eMedicine Specialties > Ophthalmology > Ophthalmology for the General Practitioner

Sudden Visual Loss: Differential Diagnoses & Workup

Author: Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Coauthor(s): Angel Feliciano, MD, Consulting Physician, EMS Medical Director, St Vincent and St Mary's Hospital, Infinity HealthCare, Inc; Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Contributor Information and Disclosures

Updated: Mar 17, 2009

Differential Diagnoses

Branch Retinal Artery Occlusion
Optic Neuritis, Adult
Branch Retinal Vein Occlusion
Optic Neuritis, Childhood
Central Retinal Artery Occlusion
Optic Neuropathy, Anterior Ischemic
Central Retinal Vein Occlusion
Optic Neuropathy, Compressive
Corneal Abrasion
Papilledema
Endophthalmitis, Bacterial
Retinal Detachment, Exudative
Endophthalmitis, Fungal
Retinal Detachment, Rhegmatogenous
Episcleritis
Scleritis
Foreign Body, Intraocular
Sickle Cell Disease
Giant Cell Arteritis
Ulcer, Corneal
Headache, Migraine
Hyphema

Other Problems to Be Considered

Basilar artery occlusive disease
Brainstem ischemia
Cerebellar ischemia
Hemispheric ischemia

Workup

Laboratory Studies

  • Individualize the evaluation of patients with transient monocular visual loss (TMVL).
  • Laboratory studies should include blood counts and coagulation studies.
  • Obtain sedimentation rate in patients older than 55 years to screen for giant cell arteritis.

Imaging Studies

  • Treating transient monocular blindness (TMB) and atherosclerosis is important because they increase the risk of stroke.
  • Noninvasive evaluation of the carotid artery and heart is useful in patients older than 40 years; it provides information on the degree of stenosis.
  • Ulceration is more difficult to detect noninvasively than invasively, so angiography remains the diagnostic standard for detecting carotid atherosclerotic disease.
    • Fluorescein angiography is helpful for detecting embolic retinal vascular occlusion. The most common embolic particles are cholesterol crystals, which are often small; they disappear rapidly but not without damaging the vessel wall.
    • Fluorescein angiography may show hyperfluorescent crystals or areas of fluorescein leakage that are caused by crystal-related endothelial damage.

Other Tests

  • Noninvasive study of the heart can detect abnormal valves, dyskinetic wall segments, and arrhythmias, all of which predispose to the formation of emboli.
  • Holter monitoring is the preferred method to screen for intermittent cardiac arrhythmias.
  • Temporal artery biopsy is performed often to rule out giant cell arteritis. A clinician should perform biopsies frequently. The risk of missing the diagnosis of giant cell arteritis far outweighs the minor inconvenience of this very benign procedure.

More on Sudden Visual Loss

Overview: Sudden Visual Loss
Differential Diagnoses & Workup: Sudden Visual Loss
Treatment & Medication: Sudden Visual Loss
Follow-up: Sudden Visual Loss
References

References

  1. Hedges TR. The terminology of transient visual loss due to vascular insufficiency. Stroke. Sep-Oct 1984;15(5):907-8. [Medline].

  2. Wray SH. Visual aspects of extracranial internal carotid artery disease. In: Bernstein EF, ed. Amaurosis Fugax. New York: Springer-Verlag; 1988:72-80.

  3. Aldrich EM, Lee AW, Chen CS, et al. Local intra-arterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience. Stroke. Jun 2008;39(6):1746-50. [Medline].

  4. Bruno A, Corbett JJ, Biller J, Adams HP Jr, Qualls C. Transient monocular visual loss patterns and associated vascular abnormalities. Stroke. Jan 1990;21(1):34-9. [Medline].

  5. Burde RM. Amaurosis fugax. An overview. J Clin Neuroophthalmol. Sep 1989;9(3):185-9. [Medline].

  6. Carter JE. Chronic ocular ischemia and carotid vascular disease. In: Bernestein EF, ed. Amaurosis Fugax. New York: Springer-Verlag; 1988:118-134.

  7. FDA. US Food and Drug Administration Center for Drug Evaluation and Research [Web site]. Available at http://www.fda.gov/cder/. Accessed November 2008.

  8. Fisher CM. Observations of the fundus oculi in transient monocular blindness. Neurology. May 1959;9(5):333-47. [Medline].

  9. Pfaffenbach DD, Hollenhorst RW. Morbidity and survivorship of patients with embolic cholesterol crystals in the ocular fundus. Am J Ophthalmol. Jan 1973;75(1):66-72. [Medline].

Further Reading

Keywords

sudden visual loss, sudden vision loss, acute visual dysfunction, transient visual loss, eye ischemia, transient visual obscuration, TVO, papilledema, increased intracranial pressure, amaurosis fugax, monocular blindness, partial blindness, total blindness, transient monocular visual loss, TMVL, transient monocular blindness, TMB, transient bilateral visual loss, TBVL, ocular infarction, ischemic damage to the eye, internal carotid artery disease, ICA disease, angle-closure glaucoma, central retinal artery occlusion, CRAO, branch retinal artery occlusion, BRAO, ischemia of the optic nerve, anterior ischemic optic neuropathy, AION, ruptured globe, decreased vision, nonarteric anterior ischemic optic neuropathy, NAION, migraine, scintillating scotoma, intraocular foreign body, cardiac disease, stenotic vascular disease, carotid or vertebral artery atherosclerotic disease, fibromuscular dysplasia, arteritis, carotid artery dissection, vertebral artery dissection, platelet-containing emboli,antiphospholipid syndrome, anemia, hypercoagulable states

Contributor Information and Disclosures

Author

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Angel Feliciano, MD, Consulting Physician, EMS Medical Director, St Vincent and St Mary's Hospital, Infinity HealthCare, Inc
Angel Feliciano, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Medical Editor

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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