Vision Loss


Vision loss


Vision loss is an emergency and should be evaluated immediately in the emergency setting.


Treatment depends on the correct diagnosis and evaluation by the appropriate specialty. Most vision loss disorders can be localized to the eye or the brain depending on if one eye is affected or both eyes are affected simultaneously respectively. It is helpful to close each eye turn by turn and assess which eye and what part of the view is affected.


If only one eye is affected then it is likely an ocular or eye problem. This can be evaluated emergently by an ophthalmologist to help ascertain the cause. Diagnosis depends on the part of eye involved.


Trauma is a common cause and can cause corneal damage ( corneal abrasions, ulcers and infections or keratitis, lens damage such as lenticular dislocation, and bleeds in the anterior (hyphema) and posterior chambers (vitreous hemorrhage) of the eye. Cataracts do not cause sudden vision loss.


Any trauma or infection is likely to be associated with redness, tearing, vision blurring and irritation. Infections and inflammation of the inner eye known as uveitis and endophthalmitis are worrisome conditions.


Similarly acute angle glaucoma can cause sudden vision loss with the same symptoms.


If floaters are seen then the inside compartment of the eye or vitreous compartment may have bleeding or damage.


Flashes of light can point to the retina as a possible site of involvement eg:- retinal tears, retinal detachment, retinal artery or vein occlusions.


Frequently ocular migraines can cause transient vision loss associated with transient flashes of light, floaters and colored spectrums or vision distortions without headaches.


If vision loss occurs in one eye post operatively or after intake of any blood pressure medications in an elderly person then ischemic optic neuropathy may be the etiology of sudden vision loss in an eye.


If the eye is sore to movement and associated with central vision loss, loss of color saturation a worrisome condition known as optic neuritis is a distinct possibility. This is often associated with an immune reaction and may be an initial presenting symptom of MS Multiple Sclerosis though more often than not it is an isolated occurrence and can be associated with West Nile viral infections, other viral infections, sarcoidosis a lung condition, inflammatory conditions,etc. The treatment usually consists of IV steroids such as solumedrol high doses for 3-5 days under the care of a neurologist or ophthalmologist.


If both eyes are affected then ocular migraines, and problems arising from the brain should be evaluated. Common disorders in the brain causing blindness include pituitary gland bleeds ( pituitary apoplexy), tumors (pituitary macroadenomas) or occipital lobe bleeds or strokes or tumors.


Other causes such as elevated blood pressures (or hypertensive encephalopathy) or elevated intracranial pressures (due to pseudotumor cerebri) can be associated with vision loss due to pressure on the optic nerve and swelling. Venous sinus thrombosis (usually in the setting of use of birth control pills or dehydration or clotting abnormalities) in the brain can cause increased intracranial pressures and is an emergency requiring anticoagulation emergently. All the above etiologies are usually associated with headaches followed by blurry vision.


In the elderly in the setting of severe headaches giant cell arteritis or temporal arteritis can cause sudden blindness due to ophthalmic artery blockage. This occurs due to severe inflammation and this can easily be tested with a blood test known as ESR or erythrocyte sedimentation rate. If  >50-100 (normal < 20) a temporal artery biopsy is usually indicated to confirm the diagnosis as long term oral steroids for upto a year may be indicated.


Finally a common condition known as amaurosis fugax a form of transient ischemic attack and occasionally leading to permanent vision loss in an eye can be due to a carotid stenosis or occlusion with downstream loss of flow in the ophthalmic artery. This can be emergently evaluated with a carotid ultrasound.


In summary,


If the vision loss is sudden and involves one eye then emergent evaluation would require:


An ophthalmic evaluation by an ophthalmologist


A carotid Ultrasound


A sedimentation rate for those over 60 yrs of age.


If both eyes simultaneously are affected with vision loss then evaluation by a neurologist and further testing with:


Emergent CT brain


Carotid Ultrasound


MRI brain and


ESR would be in order.


Treatment would be varied as above. Trauma, infection, inflammation and ocular issues would require eye drops, surgery, laser photocoagulation, etc as deemed appropriate by the ophthalmologist.


For brain lesions or pituitary abnormalities, usually neurosurgical consultation is helpful for decompression of the lesion or bleed. If optic neuritis diagnosed then IV steroids may be instituted to facilitate a faster recovery.