Evaluation of patients with decreased vision or blindness

A good ocular examination and careful evaluation of the pupillary light reflexes will localize most lesion(s) producing a complaint of blindness. Lesions of the clear media severe enough to produce blindness will prohibit fundus examination. Retinal, optic nerve, and complete chiasmal lesions will produce dilated, slowly reactive pupils. Retinal blindness is usually associated with dramatic ophthalmoscopic lesions of diffuse altered reflectivity and vascular attenuation, the major exceptions being the sudden acquired retinal degeneration syndrome and some patients with glaucoma. Optic nerve lesions may involve the optic disc where they may be recognized by either pallor or hyperemia and cupping or elevation. Confirmation of optic nerve blindness in practice usually is by ruling out retinal blindness, but a more definitive methodology is to have a normal electroretinogram, slow or absent direct pupillary light reflexes (PLR), and abnormal visual evoked potentials. Central blindness is diagnosed by normal eyes, normal PLR, and often central nervous system (CNS) signs indicative of a diffuse or multifocal CNS disease.