Vision Loss ComplaintAPPROACH

ENT, EYE, DENTAL · 19 SECTIONS

⚲

523 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Dysphagia And Odynophagia Throat Pain Ear Pain Foreign Body In Ear Or Nose Vision Loss Complaint Flashes And Floaters Atraumatic Eye Pain Red Eye Dental Abscess Concern Post Extraction Pain And Complications

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx74

Presenting pattern

›Vision loss pattern

›Monocular

›Binocular

›Central

›Peripheral

›Transient

›Persistent

›Sudden

›Gradual

OPQRST

›Onset

›Last known normal time

›Time to maximal deficit

›Provocation and palliation

›Positional change

›Exertion

›Valsalva

›Light exposure

›Symptom relief with blinking

›Symptom relief with pinhole

›Quality

›Blurry

›Curtain or shadow

›Flashers

›Floaters

›Distorted

›Diplopia

›Complete blackout

›Region and radiation

›Right eye

›Left eye

›Both eyes

›Visual field location

›Severity

›Cannot count fingers

›Cannot see hand motion

›Light perception only

›Near normal with blur

›Timing

›Single episode duration

›Recurrent episodes

›Progressive worsening

Associated symptoms

›Eye symptoms

›Eye pain

›Pain with eye movement

›Redness

›Photophobia

›Discharge

›Foreign body sensation

›Neurologic symptoms

›Weakness

›Numbness

›Dysarthria

›Aphasia

›Ataxia

›Vertigo

›Severe headache

›Systemic symptoms

›Fever

›Weight loss

›Night sweats

›Jaw claudication

›Scalp tenderness

›Polymyalgia rheumatica symptoms

Precipitating context

›Trauma and exposures

›Blunt trauma

›Penetrating trauma

›Chemical exposure

›Welding or UV exposure

›Contact lens wear

›Vascular triggers

›Recent neck manipulation

›Recent surgery

›Dehydration

›New arrhythmia symptoms

02Alarm Features/alarm29

Immediate threats

›Time critical eye emergencies

›Suspected central retinal artery occlusion

›Suspected acute angle closure glaucoma

›Suspected endophthalmitis

›Suspected globe rupture

›Suspected chemical burn

›Suspected retinal detachment with macula threatened

›Time critical neurologic emergencies

›Suspected stroke or TIA affecting vision

›Suspected intracranial hemorrhage with vision symptoms

›Suspected pituitary apoplexy

›Suspected carotid dissection

Escalation triggers

›Escalate to resuscitation workflow

›Vision loss within 24 hours with focal neurologic deficit

›Painful red eye with nausea or vomiting

›Penetrating eye injury

›Chemical exposure to eye

›Severe headache with vision loss and altered mental status

High risk vitals and physiology

›High risk physiology

›Hypotension with vision symptoms

›Severe hypertension with neurologic symptoms

›Fever with ocular pain

›Hypoxia with neurologic symptoms

High risk historical features

›High risk history

›Age 50 or older with jaw claudication

›Transient monocular vision loss

›Immunocompromised state with eye pain

›Contact lens wearer with severe pain and photophobia

›Recent eye surgery or injection

03Medications/meds23

Current and recent medications

›Medication inventory

›Anticoagulants

›Antiplatelets

›Antihypertensives

›Diabetes medications

›Migraine therapies

›Erectile dysfunction medications

›Ocular medications

›Topical steroids

›Topical glaucoma drops

›Mydriatic drops

›Recent antibiotic drops

High risk medication effects

›Medication related risks

›Anticholinergics and adrenergics with angle closure risk

›Phosphodiesterase 5 inhibitors with visual adverse effect concern

›Amiodarone with optic neuropathy concern

›Ethambutol with optic neuropathy concern

›Hydroxychloroquine with retinopathy risk

Allergies and contraindications

›Therapy constraints

›Sulfonamide allergy relevance to acetazolamide decision

›Beta blocker contraindications for timolol

›Pregnancy relevance to acetazolamide

›Asthma or COPD relevance to topical beta blocker

04Diet/diet12

Intake and hydration

›Recent intake pattern

›Poor oral intake

›Dehydration symptoms

›Recent vomiting or diarrhea

Caffeine and stimulants

›Stimulant exposures

›High caffeine intake

›Energy drinks

