Abnormal Vision: Making a Difficult Diagnosis When Eyesight is at Risk

An Evidence-Based Approach to Abnormal Vision in the Emergency Department

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Table of Contents
About This Issue

Nontraumatic visual disorders can have many causes, but they are potentially concerning for the patient as well as the emergency clinician. Four divisions can assist in considering the differential diagnosis: (1) unilateral or bilateral; (2) painful or painless; (3) presence or absence of diplopia; and (4) timing of onset.

What are the red flags to watch out for?

What are the essential components of the eye exam and visual exam? What are the important diagnoses that might be missed if it’s not complete?

What does anisocoria indicate, and what will the swinging flashlight test tell you about the pathology?

When is ultrasound useful, and when is CT preferred?

What is the latest evidence on managing central retinal artery occlusion: anticoagulation therapy, systemic thrombolysis, or intra-arterial thrombolysis?

If optic neuritis is diagnosed, what does this portend for a diagnosis of multiple sclerosis?

Is there any reliable way to tell whether a patient is suffering from functional blindness?

How does sickle cell disease affect the eyesight of patients?

What are the important eye complaints that may arise in HIV patients?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Anatomy, Etiology, and Pathophysiology
    1. Disorders of the Ocular Media
      1. Corneal Abnormalities
      2. Hyphema, Hypopyon, and Iritis
      3. Glaucoma
    2. Disorders of the Lens
    3. Retinal and Vitreal Disorders
      1. Retinal and Vitreal Detachments
      2. Retinal Vein Occlusion
      3. Retinal Artery Occlusion and Ischemia
      4. Retinal Migraine
    4. Disorders of the Optic Nerve
      1. Optic Neuritis
      2. Anterior Ischemic Optic Neuropathy
      3. Posterior Ischemic Optic Neuropathy
      4. Idiopathic Intracranial Hypertension
      5. Neuro-Ophthalmologic and Other Retrobulbar Etiologies of Abnormal Vision
        • Diplopia
        • Cranial Nerve Palsies
    5. Cavernous Sinus Thrombosis
    6. Pharmacologic, Toxicologic, and Metabolic Etiologies of Abnormal Vision
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
      1. Red Flags
      2. Past Medical History and Specific Risk Factors
    2. Physical Examination
      1. Visual Acuity
      2. Visual Fields
      3. Exterior Eye and Facial Examination
      4. Extraocular Movements
      5. The Pupil
      6. Anterior Eye Segment
      7. The Posterior Eye
      8. Measuring Intraocular Pressure
  9. Diagnostic Studies
    1. Laboratory Studies
    2. Lumbar Puncture
    3. Imaging Studies
      1. Computed Tomography
      2. Ultrasound
      3. Magnetic Resonance Imaging
  10. Treatment
    1. Unilateral Eye Conditions
      1. Floaters/ Retinal Detachment
      2. Amaurosis Fugax
      3. Central Retinal Artery Occlusion
      4. Central Retinal Vein Occlusion
      5. Arteritis
      6. Anterior Ischemic Optic Neuropathy
      7. Posterior Ischemic Optic Neuropathy
      8. Abnormal Pupil
      9. Acute Angle-Closure Glaucoma
      10. Optic Neuritis and Demyelinating Disease
    2. Bilateral Painless Vision Loss
      1. Idiopathic Intracranial Hypertension
      2. Psychogenic Blindness
      3. Bilateral Field Cuts
    3. Cavernous Sinus Thrombosis
    4. Diplopia
      1. Binocular Diplopia
  11. Special Populations
    1. Patients With Sickle Cell Disease
    2. Patients With HIV
    3. Patients With Ventricular Shunts
  12. Cutting Edge
  13. Disposition
  14. Summary
  15. Time and Cost-Effective Strategies
  16. Risk Management Pitfalls for Patients With Abnormal Vision in the Emergency Department
  17. Case Conclusions
  18. Clinical Pathways
    1. Clinical Pathway for Managing Patients With Acute Visual Change
    2. Clinical Pathway for Managing Patients With Bilateral Visual Change
    3. Clinical Pathway for Managing Patients With Unilateral Painful Visual Change
    4. Clinical Pathway for Managing Patients With Diplopia
  19. Tables and Figures
    1. Table 1. Nonarteritic Anterior Ischemic Optic Neuropathy-Associated Diseases and Causes
    2. Table 2. Causes of Monocular Diplopia
    3. Table 3. Causes of Toxic Optic Neuropathy
    4. Table 4. Differential Diagnosis of Abnormal Vision
    5. Table 5. Diagnoses That May Be Missed With an Incomplete Eye Examination
    6. Table 6. Uses of Point-of-Care Ultrasound in Eye Conditions
    7. Table 7. Causes of Anisocoria
    8. Table 8. Emergency Department Treatment of Acute Angle-Closure Glaucoma
    9. Table 9. Medical Treatment of Idiopathic Intracranial Hypertension
    10. Table 10. Signs of Functional Blindness
    11. Table 11. Causes of Field Cuts
    12. Table 12. Causes of Binocular Diplopia
    13. Table 13. Ocular Infections Associated With HIV Infection
    14. Figure 1. Eye Anatomy
    15. Figure 2. Hyphema
    16. Figure 3. Hypopyon
    17. Figure 4. Central Retinal Vein Occlusion
    18. Figure 5. Retinal Artery Occlusion
    19. Figure 6. Anterior Ischemic Optic Neuropathy
    20. Figure 7. Anatomy of the Cavernous Sinus
    21. Figure 8. Visual Field Defects Correlate to Location of Pathology Along the Optic Pathway
    22. Figure 9. Swinging Flashlight Test
    23. Figure 10. Ultrasound Image of Retinal Detachment-Hyperechoic Membrane Attached to the Retina
    24. Figure 11. Ultrasound Image of Vitreous Hemorrhage-Hyperechoic Echoes in the Vitreous
    25. Figure 12. Ultrasound Image of Papilledema With Optic Nerve Measurement Made at 3-mm Depth
    26. Figure 13. Pupillary Involvement in Cranial Nerve III Palsy
  20. References


