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Amaurosis fugax (transient monocular or binocular visual loss)

Authors
Syndee Givre, MD, PhD
Gregory P Van Stavern, MD
Section Editors
Paul W Brazis, MD
Jonathan Trobe, MD
Deputy Editor
Janet L Wilterdink, MD

INTRODUCTION AND DEFINITIONS

Amaurosis fugax (from the Greek "amaurosis," meaning dark, and the Latin "fugax," meaning fleeting) refers to a transient loss of vision in one or both eyes [1]. Varied use of common terminology may cause some confusion when reading the literature. Some suggest that "amaurosis fugax" implies a vascular cause for the visual loss [2], but the term continues to be used when describing visual loss from any origin and involving one or both eyes. The term "transient monocular blindness" is also often used but is not ideal, since most patients do not experience complete loss of vision with the episode [3]. "Transient monocular visual loss" (TMVL) and "transient binocular visual loss" (TBVL) are preferred to describe abrupt and temporary loss of vision in one or both eyes, since they carry no connotation regarding etiology.

Transient visual loss, either monocular or binocular, reflects a heterogeneous group of disorders, some relatively benign and others with grave neurologic or ophthalmologic implications. The task of the clinician is to use the history and examination to localize the problem to a region in the visual pathways, identify potential etiologies, and, when indicated, perform a focused battery of laboratory tests to confirm or exclude certain causes. Therapeutic interventions and prognostic implications are specific to the underlying cause.

This topic discusses transient visual loss. Other ocular and cerebral ischemic syndromes are discussed separately. (See "Central and branch retinal artery occlusion" and "Posterior circulation cerebrovascular syndromes".)

APPROACH TO TRANSIENT VISUAL LOSS

By definition, patients with transient visual loss almost always present after the episode has resolved; hence, the neurologic and ophthalmologic examination is usually normal. Reliance is placed on the patient's description of the nature of the visual symptoms and associated features (table 1). Pertinent medical and family history may also provide valuable clues to the underlying diagnosis.

Few case series of patients with transient visual loss are reported. Details from the Framingham cohort provide some interesting insights into the challenges of evaluating this symptom. Between 1971 and 1989, participants were systematically questioned regarding specific symptoms of transient ischemic attack (TIA) and stroke; 186 of 2110 subjects reported onset of a sudden visual deficit (not necessarily transient) [4]. Follow-up evaluation determined the underlying cause to be stroke or TIA (24 percent), ocular disease (17 percent), transient monocular blindness (10 percent), and migraine (14 percent). The cause remained unknown in 22 percent, and a miscellany of etiologies comprised the remaining 12 percent.

                            

