Painless Vision Loss

• Confirm The Loss
  • Test acuity and fields in each eye separately.
  • Compare with baseline; establish last known well.
• One Eye Or Both?
  • Distinguish monocular, homonymous, and bilateral loss before choosing the pathway.
  • Sudden homonymous loss → cerebral-stroke assessment.
• Eye Examination
  • Assess pupils, red reflex, and fundus.
  • Ocular pain / redness → painful-eye assessment.
• Vision Returned?
  • Suspected retinal TIA still requires urgent ischemia assessment.

• CRAO / Retinal Arterial Occlusion?
  • Abrupt, painless monocular loss.
  • Stroke-center evaluation + urgent ophthalmology.
  • Use the CRAO-specific treatment pathway—not automatic thrombolysis.
• GCA?
  • Age ≥50 + ischemic visual symptoms.
  • Assess jaw claudication, headache / scalp symptoms, and PMR.
  • Strong suspicion + acute / transient visual ischemia → steroids now.
    • Do not wait for laboratory results or biopsy.
• Retinal Detachment?
  • New flashes / floaters + curtain or field loss.
  • Immediate retina contact / same-day assessment.
  • Preserved central vision or negative POCUS does not replace the specialist retinal examination.
• Cerebral Stroke?
  • Sudden homonymous defect → stroke activation.
  • Do not wait for weakness or aphasia.

• CRVO / BRVO
  • Retinal hemorrhages + dilated tortuous veins.
  • Prompt ophthalmology assessment.
• Vitreous Hemorrhage
  • Haze / floaters + obscured fundus.
  • Urgent retina assessment; a tear / detachment may be hidden.
• NAION
  • Painless loss + swollen disc / altitudinal defect.
  • Ophthalmology assessment; assess GCA before accepting the nonarteritic label.
• Macular Disease
  • Central distortion / scotoma → retina assessment + OCT.
• Other Optic Neuropathy
  • Color loss / RAPD without a retinal explanation → optic-nerve assessment.
• Resolved Loss
  • Continue the appropriate urgent assessment when ischemia is suspected.
• Unexplained Acute Loss
  • A normal-appearing fundus does not end the evaluation.

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• Visual Acuity
  • Test each eye with the patient’s usual glasses.
  • Compare with baseline.
• Pinhole
  • Repeat reduced acuity through a pinhole.
  • Improvement suggests a refractive contribution.
  • It does not explain a new field defect or another concerning finding.
• Fields
  • Check confrontation fields in each eye.
  • Normal central acuity does not exclude meaningful vision loss. Vision-Loss Examination Review
• Timing
  • Record last known well and symptom discovery separately.
  • Establish sudden versus progressive onset and persistent versus resolved loss.
  • Resolved Blackout / Dimming
    • Suspected retinal TIA → urgent ischemia assessment, including GCA when appropriate.
    • See Retinal TIA. NANOS — Transient Vision Loss

• Monocular
  • Loss remains confined to one eye when the other is covered.
  • Localize to ocular media, retina, or optic nerve.
• Homonymous
  • The same right or left field is missing in both eyes.
  • The patient may report “one-eye blindness.”
  • This localizes behind the optic chiasm.
    • Sudden onset → cerebral-stroke assessment.
• Bilateral
  • Assess cerebral and bilateral ocular / optic-nerve causes.
  • Do not force the presentation into the monocular pathway. Acute Monocular Vision Loss — Clinical Review

• Angle Closure?
  • Severe ocular pain, red eye, halos, headache, or nausea / vomiting.
  • Assess the anterior segment and IOP.
• Inflammation / Infection?
  • Pain, photophobia, or redness.
  • Assess corneal disease, uveitis, scleritis, or intraocular infection.
  • Pain with eye movement supports optic neuritis / orbital disease.
• Next Action
  • Slit-lamp / anterior-segment examination and IOP when appropriate.
  • Use the painful-eye pathway.
  • Open Globe Suspected: Avoid tonometry and ocular pressure. Vision-Loss Examination Review
• Headache ≠ Ocular Pain
  • GCA may cause headache / scalp tenderness while the visual loss remains painless. BSR 2020

