 Okay, so I'm gonna talk about the most common cause of transient monocular vision loss and which is retinal ischemia due to embolism and I'm also just gonna talk about vasculitis as well because obviously when we are evaluating someone on call or in clinic, it's really important to evaluate for these things. So as far as embolism goes, if we miss a case of where we should have worked them up to minimize their stroke risk factors, we could have prevented a stroke that they could have had and then for vasculitis, obviously letting someone go out of your clinic without treating them or evaluating them for a GCA at least could lead them to become blind. So these are the most important things to keep in mind and work up. So this NASA trial, which was published in the early 1990s, evaluated the role of carotid endarterectomy in symptomatic patients and a significant number of patients that they enrolled in the study had transient monocular blindness and they found that having this transient monocular blindness or amaurosis was associated with a significantly increased risk of stroke in the next three years. And 1.4% of their patients that had amaurosis had disabling or fatal strokes. So this is why it's really important for us to evaluate patients for their stroke risk factors and try to minimize them. They found that for the patients with amaurosis, carotid endarterectomy may have benefit if they have three or more of the following risk factors in addition to having the amaurosis. So the one that we always hear about is the severity of the stenosis. So between 80 and 94% was associated with increased risk. If you have less than that, it's not as strong of a risk factor. And then if you have more than 94%, actually it's less of a risk for future stroke as well. And also age, sex, history of TIAs or stroke and claudication. So these are all things that, if you were to evaluate someone for amaurosis and they were to be or seen by a vascular surgeon, these are the things that we consider in deciding whether or not to do an endarterectomy. I thought one weakness of this study is I don't know if they all got eye examinations, which I feel like if someone, before working someone up for a stroke, I think it could be important to rule out other causes. And also another weakness was that actually their result for doing endarterectomies on the high-risk patients wasn't statistically significant, although it was like so close. But I think that clinically it is significant, but maybe the vascular surgeons may feel different. You're saying more than 94% stenosis decreases your risk of getting it? Compared to 80 to 94. I guess maybe the thought process is that's like so stable. It's just like no flow is getting through that it's not likely to shower off embolite. I don't know if you can add anything, Dr. DeGray or Eric Gergy. You know, it was, it used to be thought that 70% and above and then was the most significant, but you know this study really is the classic study. This is the one. And then they followed these people for a long time too, which is a good strength of it, that they did follow up and find that, you know, so many of these people got strokes. And I don't know what the percentages are for like, I think they also did hemispheric TIAs and then minor strokes. So the cut-offs might be different, but this is like just the results for the amaurosis patients. So there have been some subsequent studies that showed that these patients that present with amaurosis are at pretty high risk for concurrent stroke as well, now that we've moved towards evaluating these patients urgently with MRI. So this study from MGH where they saw 400 patients in the ER with monocular vision loss, half of them they diagnosed with retinal ischemia, half of them they diagnosed with other causes of their vision loss, such as, you know, ocular disease, tumors, migraine, syncope, and then, you know, of the patients with the vision loss from ischemia, 13 of 74 had acute strokes on MRI. And this study below was smaller and this was actually just patients with branch retinal or central retinal artery occlusions where they did MRI soon afterward. And basically a quarter of them had acute strokes in the same vascular territory. And interestingly, you know, their patients also had some abnormalities either on neurological history or examination. And I didn't put the study up there, but you know, the risk of concurrent stroke for artery occlusions is the highest, you know, right after the event and then kind of drops off after that. You know, I guess maybe the thought process is that there's something going on systemically that's kind of, if there's an unstable plaque that's showering emboli that it's most likely to happen acutely. So that's why it's really important to evaluate them urgently. So, you know, systemic causes. So we talked about emboli. The sources of the emboli, you know, can include, you know, carotid stenosis, which is probably the most common one. And then, you know, cardiac sources, such as hypokinesis, while aneurysms, valvular disease, and PFO, as well as atrial fibrillation. And there's also, you know, systemic stroke risk factors or, you know, also risk factors for the artery occlusion than amrosis as well. So this photo on the right came from the BCSE. I think this is something that maybe is not very commonly clinically used, but we may need to know for our examinations. So this just demonstrates like the three different types of plaques, which, hey Ray, I think he's the big proponent of it in Iowa, but in any case, cholesterol plaques are yellow, as shown in A, and they're thought to be from the carotid, and then platelet-fibrin