The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

Review Article
Primary Care
B LURRED V ISION

not readily apparent, systematic progression through

all six parts of the eye examination is essential for every patient with blurred vision.
Visual Acuity

BRADFORD J. SHINGLETON, M.D.,

AND MARK W. ODONOGHUE, O.D.

LURRED vision is the most common symptom related to the eye. It is manifested in many
ways and has a wide variety of causes. Here we
review for nonophthalmologists the examination techniques and diagnostic algorithms that are useful in the
evaluation of blurred vision. We also describe how
to determine when patients need urgent ophthalmologic consultation and treatment.
THE EYE EXAMINATION
History

In evaluating a patient with blurred vision, it is

important to note the time of onset and how the patient first noticed the symptoms. Was the blurring of
vision sudden in onset, or was it gradual? Did it occur
with or without pain? Was the blurred vision unilateral or bilateral? The differentiation of cases of blurred
vision on the basis of these characteristics will facilitate making the proper diagnosis.1 It is also important
to note any other associated conditions or events.
For example, the patient should be asked about accompanying auras preceding migraines and about focal neurologic signs. Is there a history of blunt trauma, penetrating injury, or exposure to a foreign body
that might lead to blurred vision? Medications such
as steroids (systemic, injectable, topical, or inhaled)
may be associated with cataracts, glaucoma, and keratitis due to the herpes simplex virus. Effects on
vision from antibiotics, antimalarial drugs, psychotropic agents, and other medications are rare, but toxic effects on the retina and optic nerve are possible.
Other clues that can be useful for diagnosing blurred
vision are a family history of glaucoma or macular
degeneration and a personal history of symptoms similar to the current ones.2
Examination Techniques

The eye examination, as performed by a practitioner who is not an ophthalmologist, is divided into
six parts: visual acuity, visual field, pupils, movement
of extraocular muscle, anterior segment, and posterior segment. Because some serious eye conditions are
From Ophthalmic Consultants of Boston, Boston. Address reprint requests to Dr. Shingleton at 50 Staniford St., Suite 600, Boston, MA 02114,
or at bjshingleton@eyeboston.com.
2000, Massachusetts Medical Society.

556

Blurred vision is most often associated clinically

with a reduction in visual acuity. Visual acuity should
be tested one eye at a time, with glasses or contact
lenses in place if they are normally worn by the patient. First, the patient is asked to read a standard eye
chart. If the acuity at a distance is less than 20/40,
the acuity is rechecked by placing a pinhole occluder
over the patients glasses, a maneuver that will give
an approximation of the best corrected vision. If the
patient is unable to read any of the figures on the
chart, the patient is asked to count the fingers on
the examiners hand. If the patient is unable to count
the fingers, the distance at which the patient can detect hand movements is determined. If the patient is
unable to detect hand movements, the practitioner
should determine whether the patient can perceive
light. The precise level of visual acuity and the distance at which it was achieved are recorded. The documentation of visual acuity is important for making
comparisons with the results of future examinations
and for legal reasons.
Visual Field

Blurred vision that is due to neurologic disease or

retinal detachment is occasionally manifested as a defect in peripheral vision. The confrontation method
of testing peripheral vision is a quick and simple way
to identify defects in the visual field. With each eye
tested separately, the normal visual field of the examiner is used as a base line for comparison with that
of the patient in the superior, inferior, nasal, and temporal quadrants. If the test is performed properly,
homonymous field defects that are associated with
cerebral vascular accidents can be identified, as can
quadrantic or hemispheric defects associated with retinal detachments. Another quick way to test the central visual field is with an Amslers grid (Fig. 1). The
patient looks at the central dot with one eye and
identifies any zones of distortion or loss of the visual
field. The grid is particularly helpful in diagnosing
blurred vision in patients with retinal disease.
Pupils

The pupils should be black, round, of the same size,

and reactive to light. A nonblack pupil suggests the
opacification of refracting media, which is often due
to the formation of cataracts. Misshapen or eccentric
pupils occur after blunt or penetrating trauma and
may be associated with serious ocular injuries, such
as ruptured globes. In up to 20 percent of cases, pu-

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Figure 1. An Amslers Grid, Used to Test the Central Visual Field.

