Vision loss

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Jyostna Chouturi, M.B.B.S [2]

Synonyms and keywords: Visual loss

Overview

Vision loss is the absence of vision where it existed before, which can happen either acutely (i.e. abruptly) or chronically (i.e. over a long period of time). It may be caused by media opacities, retinal disease, optic nerve disease, visual pathway disorders, or functional disorders, or it may be due to an abnormality in the central nervous system.

Classification

In order to gain insight into the pathophysiology of vision loss which will in turn guide treatment decisions, the signs and symptoms should be characterized:

• Unilateral
• Bilateral
• Transient
• Persistant
• Sudden
• Gradual
• Painless
• Painful
  

Pathophysiology

Media Opacity

Opacities of the clear refractive media of the eye such as the cornea, anterior chamber, lens, and vitreous humor may cause acute visual loss as manifested by blurry vision or reduced visual acuity. While pupillary reflexes may be affected, these conditions generally do not cause a relative afferent pupillary defect.

Causes of media opacity include corneal edema, hyphema, cataract and vitreous hemorrhage.

Retinal Disease

Retinal diseases may cause sudden visual loss. Because the retina is being affected, there is usually a concomitant relative afferent pupillary defect. Conditions that affect or destroy the retina include retinal detachment; macular disease (e.g., macular degeneration); and retinal vascular occlusions, the most important of which is central retinal artery occlusion.

Optic Nerve Disease

Diseases which affect the optic nerve may cause acute visual loss. Signs include an abnormal pupillary reflex, with an afferent pupillary defect when the optic nerve disease is unilateral.

The optic nerve can be affected by many diseases including optic neuritis, retrobulbar neuritis, papillitis, papilledema, glaucoma, ischemic optic neuropathy, and giant cell arteritis.

Hypoxia

The eye is very sensitive to restriction of its supply of oxygen. A dimming of vision (a brownout or greyout) accompanied by loss of peripheral perception may result from low blood pressure, shock, g-LOC (an aviation related problem) or simply standing up suddenly, especially if sick or otherwise infirm. Vision usually returns readily once the conditions restricting blood flow are lifted.

Visual Pathway Disorder

Visual pathway disorders are any problems that may impede the visual pathway. Rarely, acute visual loss is caused by homonymous hemianopia and, more rarely, cortical blindness.

Functional Disorder

The term functional disorder is now used where hysterical and malingering were historically used. This shift recognizes the inherent inability of the physician to identify the subjective experience of a patient (and thus whether that patient can truly see or not).

Causes

Transient Vision Loss (<24 hours)

• Amaurosis fugax

• Vision loss is unilateral and lasts only minutes

• Migrane

• Vision loss lasts 10-60 minutes

• Ocular ischemic syndrome (Cartoid Occlusive Disease)
• Papilledema

• Raised intracranial pressure
• Malignant hypertension

• Retinal detachment
• Sudden change in blood pressure

• Orthostatic hypotension

• Transient acute increase in thraocular pressure

• Acute Angle Closure Glaucoma
• Retro-or peribulbar hemorrhage

• Vertebrobasilar artery insufficiency

• Vision loss is bilateral and lasts minutes

• Vitreous hemorrhage
• Vitreous detachment

Vision Loss > 24 hours:Sudden, Painless

• Exposure(Welder's flash)

• prolonged exposure to intense light/sunlight

• Ischemic optic neuropathy

• To prevent permanent loss, rule out giant cell/temporal arteritis

• Other retinal or central nervous system disease

• Occipital lobe CVA causing cortical blindness

• Optic Neuritis
• Retinal artery/vein occlusion
• Retinal detachment
• Vitreous or aqueous hemmorrhage (hyphema)

Vision Loss >24 hours:Gradual, Painless

• Cataracts
• Cerebral Neoplasm
• Chronic retinopathy

• Age related macular degeneration
• Diabetic Retinopathy

• Chronic corneal disease

• Corneal dystrophy

• Corneal Ulcer
• Open angle Glaucoma
• Optic neuropathy/atrophy

• Compressive lesion
• Toxic-metabolic cause
• Radiation

• Pseudotumor cerebri
• Refractive error
• Retitnitis pigmentosa

Vision Loss >24 hours:Painful

• Acute Angle Closure Glaucoma
• Corneal hydrops

• Keratoconus

• Corneal abrasion/ulcer
• Herepes simplex/zoster
• Ocular onchocerciasis

• "River blindness"
• Onchocera volvulus worm

• Optic neuritis
• Orbital apex/superior orbital fissure/cavernous sinus syndrome
• Uveitis

Causes by Organ System

Cardiovascular	No underlying causes
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	No underlying causes
Musculoskeletal/Orthopedic	No underlying causes
Neurologic	No underlying causes
Nutritional/Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

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3

Diagnosis

History and Symptoms

History
include:

• Age
• Onset:
• Rate of loss
• Any specific trauma
• Headaches
• Medication
• Specific medical history
• Alcohol, drug and/or tabacco use

Physical Examination

Eyes

The examination should focus on:

• Acuity
• Blood pressure
• Color vision
• Cranial exam
• cranial nerve innervation
• Fundus
• Intraocular pressure
• Ocular media opacity
• Optic disc exam

Laboratory Findings

• ESR
• Fasting blood glucose
• HgBa1c
• PPD
• RPR
• FTR-ABS
• ACE level
• Vitamin B12
• Folate

MRI and CT

• CT/MRI of head and chest

Evaluation of Monocular Transient Visual Loss

Abbreviations: TVL, transient visual loss.

Monocular TVL

Does Monocular TVL Occur Only in Certain Positions of Gaze (Gaze-Evoked TVL)?

YES

NO

Orbital MRI

Structural lesion of orbit

No structural lesion of orbit

Duration of TVL?

Causes of Transient Visual Loss Based on the Duration TVL lasts seconds TVL lasts minutes TVL lasts hours Papilledema Optic neuropathy Congenital disc anomaly Thromboembolism (rare) Migraine Giant cell arteritis Thromboembolism Hypercoagulable state Antiphospholipid antibody syndrome Spontaneous hyphema Intermittent angle closure glaucoma Morning glory syndrome Peripapillary staphyloma Carotid artery dissection Venous stasis retinopathy Post-scleral buckle Spontaneous hyphema Thromboembolism Carotid stenosis Migraine

Treatment

Medical Therapy

• Systemic Steroids can be prescribed for the following:

• Temporal arteritis
• Optic neuritis
• Pituitary apoplexy
• Herpes zoster

• Nonarteritic ischemic optic neuropathy patients

• Asprin

• Cavernous sinus thrombosis

• Antibiotics
• Anticoagulation

• Corneal hydrops

• Cycloplegic,hypertonic NaCl ointment

Corneal Hydrops

Corneal transplant

Retinal Detachment

Surgical repair

Cataracts

Surgical removal

Temporal Arteritis

Temporal biopsy and steroids.

Related Chapters

• Blindness
• Eye examination
• Low vision
• Visual acuity
• Visual impairment

References

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