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Literature review current through: Nov 2016. | This topic last updated: Fri Jan 31 00:00:00 GMT 2014.
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References
Top
  1. Bernstein EF. Amaurosis fugax, Springer-Verlag, New York 1987. p.286.
  2. Fisher CM. 'Transient monocular blindness' versus 'amaurosis fugax'. Neurology 1989; 39:1622.
  3. Biousse V, Trobe JD. Transient monocular visual loss. Am J Ophthalmol 2005; 140:717.
  4. Tippin J, Corbett JJ, Kerber RE, et al. Amaurosis fugax and ocular infarction in adolescents and young adults. Ann Neurol 1989; 26:69.
  5. Lavallée PC, Cabrejo L, Labreuche J, et al. Spectrum of transient visual symptoms in a transient ischemic attack cohort. Stroke 2013; 44:3312.
  6. Donders RC, Dutch TMB Study Group. Clinical features of transient monocular blindness and the likelihood of atherosclerotic lesions of the internal carotid artery. J Neurol Neurosurg Psychiatry 2001; 71:247.
  7. Pessin MS, Duncan GW, Mohr JP, Poskanzer DC. Clinical and angiographic features of carotid transient ischemic attacks. N Engl J Med 1977; 296:358.
  8. Marshall J, Meadows S. The natural history of amaurosis fugax. Brain 1968; 91:419.
  9. Burde RM. Amaurosis fugax. An overview. J Clin Neuroophthalmol 1989; 9:185.
  10. Richard, KT, Chan, L, Fleming, JF, et al, for the NASCET Group, London, Ontario Canada. Neurology 1996; 46:A392.
  11. Hoyt WF. Ocular symptoms and signs. In: Extracranial Occlusive Cerebrovascular Disease Diagnosis and Management, Wylie EJ, Ehrenfeld W. (Eds), WB Saunders, Philadelphia 1970. p.64.
  12. Lord RS. Transient monocular blindness. Aust N Z J Ophthalmol 1990; 18:299.
  13. Newman NJ. Cerebrovascular disease. In: Walsh and Hoyt's Clinical Neuro-ophthalmology, 5th, Miller NR, Newman NJ. (Eds), Lippincott, Williams & Wilkins, Baltimore 1998. p.3323.
  14. Fisher CM. Late-life migraine accompaniments as a cause of unexplained transient ischemic attacks. Can J Neurol Sci 1980; 7:9.
  15. Kosmorsky GS, Rosenfeld SI, Burde RM. Transient monocular obscuration--?amaurosis fugax: a case report. Br J Ophthalmol 1985; 69:688.
  16. Russell RW, Page NG. Critical perfusion of brain and retina. Brain 1983; 106 (Pt 2):419.
  17. Kaiboriboon K, Piriyawat P, Selhorst JB. Light-induced amaurosis fugax. Am J Ophthalmol 2001; 131:674.
  18. Furlan AJ, Whisnant JP, Kearns TP. Unilateral visual loss in bright light. An unusual symptom of carotid artery occlusive disease. Arch Neurol 1979; 36:675.
  19. Galetta SL, Balcer LJ, Liu GT. Giant cell arteritis with unusual flow-related neuro-ophthalmologic manifestations. Neurology 1997; 49:1463.
  20. Levin LA, Mootha VV. Postprandial transient visual loss. A symptom of critical carotid stenosis. Ophthalmology 1997; 104:397.
  21. Knapp ME, Flaharty PM, Sergott RC, et al. Gaze-induced amaurosis from central retinal artery compression. Ophthalmology 1992; 99:238.
  22. Jehn A, Frank Dettwiler B, Fleischhauer J, et al. Exercise-induced vasospastic amaurosis fugax. Arch Ophthalmol 2002; 120:220.
  23. Imes RK, Hoyt WF. Exercise-induced transient visual events in young healthy adults. J Clin Neuroophthalmol 1989; 9:178.
  24. Miller, NR. Embolic causes of transient monocular visual loss: Appearance, source, and assessment. In: Ophthalmology Clinics of North America, Katz, B (Ed), W.B. Saunders, Philadelphia 1996. p.359.
  25. Cugati S, Wang JJ, Rochtchina E, Mitchell P. Ten-year incidence of retinal emboli in an older population. Stroke 2006; 37:908.
  26. Wang JJ, Cugati S, Knudtson MD, et al. Retinal arteriolar emboli and long-term mortality: pooled data analysis from two older populations. Stroke 2006; 37:1833.
  27. Current management of amaurosis fugax. The Amaurosis Fugax Study Group. Stroke 1990; 21:201.
  28. Anderson DC, Kappelle LJ, Eliasziw M, et al. Occurrence of hemispheric and retinal ischemia in atrial fibrillation compared with carotid stenosis. Stroke 2002; 33:1963.
  29. Mead GE, Lewis SC, Wardlaw JM, Dennis MS. Comparison of risk factors in patients with transient and prolonged eye and brain ischemic syndromes. Stroke 2002; 33:2383.
  30. Hurwitz BJ, Heyman A, Wilkinson WE, et al. Comparison of amaurosis fugax and transient cerebral ischemia: a prospective clinical and arteriographic study. Ann Neurol 1985; 18:698.
