Blurred vision resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D., Wajeeha Aiman, M.D.[2]

Synonyms and Keywords: blurry vision management, blurry vision diagnosis, blurry vision, treatment, blurry vision workup

Overview

Blurred vision is a very common visual complaint with ophthalmologic or neurologic conditions. It is an inability to see small details clearly and sharply. Decreased visual clarity can develop gradually or suddenly depending on the cause of the symptom. Refractory errors are the major causes of blurred vision complaints. Therefore most of these vision issues can be corrected with glasses. Any disease affecting eyes can cause blurriness in vision. To guide the diagnosis of blurred vision it is important to know the details like duration, progression, near or farsighted, permanent or transient, uniocular or binocular, and associated symptoms.

Causes

Life-Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Eye Trauma
• Glaucoma
• Stroke
• Brain tumor
• Retinal detachment
• Optic neuritis
• Transient ischemic attack

Common Causes

• Age related macular degeneration
• Cataract
• Diabetic retinopathy
• Myopia
• Migraines
• Dry eyes
• Presbyopia
• Need for corrective lenses
• Uveitis
• iritis
• Adverse effect (medicine)

Diagnosis

Shown below is an algorithm summarizing the diagnosis of blurred vision according to the American Academy of Ophthalmology guidelines.

Individual with blurry vision

Characterize • Onset (sudden or gradual) • Duration of symptoms • Progression • Near or far sight • Binocular or uniocular • Permanent or transient

Associated symptoms

Symptoms suggestive of eye etiology • Dry eye •EOM paralysis • Headache • Double vision • Red eyes • Pain in the eyes • Squinting

Non-specific symptoms • Tearing • Rhinorrhea • Fatigue • Nausea • Lethargy

Symptoms suggestive of neurologic etiology • Transient previous episodes • Unilateral headache • Nausea/vomiting • Loss of consciousness • Altered mental status

Inquire about past medical risk factors

Other causes • Hypoglycemia • Medication side effects or overuse • Infectious diseases • Endocrinologic diseases • Hyperviscosity • HIV • Poisoning (mushrooms)

Ophthalmologic diseases • Keratitis • Refractory blurred vision • Diabetic retinopathy • Optic neuritis • Macular degeneration • Iritis

Neurologic disorders • AV malformations (AVF) • Previous history of migraines • Diagnosis of MS • Trauma leading to concussion or hematoma • Stroke

Examine the patient

Vital signs • Fever (when infection suspected) • Heart rate (tachycardia, bradycardia) • Blood pressure (hypertension) • Tachypnea General appearance • Pale • Diaphoretic • Severe distress Neck • JVD Eye examination • Dilated fundus exam • Slit lamp examination • Visual acuity • Dry or irritated eyes • Improvement of vision Ear, nose and throat Palpate temporal area to rule-out temporal arteritis Neurologic exam if necessary

Order labs and tests according to suspected etiology • CBC • Random and fasting blood sugar (repeat test if initial measure is elevated) • Partial thromboplastin time (PTT) • Prothrombin time (PT) • ESR (important to rule-out temporal arteritis) • EEG (if seizures are suspected)

Verify if blurred vision has any findings suggestive of ophthalmologic etiology • Squint • Dry eye • Pain • Refractory error • Floaters • Conjunctivitis (red eye)

Treatment

Treatment of blurry vision will vary depending on the underlying cause:

• To view the treatment of conjunctivitis click here.
• To view the treatment of optic neuritis click here.
• To view the treatment of iritis click here.
• To view the treatment of macular degeneration click here.
• To view the treatment of keratitis click here.
• To view the treatment of Sjogren's syndrome click here.
• To view the treatment of EOM paralysis click here.
• To view the treatment of glaucoma click here.
• To view the treatment of presbyopia click here.
• To view the treatment of migraines click here.

Dos

• Ask the patient for the time of onset and how he/she first noticed the symptoms.
• Ask if the presentation was sudden in onset, or if it was gradual.
• Ask if it occurred with or without pain.
• Ask if the blurry vision was unilateral or bilateral.
• Ask for any associated conditions or events, such as auras before migraines or focal neurologic signs.
• Ask if any history of blunt trauma, penetrating injury, or exposure to a foreign body.
• Ask for the recent use of any medications such as steroids (systemic, injectable, topical, or inhaled), as these may be associated with cataracts, glaucoma, and keratitis.
• Ask for any family history of glaucoma or macular degeneration.
• Ask for any personal history of symptoms similar to the current ones.
• Test eyes one at a time; the patient should have their contact lenses or glasses in place if these are normally worn.

Don'ts

• Do not use topical corticosteroids regularly, since they may be associated with the development of cataracts, glaucoma, and reactivation of herpes simplex virus infection.