Eye, acute and subacute painless loss of vision

Probability diagnosis

Amaurosis fugax

Migraine

Retinal detachment

Acute glaucoma

‘Wet’ macular degeneration

Serious disorders not to be missed

Cardiovascular:

• central retinal artery occlusion

• central retinal vein occlusion

• hypertension (complications)

• CVA

Neoplasia:

• intracranial tumour

• intraocular tumour:

  • — primary melanoma

  • — retinoblastoma

  • — metastases

Vitreous haemorrhage

AIDS

Temporal arteritis

Acute glaucoma

Benign intracranial hypertension

Pitfalls (often missed)

Acute glaucoma

Papilloedema

Optic neuritis

Uveitis

Intraocular foreign body

Masquerades checklist

Diabetes (diabetic retinopathy)

Drugs (e.g. quinine, alcohol)

Thyroid disorder (hyperthyroidism)

Is the patient trying to tell me something?

Consider ‘hysterical’ blindness, although it is uncommon.

Key history

Past medical history including risk factors for cardiovascular disease and neurology such as migraine and cerebrovascular disease. Family history and drug history.

Key examination

• Visual acuity: Snellen chart

• Ophthalmoscopic examination, tonometry

• Cardiovascular including carotid arteries

Key investigations

The vast majority of patients should be referred urgently to an ophthalmological service or stroke unit. Initial tests are:

• FBE

• ESR/CRP

• blood sugar.

Diagnostic tips

• The visual disturbance may be the presenting symptoms of a general medical disorder such as temporal (giant cell) arteritis, hypertension or diabetes.

• A cherry-red spot on the macula is pathognomonic of retinal artery occlusion.