Differential Diagnosis for Unilateral Vision Loss in the Elderly

When evaluating unilateral vision loss in the elderly, it's crucial to consider a range of potential causes due to the complexity and variability of presentations. The differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Age-related Macular Degeneration (AMD): This is a leading cause of vision loss in older adults. The unilateral presentation can occur, although it often affects both eyes over time. AMD's risk factors, such as age, smoking, and family history, support its consideration as a primary diagnosis.
• Other Likely Diagnoses
  • Diabetic Retinopathy: Given the high prevalence of diabetes in the elderly population, diabetic retinopathy is a common cause of unilateral vision loss. It can present asymmetrically, affecting one eye more severely than the other.
  • Glaucoma: This condition, particularly open-angle glaucoma, is common in the elderly and can lead to unilateral vision loss if one eye is more severely affected than the other.
  • Central Retinal Artery Occlusion (CRAO): Although less common, CRAO can cause sudden, painless unilateral vision loss and is more likely in the elderly due to atherosclerosis and other vascular risk factors.
  • Posterior Vitreous Detachment (PVD): While often asymptomatic, PVD can cause floaters and, in some cases, lead to retinal detachment, which may present as unilateral vision loss.
• Do Not Miss Diagnoses
  • Giant Cell Arteritis (GCA): This condition is critical to identify due to its potential for rapid progression to bilateral blindness if not promptly treated. It typically presents with headache, jaw claudication, and scalp tenderness, in addition to vision loss.
  • Retinal Detachment: Early detection is crucial for successful treatment and preservation of vision. Symptoms can include sudden onset of floaters, flashes of light, and a curtain or shadow descending over the field of vision.
  • Optic Neuritis: Although more common in younger populations, optic neuritis can occur in the elderly, especially in the context of demyelinating diseases like multiple sclerosis. It presents with sudden vision loss, often accompanied by pain on eye movement.
• Rare Diagnoses
  • Ocular Malignancies (e.g., Choroidal Melanoma): These are less common causes of unilateral vision loss but are critical to diagnose early due to their potential for metastasis and impact on prognosis.
  • Intraocular Inflammation (Uveitis): While uveitis can occur at any age, certain types are more prevalent in younger populations. However, it remains a consideration in the differential diagnosis of unilateral vision loss in the elderly, particularly if associated with systemic diseases.
  • Optic Disc Drusen: These are congenital anomalies that can mimic other conditions, such as optic neuritis or papilledema, and may cause gradual, unilateral vision loss.

Each of these diagnoses has distinct clinical features, risk factors, and implications for management, underscoring the importance of a thorough diagnostic evaluation for unilateral vision loss in the elderly.