Last reviewed: March 2026
Contents
MDM Templates
Posterior Vitreous Detachment / Floaters
Patient presents with new floaters and/or flashes of light without significant vision loss. Visual acuity is preserved. No visual field deficit by confrontation. No afferent pupillary defect. Eye is painless.
Presentation most consistent with posterior vitreous detachment (PVD). Given painless visual symptoms I have also considered retinal detachment, vitreous hemorrhage, and retinal tear. The absence of a visual field cut, shower of floaters, or curtain/veil over the vision lowers but does not eliminate concern for retinal pathology.
Plan: Bedside ocular ultrasound performed — no retinal detachment identified.
Ophthalmology consulted regarding need for dilated fundoscopic exam and follow-up interval.
Disposition: Discharge with ophthalmology follow-up within 24–48 hours for dilated exam. Return precautions for increasing floaters, flashes, visual field loss (“curtain” or “shadow”), or worsening vision.
Retinal Detachment Concern
Patient presents with acute onset of floaters, photopsias (flashes), and/or peripheral visual field loss described as a curtain or shadow. Visual acuity may be reduced depending on macular involvement.
Presentation concerning for retinal detachment versus vitreous hemorrhage versus retinal tear. Bedside ocular ultrasound performed.
Plan: Bedside ocular ultrasound demonstrates ***.
Ophthalmology consulted emergently regarding exam findings, ultrasound results, and disposition. Definitive diagnosis requires dilated fundoscopic exam.
Disposition: Per ophthalmology. Macula-on detachment is a surgical emergency (within 24 hours). Macula-off detachment is urgent (within 1–2 days).
Central Retinal Artery Occlusion (CRAO)
Patient presents with sudden, painless, monocular vision loss. Visual acuity is severely reduced. Afferent pupillary defect (APD) present. No pain, no redness, no photophobia.
Presentation most consistent with CRAO — the ocular equivalent of an acute ischemic stroke. Given sudden painless vision loss I have also considered CRVO, retinal detachment, vitreous hemorrhage, and optic neuropathy.
Plan: Emergent ophthalmology consultation. Digital ocular massage performed (intermittent firm pressure for 10–15 seconds, release for 5 seconds, repeat). Timolol 0.5% 1 drop to affected eye to decrease IOP. ECG obtained. Labs including CBC, BMP, ESR, CRP (GCA screening if age >50).
If age <50: workup for hypercoagulability, vasculitis, and cardiac source of embolism.
Ophthalmology and neurology consulted regarding thrombolytic candidacy, further vascular workup, and disposition.
Disposition: Admit for stroke-equivalent workup and management.
Central Retinal Vein Occlusion (CRVO)
Patient presents with subacute painless monocular vision loss or blurring. Visual acuity is moderately reduced. APD may be present in severe cases. No pain, no redness.
Presentation most consistent with CRVO. Given painless vision loss I have also considered CRAO, retinal detachment, and vitreous hemorrhage. CRVO is distinguished from CRAO by a less dramatic onset and the fundoscopic finding of diffuse retinal hemorrhages (“blood and thunder” appearance).
Plan: Ophthalmology consulted regarding diagnosis confirmation, anti-VEGF candidacy, and follow-up. Blood pressure checked and managed. Labs including CBC, BMP, glucose, HbA1c to identify vascular risk factors.
Disposition: Discharge with urgent ophthalmology follow-up within 1–2 days. Blood pressure optimization with PCP.
Amaurosis Fugax
Patient presents with a transient episode of painless monocular vision loss that has now resolved. Visual acuity is at baseline on exam. Pupils are equal and reactive. Fundoscopic exam and ocular ultrasound are unremarkable.
Amaurosis fugax is a transient ischemic attack of the retinal circulation — a stroke warning. History and exam reassure against retinal detachment and other structural causes of vision loss given full recovery and normal exam.
Plan: CTA head and neck (carotid stenosis evaluation). ECG. Labs including CBC, lipid panel, glucose, HbA1c. ABCD2 score calculated for stroke risk stratification.
If significant carotid stenosis identified: vascular surgery or neurology consultation.
Disposition: Admit or fast-track outpatient TIA workup depending on risk stratification and imaging results. Antiplatelet therapy initiated.