›Sympathomimetic supplements

Alcohol and recreational exposures

›Substance exposures

›Alcohol binge

›Cocaine or stimulant exposure

›Inhalant exposure

05Review of Systems/ros28

Eye and ENT

›Eye and periocular

›Red eye

›Photophobia

›Tearing

›Purulent discharge

›Periorbital swelling

›ENT

›Sinus pain

›Recent upper respiratory infection

›Facial numbness

Neurologic

›Neurologic symptoms

›Headache

›Neck pain

›Speech change

›Gait instability

›Seizure

Cardiopulmonary and vascular

›Vascular symptoms

›Chest pain

›Palpitations

›Syncope

›Claudication

›Limb ischemia symptoms

Inflammatory and infectious

›Systemic inflammation or infection

›Fever

›New rash

›Arthralgia

›Oral ulcers

›Genital ulcers

06Collateral History and Family History/chafh15

Collateral and reliability

›Source

›Family or caregiver report

›EMS report

›Prior records

Family history

›Vascular and ocular risk

›Early stroke or TIA

›Early myocardial infarction

›Glaucoma

›Retinal detachment

›Autoimmune disease

Exposures and contacts

›Context

›Household infections

›Workplace chemical exposure

›Recent travel

›Poor access to urgent eye care

07Risk Factors/rf26

Vascular and thromboembolic

›Atherosclerotic risk

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Dyslipidemia (E78.5)

›Tobacco use

›Atrial fibrillation (I48.91)

›Hypercoagulable risk

›Active cancer

›Estrogen therapy

›Recent immobility

›Prior venous thromboembolism (I82.90)

Ocular and anatomic

›Ocular risk

›High myopia

›Prior retinal tear or detachment

›Cataract surgery

›Known glaucoma

Inflammatory and autoimmune

›Inflammatory risk

›Giant cell arteritis risk

›Multiple sclerosis risk

›Known vasculitis

›Immunosuppression

Trauma and iatrogenic

›Trauma and procedures

›Recent eye surgery

›Intravitreal injection

›Facial trauma

›Neck trauma

08Differential Diagnosis/ddx60

Life threatening

›Cannot miss

›Central retinal artery occlusion (H34.11)

›Sudden profound monocular loss

›Relative afferent pupillary defect

›Acute angle closure glaucoma (H40.219)

›Severe eye pain

›Headache with nausea or vomiting

›Giant cell arteritis with ischemic optic neuropathy (M31.6)

›Age 50 or older

›Jaw claudication or scalp tenderness

›Stroke or TIA with visual deficit (I63.9) (G45.9)

›Binocular field deficit pattern

›Associated focal neurologic symptoms

›Carotid dissection (I77.71)

›Neck pain or headache

›Partial Horner syndrome

›Endophthalmitis (H44.0)

›Recent eye procedure

›Severe pain with decreased vision

›Globe rupture (S05.3)

›Trauma history

›Irregular pupil or low intraocular pressure

Common

›Common etiologies

›Retinal detachment (H33.0)

›Flashes and floaters

›Curtain over vision

›Vitreous hemorrhage (H43.1)

›Sudden floaters

›Reduced fundus view

›Posterior vitreous detachment (H43.81)

›New floaters

›Flashes without field loss

›Migraine with aura (G43.109)

›Positive visual phenomena

›Recurrent stereotyped episodes

›Optic neuritis (H46)

›Pain with eye movement

›Color desaturation

›Corneal abrasion or keratitis (S05.0) (H16.0)

›Foreign body sensation

›Photophobia

Less common

›Less common and zebras

›Retinal vein occlusion (H34.81)

›Subacute monocular loss

›Vascular risk factors

›Nonarteritic ischemic optic neuropathy (H47.01)

›Painless monocular loss on waking

›Optic disc edema

›Pituitary apoplexy (E23.6)

›Thunderclap headache

›Bitemporal hemianopia

›Idiopathic intracranial hypertension (G93.2)

›Transient visual obscurations

›Papilledema

›Uveitis or iritis (H20.9)

›Photophobia

›Ciliary flush

›Functional vision loss

›Inconsistent exam

›Normal objective testing

09Past Medical History/pmh18

Ocular history

›Prior eye disease and procedures

›Glaucoma

›Cataract surgery

›Retinal tear or detachment repair

›Prior uveitis

›Herpes eye disease

Vascular and neurologic history

›Prior vascular events

›Prior stroke or TIA (I63.9) (G45.9)

›Coronary artery disease (I25.10)

›Peripheral arterial disease (I73.9)

›Neurologic disease

›Multiple sclerosis (G35)

›Seizure disorder (G40.909)

