Some Causes of Acute Vision Loss
Cause | Suggestive Symptoms or Signs | Diagnostic Approach |
|---|---|---|
Acute loss of vision without eye pain | ||
Amaurosis fugax | Monocular blindness lasting minutes to hours (typically < 5 minutes when due to cerebrovascular disease) Sometimes Hollenhorst plaque (refractile object at the site of arterial occlusion) Sometimes normal eye examination |
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Arteritic ischemic optic neuropathy (usually in patients with giant cell [temporal] arteritis) | Sometimes pale and swollen optic disk with surrounding hemorrhages, occlusion of retinal artery or its branches Sometimes only vision loss Sometimes headache, jaw or tongue claudication, temporal artery tenderness or swelling Sometimes proximal myalgias with stiffness (due to polymyalgia rheumatica) | Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelet count Temporal artery biopsy |
Functional loss of vision (uncommon) | Normal pupillary light reflexes, positive optokinetic nystagmus, no objective abnormalities on eye examination Sometimes exaggerated severity of an organic eye disorder Often inability to write name or bring outstretched hands together Sometimes indifferent affect despite severity of claimed loss of vision | History and physical examination If diagnosis is in doubt, ophthalmic evaluation and visual evoked responses |
Macular hemorrhage due to neovascularization in age-related macular degeneration | Blood within or deep to retina in and around the macula | Ophthalmic evaluation |
Nonarteritic ischemic optic neuropathy | Optic disk edema and hemorrhages Sometimes loss of inferior and central visual fields Risk factors (eg, diabetes, hypertension, hypotensive episode) | ESR, CRP, and platelet count Consideration of temporal artery biopsy to exclude giant cell arteritis |
Ocular migraine | Scintillating scotomata, mosaic patterns, or complete loss of vision lasting usually 10–60 minutes and often followed by headache Bilateral, but may be seem monocular if the scotoma is off-center (ie, a visual disturbance in the right hemifield of both eyes might be perceived as in the right eye only) Often in young patients | History and physical examination, including ophthalmic examination |
Nearly instantaneous onset, sometimes Hollenhorst plaque (refractile object at the site of arterial occlusion) Pale retina and cherry-red fovea only visible after several hours from onset Sometimes Hollenhorst plaque (refractile object at the site of arterial occlusion) Risk factors for vascular disease |
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Recent increase in floaters, photopsias (flashing lights), or both Visual field defect Abnormal retinal examination (eg, detached retina appears as a pale billowing parachute) Risk factors (eg, trauma, eye surgery, severe myopia; in men, advanced age) | Ophthalmic evaluation Sometimes ocular ultrasonography | |
Frequent, multiple, widely distributed retinal hemorrhages Risk factors (eg, diabetes, hypertension, hyperviscosity syndrome, sickle cell anemia) | Ophthalmic evaluation | |
Bilaterally symmetric (homonymous) field defects, no effect on visual acuity in the intact parts of the visual field (bilateral occipital lesions are the exception and are uncommon but can occur due to basilar artery occlusion) Risk factors for atherosclerosis |
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Vitreous hemorrhage | Previous floaters or spider web in vision Risk factors (eg, diabetes, retinal tear, sickle cell anemia, trauma) | Ophthalmic evaluation Possible ocular ultrasonography to assess retina |
Acute loss of vision with eye pain | ||
Halos around lights, nausea, headache, photophobia, conjunctival injection, corneal edema, shallow anterior chamber, intraocular pressure usually > 40 mm Hg | Immediate ophthalmic evaluation Gonioscopy | |
slit-lamp examination, or both Risk factors (eg, injury, contact lens use) | Ophthalmic evaluation | |
Floaters, conjunctival injection, decreased red reflex, hypopyon, or a combination Risk factors (infection after eye surgery or ocular injection, traumatic ruptured globe, intraocular foreign body [eg, after hammering metal on metal], fungemia, or bacteremia) | Immediate ophthalmic evaluation with microbiologic testing (eg, Gram stain and culture of aspirates for endogenous endophthalmitis, blood and urine cultures) | |
Usually mild pain with eye movement, afferent pupillary defect (occurs early) Visual field defects, typically central Abnormal color vision testing results Sometimes optic disk edema | Gadolinium-enhanced MRI to diagnose multiple sclerosis and related disorders | |