Sally Webber presentation on TIA

Sally Webber

TRANSIENT VISUAL LOSS

What’s the most important feature?

TRANSIENT VISUAL LOSS

Monocular or binocular?

Duration

Characteristics

Examination findings

TRANSIENT VISUAL LOSS

Monocular or binocular?

TRANSIENT VISUAL LOSS

Monocular or binocular?

Difficult as patients may report uniocular symptoms for migraine

Or patients may notice only the temporal side of a

homonomous visual field defect

TRANSIENT VISUAL LOSS

Duration?

TRANSIENT VISUAL LOSS

Visual obscurations

Amaurosis Fugax

Prolonged visual loss

TRANSIENT VISUAL LOSS

Visual obscurations:

last seconds to minutes

Causes?

TRANSIENT VISUAL LOSS

Visual obscurations: seconds to minutesCauses?

Lots!

VISUAL OBSCURATIONS

Causes

Optic neuritis with Uhthoff’s phenomonenRetinal migrainePapilloedemaIntermittant angle closure glaucomaPituitary tumour

VISUAL OBSCURATIONSSurface problems

○ Watery, dry, sticky

Vitreous floaters

Varifocals/bifocals/contact lenses

No obvious cause

Diagnosis mainly needs

Careful history

and on examination?

Examination tip

Usual ocular examination

IncludingIOPVisual fieldCareful check of the disc (dilate if possible)

TRANSIENT VISUAL LOSS

Amaurosis Fugax

Duration?

Symptoms?

Amaurosis Fugax

Lasts one to five minutes

Amaurosis Fugax

Symptoms○ Over 50 years○ Complete loss all or part of Visual field○ ‘Like a curtain’○ Normal vision in other eye○ No systemic/neurological symptoms

Amaurosis Fugax

• Examination• Vision, anterior segment and IOP• Visual field • Dilate pupils, look at disc, follow all retinal

arterioles to look for emboli

Amaurosis Fugax

Ask about risk factors?

Amaurosis Fugax

Ask about risk factors

○ Over 50 years○ Hypertension○ Diabetes○ Heart trouble, heart attack, angina○ Stroke, TIA

Amaurosis Fugax

Management?

Amaurosis Fugax

Management

○ Refer to GPAsk for Assessment for STROKE RISK FACTORS or

referral to the RUH STROKE CLINIC

○ Refer to Eye department to confirm diagnosis

PROLONGED MONOCULAR VISUAL

LOSS

Fifteen to sixty minutes Causes

Hypertension and blood disorders‘Retinal migraine’

PROLONGED VISUAL LOSS Fifteen to sixty minutes Causes

Hypertension and blood disorders‘Retinal migraine’

○ Rare, spasm of choroidal circulation○ Young adults○ Patchy/fading visual loss in one eye○ No positive visual phenomena○ No other neuro symptoms/signs

TRANSIENT BINOCULAR VISUAL LOSS Migraine Bilateral disease, optic nerve/angle

closure Brain tumour or Arteriovenous

malfomation Vertibrobasilar TIA or insufficency

MIGRAINE

MIGRAINE Expanding

scintillating scotoma 10-30 mins Scotoma surrounded by

Zig-zagsFlashesSparklesWaves/watery

NORMAL EXAMINATION

RETINAL ARTERY OCCLUSION

Embolus causing permenant occlusion

RETINAL ARTERY OCCLUSION

Embolus causing permenant occlusion

Complete visual loss/dense scotoma

Pale retina

Embolus may be visible

Cherry red spot

TREATMENT OF CENTRAL RETINAL ARTERY OCCLUSION?

TREATMENT OF CENTRAL RETINAL ARTERY OCCLUSION Waiting

Dilation of the artery Sub-Lingual vasodialtorsRe-breathing expired carbon dioxide

Removal of physical obstruction Eye massage

TREATMENT OF CENTRAL RETINAL ARTERY OCCLUSION

Increasing arterial perfusion pressure by reduction of intra ocular pressure

Anterior chamber paracentesis Intravenous DiamoxIntravenous Maritol

THROMBOLISIS

Anti-platelet therapy Steroids Reducing red blood cells rigidity

Pentoxifylline has been tried

Transient visual loss

Careful history

Visual fields

Check the discs

Remember the stoke clinic

Thank you