• RAPD — Relative Afferent Pupillary Defect
  • Supports asymmetric optic-nerve or substantial retinal dysfunction.
  • Not specific to optic-nerve disease.
  • Swinging-Light Test
    • Move the light from the unaffected to the affected eye.
    • Both pupils constrict less or appear to dilate as afferent input falls. EM:RAP — Pupillary Defect
• Color: Compare color perception.
• Red Reflex
  • Compare both eyes.
  • A dim / absent reflex with an obscured fundus suggests an opacity, such as cataract or vitreous hemorrhage.
  • Assess the cornea and lens for another explanation.
  • A preserved reflex does not exclude retinal or optic-nerve disease. Stanford — Fundus Examination
• Fundus
  • Assess the disc, vessels, hemorrhage, and retinal elevation.
  • A normal-appearing disc does not exclude retrobulbar optic neuropathy. Acute Monocular Vision Loss — Clinical Review

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General

• Acute Retinal Ischemic Stroke
  • Interrupted arterial flow can cause permanent visual loss.
  • CRAO is an eye emergency and a vascular warning—not an isolated ophthalmology referral. AHA 2021
• Source
  • Usually thromboembolic, often from ipsilateral carotid disease or a cardiac source.
  • GCA Can Also Cause Arterial Occlusion
    • Assess in parallel when plausible.
    • Arteritic disease requires different immediate treatment. Dattilo Et Al., 2018

Clinical / Red Flags — What Moves The Needle?

• Onset / Pattern
  • Abrupt, painless monocular loss over seconds to minutes, often severe.
  • Establish whether loss persists or has resolved.
  • Central Island Preserved: Cilioretinal supply may preserve central acuity despite substantial field loss.
  • BRAO: A branch retinal artery occlusion may cause a sectoral deficit; urgent ischemia assessment still applies. ASRS — Retinal Artery Occlusion
• Vascular / Embolic Risk
  • Carotid disease, AF, valvular disease, or prior vascular events.
  • Hypertension, diabetes, dyslipidemia, or smoking.
  • Absence of known risk factors does not exclude a convincing presentation. AHA 2021
• Prior Transient Loss
  • A preceding monocular blackout may represent retinal ischemia.
  • Ischemic transient monocular loss / amaurosis fugax is a retinal TIA.
  • Return of vision is not reassurance. Dattilo Et Al., 2018
• RAPD / Fundus
  • RAPD, retinal whitening, a cherry-red spot, attenuated arteries, or an embolus support the diagnosis.
  • Early findings may be subtle or absent.
  • Do not require a cherry-red spot or visible embolus before stroke activation. Bénard-Séguin Et Al., 2026
• GCA? — Age ≥50
  • Ask about jaw claudication, headache / scalp symptoms, PMR, and systemic illness.
  • No headache does not exclude arteritic disease.
  • See GCA. ACR/VF 2021

Diagnosis

• Eye Examination
  • Document acuity, pupils / RAPD, fields, and retinal findings.
  • Confirm true monocularity.
    • Homonymous defect → cerebral-stroke assessment.
• Ophthalmology
  • Urgent dilated examination / retinal confirmation.
  • Fundus photography or OCT may clarify subtle findings.
    • OCT can show acute inner-retinal swelling.
  • Do not delay stroke-center evaluation while awaiting confirmation. Bénard-Séguin Et Al., 2026
• GCA Testing
  • ESR / CRP + CBC / platelets in the appropriate age / clinical context.
  • Normal markers do not independently exclude GCA.
  • Strongly suspected arteritic visual ischemia → treat while testing proceeds. ACR/VF 2021

