Visual Loss (acute / Subacute)
Acute or subacute visual loss is a rapid decline in vision occurring over seconds to days (acute) or days to weeks (subacute), resulting from ocular, retinal, optic nerve, or central nervous system pathology requiring urgent evaluation.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Retinal vein occlusion (CRVO/BRVO) | Subacute painless ↓VA, "blood and thunder" fundus [2] | 「隻眼慢慢矇咗幾日？有冇痛？」 |
| Vitreous haemorrhage (from PDR) | DM + sudden painless ↓VA, worse in morning, floaters [6][7] | 「你有糖尿病？朝早起身係咪特別矇？」 | |
| Serious Not To Miss | Central retinal artery occlusion (CRAO) | Sudden painless complete ↓VA, RAPD+, cherry-red spot — ophthalmological emergency [1][2] | 「係唔係幾秒之內突然間乜都睇唔到？」 |
| Giant cell arteritis (GCA / temporal arteritis) | Age > 50, temporal headache, jaw claudication, ↑ESR/CRP, RAPD+ — sight-threatening, start steroids before biopsy [4][5] | 「太陽穴有冇痛？食嘢咬耐咗會唔會腮痠？」 | |
| Retinal detachment | Photopsia, floaters → progressive curtain-like field loss, painless [2] | 「有冇見到閃光？好似有塊窗簾慢慢落緊？」 | |
| Acute angle-closure glaucoma | Painful red eye, N/V, halos, mid-dilated fixed pupil, ↑IOP [2] | 「隻眼好痛、好紅？有冇作嘔？見到光圈？」 | |
| Stroke (occipital infarct) | Homonymous hemianopia, neurological deficits [3] | 「有冇半邊睇唔到？手腳有冇冇力？」 | |
| Pitfalls | Optic neuritis | Young female, painful eye movements, ↓colour vision, RAPD+, a/w MS [2][9] | 「郁隻眼嗰陣痛唔痛？分唔分到紅綠色？」 |
| Wet (exudative) AMD | Age > 60, subacute central scotoma, metamorphopsia on Amsler grid [10] | 「中間嗰度有冇歪咗或者有個黑點？」 | |
| Anterior ischaemic optic neuropathy (AION) | Age > 50, sudden painless altitudinal field loss, disc oedema; can be arteritic (GCA) or non-arteritic [2] | 「係咪上半或者下半嘅視野冇咗？」 | |
| Masquerades | DM complications (DR / vitreous haem) | Long-standing DM, poor control [6][7] | 「糖尿病控制得點？HbA1c幾多？」 |
| Drug-induced (ethambutol) | TB treatment, bilateral ↓VA, ↓colour vision [8] | 「有冇食肺癆藥？」 | |
| Methanol poisoning | "Snowstorm" vision, metabolic acidosis, ↑osmolal gap [11] | 「有冇飲過唔明嚟歷嘅酒或者化學品？」 | |
| Trying to Tell Me Something? | Anxiety / depression about going blind; functional visual loss | Excessive concern, inconsistent exam, secondary gain | 「你最擔心啲咩？怕唔怕盲咗？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好，我係X醫生，今日想了解吓你嘅情況，傾大概六分鐘，可以嗎？」("Hi, I'm Dr X, I'd like to understand your situation, about 6 mins, OK?") | Rapport, consent, signposting — scores interpersonal marks |
| 0:30–2:00 | HPI: onset, laterality, pain, pattern, severity, progression, associated Sx | 「隻眼幾時開始睇嘢矇咗？係一隻眼定兩隻？有冇痛？係突然間定慢慢嚟？中間定周圍嘅視野？有冇好似有塊窗簾噉遮住？」 | Defines acute vs subacute; unilateral vs bilateral; painful vs painless — critical for DDx |
| 2:00–3:00 | Red flags + targeted systems review | 「有冇頭痛？有冇太陽穴附近痛或者食嘢嗰陣腮骹痛？有冇手腳冇力或者講嘢唔清楚？有冇眼前有閃光或者好多飛蚊？有冇嘔？」 | Screens GCA (temporal headache, jaw claudication), stroke, retinal detachment, acute glaucoma |
| 3:00–3:45 | PMHx, DHx, allergy, FHx, social Hx | 「你本身有冇糖尿病、高血壓、心臟病？食緊咩藥？有冇藥物敏感？屋企人有冇青光眼或者中風？你有冇食煙飲酒？」 | Identifies CV risk factors, DM (DR), drug causes (ethambutol), glaucoma FHx |
| 3:45–4:30 | ICE — uncover hidden agenda | 「你自己覺得可能係咩原因？你最擔心嘅係咩？（怕唔怕盲？）你今日過嚟最希望醫生幫你做啲咩？」 | Directly scores ICE marks; reveals hidden concern (fear of blindness, cancer, stroke) |
| 4:30–5:15 | Functional impact + psychosocial | 「依家對你返工、揸車或者日常生活有冇影響？心情點呀？有冇家人可以幫到你？」 | Scores biopsychosocial problem identification |
| 5:15–5:45 | Summarise back to patient | 「等我總結吓：你話右眼突然間睇唔到嘢已經兩日，冇痛，本身有糖尿病……係咪咁？」 | Shows active listening, checks understanding |
| 5:45–6:00 | Safety-net and close | 「如果你嘅視力突然差咗、或者出現頭痛嘔吐，一定要即刻去急症。今日我會轉介你俾眼科跟進。有冇嘢想問？」 | Safe closure, urgent referral arranged, invitation for questions |
Hidden agenda tip: Ask 「點解揀咗今日嚟睇？」 — the patient may have tolerated symptoms for days but came today because of a specific trigger (e.g., can't drive, scared after googling stroke, relative went blind from similar).
