Amaurosis fugax

Background

Eye anatomy.

• Transient painless visual loss caused by either circulatory, ocular or a neurologic condition. Vision loss can last a few seconds to minutes.
• Fugax is greek for "fleeing"
• Greatest suspicion in assessing these patients should be to evaluation for acute stroke and embolic phenomenon as that will carry the greatest mortality

Clinical Features

• Patients report complete blackening of vision.

Differential Diagnosis

Causes are divided into embolic, hemodynamic, ocular, neurologic, and idiopathic

Embolic

• Carotid emboli or Cardiac emboli in origin causing
  • Central Retinal Artery Occlusion (CRAO)
  • Central Retinal Vein Occlusion (CRVO)
• Drug abuse-related intravascular emboli

Vascular/Hemodynamic

• Carotid stenosis
• Arteritis (Temporal arteritis, Takayasu arteritis)
• Hypoperfusion (CHF, Hyperviscosity syndrome, hypercoagulable state)

Ocular

• Ischemic optic neuropathy
  • Central Retinal Artery Occlusion (CRAO)
  • Central Retinal Vein Occlusion (CRVO)
• Nonvascular causes
  • Retinal Detachment
  • Vitreous hemorrhage
  • Malignancy

Neurologic

• Migraine
• Papilledema
• Optic neuritis
• Intracranial mass
• Intracranial hemorrhage
• Multiple Sclerosis
• Psychogenic

Idiopathic

• Diagnosis of exclusion

Acute Vision Loss (Noninflamed)

• Painful
  • Arteritic anterior ischemic optic neuropathy
  • Optic neuritis
  • Temporal arteritis^†
• Painless
  • Amaurosis fugax
  • Central retinal artery occlusion (CRAO)^†
  • Central retinal vein occlusion (CRVO)^†
  • High altitude retinopathy
  • Open-angle glaucoma
  • Posterior reversible encephalopathy syndrome (PRES)
  • Retinal detachment^†
  • Stroke^†
  • Vitreous hemorrhage
  • Traumatic optic neuropathy (although may have pain from the trauma)

^†Emergent Diagnosis

Evaluation

Workup will focus will vary significantly based on the differential and clinical presentation

In general it includes:

• ECG
• CT brain non con and CTA head and neck
• CXR
• Basic Metabolic Panel
• CBC (to assess for severe anemia or thrombocytosis)
• INR (if patient is anticoagulated)
• MRI (if suspicion for CVA, Multiple Sclerosis, or undifferentiated mass lesion)
• Ocular ultrasound (evaluate for retinal detachment or hemorrhage)

Management

Management also varies also based final diagnosis

• Intrinsic ocular causes require ophtho evaluation and referral
• Cardiologic cause requires admission and cardiology consultation
• Neurologic causes require admission and neurologic consultation
• Hematologic causes or vasculitis related causes will require sub specialist consultation

Disposition

• Close follow-up or admission depending on the final determined cause

See Also

• Acute vision loss (noninflamed)