Critical Actions

• Stroke Activation
  • Establish exact last known well—not discovery time alone.
  • Involve stroke / neurology and ophthalmology together.
• Stroke Workup — Cerebral Ischemia / Embolic Source
  • Brain Imaging
    • Follow the acute stroke pathway.
    • MRI-DWI may identify cerebral infarction without another obvious deficit.
  • CTA Head / Neck Or Equivalent
    • Assess carotid and upstream arterial disease, including dissection.
    • Routine CTA generally does not show the retinal occlusion itself.
    • Normal CTA does not exclude CRAO.
  • Cardiac Assessment
    • ECG / rhythm monitoring for AF.
    • Selected echo for a cardiac source. Dattilo Et Al., 2018
• Strong GCA Suspicion + Visual Ischemia
  • Systemic glucocorticoids now.
  • Urgent ophthalmology / rheumatology.
  • Follow the GCA treatment pathway; do not wait for biopsy. ACR/VF 2021
• IV Thrombolysis? — Within 4.5 Hours
  • Immediately discuss the CRAO-specific protocol with the stroke team.
  • AHA/ASA 2026 describes benefit as uncertain in otherwise eligible disabling nonarteritic CRAO.
  • Retinal stroke does not automatically mean IV thrombolysis. AHA/ASA 2026 — CRAO
• Traditional Maneuvers
  • Ocular massage, anterior chamber paracentesis, and hemodilution have no established benefit and may cause harm.
  • Do not delay stroke / GCA assessment for these measures. AHA 2021

Reassessment / Prevention

• Late Presentation / Vision Returned
  • Complete the urgent vascular assessment.
  • Prevention and antithrombotic selection follow the mechanism, bleeding risk, and stroke-team plan. Dattilo Et Al., 2018
• Ophthalmic Follow-Up
  • Surveillance for retinal / iris neovascularization and glaucoma.
  • Support for persistent visual impairment.
  • New pain or redness after an initially painless event → reassessment. ASRS — Retinal Artery Occlusion

In The Pit

• Sudden Painless Monocular Loss Concerning For CRAO
  • Last known well + stroke activation + urgent ophthalmology.
  • Do not require a classic fundus.
  • Normal CTA does not exclude CRAO.
• Age ≥50
  • Assess GCA.
  • Strong suspicion + visual ischemia → steroids now.
• Within 4.5 Hours
  • Immediate CRAO-specific treatment discussion.
  • Not automatic thrombolysis or ocular massage.
• Resolved / Late
  • Urgent vascular assessment and prevention still apply.

Must-Read References

View Full References

• AHA/ASA 2026 — Acute Ischemic Stroke Guideline
  • Includes the CRAO recommendation.
  • IVT benefit remains uncertain in eligible disabling nonarteritic CRAO within 4.5 hours.
• Mac Grory Et Al. — AHA CRAO Statement, 2021
  • Emergency retinal-stroke evaluation and prevention; interpret treatment alongside newer trials.
• Kovach Et Al. — AAO Retinal And Ophthalmic Artery Occlusions PPP, 2025
  • Specialty guidance on retinal arterial occlusion.
• Préterre Et Al. — THEIA, 2025
  • Randomized alteplase-versus-aspirin trial with limited statistical power.
• Ryan Et Al. — TenCRAOS, 2026
  • No significant visual-recovery advantage with tenecteplase; serious bleeding concern.

Additional Cited Guidance

• Dattilo, Newman, And Biousse, 2018
  • Retinal TIA, vascular sources, and brain / vascular / cardiac assessment.
• Bénard-Séguin Et Al., 2026
  • Diagnostic / retinal-imaging review; its treatment discussion predates some newer trial results.
• ASRS — Retinal Artery Occlusion
  • Anatomy, retinal findings, and complications; acute treatment follows the guidance and trials cited above.

