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Sudden Vision Loss: A Diagnostic Approach

J. Alexander Fraser, MD
Maksim Son, MD
Anastasiya Vinokurtseva, MD

American Family Physician. 2025;111(1):54-61.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Vision loss affects more than 7 million Americans and impacts quality of life, independence, social functioning, and overall health. Common and dangerous conditions causing sudden vision loss include acute angle-closure glaucoma, retinal detachment, retinal artery occlusion, giant cell arteritis, and optic neuritis. Acute angle-closure glaucoma features ocular pain, headache, and nausea; treatment includes pilocarpine eye drops, oral or intravenous acetazolamide, and intravenous mannitol. Retinal detachment presents with a curtain-like visual field defect and usually requires surgical intervention. Retinal artery occlusion causes painless vision loss in patients with vascular risk factors, and interventions aim to prevent vision loss in the other eye. Giant cell arteritis should be suspected in patients older than 50 years with scalp tenderness, jaw claudication, proximal muscle and joint pain, constitutional symptoms, and elevated C-reactive protein level, erythrocyte sedimentation rate, and platelet count. This condition requires immediate initiation of empiric steroids to prevent vision loss in the unaffected eye, as well as referral for a temporal artery biopsy. Optic neuritis is a demyelinating condition that features color desaturation, relative afferent pupillary defect, and pain with extraocular muscle movements. Treatment requires high-dose steroids, and patients should be evaluated for multiple sclerosis.

Vision loss significantly impacts quality of life, independence, social functioning, economic status, and general health.1,2 It has an estimated global prevalence of 96 cases per 1,000 people and affects more than 7 million Americans.3–5 Various etiologies can cause sudden vision loss, with the responsible lesion localizing anywhere between the globe and the occipital lobe. Family physicians are usually the patient's first point of contact when presenting with sudden vision loss.6

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Because intravenous thrombolysis may be beneficial in selected patients within the first 4.5 hours, emergent consultation with a stroke neurologist is recommended in the hyperacute period.27 C Expert opinion and consensus guideline
Following embolic central retinal artery occlusion, underlying modifiable systemic risk factors should be addressed because the patient is at high risk of a cerebrovascular event or a similar incident in the second eye.28–31 B Cohort studies
When there is high clinical suspicion for giant cell arteritis, empiric steroids should be started immediately (intravenous methylprednisolone pulse therapy, 15 mg/kg per day for 3 days, followed by oral prednisone, 1 mg/kg or more per day). Initiation of steroids prevents vision loss in the other eye while waiting for temporal artery biopsy.32,39,40 B Cohort studies
To reduce visual recovery time, patients with acute optic neuritis should receive high-dose intravenous methylprednisolone (1 g/day) or bioequivalent doses of oral prednisone (1,250 mg/day) for 3 days followed by oral prednisone (1 mg/kg per day) for 11 days with a 3-day taper.8,45 A Consistent findings from randomized from randomized controlled trials

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

J. ALEXANDER FRASER, MD, FRCPC, is an associate professor in the Departments of Clinical Neurological Sciences and Ophthalmology at Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada.

MAKSIM SON, MD, is a stroke neurologist and neurointerventional fellow in the Division of Neurology at McMaster University, Hamilton, Ontario, Canada.

ANASTASIYA VINOKURTSEVA, MD, is an ophthalmology resident in the Department of Ophthalmology at Western University Schulich School of Medicine and Dentistry.

Address correspondence to J. Alexander Fraser, MD, FRCPC, at alex.fraser@lhsc.on.ca.

Author disclosure: No relevant financial relationships.

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