From the Guidelines
A workup for unilateral vision loss should begin with a comprehensive eye examination by an ophthalmologist, including visual acuity testing, pupillary assessment, intraocular pressure measurement, and dilated fundoscopic examination, as immediate evaluation is necessary due to the potential for urgent treatment requirements 1.
Key Components of the Workup
- Imaging studies such as optical coherence tomography (OCT) to assess retinal structure, fluorescein angiography to evaluate blood flow, and visual field testing to map peripheral vision defects
- Blood tests including complete blood count, erythrocyte sedimentation rate, C-reactive protein, and specific tests for suspected conditions like temporal arteritis
- Brain MRI with contrast to rule out compressive lesions, demyelinating disease, or stroke
- Carotid ultrasound if vascular etiology is suspected
Differential Diagnosis
- Retinal detachment
- Central or branch retinal artery occlusion
- Optic neuritis
- Anterior ischemic optic neuropathy
- Temporal arteritis
- Compressive lesions
Importance of Prompt Diagnosis
Prompt diagnosis is critical as conditions like central retinal artery occlusion have a treatment window of only hours, while others like temporal arteritis can lead to permanent bilateral blindness if not treated quickly 1.
Recent Guidelines
Recent guidelines emphasize the importance of rapid and accurate diagnosis and recognition of the need for timely expert intervention, particularly in cases of acute retinal arterial ischemia, where immediate referral to a certified stroke center or rapid-TIA clinic is recommended 1.
Quality of Life Considerations
Unilateral uncorrectable visual loss is associated with an increased likelihood of falls and functional dependence, highlighting the need for prompt and effective treatment to improve outcomes and quality of life 1.
From the Research
Unilateral Vision Loss Workup
The workup for unilateral vision loss involves a combination of history-taking, ocular and neurological examination, and judicious use of serological and imaging investigations to guide appropriate treatment and referral 2.
- Key steps in the workup include:
- Detailed history-taking to determine the onset, duration, and characteristics of vision loss
- Complete ocular and neurological examination to identify any underlying conditions
- Use of multimodal imaging, such as fluorescein angiography, to evaluate the retina and diagnose conditions like central retinal artery occlusion (CRAO) 3
- Laboratory tests to rule out alternative vasculitides and confirm diagnoses like giant cell arteritis (GCA) 4
- Consideration of urgent referral for further investigation or treatment, particularly in cases of sudden vision loss 2
Differential Diagnosis
The differential diagnosis for unilateral vision loss includes:
- Giant cell arteritis (GCA), which can cause anterior ischemic optic neuropathy and vision loss in one or both eyes 5, 4
- Central retinal artery occlusion (CRAO), which is an ophthalmic emergency requiring timely diagnosis and treatment 3
- Other conditions, such as arteritic ischemic optic neuropathy (AION) and small vessel arteritis, which can cause vision loss and require prompt evaluation and management 4
Investigation and Management
Investigation and management of unilateral vision loss require a structured approach, including:
- Determining the underlying cause of vision loss through history-taking, examination, and imaging studies
- Initiating prompt treatment, such as pulse glucocorticoid treatment for GCA, to prevent further vision loss and preserve vision in the affected eye 5
- Considering urgent referral for further investigation or treatment, particularly in cases of sudden vision loss or suspected cerebrovascular or cardiovascular morbidity 3, 2