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General

• GCA
  • Large- and medium-vessel vasculitis, predominantly in adults ≥50.
  • A normal temporal artery examination does not exclude it. ACR/VF 2021
• Why Vision Is Lost
  • Posterior ciliary artery involvement may infarct the optic nerve head.
    • Arteritic anterior ischemic optic neuropathy — AAION.
  • GCA may also cause retinal arterial occlusion.
  • This is inflammatory arterial disease—not simply another embolic CRAO.
• Immediate Threat
  • Established ischemic loss is often permanent.
  • Treat to limit further loss and protect remaining vision—especially the fellow eye. Hayreh — Iowa Ophthalmology

Clinical / Red Flags — What Moves The Needle?

• Vision
  • Sudden painless monocular loss, often profound.
  • Transient monocular loss or new diplopia may precede permanent loss.
• Jaw / Tongue Claudication
  • Pain or fatigue with chewing that improves with rest.
  • Not simply jaw tenderness.
• Head / Scalp
  • New headache or scalp tenderness.
  • A tender / thickened temporal artery with reduced pulse.
• PMR / Systemic Clues
  • Polymyalgia rheumatica: shoulder / hip-girdle pain and morning stiffness.
  • Fever, fatigue, or weight loss.
  • These support the pattern but do not establish GCA alone. Van Der Geest Et Al., 2020
• No Headache?
  • Ocular GCA may lack headache, scalp symptoms, and constitutional illness.
  • Do not require systemic symptoms before pursuing the diagnosis. Hayreh Et Al., 1998

Diagnosis

Eye Examination

• Both Eyes: Record acuity, pupils / RAPD, fields, and fundus findings.
• Pale, Swollen Disc
  • Profound loss + pallid disc edema supports AAION.
  • The examination may be nonclassic.
  • Pallor alone is not acute pallid disc swelling. Hayreh — Iowa Ophthalmology

ESR / CRP + CBC / Platelets

• Obtain Promptly
  • Elevated markers and thrombocytosis support GCA.
  • Interpret with symptoms and the eye examination. Van Der Geest Et Al., 2020
• Before Steroids?
  • Draw blood first when immediately feasible.
  • Do not delay indicated treatment or wait for results. BSR 2020
• Normal ESR / CRP
  • Lower probability but do not exclude strongly suspected GCA.

Biopsy / Expert Vascular Ultrasound

• Confirm While Treating
  • Arrange biopsy and/or expert vascular ultrasound.
  • Neither should delay vision-protecting treatment. BSR 2020
• Temporal Artery Biopsy
  • Arrange promptly—ideally within two weeks of starting steroids.
  • ACR/VF conditionally favors biopsy in U.S. practice, partly because ultrasound expertise varies.
  • Biopsy may remain informative later; treatment does not immediately erase its diagnostic value. ACR/VF 2021
• Expert Vascular Ultrasound
  • Examine temporal and axillary arteries when suitable expertise is available.
  • EULAR recommends ultrasound first.
  • This is a dedicated vascular study—not routine ocular POCUS.
  • Timing
    • Ideally before steroids without delaying treatment, or within approximately 72 hours afterward.
    • Treatment may reduce sensitivity. EULAR 2023 Update
• Negative Test + Strong Suspicion
  • Specialist reassessment / further testing.
  • A negative biopsy can miss segmental disease. ACR/VF 2021

Critical Actions

• Strongly Suspected GCA + Acute / Transient Visual Ischemia
  • Start systemic glucocorticoids immediately.
  • Do not wait for persistent loss, laboratory results, biopsy, or ultrasound. BSR 2020 — Executive Summary
• Threatened / Established Visual Loss
  • Methylprednisolone: 500–1,000 mg IV daily, commonly for three consecutive days.
  • Follow with high-dose oral therapy under the specialist plan.
  • IV Unavailable
    • Start high-dose oral glucocorticoids under the urgent specialist protocol.
    • Arrange IV treatment / transfer without leaving the patient untreated. BSR 2020
• Ophthalmology + Rheumatology
  • Contact urgently while initiating treatment.
  • Suspected GCA + new transient / permanent visual loss or diplopia → ophthalmic assessment as soon as possible that day.
  • Not routine outpatient referral. BSR 2020

