II. Differential Diagnosis: Acute Vision Loss based on pain

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

V. Risk Factors: Acute Vision Loss predisposing factors

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

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Blurred vision (C0344232)

Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (CHV) finding
Definition (NCI_CTCAE) A disorder characterized by visual perception of unclear or fuzzy images.
Definition (NCI) Blurred vision is the loss of visual acuity (sharpness of vision) resulting in a loss of ability to see small details. (from MedlinePlus Medical Encyclopedia)
Concepts Sign or Symptom (T184)
SnomedCT 111516008, 267629007, 193695001, 155145007, 267726008, 246636008, 111517004
LNC LA15105-2
English VISION BLURRED, blurred vision, blurry vision (symptom), blurry vision, foggy vision (symptom), foggy vision, Blurring of eyes, Blurring of vision, Vision blurred, Blurry vision, cloudy vision, blurred eyes, blurring vision, Blurred;vision, vision blurry, hazy vision, blur vision, blurred eye, blur eyes, eye blur, blurring of vision, vision blur, vision blurred, Blurred vision NOS (disorder), Dull vision NOS, Cloudy vision NOS, VISION, BLURRING OF, BLURRING, BLURRED VISION, Filmy vision, Blurred vision - hazy, Cloudy vision, Foggy vision, Hazy vision, Misty vision, Blurring of visual image, Mist over eyes, Blurring of visual image (finding), Hazy vision (disorder), blurred; vision, vision; blurred, Blurred vision, NOS, Blurred Vision, Blurred vision, Blurred vision NOS
Italian Visione offuscata, Annebbiamento della vista, Visione appannata, Occhi annebbiati, Visione annebbiata, Offuscamento della vista
Dutch wazigzien, wazig gezichtsvermogen, vaag zien, troebel gezichtsvermogen, wazig voor de ogen, wazig zien, visus; wazig, wazig; visus, gezichtsvermogen wazig
French Vision floue, Vision brouillée, Trouble de la vision, Yeux troubles, BAISSE DE VISION, Vision trouble
German verschwommenes Sehen, verschwommener Seheindruck, Sehen durch einen Film, dunstiges Sehen, nebelhaftes Sehen, SEHEN VERSCHWOMMEN, Sehen verschwommen
Portuguese Turvação da vista, Visão enevoada, Visão velada, VISAO TURVA, Visão turva
Spanish Visión confusa, Borrosidad de ojos, Visión nebulosa, Visión ensombrecida, visión nebulosa, VISION BORROSA, visión borrosa, SAI (trastorno), visión borrosa, SAI, Visión borrosa, visión borrosa (hallazgo), visión borrosa, visión nebulosa (trastorno), imagen visual borrosa (hallazgo), imagen visual borrosa, visión borrosa (trastorno)
Japanese 霧視, かすみ目, カスミメ, ムシ
Czech Zamlžené vidění, Mlhavé vidění, Zastření zraku, Rozmazané vidění, Pocit mlhy před očima
Hungarian Homályos látás, Életlen látás, Fátyolos látás, Ködös látás, Látás, homályos, Homályos szemek, Látás homályosodása

Ontology: Blind Vision (C0456909)

Definition (NCI) The lack of vision. It is caused by neurological or physiological factors.
Definition (MSH) The inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of EYE DISEASES; OPTIC NERVE DISEASES; OPTIC CHIASM diseases; or BRAIN DISEASES affecting the VISUAL PATHWAYS or OCCIPITAL LOBE.
Definition (CSP) inability to see or the loss or absence of perception of visual stimuli; condition may be the result of eye, optic nerve, optic chiasm or brain diseases effecting the visual pathways or occipital lobe.
Concepts Finding (T033)
MSH D001766 , D015354, D014786
SnomedCT 40031005, 139548004, 277675000, 397540003
LNC LA17710-7
English Blindness, BLINDNESS, Cannot see, Loss of vision, Unable to see, UTS - Unable to see, Blind Vision, Blindness [Disease/Finding], blindness, blind, blind vision, Blindness NOS, Blindness (finding), Blind (finding), Blind, Blindness, NOS
French CECITE, Cécité SAI, Aveugle, Déficience de la vision, Déficience visuelle, Cécité, Vision basse, Non-voyance, Vision diminuée, Vision faible, Vision réduite
Portuguese CEGUEIRA, Cegueira NE, Cego, Cegueira
Spanish CEGUERA, Ceguera NEOM, Ciego, ciego, ciego (hallazgo), ceguera (trastorno), ceguera, Ceguera
German BLINDHEIT, Blindheit NNB, blind, Blindheit, Sehverlust, Sehschwäche, Sehvermögen, herabgesetztes, Sehvermögen, vermindertes
Dutch blindheid NAO, blind, Blindheid, laag; visus, blindheid, Amaurose
Italian Cieco, Cecità NAS, Visione ridotta, Ipovisione, Cecità
Japanese 失明NOS, シツメイ, シツメイNOS, 視覚消失症, , 亜正常視覚, 黒内障, 失明, 低視力, 低視覚, ロービジョン, 視覚-亜正常, 視覚-低
Swedish Blindhet
Czech slabozrakost, zrak subnormální, slepota, vidění snížené, Nevidomý, Slepota, Nevidomost NOS
Finnish Sokeus, Heikentynyt näkö
Polish Ślepota, Obniżenie jakości widzenia, Wzrok słaby, Wzrok subnormalny, Widzenie obniżone
Hungarian Vakság, Amaurosis k.m.n., Vak
Norwegian Redusert synsevne, Blindhet, Synshemning, Svekket syn, Nedsatt syn, Synssvekkelse, Svakt syn, Synsnedsettelse