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C3 - Vision Loss - Painful Vision Loss

Mel Herbert, MD MBBS FAAEM, Jessica Mason, MD, and Stuart Swadron, MD, FRCPC

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C3 2019 01 January - Vision Loss Written Summary 317 KB - PDF

C3 - Vision Loss - Painful Vision Loss

Jessica Mason MD, Stuart Swadron MD, Mel Herbert MD

Peer Reviewer Nicholas Testa, MD

* Drug doses are a guide only, always check a second source and follow local practice guideline


  • Background
    • Optic neuritis is a demyelinating process of the optic nerve
    • It is commonly associated with multiple sclerosis (⅓ of patients with optic neuritis will develop MS)
    • Other causes – idiopathic, infectious (syphilis, measles, TB, crypto, etc), and autoimmune diseases
  • History
    • Painful monocular vision loss
    • Painful behind eye and with eye movements
  • Examination
    • Loss of central vision, while the peripheral vision is preserved
    • Afferent pupillary defect (APD)
      • Anything that affects the optic nerve will cause an APD (this is not specific to optic neuritis, it also may occur in any condition where light cannot reach the retina)
    • Fundoscopic exam usually normal but may see optic disc pallor
    • Red desaturation test
      • Take a dark red item and have the patient look at it covering one eye and then the other. The affected eye will see it as lighter red or pink.
    • Don’t forget to complete a neurological examination
  • Management
    • Consultation with ophthalmology and neurology are both appropriate
    • MR imaging of brain looking for plaques of MS
    • Admit for IV steroids (methylprednisolone); very high doses are used, confer with specialist colleagues on plan
    • Patients may make a full recovery, but it may recur


  • Background
    • Formerly known as temporal arteritis
    • It is a vasculitis of medium sized arteries
    • There is a strong association with polymyalgia rheumatica, a painful chronic condition in older patients causing fatigue and muscle pain
    • Typically occurs in patients over 60 years old
  • History
    • Painful monocular vision loss
    • May have profound pain, headache, especially over the temporal areas
    • Jaw claudication (aching pain with eating) is an important clue
  • Examination
    • Palpate and inspect over area of temporal arteries for tenderness and nodularity
  • Management
    • If the diagnosis is suspected, empiric therapy should be started in the ED because of the potential for progression
      • Patients with any visual loss should be admitted for IV steroids, 500-1,000 mg of methylprednisolone daily for 3 days (similar to optic neuritis or MS)
      • If there’s no vision loss then you can start 1 mg/kg PO of prednisone (UptoDate)
    • An ESR should be drawn
    • A biopsy should then be performed in the next week to confirm the diagnosis (this can be tricky to arrange and may be performed by various surgical specialists)


  • Acute angle closure glaucoma (AACG) may present with painful vision loss but usually the eye is acutely red and abnormal on gross inspection
  • We covered AACG (including an excellent description by the patient) in C3 Painful Red Eye (Dec 2017)
  • It may be associated with medications, especially eye drops that dilate the eye in susceptible patients (with pre-existent narrow angles)
  • The presentation of AACG is usually extremely painful (a deep, boring pain) and frequently associated with vomiting
  • Important examination findings:
    • A red, angry appearing eye, firm to touch
    • Cloudy “steamy” cornea
    • Decreased visual acuity, may be profound
    • Markedly elevated IOP (generally >40 mm Hg)
  • Management
    • Treat pain and give antiemetic
    • Consult ophthalmologist emergently
    • Carbonic anhydrase inhibitors - acetazolamide
    • Topical beta blockers - timolol
    • IV mannitol or glycerol
    • Alpha agonist drops - apraclonidine
    • Definitive therapy is surgical; involves laser iridectomy


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C3 - Vision Loss Full episode audio for MD edition 54:23 min - 51 MB - M4AC3 2019 01 January Vision Loss Board Review Answers 242 KB - PDFC3 2019 01 January Vision Loss Board Review Questions 237 KB - PDFC3 2019 01 January - Vision Loss Individual MP3s 74 MB - ZIPC3 2019 01 January - Vision Loss Written Summary 317 KB - PDF