Resident Editor: Patrick Azcarate, MD
Faculty Editor: Jennifer Tu, OD, FAAO
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BOTTOM LINE ✔ Evaluate for emergency causes first ✔ Ask about time course, prior episodes, and associated symptoms ✔ Avoid topical anesthetics or corticosteroids until recommended by Ophthalmology |
Background
- Sudden visual acuity change or vision loss can be an ophthalmologic emergency.
- The key is to promptly identify potentially vision-threatening conditions and refer early as appropriate.
- If concurrent red eye, consider: anterior uveitis, corneal abrasion/ulcer, trauma, foreign body, hyphema, episcleritis, scleritis, keratitis, orbital cellulitis, angle-closure glaucoma, chemical burn, and thermal/UV keratopathy.
- This chapter will focus on etiologies not detailed in The Red Eye.
Signs and Symptoms
Assess:
- Tempo: acute vs chronic; recurrent vs non-recurrent
- Unilateral vs. Bilateral
- Visual acuity loss vs visual field deficit vs diplopia (see Figure 2)
- Associated symptoms (e.g., eye pain, floaters or other abnormal spots, headache, neurologic deficits, constitutional symptoms)
- Pertinent Co-morbidities (e.g., migraine, DM, HTN, CVA, inflammatory disorder, malignancy)
- Relevant Meds (e.g., anticholinergics, rifabutin, hydroxychloroquine, sildenafil)
- Recent Procedures/trauma/psychological stress
- Use of corrective lenses, esp. contact lenses
Etiologies of Blurred Vision
Chronic:
- Refractive error: myopia, hyperopia, astigmatism, presbyopia
- Related to ocular disease: cataract, macular degeneration or other macular disorder, glaucoma, corneal dystrophy/degeneration/scar, strabismus, pterygium, blepharitis, dry eyes
- Related to systemic disease or condition: poorly-controlled DM, trauma, pituitary adenoma, idiopathic intracranial hypertension (IIH), stroke
- Related to medication use: Plaquenil, Ethambutol, Topamax, Corticosteroids
Acute:
- Trauma: (micro)hyphema, iritis, cataract, retinal detachment, macular hole
- Infectious: conjunctivitis, corneal ulcer, endophthalmitis, retinitis
- Inflammatory: uveitis (episcleritis, scleritis, iritis, trabeculitis, vitritis, retinitis, optic neuritis)
- Vascular: ischemic optic neuropathy, retinal artery/vein occlusion, cranial neuropathy
- Neoplastic: ocular melanoma, choroidal metastasis, cancer-associated retinopathy
Evaluation
- See the Ocular Exam section under Eye Anatomy and Physical Exam chapter for details of tests, with a focus on: visual acuity, direct observation, and ophthalmoscopy.
- Be sure to check if visual acuity improves with pinhole occlusion—this indicates refractive error
Treatment
- Determine the cause of the vision change and if emergent intervention is needed to preserve vision
- Manage underlying co-morbidities or stop potentially offending medications contributing to blurred vision. Never prescribe topical anesthetics/corticosteroids alone or with antibiotics unless done in consultation with an ophthalmologist.
General approach
- See flow chart
Common Causes
|
Cause |
Specific Etiologies |
Typical Presentation |
Management |
|---|---|---|---|
|
Refractive Error |
Myopia (nearsightedness), hyperopia (farsightedness), astigmatism, presbyopia (age related loss of accommodation leading to impaired near vision) |
Gradual onset, painless, bilateral, responsive to correction with pinhole occluder or refractive lenses |
Routine referral for prescription corrective lenses |
|
Acquired Cataracts |
Age-related, metabolic (e.g., DM), trauma, chronic anterior uveitis, meds (steroids, phenothiazines,), prior ocular surgery (glaucoma filter, vitrectomy) |
Progressive blurring over months to years with both near and far vision affected, glare, decreased color vision diminished red reflex, difficulty visualizing fundus |
Routine referral for surgical extraction |
|
Age-Related Macular Degeneration |
Idiopathic but risk factors include: age, genetics, HTN, hyperlipidemia, smoking Dry: accumulation of drusen/macular atrophy Wet: Dry signs AND choroidal neovascularization |
Rapid or gradual onset of central vision loss with central scotomas Drusen (yellow macular exudates), macular or vitreous hemorrhage |
Amsler grid test Urgent referral for intravitreal anti-VEGF |
|
Migraine |
Classic migraine with aura Possible precipitants: OCPs, EtOH, stress, tyramine foods |
Temporary visual defects usually precede migraine HA sxs but can occur without (acephalegic migraine). Normal neuro exam. |
