What is the appropriate management for acute vision loss in a pediatric patient?

Management of Acute Vision Loss in a 5-Year-Old Female

Immediately refer this child to a pediatric ophthalmologist today without delay for any additional testing or workup. 1

Immediate Action Required

• Same-day urgent referral to pediatric ophthalmology is mandatory for children 7 years or younger with acute unilateral vision loss, as per American Academy of Pediatrics guidelines 1
• Do not delay referral to obtain imaging yourself – the pediatric ophthalmologist will coordinate appropriate neuroimaging (MRI head and orbits with and without IV contrast) if indicated based on their examination findings 2, 1
• The ophthalmologist will perform fundoscopic examination to assess the optic disc, which is critical for determining the underlying etiology 3

Critical Differential Diagnoses to Consider

The pediatric ophthalmologist will evaluate for the following time-sensitive conditions:

Neurovisual Pathway Disorders

• Optic neuritis (most common cause in children) – may be secondary to demyelinating disorders (multiple sclerosis, neuromyelitis optica spectrum disorders), inflammatory, infectious, or granulomatous disorders 2
• Acute infarct or hemorrhage involving the thalamus, optic radiations, or occipital lobes 2
• Retinal artery occlusion (ocular stroke) – requires emergency department evaluation within 24 hours if suspected 4

Structural/Infectious Causes

• Acute sphenoid sinusitis causing optic nerve compression – can cause painless vision loss and requires emergent surgical intervention 5
• Retinoblastoma or other orbital tumors – requires immediate specialist evaluation 1
• Increased intracranial pressure with papilledema 2, 3

Other Important Considerations

• Nonorganic (psychogenic) vision loss is not uncommon in school-age children but is a diagnosis of exclusion requiring negative imaging and inconsistent examination findings 2
• Retinal hemorrhages suggest traumatic origin and require evaluation for possible abuse 1, 3

Imaging Strategy (Coordinated by Ophthalmology)

MRI head and orbits with and without IV contrast is the most useful imaging modality for acute nontraumatic vision loss in children 2

• T1-weighted post-contrast images with fat suppression identify abnormal optic nerve enhancement in 95% of optic neuritis cases 2
• MRI evaluates both the intraorbital optic nerves and the extraorbital neurovisual pathway (optic chiasm, tracts, thalamus, optic radiations, visual cortex) 2
• MRI orbits alone is inadequate – must include brain imaging as pathologies frequently involve extraorbital structures 2

Complementary Imaging

• CT head without IV contrast may be complementary if acute infarct or hemorrhage is suspected 2
• MRI complete spine may be added if demyelinating disorder is suspected to assess disease burden and differentiate neuromyelitis optica spectrum disorders from multiple sclerosis 2

Imaging NOT Recommended

• CT head and orbits, CT orbits alone, CTA head and neck, CTA head, and MRA head have no supporting literature for initial evaluation of nontraumatic vision loss in children 2

Critical Pitfalls to Avoid

• Do not miss child abuse – children with suspected abuse and possible eye injury require immediate pediatric ophthalmology referral 1
• Do not delay for outpatient workup – acute vision loss in a 5-year-old is an ophthalmologic emergency requiring same-day evaluation 1
• Do not assume psychogenic cause – this requires exclusion of all organic causes through comprehensive examination and negative imaging 2
• Do not overlook bilateral involvement – unilateral visual loss may be overlooked by the child or family, so both eyes must be carefully assessed 3

Special Circumstances Requiring Emergency Department Referral

If the ophthalmologist suspects retinal artery occlusion (ocular stroke), immediate transfer to an emergency department or stroke center is required:

• Consider IV tissue plasminogen activator if within 4.5 hours of symptom onset 4
• Hyperbaric oxygen therapy may be beneficial 4
• Screen for giant cell arteritis with ESR and CRP, though this is rare in children 4
• Vascular imaging and brain MRI with diffusion-weighted imaging to identify concurrent cerebrovascular events 4