Vision Loss (In a Page: Signs and Symptoms)

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Vision Loss

Vision loss may be unilateral or bilateral; transient or persistent; of sudden or gradual onset; and painless or painful. Vision loss in one eye may be followed quickly by ensuing vision loss of the other eye, rendering the patient completely blind (e.g., untreated giant cell arteritis). In some situations, vision loss may be reversible with timely intervention. Vision loss may be a harbinger of more serious, even life-threatening, conditions (e.g., brain tumor, meningitis, giant cell arteritis, cavernous sinus thrombosis, mucormycosis).

Differential Diagnosis

Transient vision loss (<24 hours)

• Papilledema: Lasts seconds, bilateral
• Amaurosis fugax: Lasts minutes, unilateral
• Vertebrobasilar artery insufficiency: Lasts minutes, bilateral
• Migraine: Lasts 10–60 minutes
• Impending central retinal vein occlusion
• Ocular ischemic syndrome (carotid occlusive disease)
• Sudden change in blood pressure; orthostatic hypotension
• Transient acute increase in intraocular pressure (e.g., acute angle closure glaucoma, retro- or peribulbar hemorrhage)

Vision loss >24 hours: Sudden, painless
• Retinal artery or vein occlusion
• Ischemic optic neuropathy (must rule out giant cell/temporal arteritis to prevent permanent bilateral vision loss)
• Vitreous or aqueous hemorrhage (hyphema)
• Retinal detachment
• Other retinal or CNS disease (e.g., cortical blindness due to occipital lobe CVA)
• Exposure (“Welder's flash”) or prolonged exposure to intense sunlight

Vision loss >24 hours: Gradual, painless
• Cataract
• Refractive error
• Open angle glaucoma
• Chronic retinopathy (e.g., age-related macular degeneration, diabetic retinopathy)
• Chronic corneal disease (e.g., corneal dystrophy)
• Optic neuropathy/atrophy (e.g., compressive lesion, toxic-metabolic cause, dominant optic neuropathy, radiation)
• Retinitis pigmentosa
• Pseudotumor cerebri

Vision loss >24 hours: Painful

• Acute angle closure glaucoma
• Optic neuritis (pain with extraocular motion)
• Orbital apex/superior orbital fissure/ cavernous sinus syndrome
• Uveitis
• Corneal hydrops (keratoconus)
• Ocular onchocerciasis (“river blindness”)
  –Common cause of blindness in developing nations due to Onchocerca volvulus worm
• Corneal abrasion or ulcer
• Herpes simplex or zoster infection

Workup and Diagnosis

• History should include age, onset, tempo of vision loss, history of trauma, associated headache, medications, past history (e.g., carotid or cardiac disease, HTN, diabetes, vertigo, migraine, syphilis, ocular, orbital, cranial radiation, keratoconus), family history of vision loss, alcohol and tobacco use
• Physical exam should include a thorough eye examination, vision acuity, refractive error, color vision, blood pressure, refractive error, cranial examination, cranial nerve innervation, intraocular pressure, ocular media opacity (corneal edema, dystrophy, anterior chamber or vitreous cells, cataracts), and fundus and optic disc exam
• Consider a visual field exam and fluorescein angiogram
• Initial laboratory evaluation may include ESR, CRP, fasting blood glucose, Hgb_A1C, PPD, RPR, FTA-ABS, ACE level, vitamin B₁₂, and folate
• Consider CT/MRI of orbits and head with contrast, carotid Doppler, echocardiogram, electroretinography, and VEP (retinal dystrophies, optic neuropathies, nonphysiologic)
• Consider ophthalmologic consultation

Treatment

• Treat underlying causes (e.g., brain tumor, carotid stenosis, cardiac valvular vegetations, hypotension)
• Temporal arteritis: Systemic steroids
• Nonarteritic ischemic optic neuropathy: Aspirin
• Optic neuritis: Systemic steroids
• Glaucoma: Topical antiglaucoma medications; peripheral iridotomy for angle closure
• Retinal detachment: Surgical repair
• Cataracts: Surgical removal
• AV fistula: Embolize
• Cavernous sinus thrombosis: Antibiotics, anticoagulation
• Mucormycosis: Amphotericin B, debridement
• Pituitary apoplexy: Systemic steroids, neurosurgical intervention
• Herpes zoster: Systemic acyclovir
• Tolosa-Hunt: Systemic steroid
• Keratoconus/corneal hydrops: Cycloplegic, hypertonic (5%) NaCl ointment, corneal transplant

Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2007 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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