Reassessment / Disposition

• Both Eyes
  • Repeat acuity / fields and assess new symptoms.
  • Further visual loss after the first steroid dose → immediate reassessment.
  • Treatment does not guarantee immediate protection. Hayreh — Iowa Ophthalmology

Monitored Admission

• IV Pulses / Evolving Loss / No Immediate Specialist-Directed Care
  • Arrange admission or transfer for treatment and reassessment.
  • Start treatment before transfer.
• Ongoing Plan
  • Confirm steroid continuation, specialist follow-through, and diagnostic testing.
  • A resolved visual episode or normal ESR / CRP alone does not justify discharge. BSR 2020

In The Pit

• Age ≥50 + New Painless Visual Loss
  • Assess GCA—even without headache.
  • Jaw claudication or profound loss with a pale, swollen disc increases concern.
• Strong GCA Suspicion + Persistent / Transient Visual Ischemia
  • Steroids now.
  • Urgent ophthalmology / rheumatology.
• ESR / CRP + CBC / Platelets
  • Obtain promptly.
  • Do not wait for results or biopsy before indicated treatment.
• Both Eyes
  • Reassess vision and arrange ongoing treatment / admission.
  • Further deterioration → immediate reassessment.

Must-Read References

View Full References

• Maz Et Al. — ACR/VF 2021
  • U.S. confirmation and treatment guidance; IV-over-oral preference for threatened vision is conditional.
• Mackie Et Al. — BSR 2020
  • Immediate treatment, acute / intermittent visual loss, and same-day ophthalmic assessment.
• Dejaco Et Al. — EULAR 2023 Update
  • Published in 2024; expert temporal / axillary ultrasound and early imaging after steroid initiation.

Additional Cited Guidance

• Van Der Geest Et Al., 2020
  • Combined interpretation of symptoms, examination, and laboratory tests.
• Hayreh Et Al., 1998
  • Ocular GCA without systemic symptoms.
• Kermani Et Al., 2012
  • Biopsy-positive disease despite normal inflammatory markers.
• Hayreh — Iowa Ophthalmology
  • Ocular findings and prognosis; drug regimens follow newer society guidance.
• NANOS — GCA
  • Recognition of arteritic visual loss.

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General

• Detachment
  • Retina separates from its underlying support layer.
  • Most acute detachments follow a tear that allows fluid underneath—rhegmatogenous detachment. ASRS — Retinal Detachment

Clinical / Red Flags — What Moves The Needle?

• Pattern
  • New flashes / floaters followed by a curtain, shadow, or field loss.
  • Loss may advance centrally; not every patient has the full sequence.
• Risk: High myopia, prior cataract / intraocular surgery, trauma, or previous detachment.
• Posterior Vitreous Detachment — PVD
  • Vitreous separates from the retina—not retina from the eye wall.
  • PVD can cause similar symptoms and a retinal tear.
  • Symptoms alone do not establish harmless PVD. AAO 2025 — PVD / Retinal Breaks

Diagnosis

• Eye Examination
  • Record acuity, pupils, and fields.
  • Arrange a dilated peripheral retinal examination.
  • Preserved central acuity does not exclude peripheral detachment. AAO 2025
• Ocular POCUS
  • An elevated echogenic membrane tethered to the optic disc supports detachment.
  • Useful when hemorrhage obscures the fundus.
  • Negative Scan: Does not exclude a retinal tear or replace the dilated examination.
  • Macular Status: Do not rely on ED POCUS alone to distinguish macula-on from macula-off.
  • Open Globe Suspected: Avoid ocular ultrasound / pressure. ACEP — Ocular Emergencies

