CONSULTS
OPHTHALMIC ISSUES
ACUTE VISUAL CHANGES
Description & common etiologies of other visual changes
• Fluctuation in vision (ie, blurry): med-induced refractive error (eg, systemic steroids, chemotherapy), hyperglycemia, dry eye (common)
• Double vision (diplopia): fixed double vision w/ ophthalmoplegia from orbital process or cranial nerve palsy. Transient “diplopia” due to fatigue or sedation.
• Visual field defect: bilateral (homonymous → contral. CNS lesion; bitemporal → pituitary, glaucoma or toxic/nutritional); unilateral (ipsilat. orbital, retinal or optic nerve prob)
• Floaters: vitreous detachment (common, benign); retinal detachment (uncommon, “flashing lights,” unilateral visual field defect); hemorrhage; intraocular lymphoma
RED EYE
OTHER DIAGNOSES
Optic nerve disorders
• Ischemic optic neuropathy: p/w acute unilat. visual loss, altitudinal field defect anterior: a/w GCA; non-arteritic a/w HTN, hyperchol., DM, thrombophilia posterior (very rare): seen after severe blood loss; hypotension during surgery
• Optic neuritis: often p/w unilat. central scotoma, pain with EOM,↑ visual loss over days; a/w demyelinating disease (eg, MS), also seen w/ sarcoidosis & CTD
Ocular motor palsies
• CN III palsy: EOM restricted in all directions except laterally (eye is “down & out”); a/w ptosis & mydriasis; seen w/ uncal herniation, aneurysm of post com art., GCA, HTN, DM
• CN IV palsy: upward deviation & lack of depression on adduction; congenital 4th (no diplopia); a/w trauma, post fossa tumor (vertical diplopia, better with head tilt)
• CN VI palsy: failure of abduction (eye is “turned in”), horizontal diplopia worse at distance than near, worse w/ gaze to affected side; a/w ↑ ICP, HTN, diabetes, trauma
Other Dx
• Orbital cellulitis: p/w fever, proptosis, ↓ EOM, sinusitis; requires emergent abx & referral to ophtho; differentiate from preseptal cellulitis by presence of pain w/ eye movement, proptosis, pupil reaction abnl, ophthalmoplegia, ± visual changes
• SJS/TEN/facial burn/acute GVHD: conjunctival/lid/cornea involvement → may lead to corneal perforation, permanent vision loss; emerg ophtho consult
INITIAL EVALUATION
• Ocular presentation: onset (sudden or progressive) & duration of sx; unilateral vs. bilateral; pain; photophobia; discharge; Δ in near (eg, book) or far (eg, TV across room) vision
• Pre-existing ocular conditions, eye meds (incl any Ds), recent h/o ocular surgery
• Ocular exam: vision (✓with Pt’s correction [glasses/contacts]) w/ each eye; pupillary exam; EOM; confrontation visual fields (important if suspect CNS problem)
• Overall status: VS, immunocompromised, s/s of infxn, h/o malignancy, CNS issues, Δ in meds, CBC, coags