Acute Visual Disturbances

Questions

The following questions will need to be repeated during your selective history and physical examination of the patient. Nonetheless, these questions, asked prior to your arrival at the bedside, will form the starting point for your diagnostic and management algorithm.

• 1.

  Is the visual disturbance in one or both eyes?

  This is the first point for anatomic localization. Visual disturbances affecting only one eye indicate pathology between the cornea and the optic chiasm. Binocular disturbances suggest lesions in the visual pathway between (and including) the chiasm and the calcarine cortex. Keep in mind that patients sometimes misinterpret asymmetric binocular vision loss as vision loss in only one eye, so it is important to examine both eyes carefully when you see the patient. In the case of double vision, neurologic causes should resolve when either eye is covered.

• 2.

  What is the nature of the visual disturbance?

  This is an elaboration of question 1. Vision can be altered in one of the following ways: monocular visual loss (temporary or persistent), bilateral visual loss (temporary or persistent), a homonymous hemifield cut, diplopia, scotomata, or positive phenomena (e.g., flashes or lines). The first description of the disturbance will assist with localization and categorization of the vision loss into specific disease entities.

• 3.

  How old is the patient?

  Certain disorders, such as ischemic optic neuropathy, retinal artery occlusion, or transient monocular vision loss (TMVL; also called amaurosis fugax), are rare in patients under 45 years of age, whereas a first presentation of multiple sclerosis (MS) with optic neuritis, idiopathic intracranial hypertension (IIH), or migraine is much more common in a younger patient.

• 4.

  Is the patient still experiencing the visual symptom?

  Although persistent acute visual loss may require immediate, specific therapy, transient visual loss in one or both eyes may be no less ominous as a warning sign for further visual, cerebrovascular, or inflammatory events.

• 5.

  When did the visual disturbance begin?

  Acute monocular or binocular blindness is a neuroophthalmologic emergency. Ischemia in the retina resulting from a central retinal artery occlusion (CRAO) and ischemia in the occipital lobes may be irreversible without acute emergent intervention. Furthermore, even if the patient presents many hours after the onset of visual loss, efficient and accurate diagnosis may prevent contralateral visual loss caused by temporal arteritis or stroke from carotid or vertebrobasilar artery disease.

• 6.

  Was there any trauma or injury to the eyes?

  Eye injury will nearly always require ophthalmologic evaluation. Because a dilated fundoscopic examination by an ophthalmologist will interfere with your ability to get an accurate assessment of pupillary reactivity, you should try to perform your assessment first.

Orders

If there has been eye trauma, if there is a preexisting ophthalmologic condition such as glaucoma, if the patient is experiencing a great deal of flashing lights in one eye indicating retinal detachment, or if you are unable to visualize the fundus in a patient with vision loss, call the ophthalmology service for consultation.

Inform RN

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