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clinical ophthalmology
Janet Marsden MSc, BSc(Hons), RGN, OND, MIMgt is Senior Lecturer, Manchester
Metropolitan University, and Chair of the RCN Ophthalmic Forum
Janet Marsden outlines the presentation and early management of painless loss of vision
Painless loss
of vision
THERE ARE MANY CAUSES OF PAINLESS LOSS that are missing? Is the loss worse in the mid-
Fig. 1. Classification of loss of vision
of vision, however, it is difficult to differenti- dle of what the patient sees or around the
Loss of vision ate between causes that need immediate re- edges of the field.
ferral to an ophthalmologist, those which can ● Was the loss transient – has it come back
Monocular Binocular
Loss of central
be delayed referral or those which need refer- now or is it recovering. How long was vision
vision
ral to other specialists. This article will de- affected for or does it seem to be permanent?
Transient/Permanent
Profound
scribe some of the most common causes of ● Is the vision now getting better, worse, or
painless loss of vision and the decision-mak- is it about the same?
Segmental Blurring
Transient ing processes surrounding referral, and assist ● Are there any other symptoms that the pa-
Sudden A&E nurses in deciding or advising upon ef- tient is experiencing? Often the patient may
Sudden
fective management. The article will use the not consider other symptoms as the eye prob-
Progressive Gradual
classification of loss of vision illustrated in lem is the issue that worries them. If ques-
Gradual
Figure 1 in order to group together and de- tioned, however, other symptoms may be
This article has been subjected to scribe some of its many causes. ascertained which the patient does not readily
double blind peer review associate with the eye problem such as
HISTORY headache, weakness, or pain elsewhere.
In describing a loss of vision, patients will of-
ten use terms that are vague and non-specific. MONOCULAR VERSUS BINOCULAR
It is up to the nursing or medical staff to de- LOSS OF VISION
termine what has actually happened to the pa- Ocular pathology, or optic nerve problems
tient and what has prompted him or her to will cause monocular loss of vision. A prob-
attend the A&E. lem at, or posterior to, the optic chiasma in
From the point of view of vision loss, the brain will cause binocular loss of vision.
it is important to ascertain the parameters of It is most unusual for a patient to suffer from
the problem. bilateral simultaneous eye disease and,
● Are there patches or areas of actual vision should this occur, the whole field of both eyes
loss or is the vision blurred? will be affected rather than half of field,
● Was it sudden or gradual loss of vision? If which is usual in neurological eye problems.
sudden, is it possible that it has been there for The only exception to this occurs in the case
a while but only just noticed? For example, of bilateral blurring of vision, which has ap-
did the patient notice the loss of vision when peared over a small number of days. This is
he or she covered an eye – if that was the characteristic of papilleodema.
case, it may have been present for some con- A generalisation, but one that works
siderable time? If the loss was gradual, over in practice, is that if a patient complains of
what period of time has it occurred (days, binocular loss of vision, the problem is likely
weeks or even months)? to be of neurological rather than ophthalmic
● Does the loss involve some or all of the vi- origin and a neurological opinion should be
sion? Are there sectors of the field of vision sought.
clinical ophthalmology
P
atients may complain they are un- cially if no regular eye screening takes place.
aware of things approaching from The patient may be aware of the haemor-
the side of the field defect. They may rhage taking place and may describe a cloud
also have trouble with reading, as of floaters (the first blood) which becomes
they may not be able to follow a line of print. more dense over a short period, resulting in a
Visual acuity may be only mildly reduced in profound loss of vision. Any attempt by the
each eye, as part of the macular function on clinician to visualise the back of the eye will
each side is likely to be intact. Distance vi- be unsuccessful due to the blood in the vitre-
sual acuity testing may demonstrate that the ous cavity. The patient should be referred to
patient is unable to see the letters on the an ophthalmologist although it is unlikely
Snellen chart on the side of the field defect. that (laser) treatment will take place until the
The most common areas of damage vitreous haemorrhage has cleared sufficiently
are in the optic radiation and the occipital for the retina to be visualised.
