monocular vision loss--call opth first or neuro first?

[unchartedem]

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If I have a patient with monocular vision loss then both a possible retinal artery occlusion is just as emergent as an acute CVA in my opinion. If I have a patient who presents to the ED within 3 hours with monocular vision loss, no other neuro findings, would you guys call a stroke code first before opthamology? I know that an occipital infarct presenting as single vision loss would be very rare without any other exam findings but I wanted to know your thoughts? I'm also horrible at a fundoscopic exam so making my own diagnosis is out of the question.

 

[WilcoWorld]

Monocular = prechiasmal = not a neuro emergency.

I quickly assess for other neuro complaints (ROS) and localize to a single eye by having them close each eye and confirming that the unaffected side is really unaffected. If after that I still think it's isolated monocular vision loss then we're talking about ocular emergencies (or neuro non-emergencies) so there's no need to call a code stroke.

 

[Rendar5]

If I have a patient with monocular vision loss then both a possible retinal artery occlusion is just as emergent as an acute CVA in my opinion. If I have a patient who presents to the ED within 3 hours with monocular vision loss, no other neuro findings, would you guys call a stroke code first before opthamology? I know that an occipital infarct presenting as single vision loss would be very rare without any other exam findings but I wanted to know your thoughts? I'm also horrible at a fundoscopic exam so making my own diagnosis is out of the question.

Well, first, it doesn't matter if you're bad at fundoscopic exams, you need to do them until you get at least so-so. Regardless, acute CVA doesn't typically cause monocular vision loss without other symptoms. If your'e referring to Amarosis Fugax as a TIA, that's still typically to the ophthalmic or retinal artery. So even if you're considering a "neurologic' cause of acute vision loss, ophtho is the way to go.

 

[neusu]

If I have a patient with monocular vision loss then both a possible retinal artery occlusion is just as emergent as an acute CVA in my opinion. If I have a patient who presents to the ED within 3 hours with monocular vision loss, no other neuro findings, would you guys call a stroke code first before opthamology? I know that an occipital infarct presenting as single vision loss would be very rare without any other exam findings but I wanted to know your thoughts? I'm also horrible at a fundoscopic exam so making my own diagnosis is out of the question.

Occipital infarct would present with a contralateral homonymous hemianopsia. Monocular blindness is proximal to the chiasm, causes include: trauma, amaurosis fugax, corneal ulceration, occular infarction, migraine, optic neuritis, temporal arteritis, and others. Generally, if retinal artery occlusion is suspected ophthalmology is the best first call. Once the situation is stabilized, however, a ipsilateral carotid duplex (or CTA/MRA if you can) and cardiac echo would help identify a source.

 

[Groove]

Good question and good responses. I'd call optho first from what you've described.