From a distance of 40 cm (16 in.) and with eyeglasses or contact lenses used for reading in place, the patient looks at the
central dot with one eye at a time and identifies any zones of
distortion or loss of the central visual field.

for discharge, swelling, and vascular injection. The

corneal reflection of light may be the most important sign to evaluate. The reflection of light should be
clear, free of irregularities, and sharp. The application of topical fluorescein, in conjunction with illumination with cobalt-blue light, is useful for further
evaluating acute irregularities in the corneal surface.
Irregularities imply corneal disease or trauma. When
present in an eye with nontraumatic redness, they may
herald a vision-threatening corneal ulcer or herpes
simplex infection.
The anterior chamber is the space between the
cornea and the iris that is filled with aqueous humor.
When trauma has occurred, it is inspected for blood
(hyphema); it is inspected for pus (hypopyon) in any
patient who has had eye surgery. The iris is evaluated
for alterations in shape or contour. Trauma may lead
to pupillary dilatation, and in iritis, the pupil on the
involved side may be miotic. The lens is situated in
the pupillary axis, behind the diaphragm of the iris.
Opacification of the lens, which is normally clear, indicates the formation of a cataract. A cataract may
appear white when illuminated by a penlight or as a
focal dark area against the normally uniform red reflex produced by direct ophthalmoscopy.
Posterior Segment

pillary asymmetry may be the only obvious sign of

serious eye injury on examination with a penlight.
Abnormal pupillary size or reactivity to light may be
important clues to the presence of intracranial disease. An afferent pupillary defect (with paradoxical
pupillary dilatation in response to light) is an important sign of optic-nerve disease or injury. If present,
it confirms that damage to the optic nerve or retina
has occurred. Every practitioner should be comfortable performing this part of the examination.
Movement of Extraocular Muscles

Occasionally, the patient may interpret diplopia due

to disorders in ocular motility as blurred vision. Ocular motility is tested by asking the patient to follow a
penlight up and down and to the left and right with
the eyes. The extraocular muscles should work in
concert, and the movements in each eye should be
smooth, unrestricted, and symmetrical. Limitation of
movement in any of the four cardinal positions of gaze
should be noted.
Anterior Segment

The anterior segment includes the sclera, conjunctiva, cornea, anterior chamber, iris, and lens. The entire anterior segment can be examined adequately
with simple illumination by penlight and careful observation. The sclera and conjunctiva are examined

The posterior segment consists of the vitreous, the

retina, and the optic nerve. Direct ophthalmoscopy
is used to assess the clarity of the refracting media
and the posterior segment. Dilation of the pupil greatly facilitates examination of the posterior segment; it
should be carried out by the medical practitioner if
important diagnostic information can be obtained
and if there are no neurologic contraindications. We
favor the use of 1 percent tropicamide and 2.5 percent phenylephrine for routine dilation.
The red reflex as seen through the direct ophthalmoscope should look the same in all angles of view.
Alteration in the reflex may occur with cataracts, hemorrhage in the vitreous gel, retinal detachment, and
choroidal detachment. The image of the retina should
be clear. The margins of the optic nerve normally appear flat and well demarcated. Pathologic elevation
occurs with papilledema, papillitis, and ischemic optic
neuropathy; an afferent pupillary defect is associated
with papillitis and ischemic optic neuropathy. Opticdisk drusen (Fig. 2) are probably the most common
form of pseudopapilledema. The arteries and veins
should be of normal caliber, and the retinas should
be free of hemorrhages, exudates, and ischemic cotton-wool spots.
NONPATHOLOGIC CAUSES
OF BLURRED VISION
Refractive Errors

Refractive errors are the most common cause of

blurred vision and account for the vast majority of
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The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

Figure 2. Optic-Disk Drusen.

