Acute Vision Loss

Aka: Acute Vision Loss, Acute Blindness, Acute Persistent Vision Loss, Blurred Vision, Monocular Blindness

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II. Differential Diagnosis: Acute Vision Loss based on pain

  1. Painful Vision Loss or Blurred Vision
    1. Eye Injury
    2. Corneal Ulcer
    3. Acute Angle-Closure Glaucoma (esp. if Intraocular Pressure >60 mmHg)
    4. Iritis and Uveitis (anterior chamber exudates)
    5. Endophthalmitis (vitreous exudates)
  2. Painless (or Minimal or variable pain) Vision Loss or Blurred Vision
    1. Optic Neuritis, retrobulbar Optic Neuritis or Papillitis (associated with Multiple Sclerosis)
    2. Retinal Detachment
    3. Ocular tumor
    4. Central Retinal Artery Occlusion (pale fundus with cherry red Macula)
    5. Acute Maculopathy
    6. Pseudotumor Cerebri (or other cause of Increased Intracranial Pressure)
      1. Associated with Headache
    7. Transient Monocular Blindness (Amaurosis Fugax)
      1. Temporal Arteritis (Giant Cell Arteritis)
      2. Ischemic Optic Neuropathy
    8. Retinal Hemorrhage
      1. Central Retinal Vein Occlusion
      2. Vitreous Hemorrhage
      3. Retinal Hemorrhage

III. Differential Diagnosis: Acute Unilateral Vision Loss

  1. Transient
    1. Central Retinal Vein Occlusion
    2. Retinal Detachment (early)
    3. Thromboembolism
    4. Uveitis
    5. Pseudotumor Cerebri
    6. Transient Monocular Blindness (Amaurosis Fugax)
  2. Persistent
    1. Acute Angle-Closure Glaucoma
    2. Central Retinal Artery Occlusion
    3. Central Retinal Vein Occlusion
    4. Retinal Detachment (later)
    5. Optic Neuritis (Multiple Sclerosis)
    6. Ischemic Optic Neuropathy
    7. Nonarteritic anterior optic Neuropathy (see Medications with Adverse Ocular Effects)
    8. Eye Trauma
    9. Tumor
    10. Vitreous Hemorrhage
    11. Occipital cortex infarction (vertebrobasilar thromboembolic event)
    12. Endophthalmitis
    13. Keratopathy
    14. Acute Maculopathy
    15. Psychogenic visual loss

IV. Differential Diagnosis: Acute Bilateral Vision Loss or Blurred Vision

  1. Transient
    1. Migraine Headache aura
    2. Congestive Heart Failure
    3. Hypertensive Emergency
    4. Severe bilateral Carotid Artery Stenosis
    5. Transient Ischemic Attack involving visual cortex (Hemianopsia)
    6. Pseudotumor Cerebri (or other cause of Increased Intracranial Pressure)
  2. Persistent
    1. Bilateral Occipital Lobe ischemia
    2. Temporal Arteritis (Giant Cell Arteritis)
    3. Lymphoma
    4. Posterior ischemic Neuropathy

V. Risk Factors: Acute Vision Loss predisposing factors

  1. Diabetes Mellitus
  2. Hypertension
  3. Hyperlipidemia
  4. Hypercoagulable States
  5. Cardiac Arrhythmias
  6. Carotid Insufficiency
  7. Glaucoma
  8. Migraine Headaches

VI. History

  1. Timing: Red flags for urgent referral
    1. Very recent onset of Vision Loss (hours)
    2. Progressive symptoms
    3. First episode
    4. Sudden onset (Hemorrhage, ischemia)
  2. Lesion localization
    1. Monocular or binocular?
      1. Monocular: Ocular or Optic Nerve lesion
      2. Binocular: Optic Chiasm and posterior back to Occipital Lobe lesion
    2. Focal Visual Field Deficit?
      1. Retina and posterior back through Optic Nerve and Occipital Lobe
    3. Periocular pain?
      1. Anterior eye or Optic Nerve lesion (requires Trigeminal Nerve sensitization)
  3. Associated symptoms
    1. Nausea or Vomiting with Eye Pain
      1. Acute angle closure Glaucoma
    2. Flashes or Floaters
      1. Vitreous Hemorrhage
      2. Retinal Detachment
    3. Associated neurologic deficits
      1. Cerebrovascular Accident or other systemic cause

VII. Exam

  1. Visual Acuity
    1. Snellen Chart
      1. Consider pinhole for Vision testing in a patient who did not bring their glasses to evaluation
    2. Finger Counting (CF) at 1 foot and at 6 inches
    3. Hand Movements (HM)
    4. Light Perception (LP)
    5. No light Perception (NLP): total blindness
  2. Ciliary Flush
    1. Diffuse Corneal haze
      1. Acute angle closure Glaucoma
    2. Corneal opacities (especially with Fluorescein uptake)
      1. Keratitis
  3. Visual Field Deficit
    1. visualFieldDefects.jpg
    2. Monocular Blindness
      1. Optic Nerve lesion
      2. Transient Monocular Blindness (Amaurosis Fugax, Central Retinal Artery Occlusion)
    3. Homonymous Hemianopia (field cut affects both eyes in same region)
      1. Occipital lesion
    4. Bitemporal Hemianopia
      1. Bilateral peripheral Vision Loss suggests Optic Chiasm lesion
  4. Pupil abnormality
    1. EyePupillaryReaction.png
    2. Mid-dilated non-reactive pupil
      1. Acute Angle-Closure Glaucoma
    3. Afferent Pupillary Defect (sluggish or absent pupil response to light)
      1. Optic Nerve lesion
      2. Retinal lesion
  5. Funduscopic Exam
    1. Retinal Detachment
      1. Affected Retina will have the pale billowing appearance of a parachute
      2. In non-dilated Eye Exam, Ocular Ultrasound has better sensitivity
    2. Red Reflex absent
      1. Endophthalmitis
      2. Vitreous Hemorrhage
      3. Opaque Cornea
      4. Cataract
    3. Cherry red spot (red Macula)
      1. Central Retinal Artery Occlusion (e.g. Temporal Arteritis)
      2. Severe Hypertension
    4. Retinal Hemorrhage
      1. Central Retinal Vein Occlusion
      2. Other systemic causes
        1. Diabetes Mellitus
        2. Hypertension
        3. Head Trauma (or Eye Trauma)
        4. Bleeding Disorder
        5. Severe Hypertension
    5. Optic disc swelling
      1. Ischemic Optic Neuropathy
      2. Optic Neuritis

VIII. Management

  1. Rapid assessment and management if acute CNS event is suspected
    1. See Cerebrovascular Accident
  2. Indications for emergent referral to ophthalmology
    1. Keratitis
    2. Endophthalmitis
    3. Retinal Detachment
    4. Retinal Hemorrhage or Vitreous Hemorrhage
    5. Optic Neuritis
    6. Occipital infarction
    7. Central Retinal Artery Occlusion
    8. Acute angle closure Glaucoma
    9. Ischemic Optic Neuropathy
  3. Conditions with specific immediate temporizing measures by emergency provider
    1. Central Retinal Artery Occlusion
    2. Acute angle closure Glaucoma
    3. Ischemic Optic Neuropathy

IX. References

  1. Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
  2. Trobe (2012) Physician Guide to Eye Care, p. 31-35

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