Visual Loss, Emergency Medicine

Basics

Description

- Neurologic: - Cerebral (cerebrovascular accident [CVA]) or intracranial pathology (mass lesion) - Multiple sclerosis - Optic neuritis - Migraine

- Cardiovascular system: - Embolic - Thrombotic - Ischemic - Hypertensive events

- Endocrine: - Diabetic retinopathy - Thyroid disease may cause diplopia (muscle hypertrophy) or corneal erosions

- History of trauma - Use of corrective lenses: - Prior eye surgery or problems - Eye pain - Conjunctival redness or discharge - New floaters - Flashing lights - Pain with eye movement - Key elements to determine: - Acute or gradual onset - Length of symptoms - Transient vision loss or permanent - Binocular or monocular - Degree of vision loss - Painful or painless - Other comorbidities

- Cardiovascular: - Murmurs - Carotid bruits - Temporal artery tenderness

- Clinical criteria: - Unilateral, painless, dramatic vision loss - Afferent pupillary defect - Pale fundus with a cherry-red spot (macula) - Counting fingers to light perception in 94% of patients

- Therapy: - Immediate ophthalmology consultation - Maneuvers and medications to lower intraocular pressure, allowing the embolus to move to the periphery: - Ocular massage: Direct pressure to eye for 5 " 15 sec then sudden release, repeat for 15 min - Acetazolamide: 500 mg IV or PO - Topical ²-blocker - Anterior chamber paracentesis by an ophthalmologist

- Therapy: - Topical anesthetic - Copious irrigation of the eyes with LR or NS (nonsterile water is acceptable if others not available); minimum of 30 min - Goal: Neutral pH at 5 " 10 min after ending irrigation - Do not try to neutralize acids with alkalis or vice versa - Evert lids and use moist cotton-tipped applicator to sweep furnaces for residual chemical precipitants - Dilate with cycloplegic (atropine, cyclopentolate, tropicamide) - Do not use phenylephrine; vasoconstricts already ischemic conjunctival blood vessels - Erythromycin ointment q1 " 2h - Artificial tears q1h - Check intraocular pressure

- Signs and symptoms: - Unilateral, painful vision loss - Nausea, vomiting, headache - Cornea injected, edematous - Mid-dilated, sluggish/nonreactive pupil - Swollen, "steamy " lens - Cell, flare in a shallow anterior chamber - Increased intraocular pressure (>20 mm Hg)

- Antibiotic drops: - Ciprofloxacin 0.3%: 1 " 2 gtt q1 " 6h - Gentamicin 0.3%: 1 " 2 gtt q4h - Ofloxacin 0.3%: 1 " 2 gtt q1 " 6h - Levofloxacin 0.5%: 1 " 2 gtt q2h - Polymyxin (Polytrim) 1 gtt q3 " 6h - Sulfacetamide 10%, 0.3%: 1 " 2 gtt q2 " 6h - Tobramycin 0.3%: 1 " 2 gtt q1 " 4h - Trifluridine 1%: 1 gtt q2 " 4h

- Antibiotic ointments: - Bacitracin 500 U/g 1/2 in ribbon q3 " 6h - Ciprofloxacin 0.3%: 1/2 in ribbon q6 " q8h - Erythromycin 0.5%: 1/2 in ribbon q3 " 6h - Gentamicin 0.3%: 1/2 in ribbon q3 " 4h - Neosporin 1/2 in ribbon q3 " 4h - Polysporin 1/2in ribbon q3 " 4h - Sulfacetamide 10%: 1/2 in ribbon q3 " 8h - Tobramycin 0.3%: 1/2 in ribbon q3 " 4h - Vidarabine 1/2 in ribbon 5 times per day

- Corticosteroid " antibiotic combination drops (with ophthalmology consultation): - Prednisolone (Blephamide) 1 " 2 gtt q1 " 8h - Hydrocortisone/neomycin/bacitracin/polymyxin B (Cortisporin) 1 " 2 gtt q3 " 4h - Dexamethasone/neomycin/polymyxin B (Maxitrol) 1 " 2 gtt q1 " 8h - Prednisolone/gentamicin (Pred-G) 1 " 2 gtt q1 " 8h - Dexamethasone/tobramycin/chlorobutanol (TobraDex) 1 " 2 gtt q2 " 26h

