Approach to the adult with acute persistent visual loss
- Thellea Leveque, MD, MPH
Thellea Leveque, MD, MPH
- Acting Assistant Professor, Department of Ophthalmology
- University of Washington School of Medicine
Acute vision loss is a frightening experience for patients and has the potential for long-term visual consequences. The many causes of acute vision loss and the time-sensitive need for evaluation and treatment pose diagnostic and therapeutic challenges .
A careful history is key to narrowing the differential diagnosis and will allow for a more focused physical examination. Prompt diagnosis and treatment may influence the visual outcome.
This topic will present an overview of the approach to patients with acute persistent visual loss. Transient visual loss, the differential diagnosis of the red eye, and specific causes of acute vision loss are discussed separately. (See "Amaurosis fugax (transient monocular or binocular visual loss)" and "Evaluation of the red eye".)
DEFINITION OF TERMS
Acute transient visual loss (TVL) is defined as a sudden deficit in visual function in one or both eyes lasting less than 24 hours. It is caused by a temporary vascular occlusion in the circulation to the eye or visual cortex, or by neuronal depression after a seizure or migraine . Acute persistent visual loss (PVL) may be defined as lasting at least 24 hours and is typically not caused by transient ischemia . (See "Amaurosis fugax (transient monocular or binocular visual loss)".)
To achieve clear vision, light must follow an unhindered path from the front to the back of the eye, traveling through the cornea, aqueous humor, lens, and vitreous humor to the retina (figure 1). Refracted by the cornea and lens (and perhaps also by glasses or contact lenses), light is focused onto the retina where it is transformed into an electrochemical signal by photoreceptors and supporting cells. The signal is transmitted via the optic nerve through the visual pathways to the occipital lobes.
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- DEFINITION OF TERMS
- Media problems
- - Keratitis
- - Corneal edema
- - Hyphema
- - Lens changes
- - Vitreous hemorrhage
- - Uveitis
- Retinal problems
- - Retinal artery occlusion
- - Retinal vein occlusion
- - Retinal detachment
- - Acute maculopathy
- Optic nerve problems
- - Ischemic optic neuropathy
- - Optic neuritis
- - Papilledema
- Chiasmal problems
- Retrochiasmal disorders
- - Homonymous hemianopia
- - Cortical blindness
- Psychogenic problems
- APPROACH TO THE PATIENT
- Physical examination
- Patient triage
- Immediate treatment
- - Central retinal artery occlusion
- - Giant cell arteritis
- - Acutely elevated intraocular pressure
- Emergent referral