• Vision loss is a fairly common presentation to the emergency department, accounting for up to 2% of presentations. The role of the emergency physician is to narrow down a differential, initiate any urgent treatment, assess for neurologic or metabolic causes, and decide on an appropriate timeline for referral to ophthalmology.
• Acute vision loss is usually defined as a significant loss of any part of the visual field that occurs over minutes to hours. However, complaints of a sudden change in chronic vision loss, or vision loss of a slower but significant progression may also need to be managed urgently.
• All objectively measured, sudden vision loss requires urgent referral to ophthalmology, unless there is an obvious diagnosis, such as stroke, which requires non-ophthalmologic management.

Delayed referral to ophthalmology may be considered in a small number of cases:

• Vision loss caused by a large corneal abrasion
• Vision loss that has resolved
• Vision loss with no objective change in visual acuity and no other notable clinical findings suggestive of an emergent cause
• Vision loss with a metabolic or systemic cause being managed by another specialist or requiring admission (eg optic neuritis or toxic optic neuropathy)
• Vision loss that has progressed over days/weeks with no obvious emergent cause

• All patients with a complaint of vision loss require:
  • VA (visual acuity)
  • Pupils (including assessment for a Relative Afferent Pupil Defect)
  • Confrontational visual fields
  • IOP (intraocular pressure) see procedural video: Using a tonometer
  • Extraocular movements
  • CNs and a screening neurologic exam
• Vision loss can be traumatic or nontraumatic, monocular or binocular, transient or persistent, and painful or painless.

Vision loss associated with trauma

• All patients with vision loss associated with trauma require urgent assessment by ophthalmology. If accessible a CT of the orbits +/- head is useful to assess for bony involvement, associated injuries, and a retrobulbar hematoma. Patients at risk for globe rupture should have the eye shielded and be seen urgently by ophthalmology. Patients with vision loss and signs of orbital compression syndrome clinically or on CT require a lateral canthotomy (video). Depending on the time to access ophthalmology, this may be performed by the emergency physician. Any chemical injury needs to be immediately irrigated copiously until the pH is neutralized.

Transient vision loss

• Sudden transient vision loss (<24 hrs) is concerning for vascular causes. A stroke work up including CT head +/- CT Angiogram, ECG, bloodwork (CBC, Cr, INR/PTT), and outpatient referral for an echo, carotid dopplers, and neurology follow up is appropriate. If no obvious vascular cause is seen, outpatient assessment by ophthalmology is still appropriate to assess the optic nerve and rule out retinal causes.

Bilateral vision loss

• Partial or total bilateral vision loss is suggestive of an intracranial lesion, increased ICP, or a metabolic cause and requires a work-up including CT head, ECG, and bloodwork (CBC, Cr, INR/PTT, ESR/C-Reactive Protein). If no cause is found, these patients will require urgent assessment by ophthalmology or admission to neurology or internal medicine if their vision loss is severe.

Painless vision loss

• Sudden vision loss without pain is most suggestive of a retinal detachment, central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), vitreous hemorrhage, macular disorders, optic neuropathies (including GCA) or cortical blindness.
• Sudden vision loss in patients over 50 should prompt investigation for temporal arteritis. This should include assessment of an ESR (or C-Reactive Protein if unavailable) and urgent referral to ophthalmology to assess the optic nerve.

Painful vision loss

• Sudden painful vision loss is most suggestive of acute angle closure glaucoma, endophthalmitis, uveitis, optic neuritis, corneal abrasion, keratitis, orbital compartment syndrome, or trauma or corneal abrasion.
• Painful vision loss requires assessment of the anterior chamber with application of tetracaine to assess response, slit lamp examination (video), and fluorescein to assess for corneal trauma, ulcer, or keratitis as a cause.
• Painful vision loss associated with an increased IOP (>30) should be treated with:

1. Acetazolamide 500 mg oral
2. Pilocarpine 2% stat (4% in dark irides)
3. Timolol 0.25% stat
4. Apraclonidine 1% stat
5. Dexamethasone 0.1% stat
6. Lie patient supine
7. Analgesics and antiemetics as indicated
8. Consider corneal indentation with moistened cotton bud: 2-3 cycles, 30 seconds on 30 seconds off.

Note: if ophthalmology unavailable, consider consulting local optometrist for referrals.

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