  31. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325:445.
  32. Bruno A, Corbett JJ, Biller J, et al. Transient monocular visual loss patterns and associated vascular abnormalities. Stroke 1990; 21:34.
  33. Wilterdink JL, Easton JD. Vascular event rates in patients with atherosclerotic cerebrovascular disease. Arch Neurol 1992; 49:857.
  34. De Schryver EL, Algra A, Donders RC, et al. Type of stroke after transient monocular blindness or retinal infarction of presumed arterial origin. J Neurol Neurosurg Psychiatry 2006; 77:734.
  35. Benavente O, Eliasziw M, Streifler JY, et al. Prognosis after transient monocular blindness associated with carotid-artery stenosis. N Engl J Med 2001; 345:1084.
  36. Hayreh SS, Podhajsky PA, Zimmerman B. Ocular manifestations of giant cell arteritis. Am J Ophthalmol 1998; 125:509.
  37. Hayreh SS, Podhajsky PA, Zimmerman B. Occult giant cell arteritis: ocular manifestations. Am J Ophthalmol 1998; 125:521.
  38. Caselli RJ, Hunder GG, Whisnant JP. Neurologic disease in biopsy-proven giant cell (temporal) arteritis. Neurology 1988; 38:352.
  39. Wells M, Foroozan R. Transient visual loss may anticipate occipital infarction from hemodialysis. Am J Kidney Dis 2004; 43:e29.
  40. Luchi M, Warren KA, Saberhagen C, Hinthorn D. Transient visual loss due to severe anemia in a patient with AIDS. J La State Med Soc 1999; 151:82.
  41. Biousse, V. Cerebrovascular disease. In: Walsh and Hoyt's Clinical Neuro-ophthalmology, Vol 2, 6th ed, Miller, NR, Newman, NJ, Biousse, V, Kerrison, JB (Eds), Williams and Wilkins, Baltimore 2005. p.1967.
  42. Tatemichi TK, Chamorro A, Petty GW, et al. Hemodynamic role of ophthalmic artery collateral in internal carotid artery occlusion. Neurology 1990; 40:461.
  43. Mimura T, Funatsu H, Kitano S, et al. Diabetic retinopathy with repeated amaurosis fugax caused by orthostatic hypotension. Am J Ophthalmol 2003; 136:930.
  44. Schlingemann RO, Smit AA, Lunel HF, Hijdra A. Amaurosis fugax on standing and angle-closure glaucoma with clomipramine. Lancet 1996; 347:465.
  45. Asherson RA, Cervera R. Unusual manifestations of the antiphospholipid syndrome. Clin Rev Allergy Immunol 2003; 25:61.
  46. Digre KB, Durcan FJ, Branch DW, et al. Amaurosis fugax associated with antiphospholipid antibodies. Ann Neurol 1989; 25:228.
  47. Glueck CJ, Goldenberg N, Bell H, et al. Amaurosis fugax: associations with heritable thrombophilia. Clin Appl Thromb Hemost 2005; 11:235.
  48. Fry CL, Carter JE, Kanter MC, et al. Anterior ischemic optic neuropathy is not associated with carotid artery atherosclerosis. Stroke 1993; 24:539.
  49. Terao S, Takeda A, Miura N, et al. Clinical and pathophysiological features of amaurosis fugax in Japanese stroke patients. Intern Med 2000; 39:118.
  50. Cackett P, Weir C. Wegener's granulomatosis presenting with amaurosis fugax. Eye (Lond) 2002; 16:676.
  51. Libman RB, Masters SR, de Paola A, Mohr JP. Transient monocular blindness associated with cocaine abuse. Neurology 1993; 43:228.
  52. Ubogu E. Amaurosis fugax associated with phencyclidine inhalation. Eur Neurol 2001; 46:98.
  53. Pece A, Patelli F, Milani P, Pierro L. Transient visual loss after amyl Isobutyl nitrite abuse. Semin Ophthalmol 2004; 19:105.
  54. Hayreh, SS. Central retinal vein occlusion. In: The Eye and Systemic Disease, Edition 2, Mausolf, FA (Ed), CV Mosby, St. Louis 1980. p.223.
  55. Shuler RK Jr, Biousse V, Newman NJ. Transient monocular visual loss in two patients with impending central retinal vein occlusion. J Neuroophthalmol 2005; 25:152.
  56. Prisco D, Marcucci R. Retinal vein thrombosis: risk factors, pathogenesis and therapeutic approach. Pathophysiol Haemost Thromb 2002; 32:308.
  57. Biousse V, Newman NJ, Sternberg P Jr. Retinal vein occlusion and transient monocular visual loss associated with hyperhomocystinemia. Am J Ophthalmol 1997; 124:257.
  58. Cugati S, Wang JJ, Knudtson MD, et al. Retinal vein occlusion and vascular mortality: pooled data analysis of 2 population-based cohorts. Ophthalmology 2007; 114:520.
  59. O'Sullivan F, Rossor M, Elston JS. Amaurosis fugax in young people. Br J Ophthalmol 1992; 76:660.
  60. Slavin ML. Amaurosis fugax in the young. Surv Ophthalmol 1997; 41:481.
  61. Burger SK, Saul RF, Selhorst JB, Thurston SE. Transient monocular blindness caused by vasospasm. N Engl J Med 1991; 325:870.