Baseline function

›Baseline vision and supports

›Baseline visual acuity

›Corrective lenses use

›Driving status

›Ability to self administer drops

10Physical Exam/exam47

Initial stabilization and general

›General assessment

›Mental status

›Distress level

›Sepsis appearance

›Trauma survey if indicated

›Vital signs pattern

›Fever

›Severe hypertension

›Hypotension

›Hypoxia

Eye exam core

›Vision and pupils

›Visual acuity with correction

›Pinhole acuity

›Pupils size and symmetry

›Relative afferent pupillary defect

›Color vision screening

›Visual fields

›Confrontation fields

›Monocular field testing

›Pattern consistent with hemianopia

›External and anterior segment

›Eyelids and periorbital swelling

›Conjunctival injection pattern

›Corneal clarity

›Ciliary flush

›Extraocular movements

›Pain with movement

›Ophthalmoplegia

›Diplopia reproduction

›Intraocular pressure

›If globe intact

›Avoid tonometry if rupture suspected

Fundus and posterior segment

›Posterior evaluation

›Direct ophthalmoscopy findings

›Optic disc edema

›Retinal pallor

›Retinal hemorrhages

Neurologic and vascular

›Focused neurologic exam

›Cranial nerves

›Motor and sensory

›Cerebellar testing

›Gait when safe

›Vascular exam

›Carotid bruit

›Temporal artery tenderness

›Pulse asymmetry

›New murmur

11Lab Studies/labs20

Core labs for vision loss with systemic concern

›Baseline labs

›Glucose

›CBC

›Electrolytes

›Creatinine

Inflammatory and vasculitis evaluation

›Giant cell arteritis evaluation

›ESR

›CRP

›Platelets

›Anemia pattern

Stroke and vascular workup support

›Vascular evaluation support

›INR if on warfarin

›aPTT if anticoagulated concern

›Troponin if stroke pathway

Infection and exposure

›Infection assessment

›Blood cultures if febrile with endophthalmitis concern

›Lactate if septic physiology

›Toxic exposure adjuncts

›Carboxyhemoglobin if smoke exposure

›Methemoglobin if oxidant exposure concern

12Imaging/img46

Scoring Systems

›Neurologic risk tools

›NIH Stroke Scale use for suspected acute stroke

›ABCD2 score use for suspected TIA

›Not for isolated monocular vision loss without neuro features

MRI

›MRI brain and orbits considerations

›Indications

›Optic neuritis concern

›Posterior circulation stroke concern with nondiagnostic CT

›Protocol pearls

›Orbits with fat suppression

›Contrast use if optic neuritis or orbital pathology

›Contraindications and delays

›Non MRI compatible device

›Unstable patient requiring CT first

›CT based strategies

›Noncontrast CT head

›Indications

›Acute neurologic deficit

›Severe headache with neuro signs

›Limitations

›Poor sensitivity for early ischemia

›Does not evaluate retina or optic nerve well

›CT angiography head and neck

›Indications

›Suspected large vessel occlusion

›Suspected carotid dissection

›Pitfalls

›Contrast nephropathy risk assessment

›Allergy mitigation per local protocol dependent

›CT orbits

›Indications

›Orbital cellulitis concern

›Suspected foreign body

›Pitfalls

›Radiation exposure

›Limited for soft tissue compared with MRI

Ultrasound

›Ocular ultrasound

›Indications

›Suspected retinal detachment

›Suspected vitreous hemorrhage

›Do not use

›Suspected globe rupture

›Open eye injury

›Interpretation pearls

›Retinal detachment as tethered membrane to optic disc

›Vitreous hemorrhage as mobile low level echoes

13Special Tests/spec12

Bedside eye diagnostics

›Core bedside tests

›Fluorescein staining

›Seidel test for leak if safe and low suspicion for rupture

›Tonometry if globe intact

›Slit lamp exam when available

Vision function adjuncts

›Neuro ophthalmic adjuncts

›Red desaturation testing

›Ishihara color plates when available

›Swinging flashlight test for relative afferent pupillary defect

Vascular and inflammatory confirmation pathways

›Giant cell arteritis pathway tests

›Temporal artery ultrasound or biopsy planning per local protocol dependent

›High dose steroids initiation should not wait for biopsy if high suspicion

14ECG/ecg8

Indications and targets

›ECG in vision loss

›Suspected stroke or TIA pathway

›Suspected embolic source

›Chest pain or palpitations

High risk findings

›ECG red flags

›Atrial fibrillation

›Acute ischemic changes

›High grade AV block

15Assessment/ax13

Problem representation

›Vision loss syndrome classification

›Monocular painless sudden

›Monocular painful

›Binocular field deficit

›Transient recurrent episodes

Risk and severity stratification

›High risk features present

›Time window for reperfusion therapy consideration

›Evidence of ocular compartment crisis

›Systemic vasculitis concern

Uncertainty and alternative diagnoses

›Competing diagnoses to keep active

›Ocular pathology versus neurologic pathology

›Migraine aura versus TIA

