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Sudden Visual Loss

  • Author: Gino A Farina, MD, FACEP, FAAEM; Chief Editor: Edsel Ing, MD, FRCSC  more...
 
Updated: May 18, 2016
 

Background

Sudden visual loss is a common complaint with variable presentations among patients of different ages.

The differential diagnoses of sudden vision loss are vast. In general, monocular vision loss usually indicates an ocular problem. Binocular vision loss is usually cerebral in origin. Monocular vision loss may respect the horizontal midline. Binocular vision loss may respect the vertical midline.

Some patients describe their symptoms as a gradually descending gray-black curtain or as blurring, fogging, or dimming of vision. Symptoms usually last a few minutes but can persist for hours. Variation in frequency ranges from a single episode to many episodes per day; recurrences may continue for years but more frequently occur over seconds to hours.

Many different causes of sudden visual loss are recognized; however, the most common reason for painless sudden visual loss is ischemia. Vision loss with positive scotoma may be seen with migraine. Vision loss with a negative scotoma may be seen with amaurosis fugax.  Ischemia, often via mechanical obstruction, can affect any aspect of the visual system. Those who develop ischemia of the eye often have other evidence of atherosclerotic disease, such as coronary artery disease and peripheral vascular disease, which increases their susceptibility to ischemic events in other parts of the body. Risk factors include smoking, hypercholesterolemia, and hypertension.

Other etiologies of sudden visual loss include infection/inflammation, vasculitis, trauma, mechanical dysfunction, and idiopathic causes.

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Pathophysiology

Ischemia compromises cell metabolism by reducing delivery of oxygen and other important nutrients to tissues. The resulting functional deficit may be temporary or permanent, depending on the degree of damage. Nomenclature of eye ischemia as given by Hedges and others includes the following[1] :

  • Transient visual obscuration (TVO) - Episodes lasting seconds that are associated with papilledema and increased intracranial pressure
  • Amaurosis fugax - Brief, fleeting attack of monocular partial or total blindness that lasts seconds to minutes
  • Transient monocular visual loss (TMVL) or transient monocular blindness (TMB) - A more persistent vision loss that lasts minutes or longer
  • Transient bilateral visual loss (TBVL) - Episodes affecting one or both eyes or both cerebral hemispheres and causing visual loss
  • Ocular infarction - Persistent ischemic damage to the eye, resulting in permanent vision loss
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Epidemiology

Frequency

Sudden visual loss is uncommon.

Mortality/Morbidity

Transient monocular visual loss (TMVL) in a person younger than 45 years may be benign; many attacks are probably vasospastic or due to migraine.

Transient bilateral visual loss (TBVL) is almost always associated with severe occlusive disease of the internal carotid artery (ICA), aortic arch, or bilateral occipital lobe ischemia.

Patients with ICA disease often have other systemic evidence of atherosclerosis, such as coronary and peripheral vascular disease. Other risk factors include smoking, hypercholesterolemia, and hypertension.

Race

Whites, especially men, have a high incidence of ICA-origin atherosclerosis.

Blacks and Chinese and Japanese persons have a higher incidence of intracranial occlusive disease.

Sex

A strong male predominance (2:1) exists among patients with severe ICA disease.

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Contributor Information and Disclosures
Author

Gino A Farina, MD, FACEP, FAAEM Professor of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.

Lien Hong Lam, MD Resident Physician, Department of Emergency Medicine, North Shore Long Island Jewish Hospital

Lien Hong Lam, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Ellen M Menocal, MD Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

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, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

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, Wilderness Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Angel Feliciano, MD, to the development and writing of this article.

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Hyphema - Blood in anterior chamber resulting from trauma.
Central retinal vein occlusion - Diffuse retinal hemorrhages extending to periphery of fundus, "blood and thunder" appearance.
 
 
 
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