 Okay, so I kind of have the leftovers in some sense and there's a lot of things that can cause it and there is some overlap with what Renee talked about But we'll kind of touch on a few more things. So You know we talked about the emboli causing it and GCA In terms of hemodynamic causes you can kind of think of it as reduced Perfusion to the retina and so there's a few things that can kind of fall under that category including Hypotension high blood viscosity Hypertension and then just in general reduced ocular perfusion for other things and we'll talk about that kind of other bascular other than the emboli and basculitis if Fistulas causing like steel from the retinal circulation vasospasms and then I guess migraine shouldn't be there This is kind of like optic disc brain kind of other optic Tracked stuff migraine optic disc edema optic disc anomalies gave gaze of us invoked Emerosis we'll talk more about that and then there's kind of these miscellaneous ocular causes So Renee did touch on this but just to kind of try to differentiate things For retinal vascular insufficiency or hypo perfusion the symptoms in general are longer So not in the seconds to minutes range less rapid onset The vision loss is maybe more patchy less distinct But they can still describe it and positional and usually a lot of times people will describe kind of a peripheral constriction of their visual field and Again, I think we all know from being in clinic and being on call These are only general guidelines and anything is possible, which is this scary part of it all so For retinal vascular insufficiency high blood viscosity can cause reduced blood flow just as an example You know reports of people with polycythemia vera About 10% of those patients can complain and just transient monocular vision loss With reduced ocular perfusion systemic hypo attention could potentially cause it I mean it's little rare and not kind of a classic presentation to be monocular But in theory if there's a drop in systemic blood pressure and some asymmetry of the interior Circulations and stenosis on one side more than the other you could get this unilateral presentation Anything with low cardiac output, which could include, you know arrhythmias is Definitely a cause and then crowded artery occlusion not only you can have the emboli but just not enough blood flow And so you can get these situations where You're not getting enough blood flow and then there's stressors to the whole system that cause the vision loss too So again history is just really important to try to see if you can get any other clues To what's bringing this on what makes it worse so light induced transient vision loss or amorous. This is You know you're not getting enough blood flow and the thought is that the light and having that much stimuli in the retinal System is kind of putting it into a higher metabolic state that it just cannot keep up with the demand and so People will have these episodes where they say you know in the bright light or these situations is when I notice it There are some reports. I mean not this is not super common, but just kind of interesting that you know post-prandial same kind of deal that you your body is Putting all its energy into your digestive system in theory and causing this transient vision loss reports of exercise induced transient vision loss, which could be from you know Hypo perfusion it could also be you toss phenomenon if you're raising your body temperature Just to reiterate carotid dissection if you think you know definitely painful at flatter a little vision loss and Especially if there's anything else like if you see any sign of horners or anything kind of leaning you towards that Definitely something to keep on the differential with chronic ocular hypoperfusion This can be more I mean it's still transient But it can be a little bit longer like into the hours time frame and some reports of positive visual phenomenon You know again, you can read all these reports and there's always exceptions to the rules, but you can kind of just categorize it Yeah Well like Eileen's patient headache anything anything that's not Exactly like that. So I mean I think that's a good tip-off that this isn't you know It kind of puts it in another category that we need to be a little bit more worried about and I don't know on him If he had any it sounds like he didn't have anything else on exam But any ptosis any pupil abnormalities, but yeah painful including just the whole So Again under this category of just vascular insufficiency if you have venous hypertension Which could also be from if you have really high intraocular pressure causing this can do that extra cerebral steel so AV malformations that Caused the blood to be kind of shunted away anemia So I think Renee touched on this but either central retinal artery Occlusion impending or partial or impending central retinal vein occlusions Can kind of present as this transient vision loss? And so again, it's something you really need to keep on your differential and if you see any kind of asymmetry in the vasculature or Just you know something that kind of tips you off that needs to be something you can get an FA for but keep in the back of Your mind there were reports with central, you know a few case series of central retinal artery Occlusion like impending occlusions that they more commonly had these like negative visual phenomenon again, not always the case but You know, it's kind of a scary thing so we have to take these seriously so I Think Renee talked a little bit about it, but we really just you want to Look for anything that can help you figure out what category to put these in so on the fundus exam Venus distention anything that's kind of showing been a stasis retinopathy blot hemorrhages and then Think about, you know, look at the whole life. You have any signs of anterior segment ischemia You know that can tip you off to a ocular ischemic syndrome and Kind of just help you differentiate these things Okay, so we've mentioned these vasospasms before and this is kind of a difficult area