›Functional symptoms versus occult disease

16Plan/plan39

First 5 minutes

›Immediate priorities

›Cardiorespiratory monitoring if neuro emergency concern

›Point of care glucose

›IV access if stroke pathway or sick patient

›Head of bed positioning per stroke protocol local protocol dependent

Eye specific emergent actions

›Time critical eye actions

›Chemical exposure irrigation immediately until neutral pH

›Suspected acute angle closure glaucoma

›Timolol ophthalmic 0.5 percent 1 drop affected eye

›Brimonidine ophthalmic 0.2 percent 1 drop affected eye

›Acetazolamide IV 500 mg once if no contraindication

›Antiemetic for nausea

›Ophthalmology emergent for definitive therapy

›Suspected endophthalmitis

›Ophthalmology emergent for intravitreal antibiotics

›Avoid delaying consult for imaging if classic presentation

›Suspected globe rupture

›Eye shield

›NPO

›Broad spectrum IV antibiotics per local protocol dependent

›Antiemetic and analgesia to reduce Valsalva

Vascular and neurologic actions

›Stroke and retinal ischemia pathway

›Activate stroke protocol for acute binocular deficit or focal neuro signs

›Consider CRAO as stroke equivalent pathway per local protocol dependent

›Antiplatelet initiation per stroke team direction

›Giant cell arteritis treatment

›If high suspicion start steroids immediately

›Methylprednisolone IV 500 mg daily for 3 days if vision threatened local protocol dependent

›Prednisone PO 40 mg to 60 mg daily if not vision threatened local protocol dependent

›Calcium and vitamin D supplementation consideration if prolonged steroids

Diagnostic sequencing

›Test sequencing

›Visual acuity and pupils before dilation when possible

›IOP after ruling out rupture

›Neuro imaging first if focal neurologic deficit or severe headache

Reassessment loop

›Reassessment

›Repeat visual acuity after initial interventions

›Repeat pupil exam for evolving relative afferent pupillary defect

›Repeat neuro exam every 30 to 60 minutes if stroke concern

›Pain and nausea control response

17Disposition/dispo17

ICU and high acuity criteria

›ICU or high acuity

›Suspected stroke requiring thrombolysis or thrombectomy evaluation

›Pituitary apoplexy with hemodynamic instability or altered mental status

›Sepsis with endophthalmitis or orbital cellulitis concern

Inpatient and observation criteria

›Admission or observation

›Suspected giant cell arteritis

›CRAO or amaurosis fugax requiring urgent stroke workup

›Acute angle closure glaucoma requiring ongoing therapy

›Orbital cellulitis concern

Discharge criteria

›Discharge with close follow up

›Normal neuro exam with low risk migraine aura pattern

›Benign anterior segment diagnosis with improved symptoms

›Reliable follow up within 24 to 48 hours

Follow up timing

›Follow up targets

›Ophthalmology same day for retinal detachment concern

›Stroke clinic within 24 to 72 hours for transient ischemic symptoms local protocol dependent

›Primary care within 7 days for vascular risk optimization

18Discharge Instructions/di18

Copy discharge instructions

›Vision symptoms summary

›Your vision change today may have more than one cause and some causes are serious

›Do not drive until cleared if vision is not back to normal

›Medications

›Take prescribed eye drops exactly as directed

›Do not use leftover steroid eye drops unless specifically prescribed

›Activity and eye protection

›Avoid rubbing the eye

›Wear protective eyewear if injury risk

›Follow up plan

›Ophthalmology appointment timing as arranged

›Return for reassessment if unable to obtain follow up

›Return to ED immediately

›Any worsening vision

›New eye pain or severe headache

›New weakness numbness speech difficulty or trouble walking

›New vomiting with a painful red eye

›Fever with eye pain or swelling

19References/r18

Guidelines and high quality sources

›American Academy of Ophthalmology Preferred Practice Pattern Retinal Detachment 2019 to 2023 update

›Diagnostic and referral urgency guidance

›Surgical timing considerations

›American Academy of Ophthalmology Preferred Practice Pattern Primary Angle Closure 2020

›Acute angle closure initial medical therapy principles

›Definitive therapy pathways

›AHA ASA Guideline for the Early Management of Acute Ischemic Stroke 2019 with updates

›Imaging and reperfusion workflow targets

›Secondary prevention framework

›AHA Scientific Statement on Central Retinal Artery Occlusion 2021

›CRAO as ischemic stroke equivalent concept

›Urgent vascular evaluation recommendations

›ACR Appropriateness Criteria Orbital Imaging 2023

›Modality selection for orbital infection and trauma

›CT versus MRI indications

›ACR EULAR classification and management guidance for giant cell arteritis 2022 local protocol dependent

