The Patient With

Decreased
Vision :
Evaluation
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History Time course of Vision Associated Symptoms
Loss • Ipsilateral periorbital
- Sudden onset (within minutes) : pain increase w/ eye
Laterality of the ischemic event (arterial occlusion)’
movement : Optic
vision loss - Evolves over day to weeks : neuritis
inflammation
- Localization of the • Associated neurologic
lession - Gradual progression over months or symptoms :
years : compressive lesion, Toxic or
nutritional ON (although such
Demyelinating disease
- Unilateral : Lesion
lesion may present acutely), and
anterior to the chiasm glaucoma
• Nonspesific pain, facial
numbness or diplopia :
- Bilateral : bilateral - Sudden vision loss vs sudden orbital or cavernous sinus
awareness of vision loss
ocular, chiasm or lesion
retrochiasm lesion, - Patient may become acutely aware • Headache, jaw
systemic process of a chronic process only upon
covering the uninvolved eye or only claudication : GCA
after the 2nd eye become affected
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Examination

➜Fundus
➜Visual Acuity Examination
Testing ➜Visual Field
➜Color Vision Evaluation

Testing ➜Adjunc Testing

➜Pupillary Testing
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Visual Acuity Testing

➜ CDVA / BCVA, visual improvement w/ pinhole →
refractive error
➜ Distance and near CVA : similar (disparity : specific
pathology)
➜ Eccentric Fixation (possible central scotoma)
➜ Read half of the eye chart (possible hemianopic field
defect)
➜ Improvement CDVA when reading single optotypes
(amblyopia)
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Color Vision Testing

➜ Optic Nerve Disease (demyelinating optic neuritis) disproportionately affect
color vision compared than CDVA
➜ Macular disease : VA and Color vision tend to decline correspondingly
➜ Optic neuropathy is more likely etiology than a maculopathy in DD 20/30 VA but
w/ severe loss color vision
➜ Optic neuropathy : persistent dyschromatopsia can occur even after recovery of
VA
➜ Tested separately in each eye
➜ Ishihara (Red-Green Color deficiency)
➜ Hardy-Rand-Rirrler (HRR) (Blue-Yellow + Red-Green) (Blue-Yellow defects
often accompany an optic neuropathy but also can occur in a maculopathy)
➜ Farnswoth D-15 pr D-100 : comprehensively characterize a color vision decfect
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Pupillary Testing
➜ RAPD
- Swinging flashlight test
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Pupillary Testing
➜ RAPD is extremely reliable and sensitive indicator of optic nerve
dysfunction
➜ Optic neuropathy or bilateral optic nerve involvement (generally)
➜ Substansial retinal disease (CRAO or RD) (less commonly)
➜ Chiasmal lesion - RAPD secondary to assymetric optic nerve
involvement
➜ Unilateral optic tract lesion – Mild RAPD on the side of temporal
visual field defect (has been explained by the difference in light
sensitivity between intact temporal and nasal hemifield)
➜ Rare case (media opacities or amblyopia )
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Pupillary Testing
➜ Factor (dark irides, dilated or miotic) difficult
to elicit RAPD
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Fundus Examination
➜ ONH : pallor, edema, excavation, or other
abnormalities
➜ Macula : pigmentary disturbance, edema,
scarring, or other disruption of structural
integrity
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Fundus Examination
➜ ONH pallor : optic atrophy
➜ ONH pallor does not occur immediately after
injury but takes at least 4-6 weeks for the time
of axonal damage
➜ Mild form of pallor difficult to detect
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➜ A. Chalky white appearance

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➜ Initially affect the thickest portion of RNFL

➜ ONH edema : increased intracranial pressure,
local mechanism compression, ischemia,
inflammation
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ONH Edema
➜ Elevation ONH with variable filling in physiologic cup;
retinal vessels may appear to drape over the elevated ONH
margin
➜ Blurring ONH margin
➜ Peripapillary RNFL opacification
➜ Hyperemia and dilation of ONH surface capillary net
➜ Retinal venous dilation and tortuosity
➜ Peripapillary hemorrhages, exudates or cotton wool spot
➜ Retinal or choroidal fold or macular edema
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Visual Field Evaluation

➜ Confrontation Testing
- Description of the examiner face
- Finger counting in the 4 quadrant
- Kinetic red target test
- Finger or red comparison test
➜ Amsler Grid Testing
➜ Perimetry
- Kinetic perimetry
- Automated static perimetry (gold standard)
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Realibility of Perimetry test

results
➜ False positive response rate <25%
on threshold setting and <15%
SITA setting
➜ False negative response rate <25%
➜ Fixation losses
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Adjunct Testing
➜ Contrast sensitivity testing (Pelly-Robson Chart)
➜ Photostress recovery testing (macular lesion or ocular ischemia)
➜ Potential acuity meter testing (media irregularities or opacities are the
cause of decreased vision ?)
➜ Fluorescein angiography
➜ Fundus autofluorescence
➜ OCT
➜ USG
➜ Electrophysiologic testing
- Visual evoked potential testing
- Electroretinography