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset & tempo | Was it sudden (seconds-minutes) or over days? | 「係一下子睇唔到，定係幾日慢慢矇咗？」 | Acute (seconds) → vascular (CRAO, RD); subacute (days) → optic neuritis, wet AMD [1][2] | CRAO, RVO, optic neuritis |
| Laterality | One eye or both? | 「係一隻眼定兩隻？你有冇試遮住一隻眼分別試吓？」 | Unilateral → ocular cause; bilateral → neurological/chiasm [3] | Bilateral occipital infarct, pituitary apoplexy |
| Pain | Any eye pain? Pain on eye movement? | 「隻眼有冇痛？郁眼嗰陣痛唔痛？」 | Painful → optic neuritis (pain on movement), acute glaucoma, scleritis [2] | Optic neuritis, AACG |
| Visual field pattern | Central blur or peripheral curtain? | 「係中間矇定好似有塊窗簾遮住咗？」 | Central scotoma → macular/optic nerve; curtain → retinal detachment [2] | Wet AMD, RD |
| Transient episodes | Any brief episodes of vision going dark before? | 「之前有冇試過隻眼突然黑咗幾秒再返嚟？」 | Amaurosis fugax → carotid disease / GCA [1][3] | TIA / GCA |
| Flashes & floaters | Any flashing lights or new floaters? | 「有冇見到閃光或者好多飛蚊？」 | Photopsia + floaters → vitreous detachment / retinal tear [2] | Retinal detachment |
| Red flags: GCA | Temporal headache? Jaw pain when chewing? Scalp tenderness? | 「太陽穴附近有冇痛？食嘢咬嗰陣腮骹有冇攰或者痛？頭皮有冇痛？」 | GCA → urgent steroids to prevent permanent blindness [4][5] | Giant cell arteritis |
| Red flags: neuro | Limb weakness, speech difficulty, numbness? | 「手腳有冇冇力？講嘢有冇唔清楚？」 | Stroke with visual field defect | Occipital CVA |
| N/V + halos | Nausea/vomiting? Seeing halos around lights? | 「有冇嘔？有冇見到光圈？」 | N/V + halos + painful red eye → acute angle-closure glaucoma [2] | AACG |
| DM Hx | Do you have diabetes? How long? Last eye check? | 「你有冇糖尿病？幾耐？上次驗眼幾時？」 | Vitreous haemorrhage from PDR; diabetic macular oedema [6][7] | Vitreous haemorrhage |
| CV risk factors | HTN? High cholesterol? Smoking? AF? | 「有冇高血壓、高膽固醇？有冇食煙？心跳有冇唔齊？」 | Risk for retinal vascular occlusion, carotid disease [1] | CRAO, CRVO |
| Drug Hx | Any TB medications (ethambutol)? Steroids? | 「有冇食肺癆藥？有冇食類固醇？」 | Ethambutol → toxic optic neuropathy [8] | Toxic ON |
| FHx | Family history of glaucoma or blindness? | 「屋企人有冇青光眼或者眼盲？」 | Glaucoma risk | AACG, POAG |
| Functional impact | Can you still read, drive, cook? | 「你依家仲睇唔睇到字？可唔可以煮飯、揸車？」 | Documents severity for biopsychosocial | ADL impairment |
| Psychological | Feeling worried or low in mood? | 「你心情點？有冇瞓得差咗？」 | Visual loss → anxiety, depression | Psych comorbidity |
| Occupation | What is your job? Any chemical exposure? | 「你做咩工作？有冇接觸化學品？」 | Methanol, occupational hazard | Toxic ON |
Case Report Form Answer Builder
Template: "[Age] [sex] presenting with [acute/subacute] [painless/painful] visual loss in [R/L/both] eye(s) for [duration]."
