Author:
D. TaylorGammons
EricDeutsch
Description
- Decrease in visual function (i.e., visual acuity, visual fields, blurry vision)
- Visual loss has many etiologies and can be caused by multiple body systems
Etiology
- Primary ophthalmologic causes:
- Eyelid or tear film abnormality
- Anterior segment (cornea, anterior chamber, iris, lens)
- Posterior segment (vitreous, retina, optic nerve)
- Traumatic
- Other extraocular and systemic disorders including neurologic, cardiovascular, immunologic, endocrine, infectious, and toxicologic causes
Signs and Symptoms
History
- Characterization of visual loss:
- Degree of loss - blurry, complete, specific fields
- Acute vs. gradual onset
- Transient vs. persistent
- Monocular vs. binocular
- Painless vs. painful
- Presence of double vision
- History of trauma - blunt vs. penetrating
- History of exposures - chemicals, welding, metal or woodworking, toxin ingestion
- Use of corrective lenses - glasses, contacts
- Conjunctival erythema or discharge
- Flashing lights or floaters
- Pain with eye movement
- Prior eye surgery or problems
- Associated symptoms - headache, neurologic deficits, other systemic symptoms
- Relevant comorbidities:
- Atherosclerotic disease or risk factors
- Immunocompromised status - HIV, chronic steroids, or other immunosuppression
- Neurologic, endocrine, or immunologic disorders
- Coagulopathy
Physical Exam
- Ophthalmologic:
- Visual acuity - Snellen chart, finger counting, hand motion, light perception
- Pupil exam, afferent pupillary defect
- Confrontational visual field exam
- Extraocular muscle function
- Slit-lamp exam
- Intraocular pressure (tonometry)
- Dilated pupil exam with fundoscopy
- Fluorescein exam
- Cardiovascular - murmurs, carotid bruits temporal artery tenderness
- Neurologic exam - assess for other deficits
- General - signs of infectious, immune, endocrine, or toxicologic disorders
Essential Workup
- History and ophthalmologic exam
- Other exam, labs, and imaging should be guided by H&P
Diagnostic Tests & Interpretation
Lab
- May be helpful to determine extent of other comorbidities in association with vision loss (i.e., diabetes, cardiovascular disease, coagulopathy)
- Erythrocyte sedimentation rate if giant cell arteritis is suspected
Imaging
- Point of care US can detect lens or retinal detachment, vitreous hemorrhage, foreign bodies, or measure optic nerve diameter
- Temporal artery biopsy if giant cell arteritis is suspected
- Brain CT, MRI, MRA if central neurologic cause is suspected
- Cardiac and carotid US if a retinal artery occlusion is diagnosed
- Facial CT to evaluate extent of traumatic injuries
Differential Diagnosis
- Transient:
- Amaurosis fugax
- Migraine (can present without headache)
- Early presentation of persistent causes
- Persistent monocular, painless:
- Central retinal artery occlusion
- Central retinal vein occlusion
- Retinal detachment or hemorrhage
- Vitreous hemorrhage
- Internal carotid artery occlusion/dissection
- Giant cell arteritis
- Persistent monocular, painful:
- Acute angle closure glaucoma
- Endophthalmitis
- Optic neuritis
- Uveitis
- Keratitis
- Binocular:
- Papilledema
- Neurologic, infectious, toxic, immunologic, cardiovascular, and endocrine disorders should be considered for monocular and binocular visual loss
- Chronic disorders - refraction errors, cataracts, open-angle glaucoma, macular degeneration, retinopathy
- Functional vision loss, malingering, hysteria
- Trauma - front to back
- Eyelid injury/edema
- Corneal abrasion/edema
- Corneal foreign body
- Hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic cataract
- Lens dislocation
- Commotio retinae
- Retinal detachment
- Retinal or vitreous hemorrhage
- Intraocular foreign body
- Traumatic optic neuropathy
- Globe rupture
- Retrobulbar hematoma
- Orbital fractures
- CNS injury
