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Vision Loss (In A Page: Pediatric Signs and Symptoms)

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Vision Loss

Sudden decrease of vision is usually an ominous sign. Most often the cause of permanent loss is at the retinal or optic nerve level. For the optic nerve to be associated there must be inflammation. For the retina to be the cause, there must be hemorrhaging or edema. Neurologic conditions are often associated with the transient variation of vision disturbances. Sudden decrease or loss of vision is invariably unilateral; if bilateral, it is associated with posterior cortex circulation or hysteria.

Differential Diagnosis

• Vascular causes
  –Amaurosis fugax: TIA of the retina lasting 5–60 minutes
  –Stroke causes loss of side vision usually to the left or right, may be interpreted as loss of vision in the right or left eye
  –Retinal vascular occlusion: Venous shows gradual decline with retinal hemorrhaging; arterial has sudden onset with minimal to no retinal hemorrhaging

• Transient monocular blindness (TMB)
  –Lasts seconds
  –Due to positional changes in optic disc edema with increased intracranial hypertension, orthostatic hypotension, thyroid eye disease, and space-occupying lesions
• Migraine variants are transient and may be associated with headache after presentation
• Optic nerve edema or swelling from demyelinating disease, nonarteritic and arteritic optic neuropathy, toxicity (e.g., lead, chloramphenicol)
• Optic atrophy
• Retinal etiologies
  –Retinal surface wrinkling disorders
  –Idiopathic central serous retinopathy often associated with stress
  –Retinal detachment with probable history of floaters before loss of vision
• Angle closure glaucoma
• Postsurgical
  –Endophthalmitis: Often associated with ocular surgery and red eye
  –Cystoid macular edema may occur after ocular surgery
• Vitreous hemorrhage
  –You will not be able to see into the eye
• Infectious causes
  –Retinitis and/or uveitis due to toxoplasmosis, cytomegalovirus, Lyme, histoplasmosis
• Trauma
• Hysterical blindness
• Cataracts
• Hypoglycemia
• Retinitis pigmentosa

Workup and Diagnosis

History
–Be aware that patients often have vision reduction over time (e.g., from cataracts) and only perceive the loss as sudden
–Onset, duration, trauma; transience vs permanence of visual loss or change
–Associated signs and symptoms of demyelinizing disease, toxoplasmosis, bartonellosis, Lyme disease
–PMH including migraines, hypertension, diabetes, thyroid disease, rheumatic disease, vascular disease, atrial fibrillation, lipid status

• Physical exam
  –Obtain visual acuity and confrontation visual fields in both eyes
  –Redness, pain, photophobia
  –Pupillary evaluation: look for Marcus Gunn pupil, which usually differentiates optic nerve from other causes
  –Extraocular muscle evaluation
  –Perform a dilated fundus evaluation
  –Evaluate for proptosis

• Radiology
  –CT or MRI of orbits and brain is indicated for associated neurologic signs, history of trauma
• Evaluation for stroke if right- or left-sided
• Ophthalmology consultation for dilated retinal exam, evaluation, and management

Treatment

• Transient symptoms are usually due to migraine, stroke, or increased intracranial pressure; appropriate therapy for these disorders
• Manage any underlying systemic disease
• If angle closure glaucoma, stat consult for immediate medical and surgical intervention
• Retinitis or uveitis: Management of underlying cause; NSAIDs and steroids
• If hemorrhage in the macula from macular degeneration or histoplasmosis, laser therapy or intravitreal steroids may save the vision
• Vitreous hemorrhage may be evacuated after establishing and treating cause
• Macular edema may be treated with topical steroids, Diamox, intravitreal steroids, NSAIDs
• Retinal vascular occlusion: Intraocular surgery or laser therapy may alleviate symptoms

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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