What is the workup for sudden loss of vision in the left eye, also known as acute unilateral vision loss?

From the Guidelines

A workup for sudden loss of vision in the left eye should begin with an immediate ophthalmologic evaluation, ideally within 24 hours, as this represents a potential emergency. The initial assessment should include:

• Visual acuity testing
• Pupillary examination for relative afferent pupillary defect (RAPD)
• Intraocular pressure measurement
• Slit-lamp examination
• Dilated fundoscopic examination Additional testing may include:
• Optical coherence tomography (OCT)
• Visual field testing
• Fluorescein angiography Laboratory tests should include:
• Complete blood count
• Erythrocyte sedimentation rate
• C-reactive protein
• In selected cases, tests for hypercoagulable states or autoimmune conditions Neuroimaging with MRI of the brain and orbits with contrast is often necessary to evaluate for stroke, demyelinating disease, or compressive lesions, as recommended by 1. Carotid ultrasound may be indicated to assess for carotid stenosis. Common causes of sudden vision loss include central retinal artery occlusion (requiring immediate intervention within hours), central retinal vein occlusion, acute angle-closure glaucoma, optic neuritis, ischemic optic neuropathy, retinal detachment, or vitreous hemorrhage. The urgency of this workup cannot be overstated, as conditions like central retinal artery occlusion have a treatment window of only a few hours, and prompt diagnosis can be vision-saving or even life-saving in cases where vision loss is the first manifestation of a systemic disease, as highlighted in 1 and 1.

Given the potential for systemic disease, particularly stroke, immediate referral to a certified stroke center or emergency department is crucial, as emphasized in 1 and 1. The use of existing stroke code systems ensures rapid and reproducible evaluation of risk factors for hemorrhage, and the addition of a funduscopic examination to confirm the diagnosis and exclude alternative causes is necessary, as noted in 1.

In terms of specific management, the use of hyperbaric oxygen therapy (100% oxygen over 9 hours) has demonstrated efficacy over observation alone in several small randomized trials, as mentioned in 1. However, the effectiveness of thrombolytic or interventional treatments for central retinal artery occlusion is still controversial and limited to level II data, as discussed in 1.

Overall, the key to managing sudden loss of vision is prompt recognition and referral to a specialized center for further evaluation and treatment, with a focus on minimizing the risk of stroke and other systemic complications, as emphasized in 1 and 1.

From the Research

Sudden Loss of Vision in Left Eye: Workup and Diagnosis

• The workup for sudden loss of vision in one eye should include a thorough ophthalmologic examination to rule out retinal ischemia and vasculitis (giant cell arteritis) as the cause of transient monocular vision loss (TMVL) 2.
• Patients with transient retinal ischemia are at high risk of cardiovascular events and death, and their risk of cerebrovascular accidents is highest within 48 hours from the episode of TMVL 2.
• Common and dangerous conditions causing sudden vision loss include:
  • Acute angle-closure glaucoma
  • Retinal detachment
  • Retinal artery occlusion
  • Giant cell arteritis
  • Optic neuritis 3
• A diagnostic approach to sudden vision loss should include:
  • Ocular pain, headache, and nausea for acute angle-closure glaucoma
  • Curtain-like visual field defect for retinal detachment
  • Painless vision loss in patients with vascular risk factors for retinal artery occlusion
  • Scalp tenderness, jaw claudication, proximal muscle and joint pain, constitutional symptoms, and elevated C-reactive protein level for giant cell arteritis
  • Color desaturation, relative afferent pupillary defect, and pain with extraocular muscle movements for optic neuritis 3
• Abnormalities may occur at any point within the complex vision pathway, from retina to optic nerve to the visual center in the occipital lobe, and should be considered in the workup for sudden loss of vision 4.
• Retinal artery occlusion can occur in the setting of a chronic retinal detachment, and a comprehensive workup should be performed to rule out underlying conditions 5.
• Patients with retinal artery occlusion should be guided to a comprehensive and prompt neurological and cardiological diagnostic work-up, as most patients present with a large number of cardio- and cerebrovascular risk factors 6.