Neuro-ophthalmology Question of the Week: Emergency Department Evaluation of Binocular Transient Vision Loss

Question: Describe the appropriate steps to take in evaluating binocular transient vision loss (BTVL) in the emergency department.

English: Four lobes of left hemisphere. fronta...

Concerns: intracranial ischemia (embolism, thrombus), GCA, SLE, , chronic meningitis. Most common = migraine

ED Evaluation of Binocular Transient Vision Loss

  • Rule-out ocular cause – very unlikely for transient bilateral loss of vision
  • If no ocular cause – Age 50+ rule out GCA
    • obtain CBC ESR, CRP, CBC with platelet count
    • If these tests are negative but strong suspicion of GCA, consider systemic corticosteroids (discuss with on-call attending).
  • BTVL duration is seconds long – rule-out papilledema
  • visual field loss suggesting retrochiasmal visual field loss or
  • visual symptoms limited to one side (hemianopic)
    • Consider conditions that can mimic migraine: occipital masses, SLE or chronic meningitis.3
    • Obtain MRI/MRA to rule-out mass, AVM and sinus thrombosis
      • MRI/MRA negative consider epilepsy or atypical migraine
    • Signs or symptoms of collagen vascular disease
      • Obtain collagen vascular disease profile
  • BTVL only exposure to bright light – rule-out bilateral carotid artery disease
  • BTVL with typical migraine, diagnosis = migraine
  • BTVL with “migraine” and with:
    • BTVL consistent with TIA
      • Obtain diffusion-weighted MRI for all patients with TIAs, an acute central or branch retinal artery occlusion.
        • Co-occurrence of Acute Retinal Artery Occlusion and Acute Ischemic Stroke-Diffusion-weighted MRI study. Lee J, et al. AJO. 2014:157(6):1231-1238
        • Transient Ischaemic Attacks: Mimics and Chameleons. Nadarajan V, et al. Pract Neurol. 2014;14(1):23-31.
      • Rule-out likely sources of emboli and thrombi
        • Obtain evaluation of carotid arteries and if negative a cardiac source.
        • Obtain a medical consultation to rule out sources of thromboembolism and thrombophilia.

1. Clinical Decisions in Neuro-Ophthalmology,  Burde RM, Savino PJ & Trobe JD. 3nd Edition. Mosby 2002
2. Clinical Pathways in Neuro-ophthalmology:An Evidence-Based Approach. Lee AC & Brazis PW. Thieme 2003
3. Migraine: mimics, borderlands and chameleons. Angus-Leppan H. Pract Neurol. 2013;13(5):308-18.

More than 600 additional neuro-ophthalmology questions are freely available at

Questions prior to September 2016 are archived at
After that, questions are archived at
Follow to be notified of new neuro-ophthalmology questions of the week.
Please send feedback, questions and corrections to