›Steroid initiation principles for vision threat

›Diagnostic confirmation pathways

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Vision Loss ComplaintAPPROACH

ENT, EYE, DENTAL · 19 SECTIONS

⚲

523 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx74

Presenting pattern

›Vision loss pattern

›Monocular

›Binocular

›Central

›Peripheral

›Transient

›Persistent

›Sudden

›Gradual

OPQRST

›Onset

›Last known normal time

›Time to maximal deficit

›Provocation and palliation

›Positional change

›Exertion

›Valsalva

›Light exposure

›Symptom relief with blinking

›Symptom relief with pinhole

›Quality

›Blurry

›Curtain or shadow

›Flashers

›Floaters

›Distorted

›Diplopia

›Complete blackout

›Region and radiation

›Right eye

›Left eye

›Both eyes

›Visual field location

›Severity

›Cannot count fingers

›Cannot see hand motion

›Light perception only

›Near normal with blur

›Timing

›Single episode duration

›Recurrent episodes

›Progressive worsening

Associated symptoms

›Eye symptoms

›Eye pain

›Pain with eye movement

›Redness

›Photophobia

›Discharge

›Foreign body sensation

›Neurologic symptoms

›Weakness

›Numbness

›Dysarthria

›Aphasia

›Ataxia

›Vertigo

›Severe headache

›Systemic symptoms

›Fever

›Weight loss

›Night sweats

›Jaw claudication

›Scalp tenderness

›Polymyalgia rheumatica symptoms

Precipitating context

›Trauma and exposures

›Blunt trauma

›Penetrating trauma

›Chemical exposure

›Welding or UV exposure

›Contact lens wear

›Vascular triggers

›Recent neck manipulation

›Recent surgery

›Dehydration

›New arrhythmia symptoms

02Alarm Features/alarm29

Immediate threats

›Time critical eye emergencies

›Suspected central retinal artery occlusion

›Suspected acute angle closure glaucoma

›Suspected endophthalmitis

›Suspected globe rupture

›Suspected chemical burn

›Suspected retinal detachment with macula threatened

›Time critical neurologic emergencies

›Suspected stroke or TIA affecting vision

›Suspected intracranial hemorrhage with vision symptoms

›Suspected pituitary apoplexy

›Suspected carotid dissection

Escalation triggers

›Escalate to resuscitation workflow

›Vision loss within 24 hours with focal neurologic deficit

›Painful red eye with nausea or vomiting

›Penetrating eye injury

›Chemical exposure to eye

›Severe headache with vision loss and altered mental status

High risk vitals and physiology

›High risk physiology

›Hypotension with vision symptoms

›Severe hypertension with neurologic symptoms

›Fever with ocular pain

›Hypoxia with neurologic symptoms

High risk historical features

›High risk history

›Age 50 or older with jaw claudication

›Transient monocular vision loss

›Immunocompromised state with eye pain

›Contact lens wearer with severe pain and photophobia

›Recent eye surgery or injection

03Medications/meds23

Current and recent medications

›Medication inventory

›Anticoagulants

›Antiplatelets

›Antihypertensives

›Diabetes medications

›Migraine therapies

›Erectile dysfunction medications

›Ocular medications

›Topical steroids

›Topical glaucoma drops

›Mydriatic drops

›Recent antibiotic drops

High risk medication effects

›Medication related risks

›Anticholinergics and adrenergics with angle closure risk

›Phosphodiesterase 5 inhibitors with visual adverse effect concern

›Amiodarone with optic neuropathy concern

›Ethambutol with optic neuropathy concern

›Hydroxychloroquine with retinopathy risk

Allergies and contraindications

›Therapy constraints

›Sulfonamide allergy relevance to acetazolamide decision

›Beta blocker contraindications for timolol

›Pregnancy relevance to acetazolamide

›Asthma or COPD relevance to topical beta blocker

04Diet/diet12

Intake and hydration

›Recent intake pattern

›Poor oral intake

›Dehydration symptoms

›Recent vomiting or diarrhea

Caffeine and stimulants

›Stimulant exposures

›High caffeine intake

›Energy drinks

›Sympathomimetic supplements

Alcohol and recreational exposures