plaques are white, and they tend to be more distal, and they're thought to be cardiac in origin, and then the calcific emboli are also white, and they're usually thought to be more proximal or close to the disc, and also from a cardiac origin, but more likely to be something like, you know, calcific aortic stenosis or something like that. And then, so another important topic I wanted to cover is what kind of workup we should do when we see someone with amrosis. Obviously, everyone we see is gonna get an eye exam, but these are some more recently published papers telling what they do in old Germany and in Paris. So in old Germany, everyone gets sent, like from this, you know, 100 kilometer area to this one ophthalmic emergency department where they get evaluated by an ophthalmologist, and then they get, everyone with amrosis gets, if they feel that it's likely due to retinal scheming, it gets admitted for MRI, carotid, echo, all dirt, EKG, and blood tests. This was, I thought this was a good study because it kind of gave us an overview of, you know, if all these patients had eye exams, you know, what would they have? About a third of them had normal fun examinations, but two thirds of them, when you looked, did have BRAOs or CRAOs, even though their symptoms were transient. And then 23% had concurrent strokes and for 40%, their systemic workup was positive. In Paris, they have this SOS-TIA clinic where you could call in from anywhere in Paris and then, you know, a neurologist or a trained nurse answers the phone and talks you through it and if they feel that it's high suspicion enough, they'll send the patient over there and then, you know, evaluate the patient themselves and then, you know, do a complete workup as well. I thought that study was kind of interesting because they split up, they looked at all different types of transient vision loss. So over here, it's kind of small, but most of them had transient monocular blindness, obviously, but some of them had homonymous lateral hemianopia that was transient, loaned by lateral blindness and what was the other one? Diplopia or the other one was positive visual phenomenon. And, you know, obviously the patients with transient monocular blindness had increased, most increased risk of stroke or more likely to be diagnosed by the neurologist with, yes. What is a loaned monocular blindness? They didn't, loaned by lateral blindness. Yeah, they didn't really explain. Probably they just mean that current bilateral vision loss, so. Yeah, maybe in the absence of other symptoms, but I, they didn't explain it. This was all we got right there. So, yeah, in the spoke, they didn't, they didn't, maybe they did split it up by the risk of stroke, but this table on the right is just like the likelihood of the neurologist diagnosing them with a probable TIA. And, you know, just as far as things that we should consider when we're working patients up, I think, you know, sometimes we forget to check the blood pressure. You know, if they're not gonna go to the ER right away, we should probably be checking their blood pressure in clinic if we diagnose someone with a new, you know, CRAO or something like that. And then, you know, EKG, I think AFib is really important cause that, you know, we're always like looking for the physical source, but, you know, there can be, you know, products as mole, AFib. So, definitely EKG is indicated. I'm not, you know, as sure as how's far to go with the Holter monitor and event monitor. I think maybe we could leave that up to people as primary care doctors or their neurologists and then, you know, checking their blood work for hemoglobin A1C and lipids. And then, you know, as I elicited here, some, you know, other tests that we should consider based on our clinical suspicion. I think that, you know, for patients that are young, we probably need to consider, you know, other etiologies of stroke, such as hyperquigulability. And then, maybe, you know, a PFO by checking for that when you get their echo by doing a bubble study. Do you have any thoughts on that, Dr. Dre? Yeah, I would agree with that. Okay. And then, you know, also checking for things like, you know, if they have rheumatoid arthritis or syphilis or vasculatus, which we're gonna talk about and you all know about. And I just wanted to put another plug out there for a box. So, just so you know, I think we've all been over this many times, but if you don't know what to do with a patient that you diagnosed with a retinal artery occlusion, it's on box. And basically, if it's happened within the last seven days, they just go to the ER and let the neurologists, like or G, work them out. However, they think it's appropriate. Just remind them that they do need to get a ESR and CRP because that's not necessarily part of their normal stroke workup. And, but if it's been longer than seven days, we do need to initiate the outpatient workup as listed above and have them follow up in the stroke clinic as an outpatient. And the guidelines that the neurologist gave us for when they need to be seen in the stroke clinic are at the bottom there. And obviously, they need to follow up in retina, and start aspirin and acetin. Yeah. Yeah. This is a workup. Yes. This is really good, this retinal artery, because now they can't treat it. If somebody does have a retinal artery occlusion, they're gonna use TNA or something else. But anti-phospholipid anviline syndrome can also present in the transient macular blindness in young adults. So one thing I always do is check the fingernails before signs of splintering merges, and that can be a clue. Thank you. As to the moments period in seven days, do we, in