Emergency Vision Assessment Guidelines

Essential Initial Assessment Components

The American Academy of Ophthalmology recommends documenting visual acuity with current correction at distance as the first priority, establishing a critical baseline 1, 3
Record the power of any current correction being worn, as this information is crucial for accurate assessment 1
For patients with acuity less than 20/100, extend the measurement range by using portable test charts at closer distances to avoid imprecise measurements 4
Test both monocularly and binocularly, as binocular testing may reveal functional differences 4
Assess for relative afferent pupillary defect (RAPD), which indicates significant retinal or optic nerve dysfunction 2, 5
Evaluate pupil size, shape, and reactivity to light in both eyes, as slow or poorly reactive pupils suggest significant retinal or optic nerve pathology 1, 3
Perform external examination, including eyelid position, lashes, lacrimal apparatus, globe position, and facial features 1
Check red reflex bilaterally, as any asymmetry in color, brightness, or size indicates serious pathology 3
Examine the fundus, including vitreous, retina, vasculature, and optic nerve, to identify potential vision-threatening conditions 1
Perform visual fields by confrontation as part of the initial examination to identify hemianopsias, quadrantanopsias, or severe peripheral field loss 1, 6

The American Heart Association recommends transferring patients with suspected Central Retinal Artery Occlusion (CRAO) immediately to a stroke center/emergency department without delay, as this is an ocular stroke requiring evaluation within 4.5 hours for potential thrombolysis 7, 8
In patients over 50 years with acute vision loss, immediately screen for giant cell arteritis symptoms, such as headache, scalp tenderness, jaw claudication, temporal tenderness, and malaise, to prevent vision loss in the contralateral eye 2, 5, 7

Measure intraocular pressure, preferably with contact applanation (Goldmann tonometer), while deferring contact tonometry if suspected ocular infection or corneal trauma 1
Perform gonioscopy when neovascularization or elevated pressure is present or suspected 2

For children 3 years and older, use age-appropriate visual acuity testing with picture cards, wall charts, or vision testing machines 3
Children under 7 years with suspected vision problems should be discussed with ophthalmology for severity grading 10
Use linear or crowded optotypes for best accuracy in all children 11