POTD: Painless Visual Loss


  • CRAO: Occlusion of the main artery that supplies the retina or its branches (BRAO); typically due to an embolus from proximal atherosclerotic disease

  • CRVO: Occlusion of the main veins draining the retina; results in secondary hemorrhage and ischemia

Risk Factors: Older age, Vasculopathy


  • Sudden painless monocular vision loss or partial loss

  • Can be transient, stuttering, or permanent


  • Classic fundoscopy findings of CRAO: pale retina with a cherry red spot over the macula as a result of ischemia and edema

  • Classic fundoscopic finding of CRVO: blood and thunder

  • Fundoscopic findings may be subtle in:

    • Pts who present early

    • Pts with intermittent symptoms

    • Pts with branched retinal artery occlusions (BRAO)


  • Most therapies that have been studied are not very effective

  • Eyeball massage and globe paracentesis are sometimes used for CRAO

  • Intra-arterial tPA has also been used for CRAO

>> Retinal Detachment


  • May occur as a result of trauma, but the majority of cases are spontaneous

  • Typically preceded by posterior vitreous detachment (PVD)

    • As the vitreous humor dehydrates and shrinks with age, it can detach from retina

    • The resulting traction on the retina then puts the pt at risk for retinal detachment 

  • The symptoms of PVD are primarily floaters and flashers

  • Most cases of PVD are self-limited

    • However, the risk of progression to retinal detachment is high in the days and weeks following the initial symptoms

  • Can be difficult to distinguish PVD from early retinal detachment!

    • Unless symptoms are chronic and unchanging, consider retinal detachment when pts present acutely with flashers and floaters

Risk factors: Older age, Severe myopia (nearsightedness), Glaucoma, Cataract surgery, Diabetic retinopathy


  • Early warning sign is acute onset of flashers and floaters

  • Curtains moving across visual field

  • Visual field cuts

  • Painless monocular vision loss


  • Visual acuity may be completely normal if early; it is important to test visual fields

  • An advanced detachment can be seen with direct fundoscopy


  • Macula on: vision is preserved; emergent surgery may halt progression and preserve vision

  • Macula off (the macula has detached): severe vision loss in central visual field

  • Presumed retinal detachment requires emergent Ophthalmologic evaluation to preserve the pt's vision!

>> Vitreous Hemorrhage

Risk factors: Diabetes, Hypertension, Vasculopathy


  • Sudden or staggered loss of monocular vision

  • May present similarly to PVD or RD

  • May also present as blurry vision


  • Decreased red reflex; may be difficult to see fundus

  • Ultrasound is very effective at identifying blood in the vitreous!


  • Pts may follow up urgently in Ophthalmology clinic for treatment

  • Return precautions for worsening symptoms/pain

  • Anticoagulation is generally not discontinued