Acute change in or loss of vision

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Ophthalmic Causes

Acute Angle-Closure Glaucoma: Severe eye pain, headache, nausea, vomiting, red eye, fixed mid-dilated pupil.
Retinal Detachment: Flashes of light, floaters, a shadow or curtain over vision.
Central Retinal Artery Occlusion: Sudden, painless vision loss, afferent pupillary defect, cherry-red spot on the macula.
Central Retinal Vein Occlusion: Sudden, painless vision loss, retinal haemorrhages, dilated veins, cotton wool spots.
Optic Neuritis: Pain with eye movement, central scotoma, decreased colour vision, associated with multiple sclerosis.
Anterior Ischaemic Optic Neuropathy: Sudden, painless vision loss, altitudinal field defect, pale optic disc.
Vitreous Haemorrhage: Sudden vision loss, floaters, reduced red reflex, associated with diabetic retinopathy.

Neurological Causes

Stroke (Ischaemic or Haemorrhagic): Sudden vision loss, may be accompanied by other neurological deficits, homonymous hemianopia.
Migraine with Aura: Transient visual disturbances, often with scintillating scotomas, followed by headache.
Intracranial Tumours: Gradual vision loss, may present with other signs of raised intracranial pressure, visual field defects.
Multiple Sclerosis: Episodes of optic neuritis, intermittent vision loss, associated with other neurological symptoms.
Giant Cell Arteritis: Sudden vision loss in elderly, scalp tenderness, jaw claudication, raised ESR/CRP.

Systemic and Vascular Causes

Hypertensive Retinopathy: Progressive vision loss, flame haemorrhages, cotton wool spots, papilloedema.
Diabetic Retinopathy: Gradual vision loss, floaters, retinal haemorrhages, neovascularisation.
Sickle Cell Retinopathy: Gradual vision loss, “sea fan” neovascularisation, associated with systemic sickle cell disease.
Systemic Lupus Erythematosus (SLE): Retinal vasculitis, cotton wool spots, associated with systemic lupus symptoms.
Endophthalmitis: Acute vision loss, eye pain, redness, hypopyon, usually post-surgical or post-trauma.

Key Points in History 🥼

Onset and Duration

Sudden onset: Suggests vascular causes such as retinal artery or vein occlusion, stroke, or acute glaucoma.
Gradual onset: More consistent with chronic conditions like diabetic retinopathy, hypertensive retinopathy, or intracranial tumours.
Transient vision loss: Could indicate amaurosis fugax (transient ischaemic attack) or migraine with aura.

Associated Symptoms

Pain: Presence suggests acute angle-closure glaucoma, optic neuritis, or endophthalmitis. Absence of pain might suggest retinal detachment, central retinal artery occlusion.
Neurological symptoms: Symptoms like headache, nausea, or hemiparesis may indicate stroke, intracranial tumours, or giant cell arteritis.
Visual phenomena: Flashes or floaters may suggest retinal detachment, while scintillating scotomas are common in migraine with aura.

Background

Past Medical History: Consider previous ocular conditions, vascular diseases, or autoimmune diseases.
Drug History: Consider medications that can affect vision, such as corticosteroids (cataracts, glaucoma), or anticoagulants (risk of haemorrhage).
Family History: Look for familial conditions like glaucoma, or sickle cell disease.
Social History: Consider smoking (increases vascular risk), alcohol use, and trauma history.

Possible Investigations 🌡️

Ocular Examination

Visual Acuity: Essential to document the degree of vision loss.
Slit-Lamp Examination: To assess the anterior segment for signs of acute glaucoma, uveitis, or keratitis.
Fundoscopy: To identify retinal detachment, retinal artery/vein occlusion, or papilloedema.
Intraocular Pressure Measurement: Critical in suspected acute angle-closure glaucoma.

Imaging

Optical Coherence Tomography (OCT): Useful for assessing retinal and optic nerve pathology.
MRI of the Brain and Orbits: Indicated in cases of optic neuritis, intracranial tumours, or multiple sclerosis.
CT Head: Useful in acute settings to rule out haemorrhagic stroke or to assess for fractures in trauma.

Laboratory Tests

Full Blood Count (FBC): To identify anaemia or infection.
Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): Elevated in giant cell arteritis.
Blood Glucose and HbA1c: To assess for diabetes, which is a risk factor for retinopathy.
Coagulation Profile: Important in patients on anticoagulants or with suspected vascular occlusions.

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