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symptom.acute_vision_loss.v1PRODUCTION
symptom.acute_vision_loss.v1

Acute / sudden vision loss

symptomacuteundifferentiatedadult
Hard-required inputs
0 / 17
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm true vision loss vs aura / migraine; monocular vs binocular; painful vs painless; transient vs persistent (AAO PPP)

Inputs
2
Actions
0
Advance rule
Set
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Pattern classified

Patient inputs (25)

Age ≥50 raises GCA prior; AION; ≥60 raises CRAO/CRVO prior (AAN GCA 2022)

CRAO / CRVO embolic / atherosclerotic — HTN + diabetes + AF + carotid disease (AHA/ASA 2021 PMID 34024117)

Optic neuritis prior + NMO/MOG screen (Beck ONTT 1992 PMID 1734247)

Methanol intoxication — bilateral central scotomata (AAO PPP)

Anticholinergic / sympathomimetic dilation precipitates angle-closure; ethambutol optic neuropathy; PDE5 (sildenafil) NAION trigger (Hayreh NAION review)

Monocular before chiasm; binocular = chiasm/cortex (AAO PPP)

Painful: optic neuritis (worse with eye movement), angle-closure, GCA; painless: most retinal/vascular (Beck ONTT 1992)

GCA — ESR>50 LR+ ~3.4 (Halevy 2014 meta); both elevated in 95% (AAN GCA 2022)

Hypoglycemia mimic (AAO PPP)

Snellen quantification per eye (AAO PPP)

IOP > 30-40 mmHg = angle-closure; >50 cloudy cornea (AAO PPP AACG)

Afferent pupillary defect — LR+ for unilateral optic nerve disease; sensitive for optic neuritis + AION (Beck ONTT 1992)

AC inflammation, lens, RD, fundus pathology — cherry-red spot (CRAO), flame hemorrhages (CRVO), disc edema (AION), pale disc (optic neuritis) (AAO PPP)

Homonymous hemianopia = cortical/post-chiasmal; bitemporal = chiasmal; altitudinal = AION (AAO PPP)

CRAO 90-min retinal tolerance; tPA window <4.5 h emerging (Schultheiss EYE-tPA 2020)

GCA features — jaw claudication LR+ ~6, scalp tenderness LR+ ~5 (Smetana JAMA 2002; GiACTA Stone 2017 PMID 28745999)

Pituitary apoplexy / occipital stroke (AHA/ASA 2021)

Optic neuritis enhancement; pituitary apoplexy; occipital stroke (Beck ONTT 1992 PMID 1734247)

Posterior circulation + ophthalmic-artery branch as stroke-equivalent (AHA/ASA 2021 PMID 34024117)

GCA confirmatory — within 2 wk of starting steroid; do NOT delay steroid (AAN GCA 2022; GiACTA Stone 2017 PMID 28745999)

RD / vitreous hemorrhage (AAO PPP)

Angle-closure prior (AAO PPP)

GCA + post-viral arteritis — new headache pattern in age ≥50 (AAN GCA 2022)

Thrombocytosis (Plt >400) supports GCA prior (Halevy 2014)

Bedside RD/VH assessment when ophtho unavailable (AAO PPP)

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Severity triggers (11)

