Acute Loss of Vision: Non-Traumatic

Introduction

Acute loss of vision is a true ophthalmic emergency. All patients should be assessed urgently in the ED. See Chart differential here – Acute Loss of Vision: Non-Traumatic (Chart)

Classification:

• Transient vs Persistent
• Painless vs Painful
• Monocular vs Binocular

Terminology

Term	Definition
Persistent visual loss	Lasts > 24 hours — typically not due to transient ischaemia
Transient visual loss	Sudden visual deficit < 24 hours, can be due to vascular, neuronal, or migraine causes

Pathology

Acute Painless Loss of Vision

1. Migraine

• Homonymous hemianopia common
• Pain may be present but not globe-related
• May occur without headache

2. Amaurosis Fugax

• Sudden monocular loss of vision
• Indicates high-risk TIA/stroke
• Due to thromboembolism from heart/carotids/retinal arteries

3. Cerebral Ischaemia

• TIA or Stroke affecting:
  • Optic tract
  • Lateral geniculate body
  • Optic radiations
  • Visual cortex
• Causes homonymous hemianopia, no ocular findings

4. Central Retinal Artery Occlusion (CRAO)

• Sudden profound monocular vision loss
• Fundoscopy: retinal pallor, cherry-red spot

5. Central Retinal Vein Occlusion (CRVO)

• Subacute onset, monocular
• Fundoscopy: “blood and thunder” appearance

6. Vitreous Haemorrhage

• Monocular, fundus may be obscured
• May follow retinal detachment

7. Retinal Detachment

• Floaters, flashes, curtain over vision
• May progress to central vision loss
• Fundoscopy: elevated retina with folds, +/- RAPD

8. Pituitary Apoplexy

• Sudden bilateral vision loss + headache
• Requires urgent MRI (CT may miss)

9. Acute Maculopathy

• Central scotoma, blurred/distorted vision
• Often secondary to leakage, oedema or haemorrhage in macula

10. Optic Neuritis (Papillitis only)

• Painless, papilloedema on fundoscopy

11. Retinal Poisons

• Bilateral loss; associated with:
  • Quinine
  • Methanol

12. Psychogenic Visual Loss

• May be unilateral or bilateral
• Often bizarre presentation

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Acute Painful Loss of Vision

1. Acute Glaucoma

• Severe pain, red eye, cloudy cornea, fixed mid-dilated pupil

2. Infections

Condition	Notes
Orbital cellulitis	Can cause optic nerve damage
Hypopyon	Pus in anterior chamber
Endophthalmitis	Infection in vitreous/aqueous — consider intraocular FB

3. Giant Cell Arteritis

• Elderly, temporal tenderness, raised CRP/ESR

4. Optic Neuritis (Retrobulbar)

• Pain worse on eye movement
• Papilloedema if disc involved

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Clinical Assessment

History

1. Laterality — monocular or binocular
2. Duration — transient or persistent
3. Pain — present or absent
4. Visual phenomena — flashes/floaters
5. Toxin exposure — e.g. methanol, quinine

Examination

Step	Details
Visual acuity	Record both eyes; check light perception if severe
Visual fields	Determine if global loss, field deficit or scotoma
Slit lamp	Check for corneal changes, hypopyon, hyphema, fixed pupil
Fundoscopy	CRAO, CRVO, vitreous haemorrhage, retinal detachment, papilloedema
IOP check	If glaucoma suspected

Investigations

Test	Indication
FBC, U&Es, glucose	Routine screen
CRP/ESR	Suspected GCA
Coags, procoags	If vascular or bleeding concerns
B-scan US	For suspected retinal detachment / haemorrhage where fundoscopy is limited
CT brain/orbits	Evaluate for haemorrhage, stroke, apoplexy, mass
ECG, Echo, Carotid imaging	If amaurosis fugax or embolic cause suspected

Management

• Guided by underlying cause
• Treat urgently if:
  • CRAO/CRVO
  • Retinal detachment
  • Acute glaucoma
  • GCA (start steroids immediately if suspected)

Disposition

• All persistent visual loss requires urgent ophthalmology review
• Neurology referral (Code Stroke) for TIA/stroke symptoms (including amaurosis fugax)

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References

FOAMed

• Nickson C. Ophthalmology Befuddler. Clinical Cases. LITFL
• Hayes J. Acute Loss of Vision: Non-Traumatic (Chart). FFS

Publications

• The Eye Emergency Manual, NSW Department of Health, 2nd ed. 2009