When taking a history from a patient presenting with ophthalmic symptoms, it is important to ask about any vision loss.
Vision loss can be either partial or complete. It can be caused by pathologies affecting the transit of light through the eye or the transmission and processing of neuronal signals along the visual pathway.
This guide provides an approach to vision loss and potential differentials for vision loss that cannot be corrected by refractive tools.
A good approach to vision loss is categorising it into: (i) transient or intermittent (ii) sudden or gradual (iii) painful or painless.
Presenting complaint: vision loss
A helpful mnemonic for expanding on a presenting complaint is NOTEPAD
N – Nature
- Which eye(s) is affected?
- Complete vs partial vision loss?
- Central or peripheral?
- Any visual field abnormalities?
| Defect | Description | Example Causes |
|---|---|---|
| Monocular vision loss | One eye affected | Optic nerve or eye pathology |
| Scotoma | Localised blind spot in visual field | Macular degeneration, optic neuritis, glaucoma, visual aura in migraine (scintillating scotoma), diabetic retinopathy |
| Altitudinal loss | Loss of vision in the upper or lower part of the visual field | Retinal detachment, pathologies affecting the optic nerve e.g. AION, glaucoma |
| Bitemporal hemianopia | Outer visual fields/tunnel vision | Optic chiasm compression (e.g. pituitary tumour) |
| Homonymous hemianopia | Same side of visual field of both eyes | Lesions of the optic tract, optic radiation, or occipital cortex (macula-sparing) |
| Quadrantanopia | One quadrant of visual field | Optic radiation or occipital cortex lesion |
O – Onset
- When did it occur?
- Was the vision loss sudden or gradual?
- Timeframe: seconds, minutes, hours, days, months?
- Triggering events (trauma, position, activity)?
- Previous episodes?
T – Timing
- Was the vision loss persistent or intermittent?
- Did it resolve spontaneously (suggesting TIA/migraine)?
E – Exacerbating/Relieving Factors
- Does anything make vision better or worse?
- Is vision worse in bright light or in the dark? E.g. acute angle closure glaucoma symptoms may be worse with mydriasis (e.g. in dark). Retinitis pigmentosa can present with nyctalopia (night blindness).
P – Progression
- Has vision changed over time?
- Is it stable, improving, or deteriorating?
A – Associated Symptoms
Ophthalmic:
- Eye pain – was there any pain associated with vision loss?
- Flashes and floaters – may precede visual loss in retinal detachment and vitreous detachment
- Presence of a dark curtain across their field of vision – suggestive of retinal detachment
- Halos around lights – associated with acute angle closure glaucoma (acute) and cataract (chronic)
- Visual distortions (e.g. metamorphopsia – straight lines appearing wavy)
- Reddening of eye (see “red eye” guide”)
- Discharge from eye
- Grittiness/dryness
- Photophobia
- Swelling/tenderness of eye
- Visual hallucinations (Charles-Bonnet syndrome)
Systemic:
- Headache (migraine, GCA)
- Stroke symptoms: facial droop, limb weakness, dysarthria
- GCA screen: jaw claudication, scalp tenderness, fatigue
D – Disability
- Impact on daily activities, mobility, employment, driving
Red Flags
Vision loss itself is a red flag symptom. However, there are serious causes of vision loss that require urgent sight-saving intervention and it is important to demonstrate that you are considering them by asking red flag questions to screen for them.
Red flags/conditions requiring urgent referral and management (see below for typical presentation and associated features):
- Retinal detachment – curtain, floaters, painless
- Acute angle-closure glaucoma – painful, red eye, nausea, haloes around lights
- Giant cell arteritis – headache, jaw claudication, age >50, females > males
- Central retinal artery occlusion – sudden, painless monocular loss
- Neovascular (wet) AMD – distortion, central vision loss
Background
In any history you will ask about past medical history, medications, allergies, social history, and family history. In a history about vision loss you can show how much you know about the various causes by explicitly asking about relevant risk factors
Past Medical History
- Ask about other medical conditions the patient may have and what else they see the doctor for.
