| Transcript |
So today, we're going to talk a little bit about transient vision loss, also known as transient monocular blindness, or if you're a fan of Latin and Greek, amaurosis fugax. And there's another video on transient vision loss, but I just want to talk to you about what features I use to say, ‘this person needs to come to the hospital' versus ‘this person can be worked up as an outpatient'. And, as you w- might expect, when you have a transient anything, the exam for the ophthalmologist is usually normal unless they're having a residual. So, this disconnect is what creates the problem. It's- you're completely dependent on the history now because the exam does not help. I would do a visual field here just to make sure that there's not a residual deficit- either a homonymous hemianopsia or an altitudinal that would suggest an arterial occlusion or look for Hollenhorst plaque- but usually we don't see anything because it's transient. And so, the things that we're using- and there's a lot of disagreement about the validity of ABCD2, but I think it's a useful structure to use. And the ‘A' stands for ‘age'. So the older the patient is, the more likely they are to be in the vasculopathic age range, and that means the more likely they are to have a stroke risk factor. So, you can debate about the age- 60, 65- but the older you are, the- the- the more likely you are to have a problem from ischemia. If they're hypertensive, we'd like to know what their blood pressure is. So, just having that they are hypertensive isn't enough because what we need to know is, ‘Is it well controlled or poorly controlled?' and ‘How much blood pressure are we talking about?'. So, if the elevation is above 140 systolic, we're really talking about getting a ‘B' in the ABCD criterion. The patient is going to have other risk factors other than blood pressure, which is diabetes, and we're going to want to know about the duration of the vision loss. So, when we're dealing with ABCD2, we have criteria that the patient tells us about and should be loaded into the stem. The ‘C' is actually their chief complaint, which is clinical. So, nobody is not going to recognize that a transient vision loss with a transient hemiparesis needs to go to the emergency room- that is a hemispheric TIA- or ‘I couldn't speak'. So, the hemiparesis is worth two points in the ABCD2. But, that's not really that helpful to ophthalmologists because no ophthalmologistis not going to send an aphasic or a hemiparetic person to the emergency room. The person that we're most inclined to blow off or get in trouble with is when there's no ‘C' because their ‘C' is only transient vision loss. And so to me, ABCD2 should be applied to transient vision loss with the ‘C' not being hemiparesis or aphasia, but transient monocular blindness. The ‘D' is the duration- and so if we're minutes, especially more than 60 minutes, we're really worried about that being ischemic. And the other ‘D'- the ‘D2'- is diabetes. So, if we construct a stem, who would be the highest risk of having a stroke in the next two days, or in the next seven days, or in the next week, or two weeks, or 90 days- and you can look at the ABCD2 data and see what kind of numbers we're talking about. But if your score is low- and you get to get a point for each of these- a point for your age, a point for your blood pressure, a point for diabetes, a point for the duration or two points if it's more than 60 minutes, and a point for the clinical complaint- aphasia or the- the worst one, hemiparesis, two points. Once you start getting the scores that are greater than 4, that is a moderate risk for having a stroke in the next two days- even if their chief complaint was transient vision loss, even if their exam was totally normal. That person, we really should be calling the stroke service. If it's a 7 or a 6, just go to the emergency room, go to the stroke service. If it's a 0 to 3, well then, you have a decision about whether that can be worked up as an outpatient or not, but I would still call the stroke doctor to let them adjudicate it. I would call the stroke doctor here, too*, because then it becomes a duration, but not a duration of the event- a duration in terms of how long the symptoms have been there for. So, the highest risk is actually in the first two days to the first 90 days. That's- that's the risk. And you have an in-between risk in the next seven days. And that kind of decision really, an ophthalmologist shouldn't be making. So, in transient vision loss as a clinical chief complaint, if they're hemiparetic or aphasic, go to the emergency room; that's not the one we miss. Because it's transient, the exam is usually normal. You need to take into account ABCD2, which is their age, their blood pressure, whether they have diabetes or not, and the duration of the symptoms. If you get a number on ABCD2 that is above 4, but certainly if you're 6 or 7, you need to go to the emergency room and stroke service needs to adjudicate whether they have an inpatient or outpatient evaluation. And probably stroke service should even hear about it if it's a 0 to 3." *Note: referring to the score of >4 |
