Sandbox: Golnaz Holm

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief:

Overview

Blurred vision is a common ocular symptom which is define as a sudden or gradual loss of clarity or sharpness of vision and difficulty to see fine details.It can present unilateral or bilateral.

Historical Perspective

There is not much information regarding the historical perspective of blurred vision.

Classification

There is no established system for the classification of blurred vision.

Pathophysiology

Blurred vision may result from refractive errors, opacity of structures (lens, cornea, vitreous), retina disorder or optic nerve disease.

Causes

Blurred vision can be caused by a wide range of eye conditions which include:

• Refractive errors (most common)
• Age-related macular degeneration
• Cataracts
• Presbyopia
• Diabetes retinopathy
• Glaucoma
• Corneal abrasion or scarring; keratitis
• conjunctivitis
• Uveitis
• Iritis
• Retinal detachment
• Retinitis
• Eye trauma (Hyphema)
• Migraine
• Malignancy and tumor (Brain tumor, Lung cancer metastasis, Leukemia)
• Optic neuritis
• Cerebrovascular disease (TIA, stroke)
• Vasculitis (Temporal arteritis,SLE)
• High blood pressure
• Medication

Epidemiology and Demographics

Patients of all age groups may develop blurred vision.

Risk Factors

Risk factors in the development of blurred vision include Genetic, Family history, Diabetes mellitus, Age, Hyperlipidemia, Hypertension

Screening

• According to the American Diabetes Association’s patients with type 1 and type 2 diabetes should have comprehensive eye examination within 5 years after the onset of diabetes and at the time of diagnosis ,respectively. The eye examination should be considered at least annually thereafter.
• There is insufficient evidence to recommend routine screening for Glaucoma. USPSTF suggests that patients at increased risk, especially African

Americans and older adults, talk to their primary care clinician or eye care specialist for advice about glaucoma screening.

• The USPSTF recommends annual screening for adults aged 40 years or older and for those who are at increased risk for high blood pressure. Persons at increased risk include those who have high-normal blood pressure (130 to 139/85 to 89 mm Hg), those who are overweight or obese, and African Americans. Adults aged 18 to 39 years with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be rescreened every 3 to 5 years.

Natural History, Complications, and Prognosis

Prognosis of blurred vision depends on the underlying cause.

Diagnosis

There are no established criteria for the diagnosis of blurred vision. The diagnosis of blurred vision is based on taking detailed medical history and eye examination.Patient Should be asked about the onset, duration, associated symptoms and whether blurred vision is bilateral or unilateral.

History and Symptoms

• The common symptoms which accompany blurred vision include Redness of the eye,Eye pain,Epiphoria,Headache,Photophobia,Halos,Nausea,Polydipsia and polyuria,Dizziness,Numbness.

Physical Examination

• Eye examination of patients with blurred vision includes Visual acuity test,Visual fields examination,Slit lamp,Ophthalmoscopy,Tonometry,Angle Test (Gonioscopy)

• The presence of sudden hemiplegia ,abnormal gait,ataxia and dysarthria is diagnostic of cerebrovascular accident.

Laboratory Findings

• Patients with systemic disorders should have appropriate testing.
• An elevated concentration of blood sugar and HgA1C is seen in blurred vision due to diabetes mellitus.
• Urinalysis and renal function testing should be considered in patients with high blood pressure.
• Antinuclear antibodies and elevated ESR are associated with SLE and vasculitis.
• CBC with differential count and other tests are needed in some cases( Leukemia, Multiple myeleoma)

CT scan

• CT scan of brain may be helpful in diagnosis of mass occupying lesions or Ischemic and hemorrhagic stroke.

MRI

• A magnetic resonance imaging (MRI) study of the brain and orbits may confirm inflammation of the optic nerve.

Treatment

Depends upon the cause, underlying disorders should be addressed.

• Patients with refractive errors and presbyopia can be treated with Corrective lenses and eyeglasses.
• Supportive therapy for hyphema includes raising the head of the bed, wearing eye shield and cut back on physical activity.
• There is no treatment for dry macular degeneration.Patients with wet macular degeneration may be treated with Anti-VEGF medications or Photodynamic therapy which help stop the growth of new blood vessels.

Medical Therapy

• Medical therapy of diabetic retinopathy include direct injections or intravitreal administration of anti-inflammatory and antiangiogenesis agents(anti-VEGF drugs ) which are widely used pharmacotherapy to effectively treat DR and diabetic macular edema (DME).PMCID: PMC5822768
• Laser treatment is an option in treatment of diabetic retinopathy.
• Pharmacologic medical therapy with eye drops is recommended among patients with Glaucoma.
• The mainstay of treatment for treatment in infectious causes include antibacterial, antiviral or anti parasite agents.
• Patients with uveitis, iritis and optic neuritis can be treated with corticosteroids.
• Patients with temporal arteritis are treated with high dose of corticosteroids.
• Treatment of high blood pressure is medical therapy with anti hypertensive medications.

Surgery

• Surgical intervention like LASIK is commonly used to correct a refractive error.
• Surgery is the mainstay of treatment for cataract and retinal detachment.
• Vitrectomy is used in treatment of Diabetic retinopathy
• Different types of surgeries to treat glaucoma are: Trabeculoplasty ,Iridotomy and Trabeculectomy

Primary Prevention

Preventive measures in developing diabetic retinopathy include a healthy lifestyle, controlling hypertension, stringent lipid control and periodic ophthalmic examinations. PMID: 17216945

Secondary Prevention

• Effective measures for the secondary prevention of blurred vision due to refractive errors is early detection and treatment of refractive errors in school vision programs.
• Secondary Prevention of Atherosclerotic Cardiovascular Disease includes Lifestyle interventions,weight management,anti hypertensive agents, stain therapy,Anti- platelet Therapy,diabetes treatment and Cigarette/Tobacco Cessation.

References

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Cause of blurred vision	Unilateral	Bilateral	Pain	Onset	Associated symptoms!
Refractive errors	+	+	-	gradual
Glaucoma	+		+		red eye, Headache, Nausea
Age-related macular degeneration		+	-	gradual	Extra sensitivity to glare
Cataracts	+	+	-	gradual
Diabetes retinopathy		+	-	gradual
Presbyopia
keratitis	+		+
conjunctivitis	+	+	+/-
Uveitis	+		+
Iritis	+		+		light sensitivity
Retinal detachment	+		-	sudden	curtain
Infectious Retinitis	+	+	+/-		Loss of night vision,tunnel vision
Eye trauma (Hyphema)	+		+	sudden	bleeding in the front of the eye,light sensitivity
Vitreous hemorrhage	+			sudden	Floaters
Lung cancer metastasis	+	+
Migrain	+	+		sudden	aura,headache ,nausea
Central retinal artery occlusion	+		-	sudden	complete sight loss
Central retinal vein occlusion	+		-	sudden	complete sight loss
Brain tumor	+	+
Optic neuritis	+		+
stroke		+	-
Papilloedema		+	-	sudden	Headache,nausea
Temporal arteritis	Mostly			sudden	Amaurosis fugax, headache,Diplopia
High blood pressure	+	+	sudden	headache,nausea
Orbital cellulitis	+		sudden	Swollen eye,red eyes, fever
Medication like anticholinergic		+	-
Sjögren's syndrome	+		-	gradual	Eye dryness, redness,Burning eyes