Critical Actions

• Suspected Detachment
  • Immediate ophthalmology / retina contact for same-day assessment.
  • Arrange direct evaluation or transfer—not routine follow-up.
• Macular Status
  • Determines repair urgency and prognosis.
  • Macula-On: Central Retina Attached
    • Urgent repair planning to preserve central vision.
  • Macula-Off: Central Retina Detached
    • Prompt assessment / repair planning.
    • Reduced vision is not permission to delay.
    • The retina surgeon determines timing. ACEP — Ocular Emergencies
• Definitive Treatment
  • Retinal tears may require laser / cryotherapy.
  • Established detachment usually requires retinal repair.
  • Procedure and timing follow the specialist examination. ASRS — Retinal Detachment

In The Pit

• Flashes / Floaters + Curtain
  • Suspect detachment → immediate retina contact / same-day assessment.
• Central Vision Preserved
  • The macula may still be attached.
  • Do not downgrade urgency.
• Negative POCUS
  • Does not exclude a retinal tear.
  • A concerning presentation still needs a dilated examination.

Must-Read References

View Full References

• AAO 2025 — PVD, Retinal Breaks, And Lattice Degeneration PPP
  • U.S. guidance on retinal-break assessment and management.
• ACEP — Ocular Emergencies, Sonoguide
  • POCUS findings, limitations, and globe-injury precautions.

Additional Cited Guidance

• Lahham Et Al., 2019
  • Prospective ED POCUS study; retinal tears and macular status were not specifically assessed.
• ASRS — Retinal Detachment
  • Recognition, specialist treatment, and complications.

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• Homonymous Defect
  • The same right or left field is missing in both eyes.
  • This localizes behind the optic chiasm—not to isolated monocular retinal loss.
• Sudden Onset
  • Establish last known well.
  • Activate the stroke pathway, even without weakness or aphasia.
  • A normal ocular examination does not exclude occipital stroke.
  • See Acute Stroke. NANOS — Homonymous Hemianopia

Reference

View Full References

• NANOS — Homonymous Hemianopia
  • Postchiasmal localization and misleading reports of monocular loss.

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Deep Dive CorePendium — Central Retinal Vein Occlusion

• Pattern
  • Impaired venous drainage causes retinal hemorrhage and edema.
  • Painless monocular blur / loss varies in severity.
  • Ischemic CRVO may cause profound loss. ASRS — CRVO
• Fundus
  • Widespread hemorrhages, dilated tortuous veins, and disc edema.
  • Classic “blood-and-thunder” appearance.
  • BRVO: Branch retinal vein occlusion produces a sectoral rather than diffuse pattern. RCOphth 2022
• Next Action
  • Prompt ophthalmology / retina assessment.
  • Review BP, diabetes, and other vascular risks.
  • Macular edema is commonly treated with intravitreal anti-VEGF. ASRS — CRVO
• Confirmed Isolated CRVO
  • Not a CRAO reperfusion indication.
  • Systemic anticoagulation is not routine solely for CRVO. RCOphth 2022
• Pain / Redness / Elevated IOP
  • Assess for neovascular glaucoma, particularly after ischemic CRVO.
  • Urgent ophthalmic treatment. ASRS — CRVO

References

View Full References

• Nicholson Et Al. — RCOphth RVO Guideline Executive Summary, 2022
  • Ocular treatment, vascular-risk assessment, and limits of routine antithrombotics.
• ASRS — CRVO
  • Recognition, specialist treatment, and neovascular complications.

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Deep Dive CorePendium — Vitreous Hemorrhage

• Pattern
  • Painless haze, cobwebs, floaters, or variable visual loss.
  • Blood may obscure the fundus.
  • Blood explains the obscured view—not why the eye bled. ASRS — Retinal Tears
• Red Reflex / Fundus
  • A dim reflex and hazy fundus support an opacity, including hemorrhage.
  • Assess the cornea and lens for another explanation.
  • An abnormal reflex is not diagnostic of hemorrhage. Stanford — Fundus Examination
• Retina Obscured
  • Urgent ophthalmology / retina assessment.
  • A retinal tear / detachment may be hidden.
  • Specialist ophthalmic ultrasound may be needed.
  • Do not wait for the blood to clear. See Retinal Detachment. ASRS — Retinal Tears
• Ocular POCUS
  • Mobile vitreous echoes swirling with eye movement support hemorrhage.
  • Assess for associated detachment.
  • Negative Scan: Does not exclude a tear or replace specialist examination.
  • Open Globe Suspected: Avoid ocular ultrasound / pressure. ACEP — Ocular Emergencies

