What are the next steps for a patient presenting with transient visual disturbances, including squiggly lines and fogginess in one eye?

Immediate Emergency Ophthalmology Referral Required

A patient presenting with squiggly lines and fogginess in one eye requires same-day urgent ophthalmologic evaluation to rule out retinal detachment, retinal artery occlusion, or posterior vitreous detachment with retinal tear—all vision-threatening emergencies. 1, 2

Critical Immediate Actions

Triage and Referral

• Send the patient immediately to an emergency department affiliated with a certified stroke center or arrange same-day ophthalmology evaluation 1
• Do not delay for additional outpatient testing or attempt further evaluation yourself 1
• Call ahead to warn the receiving facility that "a potential ocular stroke patient is on the way" 1
• Between 8-22% of patients with acute posterior vitreous detachment symptoms have a retinal tear at initial examination 1, 2

Why This Is Urgent

The symptoms described—squiggly lines (likely photopsias/floaters) and fogginess—are classic warning signs of:

• Posterior vitreous detachment with potential retinal tear (most common) 1, 3
• Retinal detachment (ophthalmologic emergency requiring same-day treatment) 4
• Retinal artery occlusion (ocular stroke requiring evaluation within 4.5 hours for potential thrombolysis) 1

Essential Examination Components Required

The ophthalmologist must perform:

• Visual acuity testing to establish baseline 1, 2
• Pupillary assessment for relative afferent pupillary defect 2
• Vitreous examination looking for hemorrhage, pigmented cells (Shafer's sign), or detachment 1, 2
• Dilated funduscopic examination with scleral depression to evaluate the peripheral retina 1, 2
• B-scan ultrasonography if media opacity prevents adequate visualization 1, 2, 5
• Funduscopic examination to confirm diagnosis and exclude vitreous or retinal hemorrhage 1

Critical Time Windows

For Retinal Artery Occlusion (Ocular Stroke)

• Treatment window: 4.5 hours from symptom onset for intravenous tPA consideration 1
• Patients treated within 4.5 hours show 50% rate of visual recovery 1
• Mean time to workup through ED is 2.2 days vs. 13.6 days outpatient—ED referral is essential 6

For Retinal Detachment

• Same-day evaluation mandatory 1, 4
• Early diagnosis critical because success rates are higher and visual outcomes better when repaired before macular involvement 1
• Without treatment, blindness may result 4

For Posterior Vitreous Detachment

• Immediate evaluation required even if symptoms seem mild 1, 2
• Approximately 2-5% of patients with initially normal exams develop retinal breaks within 6 weeks 1, 2
• 80% of patients who later develop breaks had pigmented cells, hemorrhage, or new symptoms 2

Follow-Up Protocol

Even if initial examination is negative:

• Schedule follow-up within 6 weeks of symptom onset 1, 3, 2
• This is particularly critical for patients with vitreous pigment, hemorrhage, or visible vitreoretinal traction 1, 2
• Instruct patient to return immediately for new or worsening floaters, flashes, peripheral visual field loss, or decreased vision 1, 2, 7

Common Pitfalls to Avoid

• Never assume isolated floaters are benign without proper examination—there are no symptoms that reliably distinguish benign PVD from one with retinal tear 2
• Do not delay referral to obtain outpatient imaging or testing—this significantly increases time to diagnosis 1, 6
• Do not reassure and discharge without ophthalmologic evaluation—retinal breaks can develop weeks after initial symptoms 2, 7
• Do not forget to consider giant cell arteritis in older patients with sudden vision loss, as this requires immediate steroid therapy 1

Special Considerations

If History of Trauma

• Trauma can precipitate PVD at younger ages than typical (normally 45-65 years) 3, 7
• Symptoms may appear immediately or develop within 6 weeks post-trauma 3, 7
• Both blunt and penetrating injuries can cause vitreous detachment and retinal tears 3, 7

Risk Factors to Elicit

• Myopia (major risk factor for retinal detachment) 4
• Prior cataract surgery (major risk factor) 4
• Recent eye trauma 3, 7
• Age 45-65 years (typical PVD age range) 1, 3

The key message: This is a potential ophthalmologic emergency requiring same-day evaluation by an ophthalmologist skilled in indirect ophthalmoscopy with scleral depression. 1, 2 Do not wait, do not attempt outpatient workup—refer immediately. 1