High-yield points to capture:
- Onset (sudden vs over days), laterality, pain (± with eye movement), visual field pattern (central vs peripheral vs total), progression, associated symptoms (flashes, floaters, headache, jaw claudication, N/V, neurological deficits)
- PMHx: DM, HTN, AF, hyperlipidaemia, autoimmune disease
- Medications, smoking, occupation
| Likely RFC Examples | Best Phrasing |
|---|---|
| Unable to see → worried about blindness | "Acute painless visual loss affecting daily function, patient seeks diagnosis and treatment" |
| Prompted by inability to work/drive | "Sudden loss of vision in right eye interfering with work, wants urgent assessment" |
Phrase the RFC as what drove the patient to come today — often fear of permanent blindness or functional incapacity.
| Component | Likely Patient Wording | Example Written Answer |
|---|---|---|
| Ideas | "Maybe a stroke" or "My diabetes is causing it" | "Patient thinks the visual loss is related to her diabetes / worried it could be a stroke" |
| Concerns | Fear of going permanently blind; losing independence | "Patient is concerned about permanent blindness and losing her ability to live independently" |
| Expectations | Wants specialist referral, scan, or treatment | "Patient expects urgent referral to an eye specialist and investigation to find the cause" |
Choose based on the stem:
- Painful + young + eye movement pain → Optic neuritis
- Painless + sudden + DM → Vitreous haemorrhage (PDR)
- Painless + sudden + CV risk factors → CRAO or CRVO
- Painless + subacute + central scotoma + elderly → Wet AMD
- Elderly + temporal headache + jaw claudication → GCA-related AION
Minimum supporting evidence: onset pattern + pain status + laterality + key risk factor + one expected sign (e.g., RAPD, cherry-red spot, blood-and-thunder fundus)
| DDx | One Key Discriminator |
|---|---|
| Central retinal artery occlusion (CRAO) | Sudden complete painless ↓VA, RAPD+, cherry-red spot on fundoscopy |
| Giant cell arteritis (arteritic AION) | Age > 50, temporal headache, jaw claudication, ↑ESR > 50, tender temporal artery |
| Retinal detachment | Preceding flashes + floaters → progressive painless curtain-like VF loss |
(Adjust based on the actual case stem — swap in optic neuritis, AACG, or wet AMD as appropriate.)
| Domain | Problem |
|---|---|
| Biological | Acute visual loss with risk of permanent vision impairment; underlying uncontrolled DM/HTN |
| Psychological | Anxiety and fear of blindness; possible depression from loss of independence |
| Social / Functional | Inability to work / drive / perform ADLs; burden on family carers; social isolation |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| CRAO | Cherry-red spot on fundoscopy | Direct ophthalmoscopy — pale/milky retina with central red fovea | Retinal ischaemia → oedematous pale retina; fovea appears red as choroidal circulation shows through [1][2] |
| CRVO | "Blood and thunder" fundus | Direct ophthalmoscopy — widespread flame haemorrhages, dilated tortuous veins, disc swelling | Venous congestion → diffuse retinal haemorrhage [2] |
| GCA / arteritic AION | Tender, non-pulsatile, thickened temporal artery | Palpate temporal artery — feel for tenderness, thickening, absent pulse | Inflammation of temporal artery; absent pulse = vessel occlusion [4][5] |
| Retinal detachment | Elevated retina with folds on fundoscopy; ↓ or absent red reflex | Direct ophthalmoscopy — grey/elevated retina with folding; check red reflex | Detached retina loses normal red appearance [2] |
| Optic neuritis | RAPD (relative afferent pupillary defect) by swinging flashlight test | Swing flashlight between eyes: affected eye pupil dilates when light shone on it | Demonstrates optic nerve conduction deficit [2][9] |
| AACG | Mid-dilated, fixed pupil; ↑IOP on tonometry; shallow anterior chamber | Pen torch: mid-dilated oval pupil, non-reactive; slit lamp: shallow AC | Elevated IOP → iris sphincter ischaemia → fixed pupil [2] |
| Wet AMD | Metamorphopsia on Amsler grid; macular haemorrhage/exudate on fundoscopy | Hold Amsler grid at 33 cm — ask if lines look wavy or distorted | Subretinal neovascular membrane distorts macular photoreceptors [10] |
| Vitreous haemorrhage | Loss of red reflex; unable to visualise fundus | Direct ophthalmoscopy — absent/diminished red reflex; dark vitreous | Blood in vitreous obscures retinal view [6][7] |
Top Traps That Lose Marks
- Forgetting to ask about GCA in any patient ≥ 50 with acute visual loss — jaw claudication and temporal headache are pathognomonic and GCA is the diagnosis you must not miss because delayed steroids = permanent blindness [4][5].