- ²-blocker: - Betaxolol 0.25%, 0.5%: 1 " 2 gtt BID - Carteolol 1%: 1 gtt BID - Levobunolol 0.25%, 0.5%: 1 gtt QD " BID

Decrease in visual function (i.e., visual acuity, visual fields, blurry vision)
Visual loss has many etiologies and can be caused by multiple body systems

Etiology

Ophthalmologic:Eyelid or tear film abnormalityAnterior segment (cornea, anterior chamber, iris, lens)Posterior segment (vitreous, retina, optic nerve)Posterior to the eye (optic nerve, chiasm, radiations)
Traumatic:Corneal abrasionHyphemaLens dislocationRuptured globeCommotio retinaeRetinal detachmentRetinal/vitreous hemorrhageRetrobulbar hemorrhageIntraocular foreign body
Neurologic:Cerebral (cerebrovascular accident [CVA]) or intracranial pathology (mass lesion)Multiple sclerosisOptic neuritisMigraine
Cardiovascular system:EmbolicThromboticIschemicHypertensive events
Immunologic system:UveitisGiant cell arteritis
Infection:Orbital cellulitis/abscessCavernous sinus thrombosisHIV optic neuropathy or cytomegalovirus (CMV) retinitis
Endocrine:Diabetic retinopathyThyroid disease may cause diplopia (muscle hypertrophy) or corneal erosions
Toxic:Methanol (acute severe loss, subacute optic atrophy)Licorice (transient loss, self-limited)Digitalis (flashing lights, color changes)Amiodarone (rare cause of optic neuropathy)

Diagnosis

Categorize visual loss by the properties associated with the decrease in visual function
Transient (<24 hr):Minutes:Transient ischemic attack = amaurosis fugax (unilateral)Vertebrobasilar artery insufficiency (bilateral)Minutes to hours:MigraineSudden BP changes
Persistent (>24 hr):Painless: Sudden:Retinal artery or vein occlusionVitreous hemorrhageRetinal detachmentOptic neuritisGiant cell arteritisCerebral infarctPainless: Gradual (weeks to years):CataractPresbyopiaRefraction errorsOpen-angle glaucomaChronic retinal diseaseMacular degenerationDiabetic retinopathyCMV retinopathyCNS tumorPainful:Corneal abrasion, ulcer, burn, or foreign bodyAngle-closure glaucomaOptic neuritisIritis/uveitis/endophthalmitisKeratoconus with hydropsOrbital cellulitis/abscess
Monocular: Pathology anterior to optic chiasm
Binocular: Pathology posterior to optic chiasm
Associated with systemic neurologic symptoms of visual field defects:CVA (especially posterior or occipital circulation)Mass lesion (pituitary adenomas, aneurysm, meningioma, other tumors)
Malingering/hysteria

Signs and Symptoms

History

Decreased vision:Loss of visionBlurry visionDouble vision:
History of trauma
Use of corrective lenses:
Prior eye surgery or problems
Eye pain
Conjunctival redness or discharge
New floaters
Flashing lights
Pain with eye movement
Key elements to determine:Acute or gradual onsetLength of symptomsTransient vision loss or permanentBinocular or monocularDegree of vision lossPainful or painlessOther comorbidities

Physical Exam

Ophthalmologic:Visual acuityPupil examAfferent papillary defectConfrontational visual field examExtraocular muscle functionSlit-lamp examIntraocular pressure (Tonometry)Fundoscopy:Optic nerve swellingPale retina with a cherry-red spot
Cardiovascular:MurmursCarotid bruitsTemporal artery tenderness
Neurologic exam:Complete exam for other deficitsOptic chiasm and intracerebral lesionsOccipital and posterior circulation lesions
General:Signs of immune, endocrine, or toxic disorders

Essential Workup

Thorough history and physical exam

Diagnosis Tests & Interpretation

Lab

May be obtained to determine extent of other comorbidities in association with vision loss (i.e., diabetes, cardiovascular disease)
Erythrocyte sedimentation rate if giant cell arteritis is suspected