11 need judgement
  • informationallife_threateningcrao_within_window
    Painless monocular vision loss + cherry-red spot + retinal pallor + onset <4.5 h — STAT route to stroke pathway (AHA/ASA 2021 PMID 34024117 — ophthalmic-artery branch as stroke equivalent)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninggca_suspected
    Age ≥50 + ESR ≥50 + CRP elevated + visual symptoms (amaurosis fugax or AION) ± jaw claudication (LR+ ~6) ± scalp tenderness (LR+ ~5) ± temporal tenderness — STAT high-dose IV methylpred 1 g × 3 d BEFORE biopsy to prevent contralateral blindness (AAN GCA 2022; GiACTA Stone 2017 PMID 28745999)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningacute_angle_closure
    Severe eye pain + nausea + halos + IOP > 40-80 mmHg + cloudy cornea + fixed mid-dilated pupil — protocol.angle_closure.v1 (timolol + apraclonidine + pilocarpine + acetazolamide + mannitol simultaneously) + emergent YAG iridotomy (AAO PPP AACG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghomonymous_hemianopia
    Visual field defect respecting vertical meridian + cortical signs (alexia, agnosia, neglect) — occipital stroke; route to neuro.ischaemic-stroke.v1 (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpituitary_apoplexy
    Sudden severe headache + bitemporal hemianopia + cranial neuropathies + adrenal insufficiency features — STAT MRI pituitary + hydrocortisone 100 mg IV + neurosurgery (AAO PPP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmethanol_toxicity_visual
    Bilateral central scotomata + AGMA + osmolar gap + history of antifreeze / illicit alcohol — fomepizole + folate + dialysis (EXTRIP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereretinal_detachment
    Curtain over vision + flashes + floaters + fundus or POCUS shows detachment — macula-on = emergent OR within 24 h; macula-off = urgent within days (AAO PPP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecrvo_brvo
    Fundus shows flame hemorrhages in all 4 quadrants (CRVO) or one quadrant (BRVO) + cotton-wool spots + macular edema + HTN/DM/glaucoma history — intravitreal anti-VEGF (AAO PPP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereoptic_neuritis
    Painful (worse with eye movement) monocular vision loss + RAPD + central scotoma + young adult — IV methylpred 1 g × 3 d (ONTT); MRI brain + orbits; AQP4/MOG before chronic immunosuppression (Beck ONTT NEJM 1992 PMID 1734247)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaion_naion
    Sudden altitudinal field loss + disc edema + crowded disc (small cup-to-disc) + age ≥50 + HTN/sleep-apnea/sildenafil — NO proven Rx (avoid steroid unless GCA suspected); modify risk factors (Hayreh NAION review)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildfunctional_vision_loss
    Tubular field on confrontation, normal RAPD, normal fundus, inconsistent VA on repeat testing, secondary gain context — diagnosis of exclusion; full workup mandatory before label (AAO PPP)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

GCA visual emergency — IV pulse methylpred + ASA + tocilizumab steroid-sparing (AAN GCA 2022; GiACTA 2017)
axis: gca_emergent_steroid
Selected axis "GCA visual emergency — IV pulse methylpred + ASA + tocilizumab steroid-sparing (AAN GCA 2022; GiACTA 2017)" by default fallback (first axis)
  • methylprednisolone
    first line
    corticosteroid
    1 g IV • IV • daily × 3 days
    triggers: arteritic_AION_or_amaurosis_with_GCA_features
    Emergent visual GCA — pulse before biopsy; biopsy still informative within 2 wk; prevents contralateral blindness (AAN GCA 2022)
    rxcui 6902
  • prednisone
    first line
    corticosteroid
    1 mg/kg PO (typically 60-80 mg) • PO • daily, taper per response over 12-18 mo
    triggers: post_pulse_step_down, GCA_without_visual_symptoms
    Maintenance after pulse (AAN GCA 2022)
    rxcui 8640
  • aspirin
    add on
    antiplatelet
    81 mg • PO • daily
    triggers: GCA_with_ischemic_features
    Vascular complications — observational benefit (AAN GCA 2022)
    rxcui 1191
  • tocilizumab
    add on
    IL6_receptor_antagonist
    162 mg SC weekly • SC • weekly
    triggers: relapse_on_steroid_taper, steroid_sparing
    GiACTA NEJM 2017 PMID 28745999 — sustained remission + steroid sparing
    rxcui 612865

outpatient playbook — drug actions (5)

