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Acute Vision Loss

By

Christopher J. Brady

, MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine

Last full review/revision May 2021| Content last modified May 2021
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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 Retinal Detachment Retinal detachment is separation of the neurosensory retina from the underlying retinal pigment epithelium. The most common cause is a retinal break (a tear or, less commonly, a hole) (rhegmatogenous... read more Retinal Detachment ) may describe their symptoms as blurred vision.

Pathophysiology of Acute Vision Loss

Acute loss of vision has 3 general causes:

  • Opacification of normally transparent structures through which light rays pass to reach the retina (eg, cornea, vitreous)

  • Retinal abnormalities

  • Abnormalities affecting the optic nerve or visual pathways

Etiology of Acute Vision Loss

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 Cataract A cataract is a congenital or degenerative opacity of the lens. The main symptom is gradual, painless vision blurring. Diagnosis is by ophthalmoscopy and slit-lamp examination. Treatment is... read more Cataract ) suddenly is aware of the reduced vision in the affected eye when covering the unaffected eye.

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, local retinal detachment Retinal Detachment Retinal detachment is separation of the neurosensory retina from the underlying retinal pigment epithelium. The most common cause is a retinal break (a tear or, less commonly, a hole) (rhegmatogenous... read more Retinal Detachment ).

Less common causes of acute loss of vision include

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Evaluation of Acute Vision Loss

History

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 Floaters Floaters are opacities that move across the visual field and do not correspond to external visual objects. With aging, the vitreous humor can contract and separate from the retina. The age at... read more , 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 Giant Cell Arteritis Giant cell arteritis involves predominantly the thoracic aorta, large arteries emerging from the aorta in the neck, and extracranial branches of the carotid arteries. Symptoms of polymyalgia... read more ); 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 Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more Hypertension ), and hematologic disorders (eg, sickle cell anemia Sickle Cell Disease Sickle cell disease (a hemoglobinopathy) causes a chronic hemolytic anemia occurring almost exclusively in blacks. It is caused by homozygous inheritance of genes for hemoglobin (Hb) S. Sickle-shaped... read more Sickle Cell Disease or disorders such as Waldenström macroglobulinemia Macroglobulinemia Macroglobulinemia is a malignant plasma cell disorder in which B cells produce excessive amounts of IgM M-proteins. Manifestations may include hyperviscosity, bleeding, recurring infections... read more or multiple myeloma Multiple Myeloma Multiple myeloma is a cancer of plasma cells that produce monoclonal immunoglobulin and invade and destroy adjacent bone tissue. Common manifestations include lytic lesions in bones causing... read more Multiple Myeloma that could cause a hyperviscosity syndrome).

Physical examination

Vital signs, including temperature, are measured.

If the diagnosis of a transient ischemic attack is under consideration, a complete neurologic examination is done. 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.

  • Visual acuity is measured.

  • Peripheral visual fields are assessed by confrontation.

  • Central visual fields are assessed by Amsler grid.

  • Direct and consensual pupillary light reflexes are examined using the swinging flashlight test.

  • Ocular motility is assessed.

  • Color vision is tested with color plates.

  • The eyelids, sclera, and conjunctiva are examined using a slit lamp if possible.

  • The cornea is examined with fluorescein staining.

  • The anterior chamber is examined for cells and flare in patients who have eye pain or conjunctival injection.

  • The lens is checked for cataracts using a direct ophthalmoscope, slit lamp, or both.

  • Intraocular pressure is measured.

  • Ophthalmoscopy is done, preferably after dilating the pupil with a drop of a sympathomimetic (eg, 2.5% phenylephrine), cycloplegic (eg, 1% cyclopentolate or 1% tropicamide), or both; dilation is nearly full after about 20 minutes. The entire fundus, including the retina, macula, fovea, vessels, and optic disk and its margins, is examined.

  • If pupillary light responses are normal and functional loss of vision is suspected (rarely), optokinetic nystagmus is checked. If an optokinetic drum is unavailable, a mirror can be held near the patient’s eye and slowly moved. If the patient can see, the eyes usually track movement of the mirror (considered to be the presence of optokinetic nystagmus).

Red flags

Acute loss of vision is itself a red flag; most causes are serious.

Interpretation of findings

In addition, the following facts may help:

  • Monocular symptoms suggest a lesion anterior to the optic chiasm.

  • Bilateral, symmetric (homonymous) visual field defects suggest a lesion posterior to the chiasm.

  • Constant eye pain suggests a corneal lesion (ulcer or abrasion), anterior chamber inflammation, or increased intraocular pressure, whereas eye pain with movement suggests optic neuritis.

  • Temporal headaches suggest giant cell arteritis or migraine.

Testing

Erythrocyte sedimentation rate (ESR), C-reactive protein, and platelet count are 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.

Treatment of Acute Vision Loss

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).

Key Points

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