Acute Vision Loss
Cardinal Presentations / Presenting Problems, Ears, Eyes, Nose, and Throat
- Vision loss is a fairly common presentation to the emergency department, accounting for up to 2% of presentations. The role of the emergency physician is to narrow down a differential, initiate any urgent treatment, assess for neurologic or metabolic causes, and decide on an appropriate timeline for referral to ophthalmology.
- Acute vision loss is usually defined as a significant loss of any part of the visual field that occurs over minutes to hours. However, complaints of a sudden change in chronic vision loss, or vision loss of a slower but significant progression may also need to be managed urgently.
- All objectively measured, sudden vision loss requires urgent referral to ophthalmology, unless there is an obvious diagnosis, such as stroke, which requires non-ophthalmologic management.
Delayed referral to ophthalmology may be considered in a small number of cases:
- Vision loss caused by a large corneal abrasion
- Vision loss that has resolved
- Vision loss with no objective change in visual acuity and no other notable clinical findings suggestive of an emergent cause
- Vision loss with a metabolic or systemic cause being managed by another specialist or requiring admission (eg optic neuritis or toxic optic neuropathy)
- Vision loss that has progressed over days/weeks with no obvious emergent cause
- All patients with a complaint of vision loss require:
- VA (visual acuity)
- Pupils (including assessment for a Relative Afferent Pupil Defect)
- Confrontational visual fields
- IOP (intraocular pressure) see procedural video: Using a tonometer
- Extraocular movements
- CNs and a screening neurologic exam
- Vision loss can be traumatic or nontraumatic, monocular or binocular, transient or persistent, and painful or painless.
Vision loss associated with trauma
- All patients with vision loss associated with trauma require urgent assessment by ophthalmology. If accessible a CT of the orbits +/- head is useful to assess for bony involvement, associated injuries, and a retrobulbar hematoma. Patients at risk for globe rupture should have the eye shielded and be seen urgently by ophthalmology. Patients with vision loss and signs of orbital compression syndrome clinically or on CT require a lateral canthotomy (video). Depending on the time to access ophthalmology, this may be performed by the emergency physician. Any chemical injury needs to be immediately irrigated copiously until the pH is neutralized.
Transient vision loss
- Sudden transient vision loss (<24 hrs) is concerning for vascular causes. A stroke work up including CT head +/- CT Angiogram, ECG, bloodwork (CBC, Cr, INR/PTT), and outpatient referral for an echo, carotid dopplers, and neurology follow up is appropriate. If no obvious vascular cause is seen, outpatient assessment by ophthalmology is still appropriate to assess the optic nerve and rule out retinal causes.
Bilateral vision loss
- Partial or total bilateral vision loss is suggestive of an intracranial lesion, increased ICP, or a metabolic cause and requires a work-up including CT head, ECG, and bloodwork (CBC, Cr, INR/PTT, ESR/C-Reactive Protein). If no cause is found, these patients will require urgent assessment by ophthalmology or admission to neurology or internal medicine if their vision loss is severe.
Painless vision loss
- Sudden vision loss without pain is most suggestive of a retinal detachment, central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), vitreous hemorrhage, macular disorders, optic neuropathies (including GCA) or cortical blindness.
- Sudden vision loss in patients over 50 should prompt investigation for temporal arteritis. This should include assessment of an ESR (or C-Reactive Protein if unavailable) and urgent referral to ophthalmology to assess the optic nerve.
Painful vision loss
- Sudden painful vision loss is most suggestive of acute angle closure glaucoma, endophthalmitis, uveitis, optic neuritis, corneal abrasion, keratitis, orbital compartment syndrome, or trauma or corneal abrasion.
- Painful vision loss requires assessment of the anterior chamber with application of tetracaine to assess response, slit lamp examination (video), and fluorescein to assess for corneal trauma, ulcer, or keratitis as a cause.
- Painful vision loss associated with an increased IOP (>30) should be treated with:
- Acetazolamide 500 mg oral
- Pilocarpine 2% stat (4% in dark irides)
- Timolol 0.25% stat
- Apraclonidine 1% stat
- Dexamethasone 0.1% stat
- Lie patient supine
- Analgesics and antiemetics as indicated
- Consider corneal indentation with moistened cotton bud: 2-3 cycles, 30 seconds on 30 seconds off.
Note: if ophthalmology unavailable, consider consulting local optometrist for referrals.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
- No studies addressing emergency presentations of acute vision loss and prognosis based on time to ophthalmology.
- No studies on emergency physicians’ ability to accurately diagnosis acute vision loss.
- Studies on treatment for central retinal artery occlusion (CRAO) have had mixed results, and treatment is generally based on expert opinion.
- Studies on treatment for glaucoma have demonstrated that acute iridotomy is the definitive treatment and that lowering IOP with medications may be vision-saving, but no treatment regimen is clearly superior.
OTHER RELEVANT INFORMATION
Sharma R, Brunette DD. Ophthalmology. In: Marx, J, editor. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Elsevier/Saunders; 2014. p. 909–30.
Walker RA, Adhikari S. Eye Emergencies [Internet] In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill Education; 2016 [cited 2017 Apr 22].
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 23, 2018
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