Visual disturbance
Visual disturbances include sudden vision loss, blurred vision, double vision, floaters, flashing lights, and visual field deficits.
Differential Diagnosis
Sudden Painless Vision Loss
- Central retinal artery occlusion (CRAO) - ophthalmologic emergency
- Central retinal vein occlusion (CRVO)
- Vitreous hemorrhage
- Retinal detachment
- Optic neuritis
- Stroke (posterior circulation)
Sudden Painful Vision Loss
- Acute angle-closure glaucoma
- Optic neuritis
- Temporal arteritis (giant cell arteritis)
- Endophthalmitis
- Corneal ulcer
Gradual Vision Change
- Cataracts
- Open-angle glaucoma
- Diabetic retinopathy
- Macular degeneration
Double Vision (Diplopia)
- Cranial nerve palsy (III, IV, VI)
- Orbital fracture
- Myasthenia gravis
- Stroke
- Thyroid eye disease
Floaters/Flashes
- Posterior vitreous detachment
- Retinal detachment (photopsia with new floaters)
- Vitreous hemorrhage
Evaluation
- Visual acuity (each eye separately)
- Pupil exam (RAPD suggests optic nerve pathology)
- Extraocular movements
- Visual fields by confrontation
- Slit lamp exam and fundoscopy
- IOP measurement if glaucoma suspected
- ESR/CRP if temporal arteritis suspected (age >50 with headache)
- CT/CTA for acute stroke with visual symptoms
Management
- CRAO: ophthalmology emergency consultation, time-sensitive
- Acute angle-closure: timolol, pilocarpine, acetazolamide, emergent ophthalmology
- Temporal arteritis: high-dose IV methylprednisolone, do not delay for biopsy
- Retinal detachment: urgent ophthalmology referral
- Stroke: follow Stroke (main) protocol
Disposition
- Admit for stroke, temporal arteritis, or endophthalmitis
- Emergent ophthalmology for CRAO, acute angle-closure, retinal detachment
- Urgent ophthalmology follow-up (24-48h) for CRVO, vitreous hemorrhage
- Routine follow-up for stable floaters with normal exam