Acute vision loss (noninflamed)

(Redirigido desde «Visual loss»)

Background

Eye anatomy.
  • This page describes a general approach to the complaint of acute vision loss with a quiet (noninflamed) eye
  • Acute painless vision loss is an ophthalmologic emergency — several causes are time-sensitive
  • Central retinal artery occlusion (CRAO) is a stroke equivalent with a narrow treatment window ([1]<4.5-6 hours)
  • Key distinguishing feature: painless vision loss in a quiet eye narrows the differential to primarily vascular and retinal etiologies
  • Always check visual acuity in both eyes as a baseline

Clinical Features

Key Historical Features

  • Monocular vs. binocular vision loss (binocular suggests central/neurologic cause)
  • Onset: sudden (vascular) vs. gradual (optic neuritis, detachment progression)
  • Transient vs. persistent: amaurosis fugax (transient monocular vision loss) suggests TIA/carotid disease
  • Visual field deficit pattern: central (macular), peripheral (retinal detachment), altitudinal (branch artery/vein occlusion)
  • Associated symptoms: headache, jaw claudication, scalp tenderness (giant cell arteritis), floaters/flashes (retinal detachment)[2]
  • Pain with eye movement (optic neuritis)

Physical Exam

  • Visual acuity (each eye independently) — document with Snellen chart or near card
  • Pupillary exam: relative afferent pupillary defect (RAPD/Marcus Gunn pupil) present in optic nerve or extensive retinal pathology
  • Visual field testing by confrontation
  • Extraocular movements
  • Fundoscopy: look for pale retina with cherry red spot (CRAO), papilledema, retinal hemorrhages, retinal detachment

Differential Diagnosis

Acute Vision Loss (Noninflamed)

†Emergent Diagnosis

Vascular

Retinal

  • Retinal detachment: flashes, floaters, "curtain" over visual field, pigmented cells in vitreous
  • Vitreous hemorrhage: sudden painless vision loss, absent red reflex, history of diabetes/trauma

Neurologic

  • Optic neuritis: painful eye movements, central vision loss, RAPD, associated with MS
  • Stroke affecting visual cortex: binocular homonymous hemianopsia
  • Papilledema from elevated ICP: bilateral vision changes, headache
  • Pituitary apoplexy: bitemporal hemianopsia, headache

Evaluation

Bedside

  • Visual acuity (each eye separately)
  • Pupillary exam for RAPD
  • Confrontation visual fields
  • Fundoscopy (dilated if safe — avoid dilation if concern for neurologic cause requiring pupil monitoring)
  • POCUS: ocular ultrasound can identify retinal detachment, vitreous hemorrhage, increased optic nerve sheath diameter (elevated ICP)
  • Intraocular pressure (IOP) — elevated in acute angle closure (though this is typically painful/inflamed)

Laboratory

  • ESR and CRP (STAT) if giant cell arteritis suspected — do not delay treatment
  • CBC, BMP
  • Glucose (diabetic retinopathy)
  • Consider hypercoagulability workup for retinal vascular occlusion in young patients

Imaging

  • CT/CTA head if stroke suspected
  • MRI brain/orbits with gadolinium for optic neuritis
  • Carotid duplex ultrasound or CTA neck for amaurosis fugax / CRAO (embolic source evaluation)

Management

Time-Sensitive Emergencies

  • CRAO: true ophthalmologic emergency (treatment window <4.5-6 hours)
    • Emergent ophthalmology consultation
    • Consider ocular massage, anterior chamber paracentesis (ophthalmology)
    • Intra-arterial tPA may be considered at specialized centers
    • Evaluate for embolic source (carotid, cardiac)
  • Giant cell arteritis: start high-dose IV methylprednisolone (1g/day) immediately if clinical suspicion high — do NOT wait for biopsy results
    • Temporal artery biopsy within 1-2 weeks (steroids do not affect biopsy for several days)
  • Retinal detachment: emergent ophthalmology consultation for surgical repair
    • Macula-on detachments are more urgent (better visual outcomes with earlier repair)
  • Optic neuritis: neurology and ophthalmology consultation; high-dose IV corticosteroids may hasten recovery

Non-Emergent

  • CRVO: ophthalmology follow-up within 24-48 hours
  • Vitreous hemorrhage: ophthalmology referral, head-of-bed elevation
  • Amaurosis fugax: stroke workup (treat as TIA equivalent)

Disposition

Emergent Ophthalmology Consultation

  • CRAO (within treatment window)
  • Retinal detachment (especially macula-on)
  • Giant cell arteritis with vision loss

Admit

  • Giant cell arteritis (for IV steroids and monitoring)
  • CRAO with concern for concurrent stroke
  • Amaurosis fugax/TIA (per stroke protocol)
  • Bilateral vision loss from neurologic cause

Discharge with Urgent Follow-Up

  • CRVO: ophthalmology within 24-48 hours
  • Vitreous hemorrhage (nontraumatic): ophthalmology within 24 hours
  • Optic neuritis: neurology and ophthalmology within days
  • Return precautions: worsening vision loss, new symptoms in other eye, headache, weakness

See Also

Eye Algorithms

External Links

References

  1. ↑ Hayreh SS. Acute retinal arterial occlusive disorders. Prog Retin Eye Res. 2011;30(5):359-394. PMID 21620994
  2. ↑ Hunder GG, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990;33(8):1122-1128. PMID 2202311
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