Clinical Education
Approach to Painless Vision Loss
Painless vision loss is vascular or structural until proven otherwise. The key branch point: is this transient or persistent? Transient monocular vision loss (amaurosis fugax) is a TIA and demands vascular workup. Persistent painless vision loss = retinal artery occlusion, retinal vein occlusion, retinal detachment, vitreous hemorrhage, or optic neuropathy.[1]
The APD (afferent pupillary defect) is the most important exam finding. Use the swinging flashlight test. A positive APD in the affected eye localizes the problem to the retina or optic nerve (not the lens, cornea, or vitreous). Present in CRAO, severe CRVO, retinal detachment with macular involvement, and optic neuritis.[1]
PVD vs Retinal Detachment
PVD is common and usually benign — but 10–15% of symptomatic PVDs have an associated retinal tear. The vitreous gel separates from the retina with age, causing new floaters and flashes. The danger is that a retinal tear at the point of separation can progress to retinal detachment. This is why all new PVD presentations need dilated fundoscopy by ophthalmology, even if the ED ultrasound looks reassuring.[2]
The “3 Fs” that raise concern for detachment: increasing Floaters (especially a “shower” of new floaters), Flashes (photopsias from retinal traction), and Field loss (curtain or shadow in the peripheral vision). Any field loss suggests detachment until proven otherwise.
Ocular POCUS
ED ocular ultrasound has excellent sensitivity for retinal detachment (97–100% in studies). Use a high-frequency linear probe, apply generous gel, and scan through the closed eyelid with minimal pressure. Retinal detachment appears as a hyperechoic membrane tethered to the optic disc that moves with eye movement. Vitreous hemorrhage appears as echogenic debris floating in the vitreous cavity. PVD shows a thin membrane floating freely in the vitreous, NOT anchored to the disc.[3]
Caveat: ultrasound is not sensitive for retinal tears (the precursor to detachment). A negative ultrasound does not rule out a tear — ophthalmology still needs to do a dilated exam.
CRAO Pearls
Think of CRAO as “stroke of the eye.” The retina tolerates ischemia for about 90–100 minutes before irreversible damage occurs, analogous to brain tissue. Treatment is time-sensitive but evidence for any specific intervention remains weak. Digital ocular massage (to dislodge the embolus) and IOP-lowering agents (timolol, anterior chamber paracentesis) are traditionally attempted. Intra-arterial tPA has been studied but is not standard of care.[4]
CRAO demands a full stroke workup — these patients have the same risk factor profile and short-term stroke risk as TIA/stroke patients. Echo, carotid imaging, and cardiac monitoring are indicated. Up to 25% of CRAO patients will have a stroke or cardiovascular event within 5 years.[4]
CRVO Pearls
CRVO is associated with hypertension, diabetes, hyperlipidemia, and glaucoma. Unlike CRAO, it is not embolic and does not demand emergent vascular workup. However, vascular risk factor optimization is essential. The main complications are macular edema (treated with anti-VEGF injections by ophthalmology) and neovascular glaucoma (from retinal ischemia).[5]
GCA Screening
In any patient >50 with new vision loss, check ESR and CRP for giant cell arteritis. GCA causes anterior ischemic optic neuropathy (AION) — the most feared complication is bilateral blindness from progression to the contralateral eye. If ESR is elevated and clinical suspicion is present (headache, jaw claudication, scalp tenderness, PMR symptoms), start prednisone 60–80 mg immediately and arrange temporal artery biopsy. Do not wait for biopsy results to treat.[6]
Disposition
New floaters/flashes (PVD concern): discharge with ophthalmology in 24–48 hours for dilated exam. Retinal detachment: emergent ophthalmology — macula-on is a surgical emergency. CRAO: admit for stroke-equivalent workup. CRVO: discharge with urgent ophthalmology in 1–2 days. Amaurosis fugax: TIA workup — admit or rapid outpatient pathway.[1]
References
- Sharma R, Brunette DD. Ophthalmology. In: Tintinalli’s Emergency Medicine, 9th ed. McGraw-Hill; 2020.
- Hollands H et al. Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA. 2009;302(20):2243-2249. PubMed
- Blaivas M et al. Bedside emergency ultrasonographic diagnosis of retinal and vitreous detachments. Acad Emerg Med. 2002;9(12):1421-1427. PubMed
- Mac Grory B et al. Management of Central Retinal Artery Occlusion: A Scientific Statement from the AHA. Stroke. 2021;52(6):e282-e294. PubMed
- Scott IU et al. A randomized trial comparing the efficacy and safety of intravitreal triamcinolone with standard care to treat vision loss in CRVO (SCORE Study). Arch Ophthalmol. 2009;127(9):1101-1114. PubMed
- Hunder GG et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990;33(8):1122-1128. PubMed
tydotphrase.com 