Vision Loss, Sudden

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credit: Sourced from the MSD Manual, Consumer Version; authored by Dr Christopher J. Brady (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Loss of vision is considered sudden if it develops within a few minutes to a couple of days. It may affect one or both eyes and all or part of a field of vision. Loss of only a small part of the field of vision (for example, as a result of a small retinal detachment) may seem like blurred vision. Other symptoms, for example eye pain, may occur depending on the cause of vision loss.

An Inside Look at the Eye

When the Visual Pathways Are Damaged

Nerve signals travel along the optic nerve from each eye. The two optic nerves meet at the optic chiasm. There, the optic nerve from each eye divides, and half of the nerve fibres from each side cross to the other side. Because of this arrangement, the brain receives information via both optic nerves for the left visual field and for the right visual field. Damage to an eye or the visual pathway causes different types of vision loss depending on where the damage occurs.

How and Why Blindness Develops

Anything that blocks the passage of light from the environment to the back of the eye or disrupts the transmission of nerve impulses from the back of the eye to the brain will interfere with vision. Legal blindness is defined as a visual acuity of 20/200 or worse in the better eye, even after correction with eyeglasses or contact lenses, or a visual field restricted to less than 20° in the better eye. Many people who are considered legally blind can distinguish shapes and shadows but not normal detail.

Blindness can occur under the following circumstances:

• Light cannot reach the retina.
• Damage to the cornea caused by infections such as herpes keratoconjunctivitis or an infection that follows contact lens over-wearing, which results in an opaque corneal scar.
• Damage to the cornea caused by vitamin A deficiency (keratomalacia), which causes dry eyes and results in an opaque corneal scar (rare in developed nations).
• Damage to the cornea caused by a severe injury that results in an opaque corneal scar.
• A cataract, which causes loss of clarity of the lens.
• Light rays do not focus on the retina clearly.
• Imperfect focusing of light rays on the retina (refraction errors) that cannot be fully corrected with eyeglasses or contact lenses (such as from certain types of cataracts).
• The retina cannot sense light rays normally.
• Detached retina.
• Diabetes mellitus.
• Macular degeneration.
• Retinitis pigmentosa.
• Inadequate blood supply to the retina, usually due to a blockage of the retinal artery or vein, which may be caused by inflammation of the blood vessel wall (such as that caused by giant cell arteritis), or due to a blood clot that travels to the eye from somewhere else (such as from the carotid artery in the neck).
• Infection of the retina (such as from Toxoplasma, parasites, or fungi) in people who have AIDS.
• Nerve impulses from the retina are not transmitted to the brain normally.
• Disorders affecting the optic nerve or its pathways inside the brain, such as brain tumours, strokes, infections, and multiple sclerosis.
• Glaucoma (increased pressure in eye).
• Inflammation of the optic nerve (optic neuritis).
• The brain cannot interpret information sent by the eye.
• Disorders that affect the areas of the brain that interpret visual impulses (visual cortex), such as strokes and tumours.

Causes

Sudden loss of vision has three general causes:

• Clouding of normally transparent eye structures
• Abnormalities of the retina (the light-sensing structure at the back of the eye)
• Abnormalities of the nerves that carry visual signals from the eye to the brain (the optic nerve and the visual pathways)

Light must travel through several transparent structures before it can be sensed by the retina. First, light passes through the cornea (the clear layer in front of the iris and pupil), then the lens, and then the vitreous humor (the jellylike substance that fills the eyeball). Anything that blocks light from passing through these structures, for example, a corneal ulcer or bleeding into the vitreous humor, can cause loss of vision.

Most of the disorders that cause total loss of vision when they affect the entire eye may cause only partial vision loss when they affect only part of the eye.

Common causes

The most common causes of sudden loss of vision are:

• Blockage of a major artery of the retina (central retinal artery occlusion)
• Blockage of an artery to the optic nerve (ischemic optic neuropathy)
• Blockage of a major vein in the retina (central retinal vein occlusion)
• Blood in the jellylike vitreous humor near the back of the eye (vitreous haemorrhage)

Eye injury:

Sudden retinal artery blockage can result from a blood clot or small piece of atherosclerotic material that breaks off and travels into the artery. The artery to the optic nerve can be blocked in the same ways and can also be blocked by inflammation (such as may occur with giant cell [temporal] arteritis). A blood clot can form in the retinal vein and block it, particularly in older people with high blood pressure or diabetes. People with diabetes are also at risk of bleeding into the vitreous humor.

