Sudden visual loss - emergency department approach
Overview
Sudden visual loss is a potentially sight‑threatening emergency. The ED clinician’s priorities are rapid localisation (pre‑chiasmal/ocular vs post‑chiasmal/cortical), recognition of red flags that require immediate treatment or specialist pathways, focused bedside assessment, and prompt referral.
Time‑sensitive presentations include central retinal artery occlusion (CRAO), suspected giant cell arteritis (GCA)/arteritic anterior ischaemic optic neuropathy (AION), acute angle‑closure glaucoma (AACG) and retinal detachment.
Transient monocular visual loss (amaurosis fugax) should be managed as a possible TIA and escalated via the stroke/TIA pathway (NICE NG128).
Triage and initial priorities
- Treat all new, unexplained acute visual loss as urgent and arrange early senior review and ophthalmology input, or stroke/neurology review where indicated.
- Rapidly determine laterality: monocular (pre‑chiasmal: globe, retina, optic nerve) versus binocular/homonymous (post‑chiasmal/cortical).
- Rapidly determine onset and course: sudden maximal loss (seconds-minutes), progressive over days, or transient.
- Screen for red‑flag symptoms: pain, redness, flashes/floaters, curtain/field defect, associated headache or focal neurology, jaw claudication or scalp tenderness, and recent vascular events.
- Review medications specifically for agents linked to visual loss (for example, ask about GLP‑1 agonists such as semaglutide given the MHRA alert linking it to rare NAION).
- Activate the appropriate pathway without delay: use the stroke/TIA pathway for suspected amaurosis fugax (NICE NG128) and start immediate high‑dose glucocorticoids with urgent specialist review for suspected GCA/AION (NICE...