Patients present to the ED with visual disturbances that may be painful or painless and may include loss of visual acuity, field cuts, diplopia, and headache. A detailed history and complete ocular examination are essential to obtaining the correct diagnosis and offering expedited treatment and referral. This review discusses the differential diagnosis for patients experiencing abnormal vision from a nontraumatic or minimally traumatic etiology, and reviews diagnostic and treatment strategies from an evidence-based perspective, including point-of-care ocular ultrasound. Management of the needs of special populations, such as patients with sickle cell disease, HIV, and those with a ventriculoperitoneal shunt, is reviewed.

Case Presentations

A 40-year-old woman is brought in to the ED by her husband, complaining of blurred vision and dizziness. She said she had visited an urgent care clinic last week with a new diagnosis of migraine headache. Her examination is remarkable for right eyelid ptosis, limited movement of the right eye to left gaze, and a right dilated pupil compared to the left. Her husband comments that his brother “had the same thing with his diabetes,” and asks you to check her sugar, but you think something else might be going on...

A nurse interrupts and tells you there is another patient in the room next door who has suddenly lost sight in both eyes, and the nurse wants to know whether she should call a stroke alert. You excuse yourself and step out to see a 21-year-old woman who is hyperventilating and screaming, “I can’t see! I can’t see!” You ponder the cause of her symptoms, and you note that her medications include alprazolam and sertraline. You wonder what the best way to confirm your suspected diagnosis would be...

Before you can respond, another nurse interjects and asks for pain medicine for the man in room 4 who has a red, painful eye that developed overnight. Your first suspicion is that it's a simple case of conjunctivitis, but the patient has intense pain when light is shined in the opposite eye. You wonder what else could be going on...


The presentation of a patient with a change in vision is common in the emergency department (ED), and potential diagnoses range from the minimally significant, to vision-threatening, or even life-threatening. Clinician experience, availability of equipment and technology, and time may all impact the care of these patients. This issue of Emergency Medicine Practice focuses on a symptom-based approach to the management of a variety of nontraumatic ocular conditions. Advances in emergency ocular ultrasound techniques and other technological advances can promote diagnostic certainty, help emergency clinicians communicate with consultants, and improve outcomes. For a review on managing traumatic eye conditions in the ED, see the November 2015 issue of Emergency Medicine Practice, “Ocular Injuries: New Strategies in Emergency Department Management”.

