What Causes Sudden Vision Loss?

Patient Presentation
A 16-year-old female was admitted for evaluation of sudden visual loss in her right eye. She had gone to sleep and awoken without being able to see in her right eye including no light or movement. Her vision in her left eye was normal. She denied any pain or floaters in either eye. She had been well without fever, nausea, emesis, rhinorrhea, or cough. She also denied any head or neck trauma or neurological problems including slower mentation, speaking, difficulty with movements or gait.

The past medical history was positive for migraine with and without visual auras that begin 2 years before and occurred 3-4 times/year, and a generalized anxiety disorder that was treated with medication and therapy. The maternal family history was positive for Factor V Leiden and also Protein C deficiency, a maternal aunt who was being evaluated for an unknown neurological problem where she was having a problem with her hands and some walking, and a paternal cousin who had survived a brain tumor. The social history revealed that she was under a great deal of stress because of school, and peer interactions that had including physical fighting 3 days before.

The pertinent physical exam showed a scared teenager who had been crying. Her vital signs and growth parameters were normal. HEENT was normal and atraumatic. Her eyes appeared normal but looked like she had been crying. Her pupils were PERRLA. She had normal extra-ocular movements. Her visual acuity was 20/30 on the left and with both eyes. She denied being able to see with the right eye. Bilaterally, she did close her eyes appropriately with movement of a hand toward the eye. Corneal reflexes were normally bilaterally. She had a normal neurological examination including cranial nerves, rapid alternating movements, gait and balance. Her mini-mental status examination was normal except she was very anxious about her vision, and also talked about all the stress she felt she was currently under.

The diagnosis of sudden vision loss without pain and a normal neurological examination was made. She had been admitted from the emergency room where a radiologic evaluation of a computed tomogram of the head showed no space occupying lesion or intracranial bleeding. Ophthalmology had been called. The residents discussed the differential diagnosis including a globe problem itself, potential thrombus because of the maternal history of thrombophilias, neurological disease such as multiple sclerosis was considered much less likely, migraine and acute anxiety with conversion disorder or potentially factitious disorder was considered more likely given the negative workup and physical examination at the time. The planned work-up was to include testing for thrombophilias and after ophthalmology had seen her, the plan was to be re-evaluated their input and possibly would include more imaging and neurological and/or psychiatric consultations.

Vision loss, whether chronic or acute, is distressing at any time for patients and families. Prompt evaluation and treatment are important as maintenance of any acuity and light or movement is considered paramount. Most vision loss is due to chronic problems and aging issues but the differential diagnosis is broad. For any age, but especially children, uncorrected refractive errors can cause problems in not only in childhood but throughout someone’s lifetime.

Visual impairment for distance vision is considered mild if worse than 6/12 in meters = 20/40 in feet or 0.3 LogMAR and for moderate impairment is 6/18 meters = ~20/60 = ~0.6 LogMAR. LogMAR stands for the Logarithm of the Minimum Angle of Resolution and is considered more accurate than other charts. Near vision is considered impaired if acuity is worse than N6 or N8 at 40 cm with existing correction. N numbers are the size of the letters on the handheld card.

Examples of some visual acuity scale equivalents

Foot 20/16 20/20 20/32 20/40 20/63 20/80 20/100
Meter 6/4.8 6/6 6/9.5 6/12 6/19 6/24 5/30
LogMAR -0.1 0.0 0.2 0.3 0.5 0.6 0.7

Learning Point
Sudden vision loss is most commonly due to an acute event that has an obvious cause such as trauma, stroke, or seizure. Others can be less obvious such as a migraine or slow-growing tumor. Psychiatric causes can be more difficult to evaluate and tease out from other causes. Common presentations of factitious disorder can be found here.

The differential diagnosis of sudden vision loss includes:

  • Trauma
    • Globe injury
    • Hyphema
    • Corneal injury
    • Retinal detachment
  • Tumor
    • Brain
    • Eye
    • Adjacent structures such as sinuses
  • Infectious
    • Optic neuritis
    • Septal cellulitis
    • Sinusitis
  • Neurovascular
    • Cerebrovascular accident
    • Thrombus
    • Increased intracerebral pressure
    • Multiple sclerosis
    • Transient
      • Concussion
      • Seizure
      • Migraine
  • Psychiatric
    • Conversion disorder
    • Factitious disorder or malingering

Questions for Further Discussion
1. What is the difference between factitious disorder, conversion disorder and malingering?
2. What are some inherited thrombophilias? A review can be found here

3. How are septal and preseptal cellulitis managed?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vision Impairment and Blindness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Solebo AL, Teoh L, Rahi J. Epidemiology of blindness in children. Arch Dis Child. 2017;102(9):853-857. doi:10.1136/archdischild-2016-310532

Irwin W, Kienstra A, Vezzetti R. Sudden Unilateral Vision Loss in a Teenage Girl. Pediatrics In Review. 2021;42(Supplement_1):S112-S116. doi:10.1542/pir.2019-0110

Flaxman AD, Wittenborn JS, Robalik T, et al. Prevalence of Visual Acuity Loss or Blindness in the US. JAMA Ophthalmol. 2021;139(7):717-723. doi:10.1001/jamaophthalmol.2021.0527

Karlica Utrobicic D, Karlica H, Ljubic Z, Kusevic Z. Visual Evoked Potentials in Evaluating Sudden Visual Loss in Adolescents: A Psychosomatic Perspective. Psychiatr Danub. 2021;33(Suppl 4):674-675.

The Lancet Child Adolescent Health. Vision for the future. Lancet Child Adolesc Health. 2021;5(3):155. doi:10.1016/S2352-4642(21)00029-8

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa