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Gradual change in or loss of vision

Medicine > Endocrine & metabolic

Differential Diagnosis Schema 🧠

Ocular Causes

  • Cataract: Gradual painless loss of vision, often with glare and halos around lights, particularly at night.
  • Glaucoma (Chronic Open-Angle): Gradual loss of peripheral vision leading to tunnel vision; often asymptomatic until advanced stages.
  • Age-Related Macular Degeneration (AMD): Central vision loss, initially presenting as distortion (metamorphopsia) or difficulty reading; can progress to severe central vision loss.
  • Diabetic Retinopathy: Progressive vision loss, often with fluctuating vision, floaters, and difficulty with night vision; associated with poor glycemic control.
  • Retinal Detachment (Chronic): Gradual visual field loss, often described as a shadow or curtain; may have associated floaters or flashes of light.
  • Refractive Error: Gradual change in vision due to myopia, hyperopia, or astigmatism, correctable with glasses or contact lenses.
  • Corneal Opacities: Vision loss due to scarring or clouding of the cornea, often associated with previous trauma, infection, or inflammation.
  • Keratoconus: Progressive thinning of the cornea leading to distorted vision, often in younger patients.
  • Optic Neuropathy: Gradual loss of vision, often with a pale optic disc on fundoscopy; can be caused by glaucoma, ischemia, or compressive lesions.
  • Uveitis (Chronic): Recurrent episodes of eye pain, redness, and gradual vision loss; often associated with systemic autoimmune diseases.

Neurological Causes

  • Optic Neuritis: Gradual loss of vision with pain on eye movement; often associated with multiple sclerosis.
  • Pituitary Tumor: Gradual bitemporal hemianopia due to compression of the optic chiasm; may present with associated endocrine abnormalities.
  • Stroke (Occipital Lobe): Sudden or gradual visual field loss depending on the vascular territory involved; often associated with other neurological deficits.
  • Intracranial Hypertension: Gradual visual loss with associated headaches, nausea, and papilledema on fundoscopy; can be idiopathic or secondary to a mass lesion.
  • Migraine with Aura: Transient visual disturbances (scintillating scotoma) followed by headache; typically self-resolving.
  • Demyelinating Disease: Progressive vision loss with associated neurological symptoms; multiple sclerosis is a common example.
  • Space-Occupying Lesion: Gradual visual field loss or other visual disturbances depending on the location of the lesion; may present with headaches, nausea, and other focal neurological signs.
  • Neurodegenerative Disorders: Progressive vision loss may occur in conditions like Alzheimer’s disease, often associated with other cognitive impairments.

Systemic Causes

  • Diabetes Mellitus: Can lead to diabetic retinopathy, macular edema, and cataracts, all contributing to gradual vision loss.
  • Hypertension: Chronic hypertension can cause hypertensive retinopathy, leading to gradual vision changes.
  • Giant Cell Arteritis: Sudden or gradual vision loss in older adults, often with associated scalp tenderness, jaw claudication, and elevated ESR.
  • Autoimmune Diseases: Conditions like lupus or sarcoidosis can lead to uveitis, scleritis, or optic neuropathy, causing gradual vision loss.
  • Chronic Kidney Disease: May be associated with hypertensive retinopathy or ocular complications of dialysis, leading to visual disturbances.
  • Medication-Induced: Certain medications (e.g., corticosteroids, hydroxychloroquine) can cause cataracts, retinopathy, or other visual changes.
  • Toxicity: Chronic exposure to certain toxins (e.g., methanol, ethambutol) can cause optic neuropathy and vision loss.
  • Nutritional Deficiencies: Deficiencies in vitamin A, B12, or folate can lead to gradual vision loss, particularly in malnourished individuals.

Key Points in History 🥼

Onset and Progression

  • Timing: Gradual onset over weeks to months suggests conditions like cataracts, glaucoma, or AMD, while sudden onset is more typical of vascular events or retinal detachment.
  • Progression: Slow, progressive vision loss is often seen in cataracts, glaucoma, and diabetic retinopathy.
  • Intermittent vs. Continuous: Intermittent symptoms may suggest migraine, transient ischemic attacks (TIAs), or early-stage glaucoma.
  • Associated Triggers: Identify any activities or environmental factors that exacerbate symptoms, such as bright lights or reading.
  • Symmetry: Bilateral vision loss suggests systemic or neurological causes, while unilateral loss is more likely to be ocular or structural.
  • Pain: Painful vision loss is suggestive of optic neuritis, uveitis, or angle-closure glaucoma, while painless loss is typical of cataracts, diabetic retinopathy, or AMD.

