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Acute Vision Loss
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Acute Vision Loss
, Acute Blindness, Acute Persistent Vision Loss, Blurred Vision
See Also
Decreased Visual Acuity
Differential Diagnosis
Acute Vision Loss based on pain
Painful
Vision Loss
or Blurred Vision
Eye Injury
Corneal Ulcer
Acute Angle-Closure Glaucoma
(esp. if
Intraocular Pressure
>60 mmHg)
Iritis
and
Uveitis
(anterior chamber exudates)
Endophthalmitis
(vitreous exudates)
Painless (or Minimal or variable pain)
Vision Loss
or Blurred Vision
Optic Neuritis
, retrobulbar
Optic Neuritis
or
Papillitis
(associated with
Multiple Sclerosis
)
Retinal Detachment
Ocular tumor
Central Retinal Artery Occlusion
(pale fundus with cherry red
Macula
)
Acute Maculopathy
Pseudotumor Cerebri
(or other cause of
Increased Intracranial Pressure
)
Associated with
Headache
Transient Monocular Blindness
(
Amaurosis Fugax
)
Temporal Arteritis
(
Giant Cell Arteritis
)
Ischemic Optic Neuropathy
Retina
l
Hemorrhage
Central Retinal Vein Occlusion
Vitreous Hemorrhage
Retina
l
Hemorrhage
Differential Diagnosis
Acute unilateral
Vision Loss
Transient
Central Retinal Vein Occlusion
Retinal Detachment
(early)
Thromboembolism
Uveitis
Pseudotumor Cerebri
Transient Monocular Blindness
(
Amaurosis Fugax
)
Persistent
Acute Angle-Closure Glaucoma
Central Retinal Artery Occlusion
Central Retinal Vein Occlusion
Retinal Detachment
(later)
Optic Neuritis
(
Multiple Sclerosis
)
Ischemic Optic Neuropathy
Nonarteritic anterior optic
Neuropathy
(see
Medications with Adverse Ocular Effects
)
Eye Trauma
Tumor
Vitreous Hemorrhage
Occipital cortex infarction (vertebrobasilar thromboembolic event)
Endophthalmitis
Keratopathy
Acute Maculopathy
Psychogenic visual loss
Differential Diagnosis
Acute bilateral
Vision Loss
or Blurred Vision
Transient
Migraine Headache
aura
Congestive Heart Failure
Hypertensive Emergency
Severe bilateral
Carotid Artery Stenosis
Transient Ischemic Attack
involving visual cortex (hemianopsia)
Pseudotumor Cerebri
(or other cause of
Increased Intracranial Pressure
)
Persistent
Bilateral
Occipital Lobe
ischemia
Temporal Arteritis
(
Giant Cell Arteritis
)
Lymphoma
Posterior ischemic
Neuropathy
Risk Factors
Acute Vision Loss predisposing factors
Diabetes Mellitus
Hypertension
Hyperlipidemia
Hypercoagulable
States
Cardiac Arrhythmia
s
Carotid Insufficiency
Glaucoma
Migraine Headache
s
History
Timing: Red flags for urgent referral
Very recent onset of
Vision Loss
(hours)
Progressive symptoms
First episode
Sudden onset (
Hemorrhage
, ischemia)
Lesion localization
Monocular or binocular?
Monocular: Ocular or
Optic Nerve
lesion
Binocular:
Optic Chiasm
and posterior back to
Occipital Lobe
lesion
Focal
Visual Field
deficit?
Retina
and posterior back through
Optic Nerve
and
Occipital Lobe
Periocular pain?
Anterior eye or
Optic Nerve
lesion (requires
Trigeminal Nerve
sensitization)
Associated symptoms
Nausea
or
Vomiting
with
Eye Pain
Acute angle closure
Glaucoma
Flashes or
Floaters
Vitreous Hemorrhage
Retinal Detachment
Associated neurologic deficits
Cerebrovascular Accident
or other systemic cause
Exam
Visual Acuity
Snellen Chart
Consider pinhole for
Vision
testing in a patient who did not bring their glasses to evaluation
Finger Counting (CF) at 1 foot and at 6 inches
Hand Movements (HM)
Light
Perception
(LP)
No light
Perception
(NLP): total blindness
Ciliary Flush
Diffuse
Cornea
l haze
Acute angle closure
Glaucoma
Cornea
l opacities (especially with
Fluorescein
uptake)
Keratitis
Visual Field
deficit
Monocular Blindness
Optic Nerve
lesion
Transient Monocular Blindness
(
Amaurosis Fugax
,
Central Retinal Artery Occlusion
)
Homonymous hemianopia (field cut affects both eyes in same region)
Occipital lesion
Bitemporal hemianopia
Bilateral peripheral
Vision Loss
suggests
Optic Chiasm
lesion
Pupil
abnormality
Mid-dilated non-reactive pupil
Acute Angle-Closure Glaucoma
Afferent Pupillary Defect
(sluggish or absent pupil response to light)
Optic Nerve
lesion
Retina
l lesion
Funduscopic Exam
Retinal Detachment
Affected
Retina
will have the pale billowing appearance of a parachute
In non-dilated
Eye Exam
,
Ocular Ultrasound
has better sensitivity
Red Reflex
absent
Endophthalmitis
Vitreous Hemorrhage
Opaque
Cornea
Cataract
Cherry red spot (red
Macula
)
Central Retinal Artery Occlusion
(e.g.
Temporal Arteritis
)
Severe Hypertension
Retina
l
Hemorrhage
Central Retinal Vein Occlusion
Other systemic causes
Diabetes Mellitus
Hypertension
Head Trauma
(or
Eye Trauma
)
Bleeding Disorder
Severe Hypertension
Optic disc swelling
Ischemic Optic Neuropathy
Optic Neuritis
Management
Rapid assessment and management if acute CNS event is suspected
See
Cerebrovascular Accident
Indications for emergent referral to ophthalmology
Keratitis
Endophthalmitis
Retinal Detachment
Retina
l
Hemorrhage
or
Vitreous Hemorrhage
Optic Neuritis
Occipital infarction
Central Retinal Artery Occlusion
Acute angle closure
Glaucoma
Ischemic Optic Neuropathy
Conditions with specific immediate temporizing measures by emergency provider
Central Retinal Artery Occlusion
Acute angle closure
Glaucoma
Ischemic Optic Neuropathy
References
Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
Trobe (2012) Physician Guide to Eye Care, p. 31-35
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