Acute visual loss & retinal arterial occlusion
At a glance
Sudden visual loss is a symptom requiring immediate localisation and triage. Retinal arterial occlusion can represent an acute vascular emergency.
CAVE
- In older adults ask about new headache, scalp tenderness, jaw claudication and systemic symptoms suggesting giant cell arteritis.
Clinical presentation
- Establish monocular versus binocular loss, exact last-known-well time, pain, field pattern and neurological symptoms.
Diagnosis & investigations
- Record onset and last known well, monocular versus binocular involvement, pain, transient versus persistent loss, trauma and recent surgery/injection. Check each eye: acuity/pinhole, pupils and RAPD, confrontation fields, colour/red desaturation, ocular motility, anterior segment and fundus. Measure IOP unless open-globe injury is suspected.
- Use the pattern below to select the immediate pathway. A normal-looking fundus does not exclude retrobulbar optic neuropathy or cerebral disease. Pain on movement with dyschromatopsia and RAPD suggests optic neuritis, but atypical, bilateral or severe presentations need urgent neuro-ophthalmic assessment.
| Finding | Action | Timing / detail |
|---|---|---|
| Sudden painless monocular loss, persistent or transient | Suspect retinal/ophthalmic artery ischaemia: immediate emergency stroke assessment, even if vision has recovered | Record last known well; ocular examination must not delay transfer |
| Age >50, new headache, jaw claudication, scalp tenderness or systemic symptoms, with visual disturbance | Suspect giant cell arteritis: immediate hospital assessment and systemic glucocorticoids; threatened vision favours IV pulse treatment | Obtain CBC/platelets, ESR and CRP if this does not delay treatment; ultrasound/biopsy must not postpone it |
| Painful red eye, haloes or nausea | Measure IOP and examine cornea/anterior chamber: acute angle closure, keratitis or uveitis | Immediate ophthalmic assessment; no empirical steroid before excluding infection |
| Curtain, flashes, new floaters or obscured red reflex | Exclude retinal detachment and vitreous haemorrhage with a dilated peripheral examination; ultrasound if needed | Same-day retinal assessment; ultrasound cannot reliably exclude every small tear |
| Homonymous field loss, neurological deficit or sudden binocular loss | Emergency neurological/stroke assessment; examine each eye separately to avoid mislocalisation | Do not label a first atypical episode as migraine before excluding vascular disease |
Differential diagnosis
- Arterial occlusion, optic neuropathy, retinal detachment, vitreous haemorrhage, angle closure and cerebral visual loss.
Treatment
- For suspected retinal arterial occlusion, activate the stroke pathway immediately; reperfusion eligibility is determined by the stroke team. Ocular massage and anterior chamber paracentesis have no established visual benefit and must not delay transfer.
- For suspected giant cell arteritis with threatened vision, start urgent systemic glucocorticoid treatment through the emergency team without waiting for confirmatory tests. Normal inflammatory markers do not by themselves exclude the diagnosis.
Follow-up
- Coordinate ophthalmic and systemic follow-up, vascular prevention and visual rehabilitation according to the final diagnosis.
Risk factors & context
- Ask about vascular disease, atrial fibrillation, recent procedures and giant cell arteritis symptoms.
- The absence of known risk factors does not exclude acute retinal ischaemia.
Complications
- Permanent visual loss and associated systemic vascular events.
- Arteritic disease may threaten the fellow eye; emergency systemic care has priority.
When to refer
- Emergency assessment now for ongoing sudden visual loss or associated neurological symptoms.
References 6
- AAO · Retinal and Ophthalmic Artery Occlusions Preferred Practice Pattern ↗2025 · Highlighted recommendations; diagnosis; systemic evaluation
- AAO · Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern ↗2025 · Initial evaluation; management; follow-up
- European Glaucoma Society · Terminology and Guidelines for Glaucoma ↗6th edition · 2025 · Clinical examination; classification; treatment principles
- AHA · Management of Central Retinal Artery Occlusion ↗2021 scientific statement · Emergency stroke triage; conservative interventions
- ACR / Vasculitis Foundation · Giant Cell Arteritis and Takayasu Arteritis ↗2021 guideline · Threatened vision; immediate glucocorticoid treatment; diagnostic testing
- NICE · Multiple sclerosis in adults: management ↗NG220 · updated 3 June 2026 · 1.1.9–1.1.10: optic neuritis and specialist assessment
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