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symptom.acute_vision_loss.v1

Acute / sudden vision loss

symptomacuteundifferentiatedadultacute
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Phase C shard-3 symptom-workup deepening (2026-05-14) — patterned after symptom.chest_pain.ed_undifferentiated.v1 + neuro.ischaemic-stroke.v1. Engine scope: ED + ophtho triage + risk-stratification + disposition. Downstream confirmed diagnoses route to dedicated engines: occipital stroke → neuro.ischaemic-stroke.v1; optic neuritis + MS → neuro.ms-flare.core.v1; migraine aura ddx → neuro.migraine.core.v1. Bayesian linkage (GCA Halevy score LRs, CRAO emerging tPA evidence, AACG 5-class algorithm, ONTT workflow) lives in companion depth bundle _briefs/symptom.acute_vision_loss.v1.depth.md — schema has no first-class likelihood-ratio field. 11 severity triggers (≥6 per spec): crao_within_window + gca_suspected + acute_angle_closure + retinal_detachment + crvo_brvo + optic_neuritis + aion_naion + homonymous_hemianopia + functional_vision_loss + pituitary_apoplexy + methanol_toxicity_visual. 5 setting playbooks: home + ed + icu (rare) + inpatient + outpatient. 3 sibling-differentiation rows reference real engines neuro.ischaemic-stroke.v1 + neuro.migraine.core.v1 + neuro.ms-flare.core.v1. Schema-blocked emitted: calc.gca_probability (Halevy/RPS), calc.charles_bonnet, calc.visual_acuity — not in clinical-tools-registry; ticketed in shard-3 state file. PMIDs include 1734247 (Beck ONTT 1992), 28745999 (GiACTA 2017), 34024117 (AHA/ASA 2021 CRAO stroke equivalent); other PMIDs marked NEEDS_SOURCE_REVIEW per shard convention. last_reconciled bumped to 2026-05-14.

Entry points (7)

  • symptom
    Sudden monocular or binocular vision loss (AAO PPP 2020-2023)
    sudden_vision_loss
  • symptom
    Sudden painless visual field defect (curtain, scotoma, altitudinal) (AAO PPP)
    painless_field_defect
  • symptom
    Painful red eye with halos around lights — angle-closure (AAO PPP)
    painful_red_eye_with_halos
  • symptom
    Flashing lights, floaters, curtain — RD / vitreous hemorrhage (AAO PPP)
    flashing_lights_floaters
  • symptom
    Transient monocular blindness — TIA / GCA precursor (AHA/ASA 2021)
    amaurosis_fugax
  • symptom
    Painful monocular vision loss worse with eye movement — optic neuritis (Beck ONTT 1992)
    painful_vision_loss_with_eye_movement
  • symptom
    Homonymous hemianopia respecting vertical meridian — occipital stroke (AHA/ASA 2021)
    visual_field_defect_homonymous

Required inputs (25)

