Symptom: Vision Changes

Initial Grading Reminder

CTCAE Criteria for Vision Changes:

Grade 1: Asymptomatic or mild changes; clinical or diagnostic observations only; intervention not indicated
Grade 2: Moderate; minimal; local or noninvasive intervention indicated; limiting age-appropriate instrumental ADLs
Grade 3: Severe or medically significant but not immediately sight-threatening; hospitalization or prolongation of existing hospitalization indicated; disabling; limiting self-care ADLs
Grade 4: Sight-threatening consequences; urgent intervention indicated; blindness (20/200 or worse) in the affected eye

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had any issues with your vision in the past? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

How bad is your vision change? Are you able to carry out your normal activities? Drive? Take care of yourself? Do you have other eye issues (pain, redness, etc?)

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any headaches, dizziness, nausea, and/or vomiting?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with any vision changes should be seen immediately by an ophthalmologist.

    Patients with any of the red-flag symptoms should also be seen immediately.

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    Nursing Assessment of Potential Causes

    Vision change irAEs

    Conjunctivitis, blepharitis, episcleritis, iritis, ocular myositis, scleritis, uveitis

    Hypophysitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear fatigued?
    • Does the patient look listless?
    • Does the patient look ill?
    • Does the patient look uncomfortable?
    • Does the patient report:
      • Change in energy?
      • Headache?
      • Dizziness?
      • Nausea/vomiting?
      • Altered mental status?
      • Visual disturbances?
      • Fever?
    • Low levels of hormones produced by pituitary gland (ACTH, TSH, FSH, LH, GH, prolactin)
    • Brain MRI with pituitary cuts: enhancement and swelling of the pituitary gland
    • DDX adrenal insufficiency: low cortisol and high ACTH
    • DDX primary hypothyroidism: low free T4 and high TSH

    Differential Diagnosis

    What do you suspect is the cause of  the vision changes?