- Important conditions for screen for include:
- Any ocular conditions
- Refractive disorders – myopia/hyperopia
- Diabetes (diabetic retinopathy, increased risk of VH and retinal detachment)
- Hypertension (hypertensive retinopathy)
- Cardiovascular conditions e.g. ischaemic heart disease, atrial fibrillation, carotid artery disease (retinal vascular occlusion)
- Hypercoagulable state – cancer, thrombophilia e.g. history of DVT, PE (retinal vascular occlusion)
- It is also important to ask about any previous trauma or surgeries to the eye.
- Contact lens wear
- Daily disposables/monthly/extended wear.
- Ask about contact lens hygiene and whether the patient sleeps, showers, or swims with lenses on.
Drug History
- Understand the medications the patient is taking e.g. patients with cardiovascular disease should be on appropriate secondary prevention.
- Combined oral contraceptives increase the risk of retinal vessel occlusion.
- Antiplatelets/anticoagulants – may increase risk of intraocular haemorrhage.
- Steroids – increased risk of cataract, glaucoma
Social History
- Living environment and support at home – it is important to understand the support an individual has at home and the kind of environment they live in as these have implications for how well they may cope with any long-lasting disabilities/visual loss.
- Employment/livelihood – visual loss may have significant effects on someone’s ability to work
- Driving – individuals with visual loss will likely have to notify the DVLA and may have to stop driving
- Smoking – significant risk factor for cardiovascular disease
- Alcohol
- Recreational drugs
Family History
- Ask about any family history of eye conditions (e.g. glaucoma, retinal detachment) and loss of vision. Inherited retinal disorders are an important cause of visual loss in the younger working population.
- Ask about family history of cardiovascular disease and thrombophilic conditions (risk factor for retinal vascular occlusion)
Differential diagnoses
Vision loss can be categorised into sudden or gradual loss. Acute vision loss can be categorised into painful versus painless. There are a number of differentials to consider for each category.
Differentials for sudden loss of vision
Sudden painless loss of vision
| Differential | Classic presentation | Risk factors in the history |
| Retinal detachment | Sudden onset, painless and progressive visual loss described as a curtain/shadow progressing to the centre of the visual field from the periphery. New flashers +/- floaters may precede visual loss. | Diabetes Myopia Increasing age Previous ophthalmic surgery e.g. cataract surgery Eye trauma |
| Retinal artery occlusion (Ocular stroke) | Central retinal artery occlusion presents as sudden monocular painless loss of vision. Transient visual loss (amaurosis fugax) caused by ischaemia is considered a form of TIA. Branch retinal artery occlusion presents as a sudden painless visual field defect. | Increasing age Hypertension Diabetes Smoking Hyperlipidaemia Atrial fibrillation Carotid artery disease Thrombophilia |
| Retinal vein occlusion | Sudden monocular painless visual loss or visual field loss. | Increasing age Hypertension Diabetes Smoking Hyperlipidaemia Thrombophilia Glaucoma and ocular hypertension Oral contraceptive pill |
| Neovascular (wet) age-related macular degeneration | Subacute painless loss of central vision, usually over the course of hours. Patients may present with visual distortions (metamorphopsia). | Advancing age Smoking Family history Cardiovascular disease Hypertension Hyperlipidaemia Diabetes Northern European ancestry |
| Vitreous haemorrhage | Small bleeds cause floaters and possibly a red hue in vision. Moderate bleeds cause numerous dark spots, red hue in vision. Large bleeds can cause sudden painless visual loss. | Diabetes Ocular trauma Coagulation disorders |
| Stroke | Vision loss in stroke can present as homonymous hemianopia or quadrantanopia. Patients may present with other neurological symptoms e.g. facial, arm and/or leg weakness, speech disturbances, sensory changes. | Increasing age Hypertension Diabetes Smoking Hyperlipidaemia Atrial fibrillation Carotid artery disease Thrombophilia |
Sudden painful loss of vision
| Differential | Presentation | Risk factors in the history |