Elevation of the optic disk is commonly caused by optic-disk
drusen, but this condition can be misdiagnosed as pathologic
edema of the optic disk. The drusen typically appear as irregular, white, hyaline concretions in the substance and at the border of the head of the optic nerve.

visits to eye specialists. Blurred vision that is caused by

refractive errors is generally bilateral, of gradual onset, painless, dependent on distance, and responsive
to correction with a pinhole. Specific refractive errors
include myopia (nearsightedness), hyperopia (farsightedness), astigmatism, and presbyopia (age-related accommodative loss and impaired vision for reading).
Amblyopia occurs as a monocular condition in children, usually before five years of age. It results from
a failure of the neurosensory connections of the visual
system to develop fully, because of a loss of a clear
monocular image or because of binocular misalignment. Precipitating conditions include strabismus, unequal refractive error, and monocular occlusions of
the ocular media (congenital cataract). Amblyopia
may be responsive to treatment if therapy is initiated
while the child is in the critical developmental period
(up to seven years of age). It is important not to confuse reduced vision due to amblyopia with blurred
vision of recent onset.
Functional Loss of Vision

Blurred visual acuity that results from a perceptual

or psychological malfunction is termed functional
loss of vision. It represents real but usually transient
loss of visual acuity that is often due to severe psychological trauma. The most common diagnostic clinical finding is tubular visual fields.2
PATHOLOGIC CAUSES
OF BLURRED VISION

The pathologic causes of blurred vision are much

less common but far more urgent than the nonpathologic causes. For patients who cannot see well, a diagnostic algorithm based on the chronology of onset,
whether the symptom is unilateral or bilateral, and the
558

Figure 3. Nonproliferative Diabetic Retinopathy Showing Hemorrhages and Exudates in the Posterior Pole, with No Evidence
of Neovascularization.

presence or absence of pain helps in the categorization of the many and varied causes of blurred vision.
The ophthalmic branch of the fifth cranial nerve
provides ocular sensation. The areas of the eye that are
sensitive to pain are the ocular surface, the iris, and
the ciliary body. The periorbital areas are also sensitive to pain; therefore, inflammation around the optic nerve can cause pain as well as blurred vision. The
retina, the vitreous, and the optic nerve within the
globe are relatively insensitive to pain.
Sudden, Unilateral, Painless Loss of Vision

Sudden, unilateral, painless loss of vision often results from an abnormality in the posterior segment
of the eye. Facility with the ophthalmoscope is critical for diagnosing these problems. Each of the following problems deserves urgent ophthalmologic consultation.
Vitreous hemorrhage associated with diabetes or
trauma is a common cause of sudden, unilateral, painless loss of vision.3 The red reflex and details of the
retina will be obscured when viewed through the direct ophthalmoscope. Patients with diabetes may also
present with hemorrhages, exudates, microaneurysms,
edema, and neovascularization in the posterior segment, which result in sudden changes in vision (Fig.
3).4 Most vitreous hemorrhages are allowed to clear
spontaneously, but in patients with diabetes who have
neovascularization, emergency retinal photocoagulation may be indicated.
Serous elevations of the macula5 and hemorrhagic
macular changes due to choroidal neovascular membranes and age-related macular degeneration will occasionally present as sudden, unilateral, painless loss
of vision (Fig. 4).6,7 Age-related macular changes can
be identified with the direct ophthalmoscope.8 Pa-

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Figure 4. A Subretinal Hemorrhage Due to a Choroidal Neovascular Membrane in a Patient with Age-Related Macular Degeneration.

Figure 6. A Central Retinal-Vein Occlusion, with Widespread Intraretinal Hemorrhages.

Figure 5. A White, Billowing, and Elevated Retina, Characteristic of Retinal Detachment.

Figure 7. Occlusion of the Central Retinal Artery.

The retina appears white because of widespread edema, and
the preserved choroidal circulation underneath shines through
as a cherry-red spot at the fovea.

tients with these problems should undergo urgent

angiography with fluorescein to determine whether
the macular lesion is amenable to laser treatment.
Retinal detachments are diagnosed most easily by
an ophthalmologist using indirect ophthalmoscopy
through a dilated pupil, but occasionally the medical
practitioner can see the white, billowing retinal separation (Fig. 5).9 Retinal detachments require urgent
surgical repair.
Retinal-vein occlusions are characterized by intraretinal hemorrhages.10,11 These hemorrhages can be
widespread and diffuse throughout the fundus in an
occlusion of the central retinal vein (Fig. 6) or may
be localized to one quadrant with occlusions of the
branches of the retinal vein. Retinal photocoagulation may be indicated in cases of serious edema or
of neovascularization of the iris.