Critical Appraisal of the Literature

A literature search was conducted using Ovid MEDLINE®, requesting English language articles published since 2014 involving humans, and excluding case reports. A total of 271 full-text review articles were found. An additional search was performed using the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects (DARE). Further PubMed searches were carried out for primary studies on specific topics. Specialty guidelines were also searched and reviewed.

Overall, there is a lack of high-quality evidence for most of the therapies that are typically used in the ED for ocular complaints; specific treatment and diagnostic modalities with strong supportive evidence are highlighted. Pertinent guidelines from the American Academy of Ophthalmology are included. There are no clinical practice guidelines available from the American College of Emergency Physicians or the American Academy of Emergency Medicine for the care of ocular emergencies.

Anatomy, Etiology, and Pathophysiology

A review of the basic anatomy of the eye and the visual pathway is helpful in understanding visual pathology. (See Figure 1.) Light enters via the cornea, exits the anterior chamber through the pupil and refracts off the lens, traversing the vitreous humor to the retina. Photoreceptors generate signals; rods for dim-light vision and cones for color- and bright-light vision. The macula, in the center of the retina, contains the fovea, where there is the highest concentration of cones, making it responsible for the most precise vision. The visual signals exit along the optic nerve and travel to the optic chiasm, where the impulses decussate; ie, information from one side of the visual field is interpreted by the opposite side of the brain. The signals continue from the optic chiasm to the lateral geniculate bodies, and on to the occipital lobe via the optic radiations. Included in the pathway is the Edinger-Westphal nuclei, from which the extraocular movements of the eye, accommodation, pupillary dilatation, and convergence are affected.

Disorders of the Ocular Media

The ocular media encompass the transparent substances such as the cornea, aqueous humor, lens, and vitreous humor. As a group, these parts of the eye permit refraction and image transmission to the retina. Inflammation or deposition of cells or protein will obscure vision.

Corneal Abnormalities

Pathology of the cornea presents with pain, redness, tearing, and a foreign-body sensation. Corneal pain will typically resolve with a topical anesthetic, while pain from more serious causes (glaucoma, intraocular foreign body, etc) will not. Corneal pathology may arise from a variety of causes, including infection, minor trauma, autoimmune disease, foreign body, and exposures (both chemical and ultraviolet).

Risk Management Pitfalls for Patients With Abnormal Vision in the Emergency Department

2. “She had a headache and said her vision was off, but I checked her pressures and they were OK. She said she was better with the pain medicine, so I discharged her.”

Consider temporal arteritis in patients who are aged > 50 years with headache and visual complaints. Order an ESR and CRP in these patients. Visual loss can be rapid and sudden, so a timely diagnosis is essential.

3. “He said he saw those floaters all the time! His vision was fine.”

Always consider retinal detachment with a complaint of flashing lights or increased visual floaters. Remember that visual acuity is preserved when the macula is spared. Check for field cuts and perform a fundoscopic examination. Consider ocular ultrasound to find retinal detachment.

7. “He said he had blurred vision, but he wasn’t very specific about it, and I didn’t think much of it. I can’t believe he had a brain mass!”

Make sure you translate the patient’s words into an accurate medical diagnosis. Just as “dizzy” can mean anything from vertigo to orthostasis, “blurred vision” can signify diplopia, decreased visual acuity, a field cut, and more.

Tables and Figures

Table 1. Nonarteritic Anterior Ischemic Optic Neuropathy-Associated Diseases and Causes

Table 2. Causes of Monocular Diplopia

Table 3. Causes of Toxic Optic Neuropathy


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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Publication Information

Kelly O’Keefe, MD, FACEP; Sarah Temple, MD, FACEP

Peer Reviewed By

Ashley Norse, MD, FACEP; Jeremy Rose, MD, MPH, FRCPC

Publication Date

April 1, 2020

CME Expiration Date

April 1, 2023   

Pub Med ID: 32192282

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