GRADUAL LOSS OF VISION

ITS CAUSES, MANAGEMENT, TREATMENT & PROGNOSIS

Col (R) Dr Fazal Rabbi Department of Ophthalmology NIMS Medical College Abbottabad

1. Errors of Refraction & Presbyopia:

In myopia, whether congenital or developmental; hypermetropia, congenital or developmental, the patient usually c/o of deteriorating vision. There are associated complaints of frontal headaches, eyeache and blepharitis.

Treatment: Prescription of appropriate glasses.

Presbyopia: Is an anomaly of accommodation due to age. In this condition the patient complains of having difficulty in doing close work. This condition is due to loss of plasticity of the lens.

The neuromuscular mechanism remains normal. Treatment: It is treated by prescribing convex spherical lenses, which are added to the already prescribed glasses for distance. Normal addition for near is given as under

At the age of 40 years reading correction is +1D At the age of 45 years reading correction is +1.5D. At the age of 50 years reading correction is +2D. At the age of 55 years reading correction is +2.5D.

2. Acquired Cataract
Whether senile, traumatic, endocrine, complicated or cataract due to systemic diseases, usually cause visual problem. There is gradual deterioration of vision due to increase in the opacification of lens.
Treatment: As long as the vision can be corrected with suitable glasses, they are prescribed accordingly. When the disability becomes unbearable the cataract is removed surgically.

3. Chronic Simple Glaucoma (Primary Open Angle Glaucoma)

This is a disease of middle age and elderly people. This type of glaucoma is more common with high degree of myopia.The actual cause of glaucoma is not known. Symptoms

Onset is insidious. Mild headache and eyeache. Presbyopic glasses may require frequent change due to accommodative weekness. Visual field defect. Gradual dimness of central vision at a later stage. Night blindness when the peripheral part of the retina is affected.

Signs: Rise of intraocular pressure. Cupping of the optic discs. Visual field defects. Treatment: Medical treatment: The following drops are used in different concentration and frequency for control of the I.O.P. If the response is not good, surgical treatment is undertaken. Pilocarpine (0.5 - 4%), Timolol maleate (0.25 0.5%), Betaxalol (0.5%), Adrenaline (1 2%).

Operative Treatment (one of the following procedure may be undertaken) Laser Trabeculoplasty Trabeculectomy Trabeculotomy

4. Keratoconus
It is the congenital abnormality of the cornea which due to weakness becomes cone shaped. It manifests itself usually in girls after puberty. There is visual impairment, as the central part of the eye becomes myopic due to bulging of the cornea. But the refractive error cannot be corrected by ordinary spectacle lenses. Contact lens improves vision markedly.

Treatment:

Initially glasses are prescribed. When the condition deteriorates contact lenses are prescribed. When the cornea becomes weaker, keratoplasty becomes essential.

5. Recurrent Keratopathy
Repeated ulceration of the epithelium, cellular infiltration of the deeper layers and vascularization causes gradual deterioration of vision which makes the patient partially blind.
Treatment: Keratoplasty is the only treatment in such cases.

6. Chronic Uveitis
Repeated attacks of anterior or posterior uveitis where etiology is obscure and timely treatment is not received, it leads to complications where the vision is permanently lost. Amongst the complications anterior or posterior synechae, secondary cataract and phthisis bulbi are worth mentioning.

7. Diabetic Retinopathy
It usually occurs 8 10 years after the onset of diabetes mellitus. In the early stage there is micro-aneurysm formation with yellow waxy exudates in the retina. Later on there are haemorrhages in the deeper layer of the retina as well as in the superficial layers. Massive retinal and vitreous haemorrhages are common leading to retinitis proliferans, a very serious complication. Treatment: Early institution of treatment of diabetes and regular checkups help in delaying the complications of diabetes.

8. Retinitis Pigmentosa
It is a chronic progressive degeneration of all the layers of the retina with proliferation of the retinal pigment, occurring usually in the young and there is a hereditary tendency.
Symptoms

Night blindness Loss of peripheral vision In the later stages loss of central vision, but total blindness invariably does not occur.

Signs:

The disease has a typical fundus picture. Black pigment spots like bone corpuscles, along the blood vessels, mainly in the equatorial region. Yellow waxy appearance of the optic disc. Retinal arteries markedly narrow. An annular or ring scotoma is usually detected in the visual field.

Treatment: It is a progressive degenerative disease and there is no known treatment to stop the progress. Initially in refractive errors glasses are prescribed.

9. Senile Macular Degeneration

It occurs in the aged person. One or both eyes may be affected. Fundus shows fine pigmentary changes, fine exudates and tiny haemorrhages all restricted in the macular area. Symptoms: The central vision is lost but the patient never becomes blind. The loss of vision is due to degeneration of the cells of the outer nuclear layer and degeneration of the rods and cones. Treatment: No satisfactory treatment.

10. Chronic Retrobulbar Neuritis (Toxic Amblyopia)

This is a bilateral condition, caused by exogenous poisons, affecting primarily the ganglion cells of the retina. As there is atrophy of the macular fibres of the optic nerve, the condition was formerly known as chronic retrobulbar neuritis. But as the lesion is primarily in the retina, the toxic amblyopia is considered now-a-days as toxic retinoneuropathy. Etiology: The toxic amblyopias are due to the following poisonous agents 1. Tobacco Amblyopia It usually occurs in elderly persons consuming tobacco who have also general ill-health and suffer from vitamin B12 deficiency.

 The causative agent most probably is not nicotine, but one of its decomposition products such as collidine or luitidine. Symptoms: Gradual dimness of vision and inability to distinguish colours. Clinical Signs: On scotometry, a central or centrocoecal scotoma, both for white and coloured objects. On ophthalmoscopic examination, there is no sign except a slight pallor of the optic disc. Treatment: i. Complete withdrawal of tobacco. ii. Administration of vitamin B1 and B12. iii. Improvement of general health.

2. Ethyl Alcohol Amblyopia

Symptoms and signs are the same as for tobacco amblyopia. The only difference is that the person consumes alcohol instead of tobacco. Treatment also is similar to that for tobacco amblyopia.

3. Methyl Alcohol:
It is caused by drinking wood alcohol or methylated spirit. In chronic form there is progressive loss of vision with optic atrophy.

Treatment To withhold methyl alcohol. Injection of heavy doses of vitamin B1, B6, B12.

4. Arsenic and Lead poisoning also lead to gradual

dimness of vision and optic atrophy. The treatment is to remove the chemicals from the system.

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