Sudden Visual Loss Treatment & Management

Updated: Dec 11, 2019
  • Author: Jean Deschênes, MD, FRCSC; Chief Editor: Edsel Ing, MD, MPH, FRCSC  more...
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Treatment

Medical Care

Treatment is directed at the underlying cause of vision loss.

If GCA is suspected, prednisone 1 mg/kg should be initiated before the temporal artery biopsy is performed in order to prevent involvement of the fellow eye. Similarly, if optic neuritis is suspected, acute steroid management may hasten recovery but has not been found to affect visual acuity outcomes. [30]

Treatment of papilledema is directed at the underlying cause and consists of medical and surgical management.

For cases of suspected CRAO or BRAO, treatment is directed at prevention of future ischemic events. Patients with CRAO and BRAO should be referred for urgent stroke workup and a carotid and cardiac examination. Although acute treatments have been described in the literature, none has proven beneficial in improving visual outcome beyond the expected vision based on the natural history of ischemia. [4] Thrombolytics have been used in an attempt to dissolve clots in suspected arterial occlusions, although there are no guidelines on their use owing to mixed results from conducted studies, as well as the risks associated with administration of thrombolytics. [4]

In patients with CRVO, systemic risk factors such as hypertension, diabetes, and hyperlipidemia should be treated. Patients should be monitored for macular edema and iris neovascularization. The ophthalmic complications can be treated with anti-VEGF injections, steroids, or retinal photocoagulation. [9, 33]

For ophthalmic causes of vision loss, treatment should be aimed at the underlying etiology.

Angle-closure glaucoma should be treated with topical intraocular pressure–lowering agents, and the underlying cause of the angle closure should be addressed.

Retinal detachment is treated in conjunction with retinal specialists. Treatment can include pneumatic retinopexy or surgical treatment with scleral buckle or vitrectomy.

Globe ruptures should be repaired surgically.

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Surgical Care

Carotid artery stenosis increases the risk of hemispheric stroke. However, this risk is lower in patients with transient vision loss than in patients with other types of TIA. Thus, surgical management of carotid stenosis with carotid endarterectomy is indicated in patients with transient vision loss who have greater than 70% stenosis in addition to three other risk factors, which include male sex, age older than 75 years, absence of collaterals on angiography, TIA, peripheral vascular disease, and stenosis of 80%-94%. [2]

Nonarteritic-Ischemic Optic Neuropathy

No good surgical option or therapeutic treatment for nonarteritic ischemic optic neuropathy has been established. [34] The IONDT trial showed that optic nerve sheath fenestration was not beneficial. [35]

Central Retinal Vein Occlusion

Surgical options for CRVO include radial optic neurotomy, chorioretinal venous anastomosis, vitrectomy, and retinal vein injection with tPA. None of these surgical treatments has been proven to be more effective than nonsurgical methods for improving vision loss and are still experimental. [12]

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Consultations

Ophthalmic consultation is prudent in any case of sudden visual loss that cannot be easily and confidently explained and managed by emergency department physicians.

Patients with unexplained vision loss should undergo neuroimaging.

When appropriate, cardiac and neurologic consultation is recommended. Complete cardiac and neurologic examinations should be performed.

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Further Outpatient Care

Patients with sudden visual loss should receive follow-up care as needed.

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Transfer

Transfer of patients with sudden visual loss is necessary when emergent ophthalmologic consultation (if warranted) is unavailable at the initial treatment location.

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