Identify and avoid precipitants Prophylactic and/or abortive migraine therapy |
|
Medications |
Reversible: amiodarone, retinoids, tamoxifen, linezolid, sildenafil Irreversible: ethambutol, hydroxychloroquine |
Varies |
Stop offending meds and seek alternatives if possible |
|
Optic Neuritis |
MS, other demyelinating conditions, viral infections, syphilis, granulomatous disorders, meds (e.g., ethambutol), idiopathic |
Onset over days, usually unilateral, pain with eye movement, focal neuro sxs Visual field defects, decreased color vision, afferent pupillary defect, normal or edematous optic disc |
Assess full neuro exam for MS Consider CBC, RPR, ESR, CRP Brain MRI with gadolinium High-dose pulse systemic steroids Urgent referral: eval for other ocular disease |
|
Functional Loss |
Conversion disorder Malingering |
Acute onset, recent severe psychological trauma, history of seeking personal gain |
Reassurance, possible Psych referral Routine referral for further evaluation to r/o organic blindness |
Ophthalmologic Emergencies
|
Cause |
Specific Etiologies |
Typical Presentation |
Management |
|---|---|---|---|
|
Retinal Artery Occlusion |
Emboli, atherosclerotic, hypercoaguable states, meds (e.g., OCPs, diuretics), collagen vascular diseases, giant cell arteritis |
Acute painless vision loss/field defect, can be transient (amaurosis fugax) or permanent Afferent papillary defect, retinal whitening, retinal arteriolar “box-carring”, Hollenhorst plaques, cherry-red spot |
Urgent ophtho referral
Check BP, foused PE on carotids, CV, and neuro.
If age>50: -If embolus identified, perform embolic W/U: carotid U/S, cardiac echo, Holter, EKG and start ASA
-If concurrent headache/PMR, jaw claudication: GCA evaluation and start high dose steroids
If age<50: hypercoag W/U and start anticoagulation
|
|
Retinal Vein Occlusion |
HTN, atherosclerotic, hypercoaguable states, meds (e.g., OCPs, diuretics) |
Subacute onset, usually unilateral, can be transient or permanent +/- afferent pupillary defect, extensive retinal hemorrhage, dilated/tortuous veins, cotton wool spots, optic disc swelling |
Urgent ophtho referral for possible photocoagulation/intravitreal anti-VEGF injections
Check BP and other pertinent PE based on suspected etiology
Consider fasting glucose, A1c, CBC, coags, lipid panel, ESR, ANA
Stop offending meds
|
|
Retinal Detachment |
Recent eye surgery or trauma, DM or sickle cell retinopathy, high myopia, malignant HTN, neoplasm, may be spontaneous without clear inciting cause |
“Flashing lights” , floaters, “curtain” moving over to obscure field of vision, periph/central visual field loss Abnormal visual acuity and visual field testing, +/- afferent pupillary defect |
Emergent referral for surgical repair |
|
Giant Cell Arteritis |
Inflammation of medium and large vessels with elastic lamina, primarily of the head (but also aortic arch and branches) |
Usually unilateral but can progress to bilateral, HA, scalp tenderness, jaw claudication, fever Palpable but nontender and nonpulsatile temporal artery, afferent pupillary defect, pale swollen optic disc, possible flame-shaped hemorrhages, +/- CN 3/4/6 palsies |
Immediate steroids (Solumedrol 250mg IV q6h x 12 doses, then prednisone 80-100mg PO daily until path returns), and consider ulcer ppx Check ESR and CRP stat, temporal artery biopsy can still be done within 1 week of starting steroids Emergent referral |
|
Endophthalmitis |
Recent eye surgery or trauma, retained foreign body, septic emboli, fungemia |
Eye redness, floaters, +/- pain Conjunctival injection, discharge, hypopyon, diminished red reflex |
Emergent referral for intravitreal antibiotics or vitrectomy if severe |
References
Eva PR, Pascoe PT, Vaughan DG. Refractive change in hyperglycaemia: hyperopia, not myopia. Br J Ophthalmol 1982;66:500-505.
Fraunfelder FW and Fraunfelder FT. Adverse ocular drug reactions recently identified by the National Registry of Drug-Induced Ocular Side Effects. Ophthalmology. 2004. 111(7): 1275 – 1279.
Li J, Tripathi RC, Tripathi BJ. Drug-induced ocular disorders. Drug Safety 2008;31(2):127-141.
Palay DA and Krachmer JH (2005). Primary Care Ophthalmology. 2nd Edition. Elsevier Mosby.
Shingleton BJ and O’Donoghue MW. Blurred vision. N Eng J Med 2000;343:556-562.
Skuta GL, Cantor LB, Weiss JS. Fundamentals and Principles of Ophthalmology. 2012. American Academiy of Ophthalmology.