This document provides an overview of the diagnostic approach for acute loss of vision. It discusses the three main causes of acute loss of vision and lists specific conditions that can cause acute loss of vision with or without eye pain. For each condition, it describes suggestive clinical findings and the recommended diagnostic approach. Physical examination focuses on a complete eye exam including visual acuity, visual fields, pupil examination, and ophthalmoscopy. The interpretation of exam findings can provide clues to retinal abnormalities, retinal detachment, vein occlusion or artery occlusion. The summary aims to efficiently convey the key information on evaluating and diagnosing different causes of acute loss of vision.

1. ACUTE LOSS OF VISION
DIAGNOSTIC APPROACH
Yasser Alzainy
10/4/2018
AL-AZHAR UNIVERSITY
Faculty of Medicine
Neurology Department

2.  Acute loss of vision has 3 general causes:
 Opacification of normally transparent structures (eg, cornea, vitreous)
 Retinal abnormalities
 Abnormalities affecting the optic nerve or visual pathways

3. ACUTE LOSS OF VISION
Without eye pain
 Amaurosis fugax (transient)
 Arteretic ischemic optic neuropathy
 Non arteritic ischemic optic neuropathy
 Retinal artery occlusion
 Ocular migraine
 TIA or Stroke
 Retinal detachment
 Retinal vein occlusion
 Macular hemorrhage
 Viterous hemorrhage
 Functional
With eye pain
 Acute angle closure glaucoma
 Corneal ulcer
 Endophthalmitis
 Optic neuritis

4. HISTORY
 History of present illness: is the visual loss:
 Monocular or binocular?
 Transient or permanent?
 Pattern of onset? (acute / sudden)
 Associated symptoms
 Flashing lights?
 Eye pain ( constant or with eye movement)?
 Diplopia
 Hemihyposthesia

5.  Review of systems should seek extraocular symptoms of possible causes
 Jaw or tongue claudication, temporal headache, proximal muscle pain, and stiffness (giant cell arteritis)
 headaches (ocular migraine).
 Past medical history should seek known risk factors for
 Eye disorders (contact lens use, severe myopia, recent eye surgery or injury),
 Vascular disease (eg, diabetes, hypertension)
 Hematologic disorders (eg, sickle cell anemia or disorders such as Waldenström macroglobulinemia or multiple
myeloma that could cause a hyperviscosity syndrome).
 Family history
 migraine headaches.

6. PHYSICAL EXAMINATION
 If the diagnosis of a transient ischemic attack or ischemic stroke is under consideration, a complete
neurologic examination is done.
 The temples are palpated for pulses, tenderness, or nodularity over the course of the temporal artery.
However, most of the examination focuses on the eye.

7. EYE EXAMINATION
 Visual acuity.
 Color vision is tested with color plates.
 Peripheral visual fields are assessed by confrontation.
 Central visual fields are assessed by Amsler grid.
 Direct and consensual pupillary light reflexes.
 Ocular motility is assessed.
 Color vision is tested with color plates.

8. EYE EXAMINATION
 The eyelids, sclera, and conjunctiva are examined using a slit lamp if possible.
 The cornea is examined with fluorescein staining.
 The anterior chamber is examined for cells and flare in patients who have eye pain or conjunctival
injection.
 The lens is checked for cataracts using a direct ophthalmoscope, slit lamp, or both.
 Intraocular pressure is measured.
 Ophthalmoscopy

9. INTERPRETATION
 Retinal abnormalities that are severe enough to cause acute loss of vision are detectable during
ophthalmoscopy
 Retinal detachment may show retinal folds
 Retinal vein occlusion may show marked retinal hemorrhages
 Retinal artery occlusion may show pale retina with a cherry-red fovea.