cortex. The hemianopia may be incomplete In central retinal artery occlusion, the
and temporal lobe lesions cause predomi- patient may describe the vision disappearing
nantly upper field loss. Causes of homony- ‘like someone switching the light off’. The
mous hemianopia include vascular lesions loss may be absolute and is, at best, likely to
such as embolus or haemorrhage, tumours be ‘count fingers’ or less. Some patients re-
and inflammatory lesions in these specific ar- tain a degree of central vision due to the pres-
eas of the brain. This type of field defect may ence of a cilioretinal artery, an anatomical
accompany obvious systemic symptoms such anomaly. The retina is likely to be pale due to
as hemiparesis or hemiplegia. The patient swelling within the retina and the foveal
clinical ophthalmology
T
he detached retina will appear grey common in adults between the ages of 20 and 40
and may seem slightly wrinkled. Pa- and is more common in females. Optic neuritis
tients with retinal detachment need is the presenting feature in 25 per cent of patients
an urgent ophthalmic opinion. If with multiple sclerosis (MS) and occurs in 70 per
central vision is present, the macula is still at- cent of established cases. Many patients with
tached and it is likely that surgery will be im- idiopathic optic neuritis will go on to develop
mediate in order to preserve this situation. If MS. Various texts suggest figures of 50 per cent
central vision is affected, it is likely the mac- (Pavan-Langston), 60 per cent (Onofrey et al
ular is detached. If this has happened within a 1998) and ‘most’ (Cheng et al 1997)!
matter of hours, surgery is likely to be imme- The patient is likely to present with
diate in order to attempt to reattach it and pre- loss of central vision, which may progress to
serve some of its function. If the macula has a generalised loss of vision and can become
been detached for some time, it is likely that severe. It is maximal after approximately two
surgical delay of a few days will not ad- weeks and tends to recover after 4-6 weeks.
versely affect the outcome for vision as mac- Over a period of months, most patients re-
ular function is not likely to be restored cover 6/12 vision or better. Other symptoms
(Cheng et al 1997). include, pain around or behind the eye which
Loss of central vision Common causes of loss is worse on ocular movement due to the in-
of central vision include age related macular flamed optic nerve moving as the eye moves.
degeneration (ARMD), optic neuritis, central Perception of colour in the affected eye is
likely to be reduced. This can be tested using protection. It may be suggested that this is an
PICTURES COURTESY OF JANET MARSDEN
the top of a red pen and comparing the per- unlikely event but, as we are to experience a very
ception of red in each eye. The pupil reac- rare, total eclipse of the sun in August 1999, it is
tions will be abnormal and the optic nerve a phenomenon which nurses must start to
head may appear normal or may be swollen. consider. Even in areas in the zone of totality,
Referral to a neurologist or neuro-ophthal- such as Cornwall and Devon, as the sun starts to
mologist for further assessment and possible emerge again, people without adequate eye
treatment is the preferred course of action. A protection may easily suffer eye injury. Previous
possible diagnosis of MS should not be dis- solar eclipses have resulted in a number of
cussed in A&E as, even with a confirmed di- patients with macular burns, which involve
agnosis of optic neuritis, MS is still only a permanent loss of vision.
possibility and the A&E department has nei-
ther the time nor the resources for the coun- BLURRING OF VISION
selling which may be necessary in this Blurring of vision may be due to problems
situation. anywhere from the cornea to the optic nerve
Central serous retinopathy (CSR) may occur and the brain. Many patients will have prob-
in young adult males and has an unknown cause. lems in differentiating between generalised
Symptoms usually include a unilateral blurring blurring and loss of central vision; careful
of central vision and a generalised darkening of questioning is needed to obtain a full picture
the visual field with some distortion. Visual of the problem. Vitreous haemorrhage or vas-
acuity is usually only mildly reduced. It is rare cular occlusions may cause sudden onset
for it to be less than 6/18 but it may reduce to blurring of vision. These have been dealt with
6/60 (Cheng et al 1997). Although referral to an elsewhere. Other causes of blurring of vision
ophthalmologist is necessary, most episodes of tend to develop more gradually and may in-
CSR resolve within three-six months. Treatment clude CSR and optic neuritis. Again, these
is not usually indicated though laser treatment have been dealt with elsewhere. Patients with
has been shown to assist resolution in some cases papilloedema often present with blurring of
where the CSR episode is persisting. vision. This may be worse in one eye and
Macular burns may be caused by MIG welding may be exacerbated by, for example, standing
equipment. The light produced is high intensity up (Cheng 1997). Concurrent symptoms may
white light rather than ultra violet light as in most be ignored by the patient in favour of the eye
other welding equipment. The eye transmits this problem. Patients with bilateral swollen optic
light rather than absorbing it and it can cause discs need urgent neurological referral.
macular burns, which will result in some loss of Patients occasionally present with re-
central vision. The patient may notice a black fractive errors, which they have not noticed
mark in the centre of their vision, which stays in previously. It may be they have covered one
the same place when they move their eye. eye and noticed that their vision in the re-
Macular burns may be caused by the patient maining eye is not good. This may provoke
looking at the sun without adequate eye much anxiety and encourage them to self re-
clinical ophthalmology