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Acute Vision Loss

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Acute Vision Loss, Acute Blindness, Acute Persistent Vision Loss

  • 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
  • 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
  • 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. Monocular Blindness
      1. Optic Nerve lesion
      2. Transient Monocular Blindness (Amaurosis Fugax, Central Retinal Artery Occlusion)
    2. Homonymous hemianopia (field cut affects both eyes in same region)
      1. Occipital lesion
    3. Bitemporal hemianopia
      1. Bilateral peripheral Vision Loss suggests Optic Chiasm lesion
  4. Pupil abnormality
    1. Mid-dilated non-reactive pupil
      1. Acute Angle-Closure Glaucoma
    2. 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
  • 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
  • References
  1. Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
  2. Trobe (2012) Physician Guide to Eye Care, p. 31-35