Associated Symptoms

  • Visual Disturbances: Ask about floaters, flashes of light, halos around lights, or visual field defects, which can help localize the pathology.
  • Systemic Symptoms: Symptoms such as headache, scalp tenderness, jaw claudication, or weight loss might suggest systemic vasculitis or GCA.
  • Neurological Symptoms: Weakness, numbness, or other focal neurological deficits could indicate a stroke or space-occupying lesion affecting the visual pathways.
  • Metabolic Symptoms: Polyuria, polydipsia, or weight loss might suggest diabetes as an underlying cause of visual changes.
  • Previous Ocular History: Previous episodes of uveitis, trauma, or ocular surgery might predispose to conditions like cataracts or retinal detachment.
  • Family History: A history of glaucoma, macular degeneration, or other hereditary eye conditions can suggest a genetic predisposition.
  • Medication Use: Chronic use of corticosteroids, antimalarials, or other medications may contribute to gradual vision loss.
  • Lifestyle Factors: Smoking, alcohol use, and occupational exposures may increase the risk for conditions like AMD or cataracts.

Background

  • Past Medical History: Document any history of chronic conditions such as diabetes, hypertension, autoimmune diseases, or neurological disorders.
  • Drug History: Review all current medications, focusing on those known to affect vision, such as steroids or hydroxychloroquine.
  • Family History: Note any family history of glaucoma, macular degeneration, or other hereditary eye diseases.
  • Social History: Assess smoking status, alcohol consumption, and occupation, as these can impact the risk for certain eye conditions.
  • Environmental Exposure: Consider exposure to UV light, toxins, or irritants that may contribute to conditions like cataracts or pterygium.
  • Nutritional Status: Poor nutrition, particularly deficiencies in vitamins A, C, E, and zinc, can contribute to AMD and other ocular conditions.
  • Visual Habits: Inquire about use of corrective lenses, previous eye surgeries, or regular eye exams.
  • Recent Illnesses: Recent infections, trauma, or systemic illnesses that may have triggered or worsened vision problems.

Possible Investigations 🌡️

Ophthalmological Tests

  • Visual Acuity Testing: To assess the degree of vision loss and identify any correctable refractive errors.
  • Fundoscopy: Direct visualization of the retina, optic disc, and macula to identify signs of AMD, diabetic retinopathy, glaucoma, or other retinal pathologies.
  • Intraocular Pressure Measurement: Essential for diagnosing glaucoma.
  • Visual Field Testing: To detect peripheral vision loss, which is key in diagnosing glaucoma, stroke, or other neurological causes.
  • Slit-Lamp Examination: Provides a detailed view of the cornea, lens, and anterior chamber to identify cataracts, corneal opacities, or uveitis.
  • Optical Coherence Tomography (OCT): High-resolution imaging of the retina and optic nerve head, useful in diagnosing macular degeneration, diabetic macular edema, and glaucoma.
  • Fluorescein Angiography: Used to assess retinal blood flow and identify areas of leakage or ischemia, particularly in diabetic retinopathy or AMD.
  • Ultrasound B-Scan: Useful for evaluating the posterior segment of the eye when the view is obscured by cataracts, vitreous hemorrhage, or other opacities.
  • Electroretinography (ERG): To assess retinal function in cases of suspected inherited retinal diseases or unexplained vision loss.
  • Gonioscopy: Examination of the anterior chamber angle to evaluate for glaucoma, particularly in cases of suspected angle-closure.

Imaging and Other Tests

  • CT/MRI Brain: Indicated if a neurological cause such as stroke, tumor, or multiple sclerosis is suspected.
  • Carotid Doppler Ultrasound: To assess for carotid artery stenosis in cases of amaurosis fugax or other ischemic ocular events.
  • Blood Tests: Including ESR/CRP for suspected GCA, blood glucose and HbA1c for diabetic retinopathy, and lipid profile for cardiovascular risk assessment.
  • Visual Evoked Potentials (VEP): To assess the function of the visual pathway from the retina to the occipital cortex, useful in cases of optic neuritis or demyelinating diseases.
  • Lumbar Puncture: May be indicated in cases of suspected intracranial hypertension or infection affecting the optic nerves.
  • Serological Tests: To screen for autoimmune diseases (e.g., ANA, ANCA) if systemic vasculitis or connective tissue disease is suspected.
  • Holter Monitoring or ECG: To evaluate for cardiac arrhythmias in patients with suspected embolic events leading to visual disturbances.
  • Nutritional Assessment: Including vitamin levels (A, B12, D) in cases where nutritional deficiency is suspected.
  • Genetic Testing: Considered in cases of suspected inherited retinal diseases or optic neuropathies.

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Endocrine & metabolic