| Acute angle-closure glaucoma | Sudden unilateral painful loss of vision, red eye +/- photophobia, +/- haloes/rainbows around lights +/- nausea/vomiting. Symptoms may be worse with mydriasis e.g. watching TV in a dark room | Advancing age Asian ethnicity Hypermetropia Pupillary dilatation |
| Giant cell arteritis (arteritic anterior ischaemic optic neuropathy) | Sudden unilateral loss of vision, acute headache localised around the temporal region +/- jaw claudication +/- scalp tenderness. Systemic features: fatigue, weight loss, anorexia | Age: > 50 Female sex Past medical history of polymyalgia rheumatica Family history |
| Optic neuritis | Usually transient acute/subacute unilateral vision loss over hours or days. Vision loss varies from blur to no light perception. Typically worsens over days and resolves within 2 weeks. Eye pain worse on eye movement. Impaired colour vision (poor discrimination of red-green). Optic neuritis is closely linked to multiple sclerosis so patients may present with other signs/symptoms e.g. visual, sensory, motor changes. Uhthoff’s phenomenon (associated with MS) – worsening of vision following rise in body temperature | Middle-aged female Caucasian population Family history |
| Endophthalmitis | Blurred vision, vision loss, red eye, eye pain. | Recent ocular surgery – postoperative endophthalmitis is the most common form. |
| Migraine with aura | Migraine with aura can cause transient vision loss, typically presenting as evolving positive visual changes e.g. scintillating/flickering shapes. Usually resolves within 60 minutes and affects both eyes, but one hemifield. Usually accompanied or followed by headache (severe, unilateral, throbbing). | Female sex Family history Common triggers include: fatigue, stress, alcohol, combined oral contraceptive pill, hunger/dehydration, menstruation, bright lights, certain foods (e.g. cheese, chocolate, red wine). |
Note: vision loss can be a complication of uveitis and keratitis, but red eye and irritation are more prominent features so they are covered in the “red eye” guide.
Differentials for gradual loss of vision
| Differential | Presentation | Risk factors in the history |
| Cataract | Painless and gradual loss of vision, blurred vision. +/- glare, halos around lights, difficulty with night vision. | Advancing age (main risk factor) Ocular trauma Ocular surgery High myopia Medications: steroids |
| Age-related macular degeneration | Painless and subacute (wet AMD) or gradual (dry AMD) onset of vision loss, reduced visual acuity, reduced night vision +/- metamorphopsia, visual hallucinations (Charles-Bonnet syndrome) | Advancing age Smoking Family history Hypertension Hyperlipidaemia Diabetes |
| Open angle glaucoma | Progressive peripheral vision loss, reduced visual acuity. Asymptomatic until advanced, central vision is often preserved until late-stage disease. | Advancing age African-caribbean ethnicity Hypertension Smoking Diabetes Myopia Steroids Family history |
| Diabetic retinopathy | Often asymptomatic and picked up with diabetic screening. Patients may present with gradual painless vision loss (due to diabetic retinopathy or maculopathy) or symptoms of vitreous haemorrhage/retinal detachment (complications of proliferative diabetic retinopathy). | (Poorly controlled, long-term) diabetes |
| Hypertensive retinopathy | Often asymptomatic until advanced disease. Patients may present with gradual painless vision loss and other signs of end-organ damage | (Poorly controlled, long-term) hypertension |
| Retinitis pigmentosa | Younger patient presenting with nyctalopia (night blindness), progressive peripheral vision loss (tunnel vision). | Family history |
References
1. Bowling B. Kanski’s Clinical Ophthalmology: A Systematic Approach. 9th ed. London: Elsevier; 2019
2. Denniston A, Murray P, editors. Oxford Handbook of Ophthalmology. 4th ed. Oxford: Oxford University Press; 2018.
3. American Academy of Ophthalmology. Basic Ophthalmology: Essentials for Medical Students. 11th ed. San Francisco: American Academy of Ophthalmology; 2016.
4. Shah P, Shah S. The Duke-Elder Exam of Ophthalmology: A Comprehensive Guide. 2nd ed. Boca Raton: CRC Press; 2021.
Author – Dr Wei Jia Liu
Editor – Dr Daniel Arbide
