Table 1: Summary of Painless Vision Loss

Disease Cause(s) Presentation Physical Findings ED Treatment/Management Disposition

Optic neuritis

Inflammatory, autoimmune demyelination of the optic nerve. Idiopathic vs. multiple sclerosis

Subacute unilateral vision loss, alteration of color vision, eye discomfort

  • Optic disc edema and blurred disc margins (papillitis) on fundoscopic exam
  • Optic nerve sheath diameter > 5 mm on ultrasound

IV methylprednisolone

MRI to evaluate for multiple sclerosis

Ophthalmology and neurology consultations in the ED

Possible admission for IV steroids and work up

Giant cell arteritis/ temporal arteritis

Autoimmune, granulomatous vasculitis of the large vessels

Sudden monocular vision loss in an older patient with a history of amaurosis fugax, jaw claudication, polymyalgia rheumatica, and headache

  • Scalp tenderness, neuropathies
  • Pale optic disc on fundoscopy

Diagnosis based on clinical presentation and elevated ESR

Treatment with PO or IV corticosteroids

Consider low-dose aspirin

Immediate ophthalmology evaluation

Possible admission for IV steroids and work up

If discharged, appropriate specialty follow-up for temporal artery biopsy

Vitreous hemorrhage

Vitreous detachment and rupture of retinal vessels, leading to hemorrhage

Acute onset of vision loss or vision changes (flashing lights, floaters, cobwebs, etc.)

  • Difficulty visualizing retina on fundoscopic exam
  • Echogenic dots/linear densities within the posterior chamber on ultrasound

Allow the blood to settle

  • Elevate head of bed
  • Avoid strenuous activity

Discontinuation of antiplatelet and/or anticoagulants if possible

Ophthalmology evaluation in the ED or within 24 hours

Retinal detachment

Detachment of the neuroretina from the pigmented epithelial layer

Acute onset of vision loss or vision changes (floaters, flashing lights, visual distortions)

  • Area of detached retina or vitreous hemorrhage on fundoscopy
  • Detached retina seen on ultrasound

No specific ED management outside of diagnosis

Immediate ophthalmology evaluation

Central retinal artery occlusion

Occlusion of the central retinal artery from a thrombus or embolus

Sudden monocular vision loss in an older patient with cardiovascular risk factors

  • Pale retina with a cherry-red macula and "boxcarring" of RBCs within vessels on fundoscopic exam

General treatment involves dislodging the clot, improving retinal perfusion pressure, and vasodilating retinal vessels. This includes:

  • Ocular massage
  • Acetazolamide/mannitol
  • Isosorbide dinitrate
  • Supplemental O2

However, there is no evidence to support any specific treatment, and treatment should be guided by institutional protocols

Immediate ophthalmology evaluation