Acute Vision Loss: A Merck Manual of Patient Symptoms podcast
Loss of vision is usually considered acute if it develops within a few minutes to a couple of days. It may affect one or both eyes and all or part of a visual field. Patients with small visual field defects (eg, caused by a small retinal detachment) may describe their symptoms as blurred vision.
Acute loss of vision has 3 general causes:
The most common causes of acute loss of vision are
In addition, sudden recognition of loss of vision (pseudo-sudden loss of vision) may manifest initially as sudden onset. For example, a patient with long-standing reduced vision in one eye (possibly caused by a dense cataract) suddenly is aware of the reduced vision in the affected eye when covering the unaffected eye.
Presence or absence of pain helps categorize loss of vision (see Table 1: Symptoms of Ophthalmologic Disorders: Some Causes of Acute Vision Loss).
Most disorders that cause total loss of vision when they affect the entire eye may affect only part of the eye and cause only a visual field defect (eg, branch occlusion of the retinal artery or retinal vein, focal retinal detachment).
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Less common causes of acute loss of vision include
History of present illness should describe loss of vision in terms of onset, duration, progression, and location (whether it is monocular or binocular and whether it involves the entire visual field or a specific part and which part). Important associated visual symptoms include floaters, flashing lights, halos around lights, distorted color vision, and jagged or mosaic patterns (scintillating scotomata). The patient should be asked about eye pain and whether it is constant or occurs only with eye movement.
Review of systems should seek extraocular symptoms of possible causes, including jaw or tongue claudication, temporal headache, proximal muscle pain, and stiffness (giant cell arteritis); and headaches (ocular migraine).
Past medical history should seek known risk factors for eye disorders (eg, contact lens use, severe myopia, recent eye surgery or injury), risk factors for vascular disease (eg, diabetes, hypertension), and hematologic disorders (eg, sickle cell anemia or disorders such as Waldenström macroglobulinemia or multiple myeloma that could cause a hyperviscosity syndrome).
Family history should note any family history of migraine headaches.
Vital signs, including temperature, are measured.
If the diagnosis of a transient ischemic attack is under consideration, a complete neurologic examination is done. The facial skin is inspected for vesicles or ulcers in the V1 distribution (ophthalmic division of the trigeminal nerve), and the temples are palpated for pulses, tenderness, or nodularity over the course of the temporal artery. However, most of the examination focuses on the eye.
Eye examination includes the following:
Acute loss of vision is itself a red flag; most causes are serious.
Interpretation of findings
Diagnosis can be begun systematically. Fig. 1: Symptoms of Ophthalmologic Disorders: Evaluation of acute vision loss. describes a simplified, general approach. Specific patterns of visual field deficit help suggest a cause (see Table 1: Approach to the Ophthalmologic Patient: Types of Field Defects ). Other clinical findings also help suggest a cause (see Table 1: Symptoms of Ophthalmologic Disorders: Some Causes of Acute Vision Loss):
In addition, the following facts may help:
ESR is done for all patients with symptoms (eg, temporal headaches, jaw claudication, proximal myalgias, stiffness) or signs (eg, temporal artery tenderness or induration, pale retina, papilledema) suggesting optic nerve or retinal ischemia to exclude giant cell arteritis.
Other testing is listed in Table 1: Symptoms of Ophthalmologic Disorders: Some Causes of Acute Vision Loss. The following are of particular importance:
Causative disorders are treated. Treatment should usually commence immediately if the cause is treatable. In many cases (eg, vascular disorders), treatment is unlikely to salvage the affected eye but can decrease the risk of the same process occurring in the contralateral eye or of a complication caused by the same process (eg, ischemic stroke).
Last full review/revision November 2012 by Kathryn Colby, MD, PhD