. Prompt diagnosis and treatment with systemic and/or intravitreal antivirals are important as it can progress rapidly.

12. Alkali Chemical Injury

Symptoms: Slit-lamp photo showing perilimbal conjunctival blanching, conjunctival injection and diffuse corneal haze.
Tip: Early identification and copious irrigation is imperative. Alkali chemicals can be more harmful than acidic chemicals as they penetrate deeper. An eyelid speculum can be used to keep the eye open, while the irrigating solution is delivered through IV tubing.
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YO Info

The American Academy of Ophthalmology's newsletter for young ophthalmologists (YOs) — those in training as well as in their first few years in practice.

YO Info Editorial Board

Evan Silverstein, MD — Chair
Sruthi Arepalli, MD
Grayson W. Armstrong, MD
Liane O. Dallalzadeh, MD
Cherie A. Fathy, MD
Bradley S. Henriksen, MD
L. Claire Peterson, FRCOphth, MBBS
Dagny C. Zhu, MD

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