Sudden Visual Loss Workup

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

Approach Considerations

The workup of sudden vision loss includes a thorough ophthalmic examination. Additional tests should be performed to narrow the differential diagnoses if not clinically evident and to facilitate secondary prevention in patients with a suspected ischemic, cardiac, or cerebrovascular etiology. Patients with acute retinal ischemia are at higher risk of stroke and MI, [4] so further workup and risk stratification in patients with transient monocular blindness is important for secondary prevention.

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Laboratory Studies

Laboratory studies should include a complete blood cell count, coagulation studies, renal function testing, fasting blood glucose study, and lipid testing.

The erythrocyte sedimentation rate, C-reactive protein level, and platelet count in patients older than 50 years with suspected GCA should be obtained.

In patients with suspected optic neuritis, exclude mimicking infections (eg, Lyme disease, cat scratch disease, syphilis, herpes zoster) and noninfectious causes (eg, sarcoidosis, systemic lupus erythematosus [SLE], and other vasculitides).

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Imaging Studies

Noninvasive evaluation of the carotid artery and heart (eg, electrocardiography, echocardiography, carotid Doppler) is useful, particularly in older patients. This evaluation provides information on the degree of stenosis. Noninvasive study of the heart can detect abnormal valves, dyskinetic wall segments, and arrhythmias, all of which predispose to the formation of emboli.

However, angiography remains the diagnostic standard for detecting carotid atherosclerotic disease.

Fluorescein angiography is helpful in retinal vascular occlusive disease. 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.

Neuroimaging is often useful unless the vision loss has an obvious ocular explanation. CT imaging can be useful to rule out vascular abnormalities and tumors and to assess for possible globe rupture in the context of ocular trauma.

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Other Tests

Holter monitoring is the preferred method to screen for intermittent cardiac arrhythmias.

GCA should be considered in elderly patients presenting with vision loss. Many authors advocate the liberal performance of temporal artery biopsy since the risk of permanent vision loss due to a missed GCA diagnosis outweighs the risks associated with biopsy. Diagnostic prediction models can help guide the decision for temporal artery biopsy but should be used in conjunction with clinical judgment. [32] In centers with radiologic expertise and high-quality imaging, tests such as Doppler ultrasonography of the temporal artery may be considered.

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