Im Board Review

Acute monocular vision loss: Don’t lose sight of the differential

Justin R. Abbatemarco, MD, Rushad Patell, MD, Janet Buccola, MD and Mary Alissa Willis, MD
Cleveland Clinic Journal of Medicine October 2017, 84 (10) 779-787; DOI: https://doi.org/10.3949/ccjm.84a.16096

Article Figures & Data

Figures

  • FIGURE 1
    FIGURE 1

    Common causes of monocular vision loss can arise in the media (cornea, anterior chamber, or lens), retina, or optic nerve.

  • FIGURE 2
    FIGURE 2

    The patient’s funduscopic examination revealed a cherry red spot (arrow), a characteristic finding in central retinal artery occlusion.

  • FIGURE 3
    FIGURE 3

    Vascular supply to the eye. The internal carotid artery’s first major branch is the ophthalmic artery. Four major vessels break off from the ophthalmic artery:

    Central retinal artery: large-diameter vessel that supplies the retina (vulnerable to embolic disease)

    Short and long posterior ciliary arteries: small vessels that supply the optic nerve and macula (susceptible to small-vessel disease)

    Anterior ciliary arteries supply the iris and ciliary body.

    Information from references 4 and 5.

Tables

  • TABLE 1

    Acute monocular vision loss: Diagnostic clues from the history

    FeatureCommon conditionsAdditional features
    Eye painAcute angle-closure glaucomaAge > 60 and family history
    Deep brow, headache with nausea and vomiting
    Halos around lights
    Optic neuritisPain worsens with eye movements
    Loss of color vision (red desaturation)
    Keratitis (inflammation of the cornea)Sharp superficial pain (“grittiness”)
    Discharge from the eye
    Conjunctival hyperemia (red eye)Acute angle-closure glaucomaSee above
    KeratitisSee above
    UveitisRedness prominent at limbus (convergence between cornea and sclera)
    Photophobia
    Systemic features suggesting autoimmune disease
    HeadacheGiant cell arteritisAge > 50
    Scalp tenderness (new onset, temporally based headache)
    Jaw claudication
    Proximal muscle pain
    MigraineYounger patients
    Preceded by migraine prodrome
    Symptoms resolve within hour
    Photopsia (flashes of bright light)Retinal detachmentMyopia
    Recent history of ophthalmic procedures
    Partial loss of peripheral field
    Preceding traumaKeratitis or uveitisAccompanying milder trauma
    Hyphema (blood in the anterior chamber)History of blunt trauma
    Recent history of ophthalmic procedures
    Lens dislocation or rupturePredisposed by congenital conditions
    Associated small, irregular pupil

    • Information from references 2 and 3.

  • TABLE 2

    Key physical examination features in monocular vision loss

    Physical examinationHelpful techniquesResults
    Visual acuityVision screening apps (eg, EyeChart Vision Screening App by Dok LLC)
    Use corrective lens or pinhole occluder    		Pinhole test corrects refractory error by permitting central rays of light into the eye; will not correct underlying neurologic impairment
    Visual fieldMonocular assessment
    Confrontation visual field testing uses small-amplitude finger movements in all quadrants
    Central fields tested by Amsler grid    		Scotoma: discrete area of visual impairment surrounded by intact vision; positive scotoma (seeing something that is not there) may be a sign of retinal damage; negative scotoma may indicate optic nerve dysfunction
    Hemianopia: bilateral visual impairment suggesting a lesion posterior to optic chiasm
    Color testingUse red objects (sharps container or bottle cap)Unilateral color desaturation: optic nerve dysfunction
    Pupillary examinationExamine for size, shape, symmetry
    Swinging flashlight examination: paradoxical dilation when stimulating ipsilateral eye after shining light into contralateral eye    		Afferent pupillary defect: optic nerve dysfunction
    Red reflexPerformed with ophthalmoscope when standing 1 foot away from patientLoss of reflex: localizes to media and possibly retinal detachment
    Direct ophthalmoscopyUse dilating drops to enhance the examination
    Disc: neuroretinal fibers entering the eye
    Macula: located temporally to disc and lacking blood vessels    		Cherry red macula: ischemic retina from central retinal artery occlusion that contrasts with nourished macula supplied by posterior ciliary arteries
    Hollenhorst plaque: cholesterol emboli signifies atherosclerotic disease in carotid or aortic arch
    Pale and swollen optic nerve head: ischemic optic neuropathy from posterior ciliary artery obstruction

    • Information from references 2 and 3.

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