What is the appropriate workup and management for an elderly patient presenting with acute blindness?

Acute Blindness Workup in the Elderly

Immediate Emergency Assessment

The most critical first step is to immediately rule out Giant Cell Arteritis (GCA) and retinal artery occlusion, as both represent ophthalmologic emergencies requiring treatment within minutes to hours to prevent permanent bilateral blindness. 1, 2

Priority 1: Giant Cell Arteritis Evaluation (Same-Day Emergency)

If GCA is suspected based on clinical features, initiate high-dose corticosteroids (prednisone 40-60 mg) immediately—before any diagnostic testing—as delaying treatment is the strongest risk factor for permanent blindness. 1, 2

Key clinical features that mandate immediate GCA workup: 1, 2

• Age >50 years with new-onset headache (especially temporal)
• Jaw claudication (highly specific, positive likelihood ratio 4.90)
• Scalp or temporal artery tenderness
• Constitutional symptoms (fever, weight loss, fatigue)
• Visual symptoms (transient vision loss, diplopia, acute vision loss)

Immediate actions for suspected GCA: 1, 2

• Draw ESR and CRP stat (but do NOT wait for results before treating)
• Start prednisone 40-60 mg daily immediately
• Arrange same-day ophthalmology consultation
• Temporal artery biopsy can be performed up to 2 weeks after starting steroids without affecting diagnostic yield

Critical pitfall: Never delay corticosteroids while awaiting laboratory confirmation or biopsy in suspected GCA with visual symptoms—this is the most common and dangerous error. 1, 2

Priority 2: Retinal/Ophthalmic Artery Occlusion (Ocular Stroke)

Patients with acute painless monocular vision loss should be immediately referred to the nearest emergency department affiliated with a stroke center, as this represents an "eye stroke" with 20-24% concurrent cerebral stroke rate and peak stroke risk of 11.5% within 14 days. 1

Distinguishing features of arterial occlusion: 1

• Sudden painless vision loss (not gradual)
• Absence of temporal symptoms or jaw claudication
• May have history of transient monocular vision loss (amaurosis fugax)
• Fundoscopic findings: pale retina, cherry-red spot (CRAO), or segmental whitening (BRAO)

Immediate actions for suspected arterial occlusion: 1

• Send immediately to ED with note stating "Ocular Stroke" or "Ocular TIA"
• Call ahead to stroke center to expedite evaluation
• Patient needs urgent brain MRI with diffusion-weighted imaging (19-25% have silent brain infarction)
• Carotid imaging and cardiac evaluation for embolic source
• Antiplatelet therapy should be initiated without delay

Critical distinction: If patient has GCA risk factors (age >50, new headache, jaw claudication, elevated ESR/CRP), treat as GCA first, as arteritic CRAO requires corticosteroids, not just stroke workup. 1

Secondary Differential Diagnosis Workup

Bilateral vs. Unilateral Vision Loss

Bilateral simultaneous vision loss is a red flag requiring same-day emergency evaluation, as it suggests cortical blindness (stroke), bilateral arterial occlusion, or severe GCA. 3, 4

Causes of bilateral acute blindness: 4, 5

• Bilateral occipital lobe infarction (cortical blindness)
• Bilateral GCA involvement
• Severe systemic hypotension with watershed infarcts
• Pituitary apoplexy with chiasmal compression

Acute Angle-Closure Glaucoma

If patient presents with painful red eye, mid-dilated fixed pupil, and corneal edema, measure intraocular pressure immediately to rule out acute angle-closure glaucoma. 6

Key features: 6

• Severe eye pain (not just vision loss)
• Red eye with conjunctival injection
• Nausea/vomiting
• Halos around lights
• IOP typically >40 mmHg

Immediate treatment if confirmed: Topical beta-blocker, alpha-2 agonist, systemic acetazolamide, hyperosmotic agent, followed by laser peripheral iridotomy. 6

Posterior Reversible Encephalopathy Syndrome (PRES)

In patients with acute vision loss and severe hypertension (especially >180/120 mmHg), consider PRES, which requires urgent brain MRI and blood pressure management. 5

Systematic Clinical Examination

Essential History Elements

Obtain these specific details: 1, 5

• Onset: Sudden (seconds to minutes) vs. gradual (hours to days)
• Unilateral vs. bilateral
• Painful vs. painless
• Associated symptoms: headache location/character, jaw pain with chewing, scalp tenderness, diplopia, neurologic deficits
• Vascular risk factors: diabetes, hypertension, smoking, atrial fibrillation, prior stroke/TIA
• Recent trauma or surgery

Focused Physical Examination

Critical examination components: 1, 5

• Visual acuity testing (each eye separately)
• Pupillary examination (relative afferent pupillary defect suggests optic nerve or retinal pathology)
• Confrontational visual fields
• Extraocular movements (diplopia suggests cranial nerve palsy or GCA)
• Temporal artery palpation (tenderness, thickening, absent pulse)
• Fundoscopic examination (optic disc swelling, pale retina, cherry-red spot, emboli)
• Blood pressure measurement
• Neurologic examination (focal deficits suggest stroke)

Laboratory and Imaging Algorithm

Immediate Laboratory Tests (Stat)

For all elderly patients with acute vision loss: 1, 2

• ESR and CRP (elevated in >95% of GCA cases, but 11% have normal values)
• Complete blood count
• Comprehensive metabolic panel
• Glucose

ESR interpretation: 2

• ESR >50 mm/h: 78.9% sensitivity for GCA
• ESR >100 mm/h: positive likelihood ratio 3.11 for GCA

Imaging Decisions

Brain MRI with diffusion-weighted imaging is indicated for: 1, 5

• Suspected retinal artery occlusion (to detect concurrent stroke)
• Bilateral vision loss (to evaluate for cortical blindness)
• Any neurologic symptoms or signs
• Visual field defects suggesting posterior circulation involvement

Carotid imaging (ultrasound or CTA) is indicated for: 1

• Retinal artery occlusion (70% have significant carotid stenosis)
• Transient monocular vision loss
• Age >50 with vascular risk factors

Temporal artery ultrasound or MRI can support GCA diagnosis but should never delay treatment. 1

Disposition and Referral Pathways

Same-Day Emergency Referrals

Immediate ED referral to stroke center: 1

• Central or branch retinal artery occlusion
• Transient monocular vision loss (amaurosis fugax)
• Bilateral acute vision loss
• Vision loss with neurologic symptoms

Same-day ophthalmology consultation: 1

• Suspected GCA with visual symptoms
• Acute angle-closure glaucoma
• Optic disc swelling
• Unexplained acute vision loss

Same-day rheumatology consultation (fast-track clinic): 1, 2

• Confirmed or highly suspected GCA for temporal artery biopsy planning
• Can be arranged after initiating corticosteroids

Urgent (1-7 Day) Referrals

Ophthalmology within 1-3 days: 1, 5

• Subacute vision loss without emergency features
• Suspected cataract or age-related macular degeneration
• Diabetic retinopathy screening in newly diagnosed diabetes

Common Pitfalls to Avoid

Never attribute new-onset headache in patients >50 years to migraine, especially with jaw claudication—this is GCA until proven otherwise. 2

Never pursue neuroimaging first when GCA is suspected based on classic symptoms—this wastes critical time. 2

Never delay corticosteroids for ESR/CRP results or temporal artery biopsy in suspected GCA. 1, 2

Never assume painless vision loss is "just old age"—it requires urgent stroke workup. 1

Never discharge elderly patients with acute vision loss without clear follow-up plan, as stroke risk remains elevated for 30 days. 1