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

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

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