  62. Winterkorn JM, Teman AJ. Recurrent attacks of amaurosis fugax treated with calcium channel blocker. Ann Neurol 1991; 30:423.
  63. Heckmann JG, Gaul C, Neundörfer B, et al. Vasospastic amaurosis fugax. J Neurol Neurosurg Psychiatry 2003; 74:149.
  64. Bernard GA, Bennett JL. Vasospastic amaurosis fugax. Arch Ophthalmol 1999; 117:1568.
  65. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24suppl1:9.
  66. Winterkorn JM, Kupersmith MJ, Wirtschafter JD, Forman S. Brief report: treatment of vasospastic amaurosis fugax with calcium-channel blockers. N Engl J Med 1993; 329:396.
  67. Flammer J, Pache M, Resink T. Vasospasm, its role in the pathogenesis of diseases with particular reference to the eye. Prog Retin Eye Res 2001; 20:319.
  68. Smith KJ, McDonald WI. The pathophysiology of multiple sclerosis: the mechanisms underlying the production of symptoms and the natural history of the disease. Philos Trans R Soc Lond B Biol Sci 1999; 354:1649.
  69. Beck, RW. Optic Neuritis. In: Walsh and Hoyt's Clinical Neuro-ophthalmology, 5th Ed, Miller, NR, Newman, NJ (Eds), Lippencott, Williams & Wilkins, Baltimore 1998. p.599.
  70. Lepore FE. Uhthoff's symptom in disorders of the anterior visual pathways. Neurology 1994; 44:1036.
  71. Sadun AA, Currie JN, Lessell S. Transient visual obscurations with elevated optic discs. Ann Neurol 1984; 16:489.
  72. Miller, NR. Papilledema. In: Walsh and Hoyt's Clinical Neuro-ophthalmology, 5th Ed, Miller, NR, Newman, NJ (Eds), Lippencott, Williams & Wilkins Baltimore 1998. p.487.
  73. Otto CS, Coppit GL, Mazzoli RA, et al. Gaze-evoked amaurosis: a report of five cases. Ophthalmology 2003; 110:322.
  74. Khan MA, Dhillon B. Epiphora due to Kaposi's sarcoma of the nasolacrimal duct. Br J Ophthalmol 1999; 83:501.
  75. Ravits J, Seybold ME. Transient monocular visual loss from narrow-angle glaucoma. Arch Neurol 1984; 41:991.
  76. Cates CA, Newman DK. Transient monocular visual loss due to uveitis-glaucoma-hyphaema (UGH) syndrome. J Neurol Neurosurg Psychiatry 1998; 65:131.
  77. Hsu HY, Chao AC, Chen YY, et al. Reflux of jugular and retrobulbar venous flow in transient monocular blindness. Ann Neurol 2008; 63:247.
  78. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24 Suppl 1:9.
  79. Leao, AA. Spreading depression of activity in the cerebral cortex. J Neurophysiol 1944; 7:359.
  80. Russell MB, Olesen J. A nosographic analysis of the migraine aura in a general population. Brain 1996; 119 ( Pt 2):355.
  81. Wijman CA, Wolf PA, Kase CS, et al. Migrainous visual accompaniments are not rare in late life: the Framingham Study. Stroke 1998; 29:1539.
  82. Bien CG, Benninger FO, Urbach H, et al. Localizing value of epileptic visual auras. Brain 2000; 123 ( Pt 2):244.
  83. Sadeh M, Goldhammer Y, Kuritsky A. Postictal blindness in adults. J Neurol Neurosurg Psychiatry 1983; 46:566.
  84. Barry E, Sussman NM, Bosley TM, Harner RN. Ictal blindness and status epilepticus amauroticus. Epilepsia 1985; 26:577.
  85. Pessin MS, Kwan ES, DeWitt LD, et al. Posterior cerebral artery stenosis. Ann Neurol 1987; 21:85.
  86. Tierney MC, Reid DW, Zorzitto ML, et al. The differential diagnosis of Alzheimer's disease: conceptual and methodological issues. Can J Neurol Sci 1986; 13:424.
  87. Biousse V, Touboul PJ, D'Anglejan-Chatillon J, et al. Ophthalmologic manifestations of internal carotid artery dissection. Am J Ophthalmol 1998; 126:565.
  88. Caplan LR, Wityk RJ, Glass TA, et al. New England Medical Center Posterior Circulation registry. Ann Neurol 2004; 56:389.
  89. Belden JR, Caplan LR, Pessin MS, Kwan E. Mechanisms and clinical features of posterior border-zone infarcts. Neurology 1999; 53:1312.
  90. Kramer M, Goldenberg-Cohen N, Shapira Y, et al. Role of transesophageal echocardiography in the evaluation of patients with retinal artery occlusion. Ophthalmology 2001; 108:1461.
  91. Kline, LB. The natural history of patients with amaurosis fugax. Ophthal Clin North Am 1996; 9:351.
  92. Newman, NJ. Evaluating the patient with transient monocular vision loss: the young vs the elderly. Ophthalmol Clin North Am 1996; 9:455.
  93. Biousse, V. Cerebrovascular disease. In: Walsh and Hoyt's Clinical Neuro-ophthalmology, Vol 2, 6th ed, Miller NR, Newman NJ, Biousse V, Kerrison JB (Eds), Williams and Wilkins, Baltimore 2005. p.1967.