References

View Full References

• ASRS — Retinal Tears
  • Hemorrhage and hidden retinal tears / detachments.
• ACEP — Ocular Emergencies
  • Ultrasound findings, limitations, and globe precautions.
• Stanford — Fundus Examination
  • Red reflex and ocular opacities.

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• Pattern
  • Optic-nerve-head ischemia causes painless monocular loss and disc swelling.
  • Altitudinal Defect: Upper or lower field loss supports the pattern but is not required.
• GCA First — Age ≥50
  • Assess arteritic disease before accepting “nonarteritic.”
  • Concerning symptoms / findings → urgent GCA assessment / treatment.
  • No headache does not exclude GCA.
• Next Action
  • Prompt ophthalmology / neuro-ophthalmology confirmation.
  • No proven acute vision-restoring treatment.
  • Do not automatically apply CRAO reperfusion or GCA steroids.
• Follow-Up
  • Arrange vascular-risk and sleep-apnea assessment. NANOS — NAION

Reference

View Full References

• NANOS — NAION
  • Arteritic differential, treatment limitations, and risk assessment.

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Deep Dive CorePendium — Acute Maculopathy

• Central Distortion / Scotoma
  • Wavy lines, impaired reading, or a central dark patch.
  • Relatively preserved peripheral vision supports a macular source.
  • Consider neovascular age-related macular degeneration (AMD), macular edema, or macular / submacular hemorrhage.
• New Central Loss
  • Prompt retina assessment + optical coherence tomography (OCT).
  • Suspected acute hemorrhage → urgent discussion.
  • Do not attribute sudden deterioration to chronic AMD without reassessment. ASRS — AMD

Reference

View Full References

• ASRS — AMD
  • Central visual symptoms, specialist treatment, and complications.

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Deep Dive CorePendium — Optic Neuritis

• Optic Neuritis
  • Color desaturation and pain with eye movement support the diagnosis.
  • Painless presentations occur.
  • Ophthalmology / neuro-ophthalmology assessment.
  • Appropriate brain / orbital MRI. NANOS — Optic Neuritis
• Compressive / Infiltrative Disease
  • Usually progressive rather than abrupt.
  • Unexplained optic-nerve dysfunction → specialist-directed investigation / imaging.
  • A normal-appearing retina does not end the assessment. Stanford — Compressive / Infiltrative Optic Neuropathies

References

View Full References

• NANOS — Optic Neuritis
  • Optic-nerve assessment and imaging.
• Stanford — Compressive / Infiltrative Optic Neuropathies
  • Progressive dysfunction and targeted imaging.

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• Pattern
  • Sudden monocular dimming, blackout, or a curtain that clears may be retinal ischemia.
  • Return of vision and a normal examination do not exclude retinal TIA.
• Clarify The Episode
  • Establish onset, duration, recovery, and one eye versus both.
  • Not every transient visual symptom is ischemic.
• Ischemia Suspected
  • Urgent brain / vascular / cardiac assessment.
  • Assess GCA in patients ≥50.
  • Follow the CRAO assessment, TIA pathway, and GCA section as appropriate. NANOS — Transient Vision Loss

Reference

View Full References

• NANOS — Transient Vision Loss
  • History and urgent stroke-style assessment when ischemia is suspected.

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• Persistent Acute Loss
  • Urgent specialist assessment.
  • Reassess localization.
  • Arrange the testing needed to explain the deficit.
  • A normal-appearing fundus is not a diagnosis. Acute Monocular Vision Loss — Clinical Review

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