›Substance exposures

›Alcohol binge

›Cocaine or stimulant exposure

›Inhalant exposure

05Review of Systems/ros28

Eye and ENT

›Eye and periocular

›Red eye

›Photophobia

›Tearing

›Purulent discharge

›Periorbital swelling

›ENT

›Sinus pain

›Recent upper respiratory infection

›Facial numbness

Neurologic

›Neurologic symptoms

›Headache

›Neck pain

›Speech change

›Gait instability

›Seizure

Cardiopulmonary and vascular

›Vascular symptoms

›Chest pain

›Palpitations

›Syncope

›Claudication

›Limb ischemia symptoms

Inflammatory and infectious

›Systemic inflammation or infection

›Fever

›New rash

›Arthralgia

›Oral ulcers

›Genital ulcers

06Collateral History and Family History/chafh15

Collateral and reliability

›Source

›Family or caregiver report

›EMS report

›Prior records

Family history

›Vascular and ocular risk

›Early stroke or TIA

›Early myocardial infarction

›Glaucoma

›Retinal detachment

›Autoimmune disease

Exposures and contacts

›Context

›Household infections

›Workplace chemical exposure

›Recent travel

›Poor access to urgent eye care

07Risk Factors/rf26

Vascular and thromboembolic

›Atherosclerotic risk

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Dyslipidemia (E78.5)

›Tobacco use

›Atrial fibrillation (I48.91)

›Hypercoagulable risk

›Active cancer

›Estrogen therapy

›Recent immobility

›Prior venous thromboembolism (I82.90)

Ocular and anatomic

›Ocular risk

›High myopia

›Prior retinal tear or detachment

›Cataract surgery

›Known glaucoma

Inflammatory and autoimmune

›Inflammatory risk

›Giant cell arteritis risk

›Multiple sclerosis risk

›Known vasculitis

›Immunosuppression

Trauma and iatrogenic

›Trauma and procedures

›Recent eye surgery

›Intravitreal injection

›Facial trauma

›Neck trauma

08Differential Diagnosis/ddx60

Life threatening

›Cannot miss

›Central retinal artery occlusion (H34.11)

›Sudden profound monocular loss

›Relative afferent pupillary defect

›Acute angle closure glaucoma (H40.219)

›Severe eye pain

›Headache with nausea or vomiting

›Giant cell arteritis with ischemic optic neuropathy (M31.6)

›Age 50 or older

›Jaw claudication or scalp tenderness

›Stroke or TIA with visual deficit (I63.9) (G45.9)

›Binocular field deficit pattern

›Associated focal neurologic symptoms

›Carotid dissection (I77.71)

›Neck pain or headache

›Partial Horner syndrome

›Endophthalmitis (H44.0)

›Recent eye procedure

›Severe pain with decreased vision

›Globe rupture (S05.3)

›Trauma history

›Irregular pupil or low intraocular pressure

Common

›Common etiologies

›Retinal detachment (H33.0)

›Flashes and floaters

›Curtain over vision

›Vitreous hemorrhage (H43.1)

›Sudden floaters

›Reduced fundus view

›Posterior vitreous detachment (H43.81)

›New floaters

›Flashes without field loss

›Migraine with aura (G43.109)

›Positive visual phenomena

›Recurrent stereotyped episodes

›Optic neuritis (H46)

›Pain with eye movement

›Color desaturation

›Corneal abrasion or keratitis (S05.0) (H16.0)

›Foreign body sensation

›Photophobia

Less common

›Less common and zebras

›Retinal vein occlusion (H34.81)

›Subacute monocular loss

›Vascular risk factors

›Nonarteritic ischemic optic neuropathy (H47.01)

›Painless monocular loss on waking

›Optic disc edema

›Pituitary apoplexy (E23.6)

›Thunderclap headache

›Bitemporal hemianopia

›Idiopathic intracranial hypertension (G93.2)

›Transient visual obscurations

›Papilledema

›Uveitis or iritis (H20.9)

›Photophobia

›Ciliary flush

›Functional vision loss

›Inconsistent exam

›Normal objective testing

09Past Medical History/pmh18

Ocular history

›Prior eye disease and procedures

›Glaucoma

›Cataract surgery

›Retinal tear or detachment repair

›Prior uveitis

›Herpes eye disease

Vascular and neurologic history

›Prior vascular events

›Prior stroke or TIA (I63.9) (G45.9)

›Coronary artery disease (I25.10)

›Peripheral arterial disease (I73.9)

›Neurologic disease

›Multiple sclerosis (G35)

›Seizure disorder (G40.909)