Episodes of amaurosis fugax (temporary loss of vision) may precede frank occlusion of the retinal artery.12 Occlusion of the central retinal artery is associated with profound loss of vision, an afferent pupillary
defect, and a cherry-red spot in the macula (Fig. 7).
An embolus, or Hollenhorst, plaque may be visible.
Patients with this condition benefit from an urgent
neurovascular workup to search for the source of the
embolus. Nonarteritic anterior ischemic optic neuropathy tends to occur in older patients and is associated
with an afferent pupillary defect and congestion and
elevation of the optic disk (Fig. 8).13,14
One type of presentation of sudden, unilateral,
painless loss of vision could be termed suddenly perceived unilateral, painless loss of vision. A slowly progressive condition, usually in the nondominant eye,
is suddenly noticed when the unaffected eye is inadVol ume 343

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Figure 8. Anterior Ischemic Optic Neuropathy, Characterized by

Swelling and Hemorrhages of the Optic Disk.

Figure 9. A Corneal Ulcer, Appearing as a White Infiltrate in the

Cornea.
In this fungal infection, the ulcer is associated with a ring of inflammatory cells and hypopyon.

vertently covered, making apparent the reduced vision in the other eye. To help in determining whether the condition has presented in such a fashion, the
patient should be asked how he or she first noticed
the blurred vision. Conditions that commonly have
this presentation include refractive errors, cataracts,
and age-related macular degeneration without hemorrhage or exudation.
Sudden, Unilateral, Painful Loss of Vision

The conditions that most commonly cause sudden, unilateral, painful loss of vision are centered in
the cornea and anterior chamber and are associated
with a red eye.15 The corneal causes include abrasion,
infection, and edema.16,17 Infection (corneal ulcer) is
the most critical condition to recognize. Patients with
infectious ulcers typically have a white infiltrate in the
cornea (Fig. 9) and require emergency ophthalmologic referral, cultures, and intensive treatment with
topical antibiotics. Herpes simplex ulcers often present
with a dendritic pattern, which is most easily identified with topical fluorescein (Fig. 10).
Inflammation of the iris, of the ciliary body, and of
the anterior uveal tract causes mildly decreased vision
that is commonly associated with photophobia.18 Most
cases of inflammation (uveitis) are idiopathic, but
some may be associated with sarcoid, collagen vascular
diseases, syphilis, and tuberculosis. All are clinically diagnosed with use of the slit lamp and are treated with
topical corticosteroids. Because topical corticosteroids
may be associated with the development of cataracts,
with glaucoma, and with reactivation of herpes simplex virus infection, nonophthalmologic medical practitioners should not prescribe these medications.
Traumatic hyphema is most often associated with
pain and reduces visual acuity in proportion to the
amount of blood in the anterior chamber.19 After referral, the ophthalmologist will treat patients with this
560

Figure 10. An Epithelial Ulcer (Arrow) Due to Herpes Simplex Infection, Which Has a Typical Dendritic Pattern When Stained
with Topical Fluorescein and Illuminated with Cobalt-Blue Light.

condition medically to minimize problems with increased intraocular pressure and to reduce the threat
of recurrent bleeding.
A rapid increase in intraocular pressure (acute glaucoma) causes pain and corneal edema, which results
in a moderate-to-severe reduction in visual acuity. Patients with acute angle-closure glaucoma require emergency laser iridectomy to relieve the pupillary blockage that leads to angle closure.
Temporal arteritis tends to present in older patients,
with pain and tenderness over the scalp and temple
and symptoms of polymyalgia rheumatica. Loss of vision results from ischemic optic neuropathy, and an
afferent pupillary defect is present. The erythrocyte
sedimentation rate is elevated, and prompt treatment
with systemic corticosteroids is indicated to minimize

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PR IMA RY CA R E

the risk of bilateral ocular involvement.20 A biopsy of

the temporal artery is indicated; the results of the
biopsy are not altered by short-term use of corticosteroids.
Optic neuritis generally occurs in younger patients
and may be associated with multiple sclerosis.21,22 The
reduction in visual acuity can be profound and is often accompanied by pain on movement of the eyes.
An afferent pupillary defect is generally present, and
the optic nerve may appear swollen in patients with
anterior papillitis (Fig. 11) and normal in patients
with retrobulbar neuritis. Prompt diagnosis is important, because some patients may benefit from intensive systemic treatment with corticosteroids.23
Orbital cellulitis is a vision-threatening and, in rare
instances, life-threatening infection of the retro-orbital space. Deep orbital involvement is heralded by pain,
decreased vision, limited extraocular motility, proptosis, an afferent pupillary defect, and optic-nerve congestion.24,25 Referral to an ophthalmologist and an
otorhinolaryngologist is indicated, with a workup
that includes cultures, computed tomographic scanning, and treatment that incorporates intravenous antibiotics. Treatment is particularly critical in immunosuppressed patients.