order to facilitate it, do we need to talk to any of the neurology residents, or do we just have them call the stroke clinic? I know it's kind of hard to get into burrows sometimes. Well, this is supposed to be a protocol that neurologies are going to everybody's right to, I would say, if it's somebody who's had a retinal artery occlusion, and you're on call or whatever, I'd call a neurologist and say, we've got a stroke to the retina. Okay. Then they'll burst into action, and you may have to say stroke to the retina to get the action. Okay, sounds good. But I think they will, it'll be very quick. So some of these studies compared patients with transient monocular blindness to hemispheric TIA, actually that NASA paper that I cited earlier, found a lower risk for stroke in the patients that just had vision loss compared to the ones that had weakness of their half of their body. And this other paper looked at and found that the patients that had, where you transient monocular blindness and you looked in and you saw a B.R.A.O. had a higher risk of stroke than patients where you looked in and you used to look normal. And I think that possibly some of these are due to misclassification, it's hard to make that, it's a little scary for me to make that diagnosis just based on history, it's a lot more, it's a lot different when you actually look and you definitely see there's a B.R.A.O. But still, even if they don't have one, I think they need to be worked up. So temporal arthritis, this is the other thing that we really need to make sure to roll out. 33% of the patients that had temporal arthritis did have some transient visual loss. And I did read that it's kind of like a sign of impending really bad permanent vision loss, but I didn't see any definite proof that that was the case. So obviously ask everyone about their GCA review of systems and get ESR, CRP and platelets on everyone. Fluorescene angiography, if you're kind of suspicious for GCA and you need some help making that diagnosis can pick up kind of early disease by delayed filling, which can be a choroidal retinal or papillary. So I have some cases, they're not necessarily due to emboli, but it's just a couple of people I've seen on call with Amorosis recently. So this patient is a 33-year-old female with transient monocular vision loss. She felt dizzy while she was working her computer, put her head down her arm to rest for several minutes, and then when she sat up, vision was totally black in her right eye. After about 10 minutes, it started to return just as a pinhole, then it got larger, and then it was totally back to room after 20 minutes. She has a history of migraines with aura, which is usually blotchy vision in one eye for five to 10 minutes, followed by a terrible one-sided headache with light sensitivity. She is taking oral contraceptives, and there are some relations to the oral contraceptives in her headaches. The visual ones that she had needed to be as a visual phenomenon would have been changed as it was stressed by anxiety. It was totally black, and she felt dizzy, and she didn't get a headache, which I forgot to tell you after. What would you guys do in her workup? Eye exam, good. Yes, so her eye exam, she was 20, 20, no APD, so the lab exam was normal. What else would you do? I don't think that was done, but. And her fun, I mean, funness was normal. Her funness was totally normal, dilated exam normal. What do you think Renee, what would you get? I mean, just based on the history, I'm telling you, on the marco exam, the hospital pathologist had to embalise her cognitive condition. Even though she's 33? Just the way that it presents. And no fame in the strict class. Nope. Would you have her go to the ER to get an MRI with a DWI? And it was just one eye, right? Is it the same eye she gets her a MRI? They alternate. I think she needs a workup with hyperglobal ability, hyperdiscosity, anti-phosphorylid antibodies. Okay. EKG and blood pressure. Okay, blood pressure, very good, it was normal. Dr. Tabin also got a visual field, which was basically normal. And then she got an MRI and an MRA that day, which was normal. And then, you know, she discussed it, you know, with the neuroophthalmology team, and they decided not to get a hyperglobal ability workup. And then the patient came back to clinic to see Dr. Katz, and he felt that it was most likely vasospasm, retinal vasospasm, which you'll talk about. Okay, another case. This is a 40-year-old guy with vision loss in the left eye. He never had any headaches, or like childhood car sickness, or childhood abdominal pain, or anyone in his, no one in his family has migraines. But just a few weeks ago, he diagnosed himself with migraines because he's had some squiggles, which were followed by headache. And he looked, Googled it, he's like, okay, I have migraine, I'm fine. And then, but one day, he got a really, really bad headache, and his vision like almost totally went black in the left eye, suddenly. And it got better within a day. And then he has no medical history, anything like that. He went to Instacare. If you were the Instacare doctor, what would you do? I exam, I exam, I exam's normal. No ophthalmologist was consultant. That's a transfer. Call the Transfer Center, okay. What would you, initial test would you order before calling the Transfer Center? I mean, in these series of events happened at the age of 40, he's never had this at all when he was younger. Probably get a scan. What kind of scan would you get? I mean, at this point, just in an acute phase, if MRI, if MRI is available, I would get one. But if you're worried about, if you said like, you had a really bad headache, the worst