What is the ongoing treatment for amaurosis fugax (transient monocular vision loss) after emergency management?

From the Guidelines

Ongoing treatment for amaurosis fugax after emergency care should prioritize antiplatelet therapy, risk factor modification, and consideration of carotid endarterectomy or stenting for significant carotid stenosis, as outlined in the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1.

Key Components of Treatment

• Antiplatelet therapy with aspirin 81-325 mg daily or clopidogrel 75 mg daily to reduce the risk of stroke and permanent blindness
• Risk factor modification, including:
  • Statin therapy (such as atorvastatin 40-80 mg daily) to achieve LDL levels below 70 mg/dL
  • Blood pressure control targeting <140/90 mmHg
  • Smoking cessation
  • Diabetes management if applicable
• Consideration of carotid endarterectomy or stenting for patients with significant carotid stenosis (>70%), ideally within 2 weeks of the initial event

Follow-up and Education

• Regular follow-up with both ophthalmology and neurology is recommended at 1,3, and 6 months initially, then annually
• Patients should be educated to immediately report any recurrent visual symptoms or new neurological deficits, as amaurosis fugax represents a warning sign for potential stroke

Underlying Cause

• The treatment aims to prevent progression to permanent vision loss or stroke by addressing the underlying cause, typically carotid artery disease or cardiac emboli, through reducing platelet aggregation, stabilizing atherosclerotic plaques, and eliminating modifiable risk factors, as discussed in the guideline 1.

From the Research

Ongoing Treatment for Amaurosis Fugax Post Emergency

• The management of amaurosis fugax (AF) should focus on stroke prevention strategies, which include general and specific measures 2.
• General measures include the initiation of appropriate antiplatelet therapy, encouraging a healthy lifestyle, and managing traditional risk factors, such as hypertension, dyslipidemia, and diabetes 2.
• Specific management measures require the identification of a specific AF etiology, such as moderate-severe symptomatic extracranial large vessel or intracranial steno-occlusive atherosclerotic disease, aortic arch atherosclerosis, and atrial fibrillation 2.
• Surgery may be recommended for patients with relatively focal atheroma confined to one proximal internal carotid artery, with excellent long-term results expected in a significant number of cases 3.
• Treatment of atherosclerosis, carotid artery disease, and other causes of AF are also discussed in the literature 4.

Risk Factors and Prevalence of Significant Carotid Stenosis

• Significant associations with risk of having ≥70% stenosis include male sex, current smoking, diabetes, and previous vasculitis 5.
• The prevalence of significant carotid stenosis in patients with AF is higher than has previously been demonstrated in stroke patients 5.
• Ocular findings are scarce, with only 1.7% of patients exhibiting retinal artery emboli at examination 5.

Delay Between Symptoms and Surgery

• A trend of longer delay for surgery was noted for patients first consulting a general practitioner compared to hospital-based specialties 6.
• Initially consulting an ophthalmologist does not delay the time to ultrasound or carotid endarterectomy 6.
• The overall time from symptoms to surgery is longer than recommended for a majority of the patients, especially for patients from rural areas and for patients initially consulting a general practitioner 6.