Imaging

Tests should be directed toward the suspected etiology of visual loss
Dilated fundus exam may be performed to assess for posterior segment disease
Temporal artery biopsy may be obtained if giant cell arteritis is suspected
Brain CT, MRI, MRA, and transcranial Doppler may be used to evaluate neurologic symptoms and vertebrobasilar artery
Urgent cardiac and carotid US if a retinal artery occlusion is diagnosed
Facial CT may be used to evaluate extent of traumatic injuries

Differential Diagnosis

Trauma
Neurologic lesion
Infectious
Cardiovascular
Toxic/metabolic
Autoimmune

Treatment

Pre-Hospital

Chemical burns:Begin copious irrigation with water or saline

Ed Treatment/Procedures

Direct therapy toward cause of visual loss
Ophthalmology consultation for visual loss with an uncertain diagnosis
3 conditions for which identification and treatment must begin within minutes:Central retinal artery occlusionChemical burnAcute angle-closure glaucoma

Central Retinal Artery Occlusion

Clinical criteria:Unilateral, painless, dramatic vision lossAfferent pupillary defectPale fundus with a cherry-red spot (macula)Counting fingers to light perception in 94% of patients
Therapy:Immediate ophthalmology consultationManeuvers and medications to lower intraocular pressure, allowing the embolus to move to the periphery:Ocular massage: Direct pressure to eye for 5 " 15 sec then sudden release, repeat for 15 minAcetazolamide: 500 mg IV or POTopical ²-blockerAnterior chamber paracentesis by an ophthalmologistReferral for cardiac and carotid artery workupRule out giant cell arteritis

Chemical Burn

Clinical criteria:Alkali worse than acidsWhite eye (vessels have already sloughed) worse than red eye (vessels are intact)Examples: Mace, cements, plasters, solvents
Therapy:Topical anestheticCopious irrigation of the eyes with LR or NS (nonsterile water is acceptable if others not available); minimum of 30 minGoal: Neutral pH at 5 " 10 min after ending irrigationDo not try to neutralize acids with alkalis or vice versaEvert lids and use moist cotton-tipped applicator to sweep furnaces for residual chemical precipitantsDilate with cycloplegic (atropine, cyclopentolate, tropicamide)Do not use phenylephrine; vasoconstricts already ischemic conjunctival blood vesselsErythromycin ointment q1 " 2hArtificial tears q1hCheck intraocular pressure

Acute Angle-closure Glaucoma

Signs and symptoms:Unilateral, painful vision lossNausea, vomiting, headacheCornea injected, edematousMid-dilated, sluggish/nonreactive pupilSwollen, "steamy " lensCell, flare in a shallow anterior chamberIncreased intraocular pressure (>20 mm Hg)
Therapy:Topical ²-blockerTopical prostaglandin analogAcetazolamideTopicalα-2 agonistPilocarpineMannitol: If no decrease in IOP after 1 hr