Figure 11. Optic Neuritis (Papillitis) with a Swollen Optic Nerve.

Sudden, Bilateral, Painless Loss of Vision

Loss of vision that is sudden, bilateral, and painless is extremely rare. It may be caused by sudden refractive changes due to the swelling of the lens in patients with poorly controlled diabetes or in response
to medications.26,27 Medications that contain anticholinergic agents, cholinergic agents, and corticosteroids can exacerbate refractive errors or induce sudden refractive changes.

Figure 12. A Posterior Subcapsular Cataract as It Would Appear

through the Direct Ophthalmoscope When Highlighted against
the Pupillary Red Reflex.

Sudden, Bilateral, Painful Loss of Vision

Trauma to the anterior segment in the form of foreign bodies, chemical spills, and welders exposure to
ultraviolet radiation may present as sudden, bilateral,
painful loss of vision. Corneal infections, iritis, and
acute glaucoma, which are all associated with a red
eye, very rarely present bilaterally.28 Temporal arteritis may also rarely be associated with permanent bilateral, painful loss of vision.
Gradual, Unilateral, Painless Loss of Vision

Blurred vision is commonly manifested as loss of

vision that is gradual, unilateral, and painless. Cataracts are the primary cause in the elderly population.
Cataracts may appear as a hazy opacification of the
pupillary space when the eye is examined with a penlight, and they impair visualization of the posterior
segment when the direct ophthalmoscope is used
(Fig. 12). For cataracts, routine, nonurgent ophthalmologic follow-up should be planned.
Age-related macular degeneration without hemorrhage or exudation (dry macular degeneration)

is another common cause of gradual, unilateral, painless loss of vision in older patients. It may appear as
focal yellow spots (drusen) or as variable areas of hyperpigmentation or hypopigmentation in the macula
(Fig. 13). Patients with this condition need routine
ophthalmologic consultation so that possible foci of
hemorrhage or exudation, which may not be readily
apparent but are potentially treatable with a laser,
can be located.
In rare instances, slowly compressive lesions in the
orbit and intracranial space may cause this type of vision loss. When loss of vision occurs as a result of a tumor compressing the optic nerve, optic atrophy and
defects in the visual field are invariably present.29,30
Gradual, Unilateral, Painful Loss of Vision

Gradual, unilateral, painful loss of vision is rare.

Slowly progressive inflammatory or neoplastic procVol ume 343

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REFERENCES

Figure 13. Macular Drusen in Age-Related Macular Degeneration without Hemorrhage or Exudates.

esses of the cornea or retrobulbar space are possible

causes. Orbital granulomas and optic neuromas have
been reported.31,32 Computed tomography or magnetic resonance imaging is ordered by the ophthalmologist in these cases.
Gradual, Bilateral, Painless Loss of Vision

Cataracts and age-related macular degeneration are

the most common causes of gradual, bilateral, painless loss of vision. Rare, but deserving of ophthalmologic monitoring, are conditions caused by ocular
toxicity, such as that associated with hydroxychloroquine or ethambutol.33-35 Treatment involves discontinuing the offending medication, although visual loss
in these cases is usually irreversible. In rare instances,
compressive lesions at the level of the chiasm may
present as painless bilateral loss of vision.29,30 Testing
of the visual field is critical in this condition.
Gradual, Bilateral, Painful Loss of Vision

Gradual, bilateral, painful loss of vision is exceedingly rare and is most likely to be due to a chronic
inflammatory process, as might occur in collagen vascular disease or sarcoidosis.
CONCLUSIONS

Blurred vision is a complex symptom with myriad

causes, ranging from simple refractive errors correctable with eyeglasses to life-threatening illnesses. The
ability of the clinician to distinguish pathologic causes
from nonpathologic causes is of paramount importance. Fortunately, simple tools common to all medical offices and a systematic diagnostic approach can
help the medical practitioner make an important start
in this critical delineation.

562

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