Baseline function

›Baseline vision and supports

›Baseline visual acuity

›Corrective lenses use

›Driving status

›Ability to self administer drops

10Physical Exam/exam47

Initial stabilization and general

›General assessment

›Mental status

›Distress level

›Sepsis appearance

›Trauma survey if indicated

›Vital signs pattern

›Fever

›Severe hypertension

›Hypotension

›Hypoxia

Eye exam core

›Vision and pupils

›Visual acuity with correction

›Pinhole acuity

›Pupils size and symmetry

›Relative afferent pupillary defect

›Color vision screening

›Visual fields

›Confrontation fields

›Monocular field testing

›Pattern consistent with hemianopia

›External and anterior segment

›Eyelids and periorbital swelling

›Conjunctival injection pattern

›Corneal clarity

›Ciliary flush

›Extraocular movements

›Pain with movement

›Ophthalmoplegia

›Diplopia reproduction

›Intraocular pressure

›If globe intact

›Avoid tonometry if rupture suspected

Fundus and posterior segment

›Posterior evaluation

›Direct ophthalmoscopy findings

›Optic disc edema

›Retinal pallor

›Retinal hemorrhages

Neurologic and vascular

›Focused neurologic exam

›Cranial nerves

›Motor and sensory

›Cerebellar testing

›Gait when safe

›Vascular exam

›Carotid bruit

›Temporal artery tenderness

›Pulse asymmetry

›New murmur

11Lab Studies/labs20

Core labs for vision loss with systemic concern

›Baseline labs

›Glucose

›CBC

›Electrolytes

›Creatinine

Inflammatory and vasculitis evaluation

›Giant cell arteritis evaluation

›ESR

›CRP

›Platelets

›Anemia pattern

Stroke and vascular workup support

›Vascular evaluation support

›INR if on warfarin

›aPTT if anticoagulated concern

›Troponin if stroke pathway

Infection and exposure

›Infection assessment

›Blood cultures if febrile with endophthalmitis concern

›Lactate if septic physiology

›Toxic exposure adjuncts

›Carboxyhemoglobin if smoke exposure

›Methemoglobin if oxidant exposure concern

12Imaging/img46

Scoring Systems

›Neurologic risk tools

›NIH Stroke Scale use for suspected acute stroke

›ABCD2 score use for suspected TIA

›Not for isolated monocular vision loss without neuro features

MRI

›MRI brain and orbits considerations

›Indications

›Optic neuritis concern

›Posterior circulation stroke concern with nondiagnostic CT

›Protocol pearls

›Orbits with fat suppression

›Contrast use if optic neuritis or orbital pathology

›Contraindications and delays

›Non MRI compatible device

›Unstable patient requiring CT first

›CT based strategies

›Noncontrast CT head

›Indications

›Acute neurologic deficit

›Severe headache with neuro signs

›Limitations

›Poor sensitivity for early ischemia

›Does not evaluate retina or optic nerve well

›CT angiography head and neck

›Indications

›Suspected large vessel occlusion

›Suspected carotid dissection

›Pitfalls

›Contrast nephropathy risk assessment

›Allergy mitigation per local protocol dependent

›CT orbits

›Indications

›Orbital cellulitis concern

›Suspected foreign body

›Pitfalls

›Radiation exposure

›Limited for soft tissue compared with MRI

Ultrasound

›Ocular ultrasound

›Indications

›Suspected retinal detachment

›Suspected vitreous hemorrhage

›Do not use

›Suspected globe rupture

›Open eye injury

›Interpretation pearls

›Retinal detachment as tethered membrane to optic disc

›Vitreous hemorrhage as mobile low level echoes

13Special Tests/spec12

Bedside eye diagnostics

›Core bedside tests

›Fluorescein staining

›Seidel test for leak if safe and low suspicion for rupture

›Tonometry if globe intact

›Slit lamp exam when available

Vision function adjuncts

›Neuro ophthalmic adjuncts

›Red desaturation testing

›Ishihara color plates when available

›Swinging flashlight test for relative afferent pupillary defect

Vascular and inflammatory confirmation pathways

›Giant cell arteritis pathway tests

›Temporal artery ultrasound or biopsy planning per local protocol dependent

›High dose steroids initiation should not wait for biopsy if high suspicion

14ECG/ecg8

Indications and targets

›ECG in vision loss

›Suspected stroke or TIA pathway

›Suspected embolic source

›Chest pain or palpitations

High risk findings

›ECG red flags

›Atrial fibrillation

›Acute ischemic changes

›High grade AV block

15Assessment/ax13

Problem representation

›Vision loss syndrome classification

›Monocular painless sudden

›Monocular painful

›Binocular field deficit

›Transient recurrent episodes

Risk and severity stratification

›High risk features present

›Time window for reperfusion therapy consideration

›Evidence of ocular compartment crisis

›Systemic vasculitis concern

Uncertainty and alternative diagnoses

›Competing diagnoses to keep active

›Ocular pathology versus neurologic pathology

›Migraine aura versus TIA

›Functional symptoms versus occult disease

16Plan/plan39

