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
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