Sometimes what seems like a sudden start of symptoms may instead be sudden recognition. For example, a person with long-standing reduced vision in one eye (possibly caused by a dense cataract) may suddenly become aware of the reduced vision in the affected eye after covering the unaffected eye.

Less common causes

Less common causes of sudden loss of vision (see section: Some Causes and Features of Sudden Loss of Vision) include stroke or transient ischemic attack (TIA), acute glaucoma, retinal detachment, inflammation of the structures in the front of the eye between the cornea and the lens (anterior uveitis, sometimes called iritis), certain infections of the retina, and bleeding within the retina as a complication of age-related macular degeneration.

Spotlight on Aging: Vision Loss in Older People

Most commonly, vision loss among older people is due to clouding of the lens of the eye (cataracts) or to damage to the optic nerve (as occurs in glaucoma) or the retina (as occurs in age-related macular degeneration and diabetic retinopathy). A less common cause of vision loss is blockage of the blood supply to the eye. Eyelid disorders mostly change the appearance of the eye and do not usually cause vision loss, but they can cause discomfort.

Whatever the reason for vision loss, any vision change can compromise an older person's quality of life and, indirectly, health. For example, poor eyesight may contribute to a car crash or to a fall. Loss of vision can be especially devastating to older people coping with other problems as well, such as poor balance and hearing loss. In such cases, vision loss can contribute to significant injury and can impair a person's ability to do daily activities.

Evaluation

Sudden loss of vision is an emergency. Most causes are serious.

When to see a doctor

All people who experience a sudden loss of vision should see an ophthalmologist (a medical doctor who specialize in the evaluation and treatment—surgical and nonsurgical—of eye disorders) or go to the emergency department right away.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see section: Some Causes and Features of Sudden Loss of Vision).

Doctors ask the person to describe when loss of vision occurred, how long it has been present, and whether it has progressed. People are asked whether loss affects one or both eyes and whether loss is total or affects only a specific part of the field of vision. Doctors also ask about other vision symptoms such as floaters, flashing lights, halos around lights, distorted colour vision, jagged or mosaic patterns, or eye pain. Doctors ask about symptoms that are not related to the eyes and risk factors for disorders that may cause eye problems.

The physical examination concentrates primarily on the eyes, but doctors may also do a general physical examination, including, for example, examination of the skin and the nervous system.

For the eye examination, doctors first carefully check sharpness of vision (visual acuity), usually by having the person read letters on a chart, first while one eye is covered and then with both uncovered. Doctors check how the pupils narrow (constrict) in response to light and how well the eyes can follow a moving object. Colour vision may be tested. Doctors examine the eyes and eyelids using a slit lamp (an instrument that enables a doctor to examine the eye under high magnification) and measure pressure in the eye. Ophthalmologists, after instilling drops that dilate the pupils, examine the retina thoroughly with a slit lamp or light that is shone from a head lamp through a hand-held instrument.

Some Causes and Features of Sudden Loss of Vision

Please note: Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

Sudden loss of vision without eye pain

Transient ischemic attack (TIA)

• Sudden, brief loss of vision in one eye resulting from a transient ischemic attack (called amaurosis fugax)
• Blindness in one eye lasting minutes to hours

Blockage of the central retinal artery (the artery that carries blood to the retina)

• Almost instantaneous, complete loss of vision in one eye
• In people with risk factors for atherosclerosis (such as high blood pressure, abnormal blood lipids, or cigarette smoking)

Blockage of the central retinal vein (the vein that carries blood away from the retina)

• In people with risk factors for this disorder (such as diabetes, high blood pressure, a tendency for blood to clot excessively, or sickle cell disease)

Vitreous haemorrhage (bleeding into the vitreous humor—the jellylike substance that fills the back of the eyeball)

• In people who have had specks, strings, or cobwebs in their field of vision (floaters) or who have risk factors for vitreous haemorrhage (such as diabetes, a tear in the retina, sickle cell disease, or an eye injury)
• Usually loss of the entire field of vision (not in just one or more spots)

