Sudden Loss of Vision

Name: Sudden Loss of Vision - Pulse Reference
Published: 2022-08-02T05:30:51+00:00

Differential Diagnosis

Key distinguishing features of the most common diagnoses

	Acute Glaucoma	Vitreous Haemorrhage	Retinal Artery Occlusion	Migraine	TIA/CVA
Preceded by Spots and Flashing Lights	No	Possible	No	Yes	Possible
Followed by Headache	Possible	No	No	Yes	Possible
Painful Eye	Yes	No	No	No	No
Absent Red Reflex	No	Yes	No	No	No
Affected Pupil Dilated and Fixed	Yes	No	Yes	No	No

In practice, there are none worth doing at the time, as the vast majority of cases will be referred urgently. Virtually all tests will therefore be arranged by the specialist, usually after the event, to look for underlying causes. Such investigations include the following.
Screening for diabetes: Undetected retinopathy may have preceded vitreous haemorrhage.
FBC: PCV may be raised in central retinal vein occlusion.
ESR: Raised in temporal arteritis.
Multiple microbiological investigations are needed for posterior uveitis.
Posterior pole ultrasound may be useful in vitreous haemorrhage to identify treatable causes.
CT scan only useful to investigate cerebral causes (CVA or cortical blindness).

Acute visual disturbance is often difficult to diagnose accurately and very alarming for the patient. If in doubt, refer urgently, or, at the very least, review in a few hours.
The patient’s assessment of visual loss, and its severity, is highly subjective – if at all possible, test it with a Snellen chart.
Always keep spare batteries handy for your ophthalmoscope!

Don’t forget that the visual disturbance may be the presenting symptom of some other pathology, such as hypertension, temporal arteritis or diabetes.
Don’t miss a heart murmur or carotid bruit. These may be present in retinal artery occlusion and TIA/CVA.
A cherry red spot on the fovea is pathognomic of retinal artery occlusion.
Never use mydriatics to aid examination at the bedside – these will cloud the clinical picture and may even precipitate acute glaucoma.