so it's Symptom-wise can last 15 to 30 minutes so it kind of in this mid-range Usually, it's gradual associated with positive visual phenomenon, but it can be really severe and you can have complete vision loss You you need to make this diagnosis as a diagnosis of exclusion and it can be associated kind of associated with the migraine it's this gray area, but There's reports of renaught syndrome where you don't have any systemic I think I mean really rarely having any systemic signs and then having these basis basins But basically if you're making the diagnosis as a primary basis spasm You've need to have excluded all the scary things that we've talked about and there are a lot of them so the retinal and just kind of to put this to kind of give us a little bit of Background retinal migraine classification Which kind of falls into the vasospasm category or there's some overlap between the two? They need to have two episodes of transient monocular visual loss associated with or followed by a headache with migraness features But that leaves so much room You know, it's just I guess the point of this is it's so nebulous and that really Could be a lot of other things too. So we just need to be really careful So this was an interesting case report. I found There was a 33 year old lady and she had had been having these episodes of like about 10 minutes of complete NLP vision loss in her right eye and she happened to be in a Clinic, I think it was a neurology clinic and she started having one and they Emergently wheeled her over to the neuro ophthalmology clinic and we're able to get some really interesting photos So on her exam. She was NLP. She had a right APD and this was just the fundus photos and you can see there's Venus boxcar showing Venus stasis or sorry arterial boxcar and then they did an FA and So she had this really delayed arterial filling but had normal choral blush and kind of is a really good example of this, you know a Central retinal artery having poor perfusion with normal perfusion of the ophthalmic artery when the episode resolved she You know, they repeated everything everything went back to normal in her they kind of diagnosed it as a vasospasm related to migraine and But again, it it kind of it's a scary thing and it's hard to be okay with that diagnosis without doing a big Workup, but it's just to show you if you catch these things. I mean, there's real pathology going on and Real changes. This is another case of just a vasospasm that was caught over 40 minutes and so you can see The actual changes, you know over time of the vasospasm and decreased blood flow and then the resolution So of course if you see that on exam, then you have you can feel comfortable about making that diagnosis But we don't catch people very often But the other thing that is scary is that you can have secondary vasospasm from any of these causes so Vasospasm isn't a clean diagnosis and All of these things are still on your differential even if you think it's just a vasospasm so keep all of that in mind and Then kind of our next category is optic nerve disease causing vision loss. So Papal edema, I think we're all fairly familiar with transient visual obscuration So those are more in the few seconds to minutes range smaller, you know shorter usually bilateral positional and then of course thinking about other signs of increased Intracranial pressure. We have to go through that diagnosis AION either in AION or Arteritic, you know, or GCA and Arteritic interior ischemic optic neuropathy and Eileen had touched on that with both anomalous discs and optic disc drusen just the architecture of the discs and the anatomy and it can Basically pinch off its own salary blood supply or even the salary or the central retinal artery can have decreased blood flow And so they can get these episodes of vision loss that can last for seconds. They can have them frequently They can be provoked by changing gaze or changing positions and then with optic nerve compression from you know, if you have Orbital mass you can get transient monocular vision loss as well And that's basically the same idea that you're moving the eye and that mass is changing the blood flow and causing this decreased blood flow and then the transient vision loss so again, history of when what aggravates it when do you notice that all these are just so important to try to Help us narrow down what we're looking at because obviously Anything can cause I mean a huge amount a huge differential and then Utah's phenomenon Renee touched on but again, it's a demyelinating in a demyelinating disease when you raise your Body temperature it causes nerve conduction Slowing and loss and you can get vision loss from that and then just again miscellaneous Or I guess these should I don't know I guess we could call it ocular dry eyes super common Cardiconus hyphaeema vitreous hemorrhage like Eileen talked about an intermittent angle closure glaucoma is definitely another one that we really have to Think about and there are a lot of or there's reports You know, you don't have to have pain with these episodes and so we it It's something that we can see on exam and clues that we can look for an exam So keep that in the back of your mind too. This is a bonus because apparently Renee had the same question So you guys probably get that we all touched on the same thing for number one. What do you guys think? number two I mean, that's the thing that all of these things are obviously but in terms of permanent visual loss It's a tip-off and just need to do that They all are really important. I mean and if you guys disagree I guess I would say both of those would be would be enough equal if I got a very much Well, if you're trying to rank it in the most permanent vision loss, I mean, if you're trying to prevent a stroke, you know then probably the coronary was probably more important, but this permanent vision loss We only care about the eyes. Well, well written. Well written thought. And then this one Eileen's patient But she didn't he didn't have The clues any questions or other things