- Not distinguishing painful vs painless — this is the single most important branch point. Painful = optic neuritis / AACG / scleritis. Painless = vascular / RD / vitreous haemorrhage.
- Writing "blurred vision" as chief complaint instead of "acute visual loss" — be specific about tempo and severity.
- Forgetting RAPD — it is the single best physical sign to demonstrate optic nerve involvement in a brief FM station (optic neuritis, CRAO, GCA-related AION) [9].
- Missing the ICE — students often rush through the history and forget to ask the patient's fears (usually: "Will I go blind?").
- Not asking about preceding flashes/floaters — misses retinal detachment.
- Not checking medications — ethambutol for TB is a classic exam pitfall for bilateral subacute visual loss [8].
Must-Not-Miss Red Flags → Urgent Referral
- Sudden painless complete visual loss → CRAO → ophthalmic emergency (within 90–120 min window) [1]
- Age ≥ 50 + headache + jaw claudication + ↑ESR → GCA → start high-dose IV methylprednisolone BEFORE temporal artery biopsy [4][5]
- Flashes + floaters + curtain VF loss → retinal detachment → same-day ophthalmology referral [2]
- Painful red eye + N/V + halos + ↑IOP → AACG → emergency IOP-lowering [2]
- Any acute visual loss with neurological deficits → stroke → CT brain, activate stroke pathway
Shortest safe management/safety-net line for closing:
「如果你嘅視力再差咗、或者出現嚴重頭痛、嘔吐、手腳冇力，一定要即刻去急症室。我今日會幫你安排即日轉介眼科跟進。」
High Yield Summary
What to ASK: Onset tempo (sudden vs days), laterality, pain (± with eye movement), VF pattern, flashes/floaters, GCA triad (temporal HA, jaw claudication, scalp tenderness), neuro deficits, DM/HTN/AF, medications (ethambutol), ICE.
What to WRITE: Precise chief complaint with onset/laterality/pain; one RFC tied to the patient's real concern; ICE explicitly; most likely Dx with supporting evidence (RAPD, fundus finding); three DDx with discriminators; biopsychosocial triad.
What NOT to MISS: GCA in anyone ≥ 50 (start steroids before biopsy); CRAO is a time-critical emergency; retinal detachment needs same-day referral; RAPD is your best bedside sign; always ask about pain on eye movement (optic neuritis) and flashes/floaters (retinal detachment).
Active Recall - Family Medicine Clinical Test
[1] GC 121. Acute Visual Loss.pdf [2] Ryan Ho Opthalmology.pdf (Pages 4, 40, 43, 54, 91–92) [3] Ryan Ho Neurology.pdf (Page 11); Ryan Ho Fundamentals.pdf (Page 89) [4] Block A - Rheumatology Interactive Tutorial.pdf (Case 1 — GCA/PMR) [5] AOS - Ophthalmology.pdf (Scenario 1, Patient 2 — RAPD + disc abnormality) [6] Ryan Ho Endocrine.pdf (Page 96 — DR classification) [7] Block A - Deterioration of eyesight in a diabetic patient_ diabetic complications.pdf [8] Gen Clerk Anaes + Microbiology Summary.pdf (Page 41 — ethambutol optic neuritis) [9] 2024 General Clerkship - Acute Visual Loss_Student Copy.pdf [10] GC 122. Chronic Visual Loss.pdf (Page 29 — wet AMD, Amsler grid, metamorphopsia) [11] Ryan Ho Chemical Path.pdf (Page 41 — methanol poisoning, "snowstorm" vision)
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