Medication

Antibiotic drops:Ciprofloxacin 0.3%: 1 " 2 gtt q1 " 6hGentamicin 0.3%: 1 " 2 gtt q4hOfloxacin 0.3%: 1 " 2 gtt q1 " 6hLevofloxacin 0.5%: 1 " 2 gtt q2hPolymyxin (Polytrim) 1 gtt q3 " 6hSulfacetamide 10%, 0.3%: 1 " 2 gtt q2 " 6hTobramycin 0.3%: 1 " 2 gtt q1 " 4hTrifluridine 1%: 1 gtt q2 " 4h
Antibiotic ointments:Bacitracin 500 U/g 1/2 in ribbon q3 " 6hCiprofloxacin 0.3%: 1/2 in ribbon q6 " q8hErythromycin 0.5%: 1/2 in ribbon q3 " 6hGentamicin 0.3%: 1/2 in ribbon q3 " 4hNeosporin 1/2 in ribbon q3 " 4hPolysporin 1/2in ribbon q3 " 4hSulfacetamide 10%: 1/2 in ribbon q3 " 8hTobramycin 0.3%: 1/2 in ribbon q3 " 4hVidarabine 1/2 in ribbon 5 times per day
Mydriatics and cycloplegics:Atropine 1%, 2%: 1 " 2 gtt/day to QIDCyclopentolate 0.5%, 1%, 2%: 1 " 2 gtt PRNHomatropine 2%: 1 " 2 gtt BID " TIDPhenylephrine 0.12%, 2.5%, 10%: 1 " 2 gtt TID " QIDTropicamide 0.5%, 1%: 1 " 2 gtt PRN dilation
Corticosteroid " antibiotic combination drops (with ophthalmology consultation):Prednisolone (Blephamide) 1 " 2 gtt q1 " 8hHydrocortisone/neomycin/bacitracin/polymyxin B (Cortisporin) 1 " 2 gtt q3 " 4hDexamethasone/neomycin/polymyxin B (Maxitrol) 1 " 2 gtt q1 " 8hPrednisolone/gentamicin (Pred-G) 1 " 2 gtt q1 " 8hDexamethasone/tobramycin/chlorobutanol (TobraDex) 1 " 2 gtt q2 " 26h
Glaucoma agents (always with ophthalmology consultation):α-2 agonists:Brimonidine 1% 1 gtt TIDApraclonidine 1% 1 gtt TID ²-blocker:Betaxolol 0.25%, 0.5%: 1 " 2 gtt BIDCarteolol 1%: 1 gtt BIDLevobunolol 0.25%, 0.5%: 1 gtt QD " BIDCarbonic anhydrase inhibitor:Acetazolamide 500 mg PO/IV QD " QIDMiotic (parasympathomimetic):Pilocarpine 0.25%, 0.5%, 1%, 2%, 3%, 4%, 6%, 8%, 10%: 1 " 2 gtt TID " QIDOsmotic agent:Mannitol 1 " 2 g/kg IV over 45 minProstaglandin analog:Latanoprost 0.005%: 1 gtt QD
Only if mechanical closure is ruled out:Timolol 0.25%, 0.5%: 1 gtt BID

Follow-Up

Disposition

Admission Criteria

Ruptured globe
Hyphema (depending on severity)
Orbital cellulitis/abscess
Cavernous sinus thrombosis
Significant cardiac, carotid, or neurologic disease
Unexplained, progressive vision loss

Discharge Criteria

If the diagnosis is certain and visual loss will not progress

Follow-Up Recommendations

Follow-up should be discussed with ophthalmology for emergent or urgent issues
Referral for cardiac and carotid workup in embolic disease

Pearls and Pitfalls

Document visual acuity for all eye complaints
Topical anesthesia will aid in diagnosis as well as facilitating a proper eye exam
Consider ocular issues and a detailed eye exam with headache complaints

Additional Reading

Khare GD, Symons RC, Do DV. Common ophthalmic emergencies. Int J Clin Pract. 2008;62:1776 " 1784.
Kunimoto DY, Kanitkar KD, Makar MS. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. Website: www.eyeatlas.com
Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin North Am. 2008;26:35 " 55.
Vortmann M, Schneider JI. Acute monocular visual loss. Emerg Med Clin North Am. 2008;26:73 " 96.

Codes

ICD9

368.8 Other specified visual disturbances
368.11 Sudden visual loss
369.9 Unspecified visual loss
364.41 Hyphema of iris and ciliary body
361.9 Unspecified retinal detachment
377.30 Optic neuritis, unspecified
950.9 Injury to unspecified optic nerve and pathways

ICD10

H53.8 Other visual disturbances
H53.139 Sudden visual loss, unspecified eye
H54.7 Unspecified visual loss
H21.00 Hyphema, unspecified eye
H33.20 Serous retinal detachment, unspecified eye
H46.9 Unspecified optic neuritis
S05.90XA Unspecified injury of unspecified eye and orbit, init encntr

SNOMED

421293001 Unexplained visual loss (disorder)
246636008 Hazy vision (disorder)
15203004 Sudden visual loss (disorder)
75229002 Hyphema (disorder)
23653003 Traumatic blindness (disorder)
42059000 Retinal detachment (disorder)
66760008 Optic neuritis (disorder)