  1. 1. prednisone taper
    rxcui 8640
    taper from 60 mg over 12-18 mo • PO • daily, taper
    trigger: GCA maintenance
    AAN GCA 2022 — slow taper to prevent relapse
  2. 2. tocilizumab maintenance
    rxcui 612865
    162 mg SC • SC • weekly
    trigger: GCA steroid-sparing per GiACTA protocol
    GiACTA NEJM 2017 PMID 28745999 — 56% sustained remission at 1 yr
  3. 3. anti-VEGF intravitreal
    aflibercept / ranibizumab / bevacizumab • intravitreal • q4-6 wk then taper per disease activity
    trigger: CRVO/BRVO macular edema
    Anti-VEGF RVO meta — visual gain ~+15 letters; standard of care
  4. 4. atorvastatin 80 mg
    80 mg • PO • daily
    trigger: CRAO/AION/RVO vascular phenotype
    2026 ACC/AHA Lipid secondary prevention LDL <55
  5. 5. aspirin 81 mg
    rxcui 1191
    81 mg • PO • daily
    trigger: CRAO post-event vascular secondary prevention
    AHA/ASA 2021 PMID 34024117

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden monocular or binocular vision loss (AAO PPP 2020-2023); Sudden painless visual field defect (curtain, scotoma, altitudinal) (AAO PPP); Painful red eye with halos around lights — angle-closure (AAO PPP).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute / sudden vision loss** (symptom.acute_vision_loss.v1).
Phenotype framing: 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)
Scope: Confirm true vision loss vs aura / migraine; monocular vs binocular; painful vs painless; transient vs persistent (AAO PPP)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GCA visual emergency — IV pulse methylpred + ASA + tocilizumab steroid-sparing (AAN GCA 2022; GiACTA 2017)**.
1. methylprednisolone 1 g IV IV daily × 3 days (corticosteroid, first line) — Emergent visual GCA — pulse before biopsy; biopsy still informative within 2 wk; prevents contralateral blindness (AAN GCA 2022)
2. prednisone 1 mg/kg PO (typically 60-80 mg) PO daily, taper per response over 12-18 mo (corticosteroid, first line) — Maintenance after pulse (AAN GCA 2022)
3. aspirin 81 mg PO daily (antiplatelet, add on) — Vascular complications — observational benefit (AAN GCA 2022)
4. tocilizumab 162 mg SC weekly SC weekly (IL6_receptor_antagonist, add on) — GiACTA NEJM 2017 PMID 28745999 — sustained remission + steroid sparing

Setting playbook (outpatient) — Long-term steroid taper + tocilizumab + bone health (GCA); anti-VEGF intravitreal q4-6w (RVO/AMD); retinal detachment post-op surveillance; AION risk-factor modification; MS workup post-ON (AAN GCA 2022; GiACTA 2017)
5. prednisone taper taper from 60 mg over 12-18 mo PO daily, taper — GCA maintenance (AAN GCA 2022 — slow taper to prevent relapse)
6. tocilizumab maintenance 162 mg SC SC weekly — GCA steroid-sparing per GiACTA protocol (GiACTA NEJM 2017 PMID 28745999 — 56% sustained remission at 1 yr)
7. anti-VEGF intravitreal aflibercept / ranibizumab / bevacizumab intravitreal q4-6 wk then taper per disease activity — CRVO/BRVO macular edema (Anti-VEGF RVO meta — visual gain ~+15 letters; standard of care)
8. atorvastatin 80 mg 80 mg PO daily — CRAO/AION/RVO vascular phenotype (2026 ACC/AHA Lipid secondary prevention LDL <55)
9. aspirin 81 mg 81 mg PO daily — CRAO post-event vascular secondary prevention (AHA/ASA 2021 PMID 34024117)

Non-pharmacologic actions:
- Vitreoretinal surgery follow-up (RD post-op)
- Smoking cessation (NAION + RVO + GCA modifiable risk)
- OSA evaluation + CPAP (NAION risk)
- Discontinue PDE5 inhibitors if NAION suspected (Hayreh review)
- MS clinic referral if optic neuritis + brain MRI lesions (Beck ONTT 1992)
- Low-vision rehabilitation if persistent deficit
- Driving evaluation per state law

AVOID / contraindication checks:
- Do_not_delay_steroid_for_biopsy_in_visual_GCA (AAN GCA 2022)
- Tocilizumab_screen_TB_HBV_pre_initiation (GiACTA 2017)
- Steroid_BP_glucose_bone_monitoring (AAN GCA 2022)