Giant cell (temporal) arteritis (inflammation of the large arteries of the head, neck, and upper body), which can block blood flow to the optic nerve

• Sometimes headache, pain while combing the hair, or pain in the jaw or tongue when chewing
• Sometimes aches and stiffness in the large muscles of the arms or legs (polymyalgia rheumatica)

Ischemic optic neuropathy (damage of the optic nerve caused by blockage of its blood supply)

• In people with risk factors for this disorder (such as diabetes or high blood pressure) or in people who have had an episode of very low blood pressure, which sometimes causes fainting

Macular haemorrhage (bleeding around the macula—the most sensitive part of the retina) resulting from age-related macular degeneration

• Usually in people known to have age-related macular degeneration or in people with risk factors for blood vessel disorders (such as high blood pressure, cigarette smoking, or abnormal blood lipids)

Ocular migraine (migraines that affect vision)

• Shimmering, irregular spots that drift slowly across the field of vision of one eye for about 10 to 20 minutes
• Sometimes blurring of central vision (what a person is looking at directly)
• Sometimes a headache after the disturbances in vision
• Often in young people or in people known to have migraines

Migraine aura

• A blind spot, sometimes with a shimmering spot that drifts across the field of vision, and that lasts usually 10 to 60 minutes
• Usually a headache after the disturbances in vision
• Usually in people known to have migraines

Detachment of the retina

• Sudden, spontaneous flashes of light that can look like lightning, spots, or stars (called photopsias) that occur repeatedly
• Loss of vision that affects one area, usually what is seen out of the corners of the eye (peripheral vision)
• Loss of vision that spreads across the field of vision like a curtain
• Sometimes in people with risk factors for detachment of the retina (such as a recent eye injury, recent eye surgery, or severe near-sightedness)

Strokes or transient ischemic attack

• Usually loss of the same parts of the field of vision in both eyes
• In people with risk factors for these disorders (such as high blood pressure, atherosclerosis, diabetes, abnormal blood lipids, and cigarette smoking)
• Sometimes slurred speech, impaired eye movements, muscle weakness, and/or difficulty walking

Closed-angle glaucoma

• Severe eye ache and redness
• Headache, nausea, vomiting, and sensitivity to light
• Disturbances in vision such as seeing halos around lights

Corneal ulcer (usually caused by bacterial or viral infection)

• Often a greyish patch on the cornea that later becomes an open, painful sore
• Eye ache or a foreign object (body) sensation
• Eye redness and watering
• Sensitivity to light
• Sometimes in people who have an infection after an eye injury or who have slept with their contact lenses in

Optic neuritis (inflammation of the optic nerve), which can be related to multiple sclerosis

• Usually mild pain that may worsen when the eyes are moved
• Partial or complete loss of vision
• Eyelids and corneas that appear normal

Tests and special investigations

The presence or absence of pain helps narrow the list of possible causes of sudden vision loss considerably (see list: Some Causes and Features of Sudden Loss of Vision above). If vision returns quickly on its own, transient ischemic attack and ocular migraine are among the likely causes.

Often findings during the eye examination provide enough information for doctors to diagnose the cause of loss of vision. Sometimes, however, testing is needed depending on what disorders are suspected.

The following tests are of particular importance:

• Ultrasonography is done if the retina is not clearly visible during an ophthalmoscopic examination.
• Gadolinium-enhanced MRI is done for some people with eye pain and certain other symptoms and when optic nerve swelling is seen during the eye examination.
• Erythrocyte sedimentation rate (ESR) and C-reactive protein level (blood tests that indirectly measure inflammation in the body) are done and the number of platelets in the blood (platelet count) are sometimes measured, particularly in people over age 50 who have headache.

Treatment

Treatment of the cause

The disorder causing the loss of vision is treated as rapidly as possible, although treatment may not be able to save or restore vision. However, prompt treatment may decrease the risk of the same process occurring in the other eye.

Key Points

• Sudden loss of vision is an emergency, so people should go directly to a hospital.
• The presence or absence of pain helps indicate which causes are most likely.
• If vision returns quickly on its own, transient ischemic attack and ocular migraine are among the likely causes.

About the author

Dr Christopher J. Brady

MD

Assistant Professor of Ophthalmology, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine.

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