Persistent Monocular Vision Loss

    • Enduring visual loss affecting only one eye
    • Common causes
      • Optical disorder
      • Retinopathy
      • Optic neuropathy
      • Amblyopia
      • Psychogenic ("non-organic") disorder
    • Consider these clues to diagnosis
      • Vision impaired for distance viewing but preserved for reading = uncorrected myopia
      • Ghost image = optical (refractive or ocular media) disorder
      • Reduced vision dating from early childhood in the setting of ocular misalignment, anisometropia, ptosis, congenital corneal or lens opacity = amblyopia
      • Specks that lag behind eye movement (floaters) = vitreous detachment or other vitreous debris
      • Black areas that do not lag behind eye movement = retinopathy
      • Blank areas in the visual fields ("scotomas") = retinopathy, optic neuropathy
      • Sparkling vision (if monocular) = retinopathy
    • Double vision (diplopia), but exclude this by finding that the symptom is eliminated by covering either eye
    • Follow These Steps
      • Step 1: measure visual acuity
      • Step 2: perform the pinhole examination; if it improves visual acuity, consider a diagnosis of uncorrected refractive error or corneal or lens opacity
      • Step 3: perform refraction and biomicroscopy to confirm an optical disorder; if you do not find an optical disorder…
      • Step 4: perform the swinging flashlight pupil test to look for a relative afferent pupil defect, which would suggest an optic neuropathy or extensive retinopathy; if you do not find an afferent pupil defect…
      • Step 5: perform appropriate tests to exclude amblyopia, including detection of ocular misalignment, anisometropia, ptosis, or a congenital corneal or lens opacity; if you have excluded amblyopia…
      • Step 6: perform ophthalmoscopy to exclude retinal or optic nerve abnormalities; if the diagnosis still remains uncertain…
      • Step 7: perform formal visual field examination to detect patterns of visual loss that suggest visual pathway lesions (See Visual Fields Examination ); if the diagnosis still remains uncertain…
      • Step 8: perform ancillary studies such as optical coherence tomography (OCT), fluorescein angiography, ultrasonography, electroretinography (ERG), orbit/brain imaging
    • Most organic causes of persistent monocular visual loss should be revealed with appropriate office testing, although ancillary studies may be necessary
    • Early diagnosis may be important to improve outcomes

    Persistent Vision Loss

    Persistent Monocular Vision Loss Persistent Binocular Vision Loss