Vision - Blurred

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

Blurred vision is the most common vision symptom. When doctors talk about blurred vision, they typically mean a decrease in sharpness or clarity that has developed gradually. Sudden, complete loss of vision in one or both eyes (blindness) is considered something different.

Causes

Blurred vision has four general mechanisms:

• Disorders affecting the retina, the light-sensing structure at the back of the eye
• Clouding of normally transparent eye structures (cornea, lens, and vitreous humor—the jellylike substance that fills the eyeball) that light rays must pass through to reach the retina
• Disorders affecting the pathways of nerves that carry visual signals from the eye to the brain (such as the optic nerve)
• Imperfect focusing of light rays on the retina (refractive errors)

Certain disorders can have more than one mechanism. For example, refraction can be impaired by early cataracts or by the reversible lens swelling caused by poorly controlled diabetes.

An Inside Look at the Eye

Some disorders that cause blurred vision are more likely to cause other symptoms that prompt people to seek medical attention, such as eye pain and eye redness (for example, acute corneal disorders such as abrasions, ulcers, herpes simplex keratitis, or herpes zoster ophthalmicus).

Common causes

The most common causes of blurred vision include:

• Refractive errors (such as near-sightedness, farsightedness, or astigmatism), the most common cause overall
• Age-related macular degeneration
• Cataracts
• Damage of the retina resulting from diabetes (diabetic retinopathy)
• Glaucoma

Less common causes

• Rare disorders that can cause blurred vision include
• Inherited disorders affecting the optic nerve, called hereditary optic neuropathies (for example, dominant optic atrophy and Leber hereditary optic neuropathy)
• Corneal scarring due to vitamin A deficiency (rare in developed nations)

Evaluation

The following information can help people decide when a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with blurred vision, certain symptoms and characteristics are cause for concern. They include:

• Sudden change in vision
• Severely reduced vision, particularly in only one eye, even if the symptoms began gradually
• Eye pain (with or without eye movement)
• Loss of a specific area in the field of vision (called a visual field defect)
• Human immunodeficiency virus (HIV) infection or AIDS or other condition affecting the immune system (for example, use of chemotherapy or other immune suppressing drugs)

When to see a doctor

People who have warning signs should usually go to an emergency department right away. People who have a body-wide disorder that sometimes causes retinal damage (for example, diabetes, high blood pressure, or sickle cell disease) should see an eye doctor as soon as is practical, usually within a few days. However, if vision has been deteriorating gradually for months or years but has not been severely impaired and there are no warning signs, waiting a week or longer is usually not harmful.

Eye examinations should be done by an ophthalmologist or optometrist. Ophthalmologists are medical doctors who specialize in the evaluation and treatment (surgical and nonsurgical) of all types of eye disorders. Optometrists are health care practitioners who specialize in the diagnosis and treatment of refractive errors (which are treated by prescribing glasses or contact lenses). However, optometrists can often diagnose certain other eye problems and then refer people to an ophthalmologist for treatment. People should usually see an ophthalmologist if they have warning signs.

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 of the blurred vision and the tests that may need to be done (see section: Some Causes and Features of Blurred Vision).

Doctors ask many questions about the person's symptoms because it is important to understand exactly what the person means by blurred vision. For example, people who have actually lost vision in part of their visual field (visual field defect) may describe this sensation only as blurred vision. The presence of other eye symptoms, such as eye redness, sensitivity to light, floaters, a sensation of sudden flashes of light that can look like lightning, spots, or stars (called “photopsias”), and pain at rest or with eye movement, helps doctors determine the cause. Doctors also ask about the effects of darkness (night vision) and bright lights (for example, causing blur, star bursts, or halos) and whether the person wears corrective lenses.

Doctors also ask questions about symptoms of possible causes and about the presence of disorders that are known to be risk factors for eye disorders (for example, high blood pressure, diabetes, HIV infection or AIDS, and sickle cell disease).
 

Examination of the eyes may be all that is necessary

Testing visual acuity (sharpness of vision) is the first step. Ideally, acuity is measured while the person stands about 6 meters (20 feet) from a standard eye chart (Snellen chart) posted or projected on a wall. Each eye is measured separately while the other eye is covered. Visual acuity is measured with and without the person's own glasses. Sometimes the doctor has the person look through a device that has a pinhole. This device can usually correct refractive errors almost completely but does not correct vision that is blurred due to other causes.

