Loss of vision DDx

Overview

Causes of visual loss or blindness can be categorised by presence or absence of trauma, transient or persistent and monocular or binocular.

Causes

 Nontraumatic causes of transient (<24h) monocular vision loss

Common causes of non-traumatic transient visual loss include:

• amaurosis fugax (usually minutes) — usually embolic or thrombotic; can occur secondary to hypoperfusion states, hyperviscosity or vasospasm.
• migraine (can be without headache)
• one eye closed!

Uncommon causes include:

• papilloedema (may be associated with visual loss lasting seconds)
• other causes of ischemic optic neuropathy, e.g. giant cell arteritis
• impending central retinal vein occlusion (CRVO)
• glaucoma
• posterior reversible encephalopathy syndrome (PRES)
• large vessel occlusion or dissection, e.g. ocular ischemic syndrome (carotid occlusive disease), vertebrobasilar insufficiency, and carotid or vertebral artery dissection
• functional visual loss, e.g. hysteria, malingering

Nontraumatic causes of acute persistent monocular vision loss

Painless acute persistent loss of vision:

• central retinal artery occlusion (CRAO)
• central retinal vein occlusion (CRVO)
• retinal detachment or hemorrhage
• vitreous hemorrhage
• optic or retrobulbar neuritis
• internal carotid artery occlusion

Painful acute loss of vision:

• acute glaucoma
• endophalmitis
• uveitis
• keratoconus (vision can deteriorate rapidly and is associated with photophobia)

Nontraumatic causes of acute binocular loss of vision

Transient

• migraine
• vertebrobasilar insufficiency (transient)

Prolonged

• Stroke
• poisons/ toxic optic neuropathy (e.g. methanol, quinine, ethambutol, ergot alkaloids, salicylates)
• posterior reversible encephalopathy (PRES)
• optic or retrobulbar neuritis
• hysteria
• malingering

Post-traumatic causes of loss of vision

From ‘front to back’:

• lid injury
• orbital blow-out fracture
• corneal abrasion, irregularity or laceration
• hyphema
• traumatic mydriasis
• traumatic iritis
• ruptured globe
• traumatic cataract
• lens dislocation
• commotio retinae
• retinal detachment
• retinal or vitreous hemorrhage
• intra-ocular foreign body
• traumatic optic neuropathy or optic nerve avulsion
• CNS injury

Chris Nickson

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC