• Differential Diagnosis
  • Acute Vision Loss based on pain
  • Differential Diagnosis
  • Acute Bilateral Vision Loss or Blurred Vision
  • Risk Factors
  • Acute Vision Loss predisposing factors
  1. Diabetes Mellitus
  2. Hypertension
  3. Hyperlipidemia
  4. Hypercoagulable States
  5. Cardiac Arrhythmias (esp. Atrial Fibrillation, risk of embolic Retinal Artery Occlusion or CVA)
  6. Carotid Insufficiency
  7. Glaucoma
  8. Migraine Headaches
  9. Severe Myopia or Nearsightedness (Retinal Detachment)
  10. Recent intraocular procedures (including injections)
    1. Endophthalmitis
    2. Hypotony Maculopathy
    3. Choroidal effusion
  • History
  1. Timing: Red flags for urgent referral
    1. Very recent onset of Vision Loss (hours)
    2. Progressive symptoms
    3. First episode
    4. Sudden onset (Hemorrhage, ischemia)
  2. Lesion localization
    1. Monocular or binocular?
      1. Monocular: Ocular or Optic Nerve lesion
      2. Binocular: Optic Chiasm and posterior back to Occipital Lobe lesion
    2. Focal Visual Field Deficit?
      1. Retina and posterior back through Optic Nerve and Occipital Lobe (post-chiasm)
      2. Retinal Detachment (unilateral progressive loss peripheral to central)
      3. Amaurosis Fugax (Temporal Arteritis with transient curtain-like closure
      4. Branch Retinal Artery Occlusion (BRAO)
      5. Cerebrovascular Accident (bilateral field deficit, Hemianopia)
    3. Periocular pain?
      1. Anterior eye or Optic Nerve lesion (requires Trigeminal Nerve sensitization)
      2. Acute Angle-Closure Glaucoma
      3. Uveitis
      4. Endophthalmitis
      5. Optic Neuritis (pain with eye movement, painless at rest)
    4. Disproportionate change in color Perception
      1. Optic Neuritis (red color desaturation)
  3. Associated symptoms
    1. Nausea or Vomiting with Eye Pain
      1. Acute angle closure Glaucoma
    2. Flashes or Floaters
      1. Vitreous Hemorrhage
      2. Retinal Detachment
    3. Associated neurologic deficits
      1. Cerebrovascular Accident or other systemic cause
    4. Headache
      1. Optic Neuritis
      2. Migraine Headache with aura
      3. Pseudotumor Cerebri (Idiopathic Intracranial Hypertension)
      4. Temporal Arteritis (temporal Headache, Jaw Claudication, scalp tenderness)
  • Exam
  1. Visual Acuity (perform with prescription lenses for distance)
    1. Snellen Chart
      1. Consider Pinhole Test for Visual Acuity in a patient who did not bring their glasses to evaluation
    2. Finger Counting (CF) at 1 foot and at 6 inches
    3. Hand Movements (HM)
    4. Light Perception (LP)
    5. No light Perception (NLP): total blindness
  2. Ciliary Flush
    1. Diffuse Corneal haze
      1. Acute angle closure Glaucoma
    2. Corneal opacities (especially with Fluorescein uptake)
      1. Keratitis
  3. Visual Field Deficit
    1. visualFieldDefects.jpg
    2. Monocular Blindness
      1. Optic Nerve lesion
      2. Transient Monocular Blindness (Amaurosis Fugax, Central Retinal Artery Occlusion)
    3. Homonymous Hemianopia (field cut affects both eyes in same region)
      1. Occipital lesion
    4. Bitemporal Hemianopia
      1. Bilateral peripheral Vision Loss suggests Optic Chiasm lesion
  4. Pupil abnormality
    1. EyePupillaryReaction.png
    2. Mid-dilated non-reactive pupil
      1. Acute Angle-Closure Glaucoma
    3. Relative Afferent Pupillary Defect (sluggish or absent pupil response to light, but consensual reflex)
      1. Optic Neuritis
      2. Retinal lesion
      3. Central Retinal Artery Occlusion
      4. Large Retinal Detachment
      5. Temporal Arteritis
  5. Funduscopic Exam
    1. Retinal Detachment
      1. Affected Retina will have the pale billowing appearance of a parachute
      2. In non-dilated Eye Exam, Ocular Ultrasound has better sensitivity
    2. Red Reflex absent or dulled
      1. Endophthalmitis
      2. Vitreous Hemorrhage
      3. Opaque Cornea
      4. Cataract
      5. Retinal Artery Occlusion
      6. Choroidal effusion
    3. Cherry red spot (red Macula)
      1. Central Retinal Artery Occlusion (e.g. Temporal Arteritis)
      2. Severe Hypertension
    4. Retinal Hemorrhage
      1. Central Retinal Vein Occlusion
      2. Other systemic causes
        1. Diabetes Mellitus
        2. Hypertension
        3. Head Trauma (or Eye Trauma)
        4. Bleeding Disorder
        5. Severe Hypertension
    5. Optic Disc swelling
      1. Ischemic Optic Neuropathy
      2. Optic Neuritis
      3. Pseudotumor Cerebri (Idiopathic Intracranial Hypertension)
  • Management
  1. Rapid assessment and management if acute CNS event is suspected
    1. See Cerebrovascular Accident
  2. Indications for emergent referral to ophthalmology
    1. Keratitis
    2. Endophthalmitis
    3. Retinal Detachment
    4. Retinal Hemorrhage or Vitreous Hemorrhage
    5. Optic Neuritis
    6. Occipital infarction
    7. Central Retinal Artery Occlusion
    8. Acute angle closure Glaucoma
    9. Ischemic Optic Neuropathy
  3. Conditions with specific immediate temporizing measures by emergency provider
    1. Central Retinal Artery Occlusion
    2. Acute angle closure Glaucoma
    3. Ischemic Optic Neuropathy
  • References
  1. Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
  2. Trobe (2012) Physician Guide to Eye Care, p. 31-35
  3. Fraser (2025) Am Fam Physician 111(1): 54-61 [PubMed]