10. RETINAL DETAHCMENT

11. RETINAL VEIN OCCLUSION

12. RETINAL ARTERY OCCLUSION

13. GENERAL RULES
 Monocular symptoms suggest a lesion anterior to the optic chiasm.
 Bilateral, symmetric (homonymous) visual field defects suggest a lesion posterior to the chiasm.
 Constant eye pain suggests a corneal lesion (ulcer or abrasion), anterior chamber inflammation, or
increased intraocular pressure, whereas eye pain with movement suggests optic neuritis.
 Temporal headaches suggest giant cell arteritis or migraine.

14. AMAUROSIS FUGAX
Suggestive findings
 Monocular blindness lasting minutes to hours
 Typically less than 5 minutes
Diagnostic approach
 Carotid U/S
 Echo
 MRI
 ECG / Holter ECG

15. ARTERITIC ISCHEMIC OPTIC NEUROPATHY (AION)
Suggestive findings
 Headache
 Jaw or tongue claudication
 Temporal artery tenderness or swelling
 Pale and swollen disk with surrounding
hemorrhages
 Occlusion of retinal artery or its branches
 Proximal myalgia (PMR)
Diagnostic approach
 ESR, C-reactive protein (CRP), platelet count
 Temporal artery biopsy

16. NONARTERITIC ISCHEMIC OPTIC NEUROPATHY
Suggestive findings
 Optic disk oedema and haemorrhages
 Sometimes loss of inferior and central visual
fields
 Risk factors (e.g. diabetes, hypertension,
hypotensive episode)
Diagnostic approach
 ESR, CRP, and platelet count
 Consideration of temporal artery biopsy to
exclude giant cell arteritis

17. OCULAR MIGRAINE
Suggestive findings
 Scintillating scotomata, mosaic patterns, or
complete loss of vision lasting usually 10–60 min
and often followed by headache
 Often in young patients
Diagnostic approach
 Clinical evaluation

18. SCINTILLATING SCOTOMA

19. RETINAL ARTERY OCCLUSION
Suggestive findings
 Nearly instantaneous onset, pale retina, cherry-
red fovea, sometimes Hollenhorst plaque
(refractile object at the site of arterial occlusion)
 Risk factors for vascular disease
Diagnostic approach
 ESR, CRP, and platelet count to exclude giant
cell arteritis
 Carotid ultrasonography
 Echocardiography
 Consideration of MRI or CT
 ECG
 Continuous monitoring of cardiac rhythm

20. HOLLENHORST PLAQUE

21. TIA OR STROKE
Suggestive findings
 Bilaterally symmetric (homonymous) field
defects, no effect on visual acuity in the intact
parts of the visual field (bilateral occipital lesions
are the exception and are uncommon but can
occur due to basilar artery occlusion)
 Risk factors for atherosclerosis
Diagnostic approach
 Carotid ultrasonography
 Echocardiography
 Consideration of MRI or CT
 ECG
 Continuous monitoring of cardiac rhythm

22. PCA STROKE

23. OPTIC NEURITIS
Suggestive findings
 Mild pain with eye movement, afferent pupillary
defect (occurs early)
 Visual field defects, typically central
 Abnormal color vision testing results
 Sometimes optic disk edema
Diagnostic approach
 Gadolinium-enhanced MRI to diagnose multiple
sclerosis and related disorders

24. FUNCTIONAL LOSS OF VISION (UNCOMMON)
Suggestive findings
 Normal pupillary light reflexes, positive
optokinetic nystagmus, no objective
abnormalities on eye examination
 Often inability to write name or bring
outstretched hands together
 Sometimes indifferent affect despite severity of
claimed loss of vision
Diagnostic approach
 Clinical evaluation
 If diagnosis is in doubt, ophthalmologic
evaluation and visual evoked responses

25. CASE EXAMPLE

26. HER FUNDUS …. WHAT IS THE DIAGNOSIS?
 Papilledema
 Giant cell arteritis
 Posterior ischemic optic neuropathy
 Acute optic neuritis
 Anterior ischemic optic neuropathy

29. Thanks you.