- Infectious - orbital cellulitis, endophthalmitis, cavernous sinus thrombosis, HIV neuropathy, CMV retinitis, HSV/Zoster, viral/bacteria conjunctivitis
- Toxins - methanol, digoxin, amiodarone, certain antibiotics/antimalarial/antitubercular drugs/chemotherapy agents, others
- Neurologic - MS, CVA, migraine, tumor, posterior reversible encephalopathy syndrome (PRES), vertebrobasilar insufficiency
- Immunologic - Behçet, lupus, uveitis, sympathetic ophthalmia, giant cell arteritis
- Cardiovascular - thrombotic, embolic, hypertensive, dissection
- Endocrine - diabetes, Graves disease
Prehospital
Chemical burns - initiate irrigation with water or saline
ED Treatment/Procedures
- Direct therapy toward cause of visual loss
- Ophthalmology consultation for visual loss with serious underlying etiology, significant degree, or uncertain diagnosis
- Time-sensitive conditions for which ED identification and treatment must begin rapidly:
- Central retinal artery occlusion
- Chemical burn
- Acute angle-closure glaucoma
- Open globe
- Retrobulbar hematoma
Central Retinal Artery Occlusion
- Clinical criteria:
- Unilateral, painless, sudden, dramatic vision loss
- Afferent pupillary defect
- Pale fundus with a cherry-red spot (macula)
- Therapy:
- Maneuvers and medications to lower IOP, allowing the embolus to move to the periphery:
- Ocular massage: Direct pressure to eye for 5-15 s then sudden release, repeat for 15 min
- Acetazolamide
- Topical β-blocker
- Emergent ophthalmology consultation - paracentesis of anterior chamber
- Cardiac and carotid artery workup
- Rule out giant cell arteritis
Chemical Burn
- Clinical criteria:
- Alkali worse than acids
- Examples: Mace, cements, plasters, solvents, bleach, cleaners
- Therapy:
- Topical anesthetic
- Copious irrigation of the eyes with LR or NS (water acceptable if others not available)
- Morgan lens if available, otherwise nasal cannula connected to saline bag or eyewash station
- Goal: Neutral pH at 5-10 min after ending irrigation - repeat if pH not neutralized
- Do not try to neutralize acids with alkalis or vice versa
- Evert lids and use moist cotton-tipped applicator to sweep for residual chemical precipitants
- Dilate with cycloplegic
- Do not use phenylephrine - vasoconstricts already ischemic conjunctival blood vessels
- Erythromycin ointment q1-2h
- Artificial tears q1h
- Check intraocular pressure
Acute Angle-Closure Glaucoma
- Clinical criteria:
- Unilateral, painful vision loss
- Nausea, vomiting, headache
- Cornea injected, edematous
- Mid-dilated, sluggish/nonreactive pupil
- Swollen, “steamy” lens
- Cell, flare in a shallow anterior chamber
- Increased intraocular pressure (>20 mm Hg)
- Therapy:
- Elevated head of bed
- Topical β-blocker
- Topical prostagland in analog
- Acetazolamide
- Topical α2-agonist
- Topic miotic
- Consider mannitol if no decrease in IOP after 1 hr
- Emergent ophthalmology consult for potential topical steroids, compression gonioscopy, peripheral iridotomy
Globe Rupture
- Clinical criteria:
- History of traumatic mechanism - may be less apparent, i.e., metalworking without eye protection
- Pain and visual loss
- Fluid leakage/Seidel sign
- Peaked pupil
- 360 degree bullous subconjunctival hemorrhage
- Full thickness corneal/sclera laceration
- Do not check IOP if suspected
- Therapy:
- Shield eye
- CT orbits, especially if concerning for foreign body
- NPO, bedrest
- Analgesic and antiemetic
- Update tetanus
- IV antibiotics - fluoroquinolone + vancomycin
- Emergent ophthalmology consult for OR repair
- Clinical criteria:
- History of blunt trauma
- Pain and visual loss
- Edema and proptosis
- Diminished extraocular movement
- Afferent pupillary defect
- Elevated IOP
- CT can confirm diagnosis, but imaging should not delay treatment if there is visual acuity loss
- Therapy:
- Lateral canthotomy