headache ever, CP scan for that one, are you okay? Right, I think that might be appropriate for an initial workup, just to make sure he doesn't have like bleed, you know, or something like that. But in any case, he got a non-contrast CT and then that was normal. So he got discharged from the Instacare. And then he came back with an even more severe headache and being NLP in that eye permanently. From a carotid dissection with total thrombus of the left internal carotid. Do you have trauma or anything? No. I think he had said. You know, others like, you know, other associated noses, spontaneous. Yeah. So. No, no, no, no, no, no, no. I think he said something like, he got like, I don't know. There was something like months prior, which sounded unlikely to cause, I don't remember exactly what it was. You could get a dissection for client issues. No. No, no, no, no. I don't know. I don't know. Give me your hair fix. I saw that you had some. That's well described as well. Oh, no. It's scary on this. It's scary as well. You got one vessel sitting exactly on this. It's scary. Okay. He did have some irregularities with his right internal carotid, which they felt like could have been FMD or fibromuscular displacement. But anyway. So wait, so what's the exact mechanism? They had a dissection through a clock. No, it's like the dissection closed off, I think his, like, blocked off and all flow. He had distal, like, it was like, there was no flow. But then there was distal circulation. Okay. Well, that's a little more than what it was. Give me your hair fix. Yeah, so that's kind of scary. Anyway, okay, there's another one. Here, 98-year-old female. These are all from your call? Yeah. Wow. 98-year-old female with sudden vision loss. I got, it got kind of exciting last night. So, when I was just like, last night. No, no, no, no, no, no, no, no, no, no, no, no, no. Whoa. No, I keep these, like, books of all the patients that I see on call, so I was looking back through them. So, this was a 98-year-old female. She had sudden vision loss and that left eye. She has a history of aphib, aortic stenosis, breast cancer, hypothyroidism, AMD, and pseudophakia. And she said it got, like, so blurry she couldn't, like, see any letters through it. But by the time I saw her, oh, actually, by the time she presented in the ER, she said it gradually improved over a few hours, but it didn't get all the way back to normal, so that's why she came into the ER. So, you know, she takes digoxin, corvettol, aspirin, synthroid. So, she showed up to the ER and they were like, okay, this is like, she's got lots of risk factors. She's 98, like, we're gonna go down the amrosis route right away. Neurology saw her, like, wrote her consult. She was, like, being, she had had her CT and CTA and she's being wheeled back to the MRI. And I was like, wait, can I look at her eye before we MRI her? So, her, and her intraocular pressure was 27. She had four-plus RBCs and a vitreous hemorrhage as well. And so, I was like, I don't think we need the MRI. I think this is, you know, there's a clear absolving cause, so I think that was a good, I know we feel like they should consult us less often, but maybe sometimes they need to consult us more often. Like, I really think anyone with severe vision loss in one eye needs to do my exam. But maybe that's not available in every ER. And they're like, Park City ER, they're not gonna get it off them all. Like, do they even have a neurologist at Park City ER? I don't think so. So, anyway. Interestingly, the patient has continued to have similar vision loss episodes, but she hasn't come in acutely for it. And then by the time Shakur sees her, like, two days later, everything's normal. She also has really bad dry eyes, but she definitely did have vitreous hemorrhage when I saw her. Okay, so here's some quiz questions. I just want to say on that case, so always, you know, 98 foam separates the ERP. Yeah. You know, just flush. Okay. And even though that isn't it, it's just that each room is such high risk. Yes. So this was due to a vitreous hemorrhage. And hyphae, microhyphaeema. Spontaneous. It wasn't like leakage of the blood from the vitreous into the, or from the posterior fundus. To the anterior tumor. Yeah, I think so. Or that's what it was, okay. Yeah. Or maybe UGG syndrome. But we don't know, like, she didn't have any, like, you know, cause for the thing. But anyway, it keeps happening too. All right, so quiz. Platelet fibrin plaques are usually found in this location. Distal or proximal? Yeah. No, your answer is five minutes. Okay. Fluorescent angiography and temporal arthritis can demonstrate delayed choroidal filling, delayed retinal filling, or delayed optic disc filling for all of the above. And then you see a 70 year old male with a history of atrial fibrillation who tells you he totally lost vision in his right eye for 30 minutes yesterday. A gray curtain descended and then the grayness gradually dissipated. He feels well otherwise. His eye exam is totally normal. What should you do? A, order a crowded Doppler to be done within the next week. B, call Interventional Radiology to see if they want to do interarterial TPA. C, check blood pressure and send the patient to the ER and request a neurology consult. D, call Laura Hansen and ask her what to do. For sure, D. Yeah, it's D, no question about it. Okay. Oh. We're going in the answer. Do you need more time to look? Oh yeah, so the answer is, for this one, I'd say C and D are correct either one. If you chose either one, you're okay. Okay. And then bi-brim plaques are distal, classically. And you can have delayed feeling of all those areas in temporal arthritis.