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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.

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clinical ophthalmology

should be referred to neurologist for further


Fig. 2. Field loss in homonymous hemianopia
assessment.
Bitemporal hemianopia (Loss of the field of
vision on the temporal side in each eye) (Fig. 3).
Bitemporal field loss usually indi-
cates a lesion in or around the optic chiasma.
Most chiasmal lesions result from compres-
sion by tumours arising from structures
around the chiasma such as pituitary ade-
noma, meningioma, craniopharyngiomas or
aneurysm (Cheng et al 1997). The patient
BINOCULAR LOSS OF VISION may complain of blurring of the temporal
Migraine One of the most common causes of field or of difficulty undertaking tasks such
transient, bilateral loss of vision is classic as driving. Cranial nerve palsies may also oc-
migraine. The patient is likely to complain of cur due to compression by a tumour and the
transient loss of vision, flashing lights and patient should be asked about symptoms of
scintillating images may appear, as may double vision. Evaluation by a neurologist is
fortification spectra. The patient may experience the most appropriate course of action for the
the loss of large parts of the visual field. This aura patient.
usually lasts for 20 - 30 minutes and then
resolves and is followed by a severe headache. MONOCULAR LOSS OF VISION
In a first episode of migraine, the patient may be Profound loss of vision This is characterised
frightened by the visual symptoms and may not by complete or severely diminished vision
associate the headache with the loss of vision. affecting the whole of the visual field. This may
Another migraine type is known as acephalgic occur suddenly or gradually over a period of
migraine. The patient experiences the aura but days. Sudden, profound loss of vision suggests a
does not go on to develop the headache. It may vascular cause and the most likely of these are
be difficult to convince the patient that these central retinal artery occlusion and vitreous
symptoms do not constitute an eye problem. haemorrhage.
Homonymous hemianopia (hemianopia – Vitreous haemorrhage is the most
loss of half of the visual field, homonymous – on likely cause if there is an associated history
the same side) (Fig. 2). of diabetes. The patient may not be aware of
eye changes related to the diabetes, espe-

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

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retinal detachment. This is described under


Fig. 3. Field loss in bitemporal hemianopia segmental loss of vision.

SEGMENTAL LOSS OF VISION


The most likely causes of the loss of an area
of the visual field in one eye are vascular
causes such as occlusions of branches of the
retinal artery or vein (branch retinal artery or
vein occlusions) or retinal detachments. If the
onset is sudden and stays the same, the cause
is likely to be vascular. If the area of visual
(macular) area is seen as a ‘cherry red spot’ as loss changes over time, the cause is likely to
the retina is very thin and the choroid is seen be a retinal detachment.
underneath the retina, without swelling to Branch retinal artery and vein occlusions
mask the colour. An embolus in the central These may be seen with an ophthalmoscope;
retinal artery may be seen. This condition is the branch artery occlusion will lead to a
an ophthalmic emergency and while investi- segment of retina being paler than the rest.
gations as to the cause of the condition are All the vessels will appear in the correct lo-
necessary. (These include urgent ESR as gi- cation and an embolus may be seen in one of
ant cell arteritis may be a factor, lipid pro- the vessels. There may be multiple retinal
files, full blood count – to rule out haemorrhages seen if the cause of the loss of
coagulopathies and ultrasound scan of the vision is a branch retinal vein occlusion. The
coronary arteries and echocardiography – in haemorrhages will be in the area of the
order to identify the site of the embolus.) Im- retina which is served by the blocked vein.
mediate treatment must start in A&E, even Retinal oedema may be seen and an occlu-
before the patient sees an ophthalmologist. sion may be visible. There is no immediate
Treatment is aimed at allowing in- treatment for either condition, although fol-
creased perfusion of the retina by reducing low up by an ophthalmologist will be neces-
the intraocular pressure. It includes the ad- sary. Local ophthalmologists will give
ministration of intravenous acetazolamide advice about the appropriate timing of out-
500mg to reduce intraocular pressure, ocular patient appointments.
massage, to encourage the outflow of aque-
ous and often in ophthalmic units, the patient RETINAL DETACHMENT
is asked to rebreathe exhaled air by breathing Spontaneous retinal detachment affects one
into a paper bag. This increases the carbon in 10,000 of the population each year (Kanski
dioxide concentration in the body, thus dilat- 1990). It is more common in males and in
ing blood vessels and possibly allowing the short-sighted (myopic) eyes (Pavan-
embolus to move further into the retinal cir- Langston 1996). It usually occurs due to col-
culation. If this occurs, a sector of visual loss, lapse of the vitreous gel in middle age
rather than profound loss may be a good out- causing traction on a weak area of retina and
come for the patient. An anoxic retina is irre- causing a hole to form in it. Other causes in-
versibly damaged in 90 minutes clude traction on the retina in conditions
(Pavan-Langston 1996) and for patients who where fibrovascular tissue has developed be-
wake up with this condition, or for patients tween the retina and vitreous such as in dia-
who do not attend A&E immediately, the vi- betic retinopathy and sub-retinal disorders
sual outcome is poor. such as tumours or inflammation that allow
In some conditions, vision loss may passage of fluid between the retina which
become progressively profound over the pushes it off its basement membrane.
whole field of vision over a number of days. Symptoms characteristic of retinal
The most likely cause of this is optic neuritis, detachment include:
described under blurring of vision, which is ● FLASHING LIGHTS – due to traction on the
its more likely presentation. Profound loss of retina or to areas of the retina moving. The
vision which appears gradually, starting with only way that the brain can interpret move-
a segment of the visual field and enlarging to ment of the retina is in terms of light so as the
cover the whole of it, is likely to be due to a retina moves, the brain interprets and the pa-

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clinical ophthalmology

tient ‘sees’ flashes of light. serous retinopathy and macular burns.