- Indications:
- Decreased visual acuity/presence of optic neuropathy
- Intraocular pressure > 40 mm Hg
- Contraindication - globe rupture
- Procedure:
- Inject local anesthetic and apply hemostats to lateral canthus for 1 min
- Use suture scissors to cut the lateral canthus
- Identify and cut the inferior canthal tendon
- If IOP remains elevated, identify and cut the superior canthal tendon
- If IOP is moderately elevated without optic neuropathy (>30 mm Hg but <40 mm Hg) medical management to lower IOP may be considered
- Emergent ophthalmology consult
Medication
- Antibiotic drops:
- Ciprofloxacin 0.3%: 1-2 gtt q1-6h
- Gentamicin 0.3%: 1-2 gtt q4h
- Ofloxacin 0.3%: 1-2 gtt q1-6h
- Levofloxacin 0.5%: 1-2 gtt q2h
- Polymyxin (Polytrim) 1 gtt q3-6h
- Sulfacetamide 10%, 0.3%: 1-2 gtt q2-6h
- Tobramycin 0.3%: 1-2 gtt q1-4h
- Trifluridine 1%: 1 gtt q2-4h
- Antibiotic ointments:
- Bacitracin 500 U/g 1/2-in ribbon q3-6h
- Ciprofloxacin 0.3%: 1/2-in ribbon q6-q8h
- Erythromycin 0.5%: 1/2-in ribbon q3-6h
- Gentamicin 0.3%: 1/2-in ribbon q3-4h
- Neosporin 1/2-in ribbon q3-4h
- Polysporin 1/2-in ribbon q3-4h
- Sulfacetamide 10%: 1/2-in ribbon q3-8h
- Tobramycin 0.3%: 1/2-in ribbon q3-4h
- Vidarabine 1/2-in ribbon 5 times per day
- Mydriatics and cycloplegics:
- Atropine 1%, 2%: 1-2 gtt/d to q.i.d
- Cyclopentolate 0.5%, 1%, 2%: 1-2 gtt p.r.n
- Homatropine 2%: 1-2 gtt b.i.d-t.i.d
- Phenylephrine 0.12%, 2.5%, 10%: 1-2 gtt t.i.d-q.i.d
- Tropicamide 0.5%, 1%: 1-2 gtt p.r.n dilation
- Corticosteroid-antibiotic combination drops (with ophthalmology consultation):
- Prednisolone (Blephamide) 1-2 gtt q1-8h
- Hydrocortisone/neomycin/bacitracin/polymyxin B (Cortisporin) 1-2 gtt q3-4h
- Dexamethasone/neomycin/polymyxin B (Maxitrol) 1-2 gtt q1-8h
- Prednisolone/gentamicin (Pred-G) 1-2 gtt q1-8h
- Dexamethasone/tobramycin/chlorobutanol (TobraDex) 1-2 gtt q2-26h
- Glaucoma agents (always with ophthalmology consultation):
- α2-agonists:
- β-blocker:
- Betaxolol 0.25%, 0.5%: 1-2 gtt b.i.d
- Carteolol 1%: 1 gtt b.i.d
- Levobunolol 0.25%, 0.5%: 1 gtt q.d.-b.i.d
- Carbonic anhydrase inhibitor:
- Acetazolamide 500 mg PO/IV q.d-q.i.d
- Miotic (parasympathomimetic):
- Pilocarpine 0.25%, 0.5%, 1%, 2%, 3%, 4%, 6%, 8%, 10%: 1-2 gtt t.i.d-q.i.d
- Osmotic agent:
- Mannitol 1-2 g/kg IV over 45 min
- Prostagland in analog:
- Brimonidine 1% 1 gtt t.i.d
- Apraclonidine 1% 1 gtt t.i.d
- Prostagland in analog:
- Latanoprost 0.005%: 1 gtt per day
- Only if mechanical closure is ruled out:
- Timolol 0.25%, 0.5%: 1 gtt b.i.d
Disposition
Admission Criteria
- Globe rupture
- Significant hyphema
- Endophthalmitis, orbital cellulitis/abscess, cavernous sinus thrombosis, and other significant infections
- Significant cardiovascular, carotid, or neurologic disease
- Retrobulbar hematoma with ocular compartment syndrome
- Fractures with signs of entrapment
- Unexplained, progressive vision loss
- Other diagnoses as recommended by ophthalmology consultation
Discharge Criteria
If the diagnosis is certain and visual loss will not progress
Follow-up Recommendations
- Follow-up should be discussed with ophthalmology for emergent or urgent issues
- Urgent referral needed for bacterial conjunctivitis, HSV/Zoster infection, recurrent unprovoked subconjunctival hemorrhage, corneal ulcer, hyphema, posterior vitreous detachment, retinal detachment, optic neuritis, uveitis
- Referral for cardiac and carotid workup in thrombotic and embolic disease
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- LevinLA, AlbertDM. Ocular Disease: Mechanisms and Management. 1st ed.China: Elsevier Publishers, 2010.
- PflipsenM, MassaquoiM, WolfS. Evaluation of the painful eye . Am Fam Physician. 2016;93:991-998.
- TarffA, BehrensA. Ocular emergencies: Red eye . Med Clin North Am. 2017;101:615-639.
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