 So we're gonna talk a little bit about transient visual loss. Let's just start by defining what it is. So it's a sudden loss of visual function. It could be partial or complete in one or both eyes. However, it lasts less than 24 hours, so that's the key right there. Most common cause of monocular transient vision loss is retinal schema due to carotid artery disease, and the most common cause of binocular transient visual loss is migraine. Just remember that. And as you always hear, you know, Dr. DeGruy and Warner always belabor this point about obtaining a good history. This is the key to making the diagnosis. This is not like, you know, it's not just in their ophthalmology, but it's also in UVI it is, and one of the more complicated sub-specialties. But the history is very, very important. It's alive and well in ophthalmology. So a little bit about the some key points when you're taking the history. Monocular versus binocular visual loss, it helps to localize the lesion. Typically, if it's a monocular issue, you always think about a lesion that's that's pre-chiasmal, and if it's binocular, think about chiasma or retrochiasma. You should also be aware that, you know, when patients experience a transient monomous hemianopia, they a lot of times describe it as monocular vision loss. However, it's usually in the eye where it has the or is experiencing temporal deficit. Okay, so keep that in mind. Age is also important to believe if they're younger than 50 years old, think a lot of, you know, think horses, not zebras, so migraine, vasospasm. However, in pregnant women, you should always consider the diagnosis of eclampsia. It's typically occurs, you know, right around the times, the time of delivery, and it's due to a more serious pathogenic cause, something known as vasogenic edema, edema of the occipital cortex. So remember that. Older than 50 years old, think about cerebrovascular disease or giant cell artery, right? It's typically if they're even, you know, older than like 60. All right, so duration of vision loss is actually very important as well. So if it's lasting seconds and it's associated with changes in posture, think about optic disc drusen or papillodema. If it's monocular lasting several minutes, but no more than 15, think about ipsolatal internal carotid artery stenosis. If it's binocular lasting 20, 30 minutes with scintillating scatomas, you would, everybody in this room would think about migraines. However, retinal artery spasm, this is something I wasn't really familiar with, but this can present, I mean, this kind of, it kind of throws, you know, a curveball in your diagnosis or your differential because it can last from seconds to an hour as well. So this is something to consider. Here's a good chart, thinking about, you know, your differential, depending on how long the vision loss lasts. And I can send you guys this slide afterwards. It can help you when you're seeing patients with vision loss, but it typically happens for, you know, a couple of seconds. Think about tear film abnormalities, papillodema, optic nerve hitches, and what we spoke about, some congenital anomalies of the disc. Think about a large PVD, especially when it moves with the eye movement, as well as gaze evoked hemorrhosis. Does anybody know what that is? Chris, you'll talk about it. Perfect. Perfect. Okay. And then minutes. I don't want to steal any thunder from Eileen or Julia, but a lot of the vascular pathic causes, you should think about that hypercoagulable conditions, cardiac abnormalities, utophth phenomenon. I don't know if either of you are going to be covering you. I'll be covering that. Okay, great. Pattern of visual loss and recovery is also important. Monocular descending curtain, tunnel-like constriction, sudden loss of vision. Think about retinal emboli, altitudinal aspect of visual loss. Think about carotid artery disease, vasospasm, or Naion. It's classically, you can see it. As well as vision loss precipitated by exercise. Think about vasospasm and demyelinating disease. And Julia said that she's going to elaborate a little bit more about Udhoff's phenomenon, but this is typically seen in patients with a demyelinating disease where they get transient visual blurring with activity or elevation of their body temperature. A little bit more. You should always think about the posterior circulation, particularly ischemia occurring there when they have complete simultaneous bilateral visual loss or hamonomes, hemianopia. And this is something I didn't know of. There was that binocular visual disturbance that's described with a geometric quality, typically this hexagonal chicken wire pattern. Think about occipital lobe dysfunction. Some associated symptoms and additional signs, positive visual phenomenon associated with headache as the classic migraine. If you have persistent headache with intra-cranial noises like a pulsatile tinnitus, you always think about increased intra-cranial pressure. GCA, everybody probably had this beaten into their heads about scalp tenderness, jaw colotication, headache, weight loss, fever, a lot of the other constitutional symptoms. You also get loss of consciousness associated with dizziness, diplopia, dysarthria, a lot of the bulbar symptoms. Think about global perfusion problems, typically affecting the brainstem or the cortex. And the skin and joint changes, renaughts phenomenon. Think about collagen vascular diseases as well. Some pertinent points that you want to pick up from the past medical history. Ask about vascular pathogryst factors, hypertension, diabetes, hyperlipidine and carotid stenosis, hypercoagulable risk factors, their migraine history, their smoking history, if there's increased risk for clots, recent surgery, their medication history, typically more importantly, their oral contraceptive pills or hormone replacement therapy, which makes them more coagulopathic, IV drug use, recent trauma, any congenital heart defects or acquired heart defects as well as demyelinating diseases. Examination, as many of you have already gone through the neurophemology rotation, you always want to do a full exam most of the time. Most of the time, you guys are probably going to see the patients in the ED, so just check everything. So from their visual acuity, their fields, extracurricular movements, Dr. Bird's going to talk a little bit more about the gaze about the amaurosis and the significance of that, but that's also important as well. Any abnormalities and movements, it's important as well. Color vision, pupils, DFE, and the photo stress recovery test. Can anybody tell me, Chris, can you tell me what the photo stress recovery test is? So you basically hold the lights for a certain amount of time and see how quickly vision recovers should be like 10 to 15 seconds. 45 seconds. Yeah. What's the cutoff for? So what does it help you distinguish? So whether it's like retina pathology or macular pathology versus optic nerve. Yeah. And the cutoff, do you know if it's a macular or retina problem? 90 seconds. Typically 90. If it's more than 90 seconds, you think more of a retina pathology. So examination, here's a good chart. Think about differential depending on your examination findings. So if you have a normal ocular or neurothalamic exam, migraine, intravascular embolus, that's already cleared, retinal arterial vasospasm or retinal optic nerve hyperprofusion due to systemic hypertension. The thing that I did not know about with retinal vasospasm is that if there's an acute episode and you actually look at the fundus, you can see retinal arterial constriction. Is that true, Dr. Degree? Have you ever seen that? Perfect. Great. So we won't have to talk about that good. No, no, no. I mean, that's why I mean, my part was just an overview. So I didn't want to steal anybody's thunder. And then yeah, so I'm not going to go into these, these other findings because Julie is going to talk about that. And these are just some common nonvascular ocular causes of vision loss of tear film abnormalities, corneal disease, recurrent hyphemes, something I also thought about was like uveidities as well, something you should think about. Angle closure glaucoma, vitreous debris, macular disease, and a lot of the optic nerve problems that we already kind of covered at this point. So just quick quiz. And then I just want to say something about because this will be the only time you cover the ocular causes. Yesterday in clinic, we had a woman who had numerous complaints and numerous types of ocular visual loss. But but hurdles have come and went in monocular and binocular. The tear film don't, don't just call it tear film because it's really very heavy. All right, everybody done. Next one. Ready with that one. Everybody done? Got those. Alright, so question number one. What is it? You call it out? Anybody? Yeah. Number two. Well, I have to say it's a big comment. But these are the way you have to distinguish it like that woman. I said, could you she goes, Well, it's blurred. I said, but could you see print? You know, through this work. And yes, she could. It was, you know, I have to say it's it's so common. And I've seen people get worked up for my carotid. And utop phenomenon. Someone tell me what that is. Absolutely perfect. Last but not least. Call him out. Good tunnel vision. Good. And last