Figs 4-7 (from left to right:
● FLOATERS – the appearance of a large cir- ARMD refers to a gradual degeneration of the
4. A normal fundus or retina (this is how cular floater is due to the detachment of the macula. It is the most common cause of visual
the eye would look if there were nothing vitreous gel from its ring shaped attachment loss in the over 75s and affects around 20 per
wrong with it). at the optic disc. A shower of tiny floaters is cent of individuals. There is usually a very
5. Central retinal vein occlusion due to haemorrhage into the vitreous as a gradual loss of central vision. The patient may
(showing haemorrhages). small retinal blood vessel is involved in the have noticed that they have to use a bright light
retinal tear. to read by and that words fade after a few
6. Central retinal artery occlusion (show-
● A sector of loss of vision may be noticed minutes. Although this is not an acute problem,
ing the ‘cherry red spot’ of the macula).
which tends to enlarge over a period of hours elderly patients may present in A&E because
7. Cataract caused by nuclear sclerosis or days The patient may complain of seeing a they have reached a point where they can no
‘shadow’ which tends to move, or a curtain longer manage the problems alone. Referral to
descending over the eye. This is due to an an ophthalmologist is essential although there is
area of retina which is detached and may be little effective treatment for this condition.
enlarging or moving within the patient’s field Patients retain navigating vision - their peripheral
of vision. visual field is not affected.
● Central vision may be lost due to macular Optic neuritis refers to inflammation of the
detachment. optic nerve. Episodes are usually monocular,
although they may be binocular. It is most

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

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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-

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clinical ophthalmology

and giant cell arteritis. Intermittent angle clo-


sure glaucoma is a rare but possible cause of
these symptoms. Retinal emboli from carotid
artery disease often produce transient visual
loss known as amaurosis fugax. This may be

Cataract is not an urgent


described as a curtain being lowered and then
lifting over the vision. It is likely to last sec-
onds to minutes rather than hours. It may be a
condition sign of impending cerebro vascular accident
and therefore, cardio-vascular investigations
are appropriate. Turning the head may pre-
cipitate an attack and this is characteristic of
carotid artery disease.
Patients with giant cell arteritis often
complain of headache and tenderness over
the scalp. This may be obvious when they
fer to A&E. Visual acuity should be checked comb their hair. They may also notice jaw
using pinholes to negate the effect of any re- claudication and pain on chewing. An urgent
fractive error. If vision improves dramatically ESR is indicated and may be more than 80
with pinholes, a significant proportion of the mm. Urgent referral is required.
blurring is likely to be due to refractive error Patients may present with symptoms
and, in the absence of any other findings, the of pain in and around the eye and blurring of
patient may be referred to an optometrist. vision which begins, usually at night, when
Opacities in any of the clear struc- the pupil becomes larger due to the reduced
tures of the eye will result in blurring of vi- light levels and may last a number of hours, It
sion as less light is allowed to reach the may have resolved by the time the patient at-
retina. The most common opacity is due to tends A&E. If the anterior chamber appears
cataract. Again, the patient may have noticed shallow, and the symptoms are as described,
the loss of vision by closing one eye, or intermittent angle closure glaucoma may be
worry about their symptoms may have suspected and urgent referral to an ophthal-
prompted self referral. Cataract causes glare mologist is required so that the eye can be
and reduction in vision. There is likely to be evaluated and if necessary, prophylactic laser
reduction of the red reflex and lens opacities treatment can be undertaken to prevent fur-
may be seen on examination with a slit lamp ther attacks.
or, if severe, with a pen torch. Cataract is not
an urgent condition and it may be most ap- CONCLUSION
propriate, in the absence of any other cause The patient presenting to A&E with loss of
for the loss of vision to reassure the patient vision may cause some diagnostic and man-
that cataract does not progress very quickly agement problems. It is hoped this article has
and to refer them back to their general practi- clarified some of the issues surrounding this
tioner for referral to an ophthalmologist. If area of practice, enabling A&E nurses to con-
the lens opacity had occurred after trauma, or tinue to facilitate the best possible care for
is in a younger person, more urgent referral to this client group. En
an ophthalmologist should be considered.
Corneal problems resulting in blurring of vi- REFERENCES

sion such as opacities or irregularities should Cheng H et al (1997) Emergency Ophthalmology.


be referred to an ophthalmologist as a matter London, BMJ Publishing Group.
of some urgency. Kanski J (1990) Synopsis of Ophthalmology. London,
Wright.
Transient loss of vision
Onofrey B, Skorin L Jr, Holdeman N (1998) Ocular
Transient loss of vision may be due to a vast Therapeutics Handbook. Philadelphia,
range of conditions. A number of these such Lippincott-Raven.
as papilloedema and migraine have been Pavan-Langston D (1996) Manual of Ocular Diagnosis
dealt with earlier. Other, common causes of and Therapy. Fourth edition. Boston, Little
transient loss include carotid artery disease Brown and Company.

18 EMERGENCY nurse Vol 6 No 9 February 1999

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