Monitoring

Regimen monitoring:
- visual acuity q shift (AAO PPP)
- ESR CRP q visit (AAN GCA 2022)
- temporal biopsy within 2 weeks (AAN GCA 2022)
- glucose BP BMD on long term steroid (AAN GCA 2022)

Setting (outpatient) monitoring:
- ESR + CRP per visit until taper complete (GCA)
- Glucose + BP + DEXA on chronic steroid
- Annual ophtho follow-up after stable
- Brain MRI q6-12 mo if MS workup (Beck ONTT 1992)

Follow-up plan: 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)
- Close-out criterion: Referrals scheduled

Monitoring phase: Serial VA, IOP if angle-closure, ESR/CRP for GCA, MRI follow-up for ON, telemetry if CRAO/stroke (AAN GCA 2022)

Disposition

Current setting: outpatient — Long-term steroid taper + tocilizumab + bone health (GCA); anti-VEGF intravitreal q4-6w (RVO/AMD); retinal detachment post-op surveillance; AION risk-factor modification; MS workup post-ON (AAN GCA 2022; GiACTA 2017)

Disposition criteria:
- Stable taper-complete: annual ophtho follow-up
- Relapsing: rheumatology + ophtho q3 mo

Escalation triggers (move to higher acuity):
- GCA relapse symptoms → emergent ED + restart pulse (AAN GCA 2022)
- New optic neuritis episode → MS clinic urgent + neuro.ms-flare.core.v1 pathway
- New CRAO/amaurosis → ED + neuro.ischaemic-stroke.v1 pathway

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Painless monocular vision loss + cherry-red spot + retinal pallor + onset <4.5 h — STAT route to stroke pathway (AHA/ASA 2021 PMID 34024117 — ophthalmic-artery branch as stroke equivalent)
- [LIFE_THREATENING] Age ≥50 + ESR ≥50 + CRP elevated + visual symptoms (amaurosis fugax or AION) ± jaw claudication (LR+ ~6) ± scalp tenderness (LR+ ~5) ± temporal tenderness — STAT high-dose IV methylpred 1 g × 3 d BEFORE biopsy to prevent contralateral blindness (AAN GCA 2022; GiACTA Stone 2017 PMID 28745999)
- [LIFE_THREATENING] Severe eye pain + nausea + halos + IOP > 40-80 mmHg + cloudy cornea + fixed mid-dilated pupil — protocol.angle_closure.v1 (timolol + apraclonidine + pilocarpine + acetazolamide + mannitol simultaneously) + emergent YAG iridotomy (AAO PPP AACG)

Citations

- AAO Preferred Practice Patterns 2020-2023 + AAN GCA 2022 + ONTT NEJM 1992 + GiACTA NEJM 2017 + EUSO 2024 CRAO + AHA/ASA 2021 (CRAO stroke equivalent) [PMID:1734247](https://pubmed.ncbi.nlm.nih.gov/1734247/)
- Cited evidence (PMID 28745999) [PMID:28745999](https://pubmed.ncbi.nlm.nih.gov/28745999/)
- Cited evidence (PMID 34024117) [PMID:34024117](https://pubmed.ncbi.nlm.nih.gov/34024117/)
- Cited evidence (PMID 33677974) [PMID:33677974](https://pubmed.ncbi.nlm.nih.gov/33677974/)
- Cited evidence (PMID 11754714) [PMID:11754714](https://pubmed.ncbi.nlm.nih.gov/11754714/)

Last reconciled with current guidelines: 2026-05-14.
References
  • AAO Preferred Practice Patterns 2020-2023 + AAN GCA 2022 + ONTT NEJM 1992 + GiACTA NEJM 2017 + EUSO 2024 CRAO + AHA/ASA 2021 (CRAO stroke equivalent) — PMID:1734247
  • Cited evidence (PMID 28745999) — PMID:28745999
  • Cited evidence (PMID 34024117) — PMID:34024117
  • Cited evidence (PMID 33677974) — PMID:33677974
  • Cited evidence (PMID 11754714) — PMID:11754714