First 5 minutes

›Immediate priorities

›Cardiorespiratory monitoring if neuro emergency concern

›Point of care glucose

›IV access if stroke pathway or sick patient

›Head of bed positioning per stroke protocol local protocol dependent

Eye specific emergent actions

›Time critical eye actions

›Chemical exposure irrigation immediately until neutral pH

›Suspected acute angle closure glaucoma

›Timolol ophthalmic 0.5 percent 1 drop affected eye

›Brimonidine ophthalmic 0.2 percent 1 drop affected eye

›Acetazolamide IV 500 mg once if no contraindication

›Antiemetic for nausea

›Ophthalmology emergent for definitive therapy

›Suspected endophthalmitis

›Ophthalmology emergent for intravitreal antibiotics

›Avoid delaying consult for imaging if classic presentation

›Suspected globe rupture

›Eye shield

›NPO

›Broad spectrum IV antibiotics per local protocol dependent

›Antiemetic and analgesia to reduce Valsalva

Vascular and neurologic actions

›Stroke and retinal ischemia pathway

›Activate stroke protocol for acute binocular deficit or focal neuro signs

›Consider CRAO as stroke equivalent pathway per local protocol dependent

›Antiplatelet initiation per stroke team direction

›Giant cell arteritis treatment

›If high suspicion start steroids immediately

›Methylprednisolone IV 500 mg daily for 3 days if vision threatened local protocol dependent

›Prednisone PO 40 mg to 60 mg daily if not vision threatened local protocol dependent

›Calcium and vitamin D supplementation consideration if prolonged steroids

Diagnostic sequencing

›Test sequencing

›Visual acuity and pupils before dilation when possible

›IOP after ruling out rupture

›Neuro imaging first if focal neurologic deficit or severe headache

Reassessment loop

›Reassessment

›Repeat visual acuity after initial interventions

›Repeat pupil exam for evolving relative afferent pupillary defect

›Repeat neuro exam every 30 to 60 minutes if stroke concern

›Pain and nausea control response

17Disposition/dispo17

ICU and high acuity criteria

›ICU or high acuity

›Suspected stroke requiring thrombolysis or thrombectomy evaluation

›Pituitary apoplexy with hemodynamic instability or altered mental status

›Sepsis with endophthalmitis or orbital cellulitis concern

Inpatient and observation criteria

›Admission or observation

›Suspected giant cell arteritis

›CRAO or amaurosis fugax requiring urgent stroke workup

›Acute angle closure glaucoma requiring ongoing therapy

›Orbital cellulitis concern

Discharge criteria

›Discharge with close follow up

›Normal neuro exam with low risk migraine aura pattern

›Benign anterior segment diagnosis with improved symptoms

›Reliable follow up within 24 to 48 hours

Follow up timing

›Follow up targets

›Ophthalmology same day for retinal detachment concern

›Stroke clinic within 24 to 72 hours for transient ischemic symptoms local protocol dependent

›Primary care within 7 days for vascular risk optimization

18Discharge Instructions/di18

Copy discharge instructions

›Vision symptoms summary

›Your vision change today may have more than one cause and some causes are serious

›Do not drive until cleared if vision is not back to normal

›Medications

›Take prescribed eye drops exactly as directed

›Do not use leftover steroid eye drops unless specifically prescribed

›Activity and eye protection

›Avoid rubbing the eye

›Wear protective eyewear if injury risk

›Follow up plan

›Ophthalmology appointment timing as arranged

›Return for reassessment if unable to obtain follow up

›Return to ED immediately

›Any worsening vision

›New eye pain or severe headache

›New weakness numbness speech difficulty or trouble walking

›New vomiting with a painful red eye

›Fever with eye pain or swelling

19References/r18

Guidelines and high quality sources

›American Academy of Ophthalmology Preferred Practice Pattern Retinal Detachment 2019 to 2023 update

›Diagnostic and referral urgency guidance

›Surgical timing considerations

›American Academy of Ophthalmology Preferred Practice Pattern Primary Angle Closure 2020

›Acute angle closure initial medical therapy principles

›Definitive therapy pathways

›AHA ASA Guideline for the Early Management of Acute Ischemic Stroke 2019 with updates

›Imaging and reperfusion workflow targets

›Secondary prevention framework

›AHA Scientific Statement on Central Retinal Artery Occlusion 2021

›CRAO as ischemic stroke equivalent concept

›Urgent vascular evaluation recommendations

›ACR Appropriateness Criteria Orbital Imaging 2023

›Modality selection for orbital infection and trauma

›CT versus MRI indications

›ACR EULAR classification and management guidance for giant cell arteritis 2022 local protocol dependent

›Steroid initiation principles for vision threat

›Diagnostic confirmation pathways

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.