  • agerequired
    demographic • used at CONTEXT
    Age ≥50 raises GCA prior; AION; ≥60 raises CRAO/CRVO prior (AAN GCA 2022)
  • monocular_or_binocularrequired
    symptom • used at FRAME
    Monocular before chiasm; binocular = chiasm/cortex (AAO PPP)
  • painful_or_painlessrequired
    symptom • used at FRAME
    Painful: optic neuritis (worse with eye movement), angle-closure, GCA; painless: most retinal/vascular (Beck ONTT 1992)
  • time_of_onsetrequired
    symptom • used at RED_FLAGS
    CRAO 90-min retinal tolerance; tPA window <4.5 h emerging (Schultheiss EYE-tPA 2020)
  • jaw_claudication_scalp_tenderrequired
    symptom • used at RED_FLAGS
    GCA features — jaw claudication LR+ ~6, scalp tenderness LR+ ~5 (Smetana JAMA 2002; GiACTA Stone 2017 PMID 28745999)
  • flashing_lights_floaters_curtain
    symptom • used at CONTEXT
    RD / vitreous hemorrhage (AAO PPP)
  • headache_or_neurological_deficitrequired
    symptom • used at RED_FLAGS
    Pituitary apoplexy / occipital stroke (AHA/ASA 2021)
  • vascular_risk_factorsrequired
    history • used at CONTEXT
    CRAO / CRVO embolic / atherosclerotic — HTN + diabetes + AF + carotid disease (AHA/ASA 2021 PMID 34024117)
  • ms_or_autoimmunerequired
    history • used at CONTEXT
    Optic neuritis prior + NMO/MOG screen (Beck ONTT 1992 PMID 1734247)
  • methanol_or_toxinrequired
    history • used at CONTEXT
    Methanol intoxication — bilateral central scotomata (AAO PPP)
  • glaucoma_history
    history • used at CONTEXT
    Angle-closure prior (AAO PPP)
  • current_medsrequired
    medication • used at CONTEXT
    Anticholinergic / sympathomimetic dilation precipitates angle-closure; ethambutol optic neuropathy; PDE5 (sildenafil) NAION trigger (Hayreh NAION review)
  • recent_covid_or_headache_pattern
    history • used at CONTEXT
    GCA + post-viral arteritis — new headache pattern in age ≥50 (AAN GCA 2022)
  • esr_crp_if_age_ge_50required
    lab • used at INITIAL_WORKUP
    GCA — ESR>50 LR+ ~3.4 (Halevy 2014 meta); both elevated in 95% (AAN GCA 2022)
  • platelets
    lab • used at INITIAL_WORKUP
    Thrombocytosis (Plt >400) supports GCA prior (Halevy 2014)
  • glucose_fingerstickrequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia mimic (AAO PPP)
  • visual_acuity_OD_OS_each_eyerequired
    imaging • used at INITIAL_WORKUP
    Snellen quantification per eye (AAO PPP)
  • iop_tonopenrequired
    imaging • used at INITIAL_WORKUP
    IOP > 30-40 mmHg = angle-closure; >50 cloudy cornea (AAO PPP AACG)
  • rapdrequired
    imaging • used at INITIAL_WORKUP
    Afferent pupillary defect — LR+ for unilateral optic nerve disease; sensitive for optic neuritis + AION (Beck ONTT 1992)
  • slit_lamp_dilated_fundusrequired
    imaging • used at INITIAL_WORKUP
    AC inflammation, lens, RD, fundus pathology — cherry-red spot (CRAO), flame hemorrhages (CRVO), disc edema (AION), pale disc (optic neuritis) (AAO PPP)
  • confrontation_visual_fieldsrequired
    imaging • used at INITIAL_WORKUP
    Homonymous hemianopia = cortical/post-chiasmal; bitemporal = chiasmal; altitudinal = AION (AAO PPP)
  • mri_brain_orbits_contrast
    imaging • used at BRANCHING_WORKUP
    Optic neuritis enhancement; pituitary apoplexy; occipital stroke (Beck ONTT 1992 PMID 1734247)
  • cta_or_mra
    imaging • used at BRANCHING_WORKUP
    Posterior circulation + ophthalmic-artery branch as stroke-equivalent (AHA/ASA 2021 PMID 34024117)
  • point_of_care_ocular_us
    imaging • used at INITIAL_WORKUP
    Bedside RD/VH assessment when ophtho unavailable (AAO PPP)
  • temporal_artery_biopsy
    imaging • used at BRANCHING_WORKUP
    GCA confirmatory — within 2 wk of starting steroid; do NOT delay steroid (AAN GCA 2022; GiACTA Stone 2017 PMID 28745999)

12-phase flow (12)