The eye examination is also important. The doctor carefully examines the entire eye using an ophthalmoscope (a light with magnifying lenses that shines into the back of the eye), slit lamp (an instrument that enables a doctor to examine the eye under high magnification), or both. Often the eyes are dilated for ophthalmoscopy with eye drops. Pressure inside the eye (intraocular pressure) is measured (called tonometry).

Symptoms and findings during the eye examination often help suggest a cause. For example, if visual acuity returns while corrective lenses or a pinhole device is used, and the remainder of the eye exam is normal, simple refractive error is usually the cause of blurring.

Some Causes and Features of Blurred Vision

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

Clouding of normally transparent eye structures

Cataracts

• Symptoms that begin gradually
• Loss of the ability to distinguish between light and dark (loss of contrast) and glare (seeing halos and star bursts around lights)
• Often in people with risk factors (such as older age or use of corticosteroids)

Corneal scarring after an injury or an infection

• Usually in people with a previous injury or infection

Disorders that affect the retina

Age-related macular degeneration

• Usually symptoms that begin gradually
• Loss of central vision (what a person is looking at directly) much more than peripheral vision (what is seen out of the corner of the eye)
• Infection of the retina (as may be caused by cytomegalovirus or Toxoplasmaparasites)
• Usually in people who have HIV infection or another disorder that weakens the immune system
• Often eye redness or pain

Retinitis pigmentosa (progressive deterioration of the retina)

• Symptoms that begin gradually
• Primarily night blindness
• Retinopathy (damage of the retina) associated with a bodywide disorder such as high blood pressure, systemic lupus erythematosus (lupus), diabetes, Waldenström macroglobulinemia, and multiple myeloma or other disorders that can cause thickening of the blood (hyperviscosity syndrome)
• Often in people known to have such disorders
• Usually other symptoms in addition to loss of vision

Epiretinal membrane

• Risk factors (eg diabetic retinopathy, uveitis, retinal detachment or ocular injury)
• Blurry or distorted vision (eg, straight lines appear wavy)

Macular hole

• Blurry vision initially in straight vision

Retinal vein occlusion

• Risk factors (eg hypertension, age, glaucoma)
• Painless vision loss (usually sudden)
• Sometimes, blurry vision

Disorders that affect the optic nerve or its connections in the brain

Open-angle glaucoma

• Missing stairs and not seeing parts of written or typed words

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

• Usually mild pain that may worsen when one eye (often) or both eyes are moved
• Partial or complete loss of vision
• Symptoms that can become severe in hours or days
• No effect on the eyelids and cornea

Disorders that affect focus

Refractive errors (such as nearsightedness, farsightedness, and astigmatism)

• Sharpness of vision (visual acuity) that varies with distance from objects
• Decreased acuity that can be corrected by using glasses or a pinhole device

What Is Astigmatism?

Astigmatism is an irregularity in the curvature of the cornea or lens. That is, the cornea or lens is curved differently in different directions. This difference causes light traveling in different planes to be focused differently. For example, vertical lines may be in focus when horizontal lines are not (or vice versa). The irregularity can be in any plane, however, and is often different in each eye. A person with astigmatism (each eye should be tested separately) tends to see certain lines more boldly (that is, in better focus) than the others. Astigmatism can be corrected with prescription eyeglasses or contact lenses. It often occurs together with nearsightedness or farsightedness.

The diagram below is of a standard chart used to test for astigmatism in one eye at a time.

Astigmatism

Testing

Testing depends on the suspected cause of the blurred vision. People with symptoms of bodywide disorders should have appropriate testing. For example, testing might include blood tests for diabetes, systemic lupus erythematosus, or HIV infection, blood pressure monitoring, and possibly electrocardiography if high blood pressure or a kidney disorder is suspected.

Treatment

• Treatment of the cause
• Measures to improve sharpness of vision
• Underlying disorders are treated. Corrective lenses or surgery may be used to improve visual acuity, sometimes even when the cause is not just refractive error (for example, for early cataracts).

Essentials for Older People

Although some decrease in visual acuity normally occurs with aging, acuity normally is correctable to 20/20 with refraction, even in very old people.

Key Points

• Refractive error is the most common cause of blurred vision.
• If refractive error is the problem, corrective lenses or surgery (particularly if cataracts are the cause of the change in refractive error) can usually correct the blurriness.
• Doctors check visual acuity and determine whether glasses or a pinhole device corrects the problem, and if it does not, they dilate the eye with drops and carefully examine the retina.
• Because glaucoma is common, intraocular pressure is usually measured.

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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