  1. 1FRAME
    Confirm true vision loss vs aura / migraine; monocular vs binocular; painful vs painless; transient vs persistent (AAO PPP)
    inputs: monocular_or_binocular, painful_or_painless
    advance: Pattern classified
  2. 2ENTRY
    Sudden vision loss, scotoma/curtain, painful red eye + halos, flashing lights + floaters, amaurosis fugax, painful with eye movement (Beck ONTT 1992)
    inputs: age
    advance: Entry pattern recognized + clock started
  3. 3CONTEXT
    Age (≥50 GCA, ≥60 vascular), vascular risks, MS / autoimmune, glaucoma history, drugs (anticholinergics, PDE5, ethambutol, amiodarone), methanol, recent headache pattern (AAN GCA 2022)
    inputs: vascular_risk_factors, ms_or_autoimmune, methanol_or_toxin, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    CRAO within window, jaw claudication / scalp tenderness (GCA), severe eye pain + halos (AACG), trauma + hyphema, neurologic deficit (occipital stroke / homonymous hemianopia), bitemporal hemianopia (pituitary), methanol exposure (AHA/ASA 2021; AAN GCA 2022)
    inputs: jaw_claudication_scalp_tender, headache_or_neurological_deficit, time_of_onset
    actions: workup.gca_temporal_arteritis, workup.acute_stroke
    advance: Red flags routed
  5. 5INITIAL_WORKUP
    VA OD/OS, IOP, RAPD, slit lamp + dilated fundus, confrontation visual fields, ESR + CRP + platelets if ≥50, fingerstick glucose, POCUS for RD if ophtho unavailable (AAO PPP)
    inputs: visual_acuity_OD_OS_each_eye, iop_tonopen, rapd, slit_lamp_dilated_fundus, confrontation_visual_fields, esr_crp_if_age_ge_50, glucose_fingerstick
    actions: workup.acute_vision_loss, workup.acute_red_eye, panel.inflammation
    advance: Bedside ophthalmologic workup complete
  6. 6BRANCHING_WORKUP
    MRI brain + orbits with fat-sup contrast for ON; CTA/MRA + carotid duplex for CRAO + posterior circulation; temporal artery biopsy within 2 wk if GCA; OCT if available; methanol level + AGMA if exposure; AQP4/MOG before chronic immunosuppression (Beck ONTT 1992; AHA/ASA 2021)
    inputs: mri_brain_orbits_contrast, cta_or_mra, temporal_artery_biopsy, point_of_care_ocular_us
    actions: workup.toxic_alcohols, workup.acute_stroke
    advance: Etiology workup completed
  7. 7DIFFERENTIAL
    CRAO (~1-2 ED) / CRVO+BRVO / arteritic AION (GCA) / non-arteritic AION / RD / vitreous hemorrhage / AACG / optic neuritis / pituitary apoplexy / occipital stroke / methanol / migraine aura / functional (Bösner-style ED priors; AAO PPP)
    advance: Differential ranked with pre-test priors documented
  8. 8RISK_STRATIFICATION
    Time-since-onset (CRAO <4.5 h for tPA; <90 min retinal tolerance); GCA bilateral risk if untreated; AACG IOP severity; macula-on vs macula-off RD (AHA/ASA 2021; AAN GCA 2022)
    inputs: time_of_onset
    actions: calc.nihss, calc.anion_gap
    advance: Time-to-treatment + bilateral risk documented
  9. 9TREATMENT
    protocol.crao.v1 (ocular massage, AC paracentesis, IOP-lowering, hyperbaric / consider tPA in select <4.5 h); protocol.angle_closure.v1 (timolol + apraclonidine + pilocarpine + acetazolamide + IV mannitol + emergent YAG iridotomy); IV methylpred 1 g × 3 d for arteritic AION (do NOT delay biopsy); ONTT methylpred for ON; ophtho RD repair; neurology stroke pathway; fomepizole + dialysis methanol (AAN GCA 2022; GiACTA 2017; AHA/ASA 2021)
    inputs: esr_crp_if_age_ge_50
    actions: protocol.crao.v1, protocol.angle_closure.v1, protocol.acute_ischemic_stroke.v1
    advance: Targeted protocol initiated
  10. 10DISPOSITION
    Emergent ophthalmology + neurology consults in parallel; admit GCA pulse / CRAO tPA / vitreoretinal OR / AACG; transfer to retinal/neuro-ophthalmology if specialty unavailable (AAO PPP)
    advance: Disposition + level of care set
  11. 11MONITORING
    Serial VA, IOP if angle-closure, ESR/CRP for GCA, MRI follow-up for ON, telemetry if CRAO/stroke (AAN GCA 2022)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Ophthalmology, neurology, rheumatology / vascular as warranted; long-term steroid taper + tocilizumab + bone health (GCA); anti-VEGF q4-6w (RVO); AION risk-factor modification (GiACTA 2017; AAN GCA 2022)
    advance: Referrals scheduled