What is the likelihood of an acute Cerebrovascular Accident (CVA) with sudden unilateral blindness in one eye?

From the Guidelines

Sudden unilateral blindness in one eye is more likely associated with retinal or optic nerve pathology, such as central retinal artery occlusion, rather than an acute cerebrovascular accident (CVA). While a CVA can cause visual field defects, complete blindness in one eye typically suggests conditions like central retinal artery occlusion, retinal detachment, or anterior ischemic optic neuropathy 1. A true CVA affecting vision usually causes homonymous hemianopia (loss of the same half of the visual field in both eyes) because visual pathways beyond the optic chiasm affect both eyes.

If a patient presents with sudden monocular blindness, immediate medical attention is required as it could represent an ocular emergency or a transient ischemic attack (TIA) that might precede a stroke. The most common vascular cause of sudden monocular vision loss is central retinal artery occlusion, which requires urgent treatment within hours of onset 1. Patients with sudden vision loss should undergo immediate ophthalmologic evaluation, neuroimaging, and vascular studies to determine the cause and appropriate treatment.

Some key points to consider in the management of sudden unilateral blindness include:

• The risk of stroke is associated with transient monocular blindness, and the 3-year risk of stroke with medical treatment alone is related to the number of stroke risk factors (hypertension, hypercholesterolemia, diabetes, and cigarette smoking) 1.
• Central retinal artery occlusion is a form of acute ischemic stroke, and its management involves acute therapy and cardiovascular secondary prevention strategies 1.
• Acute retinal arterial ischemia, including vascular transient monocular vision loss and branch and central retinal arterial occlusions, are ocular and systemic emergencies requiring immediate diagnosis and treatment 1.

Risk factors for both ocular vascular events and CVAs include hypertension, diabetes, smoking, hyperlipidemia, and atrial fibrillation, so addressing these underlying conditions is essential for prevention 1.

From the Research

Likelihood of Acute CVA with Sudden Right Eye Blindness

• The likelihood of an acute Cerebrovascular Accident (CVA) with sudden unilateral blindness in one eye is a significant concern, as it can be a symptom of a transient ischemic attack (TIA) or a stroke 2.
• Transient monocular blindness, which is an acute episode of ischemic origin in one eye, is often a sign of retinal ischemia secondary to carotid embolism or other vascular causes 2.
• Studies have shown that patients with atrial fibrillation who undergo carotid angioplasty and stenting (CAS) are at risk of stroke and other vascular events, highlighting the importance of appropriate antithrombotic therapy 3, 4, 5.
• The choice of antithrombotic therapy for patients with atrial fibrillation undergoing CAS is crucial, with some studies suggesting that a combination of antiplatelet and anticoagulation agents may be beneficial in reducing mortality and vascular events 5.
• Sudden loss of vision can be caused by various factors, including abnormalities in the retina, optic nerve, or visual center in the occipital lobe, and requires prompt medical attention to determine the underlying cause and prevent further complications 6.

Key Findings

• Transient monocular blindness is a transient ischemic attack originating in the carotid arteries and requires management similar to a TIA involving the brain to prevent a subsequent stroke 2.
• Carotid endarterectomy is usually preferred over CAS for patients with atrial fibrillation, but CAS can be safely performed in selected patients with appropriate antithrombotic therapy 3.
• The optimal anticoagulation strategy for patients with atrial fibrillation after carotid endarterectomy is unclear, but a combination of warfarin and aspirin may be feasible 4.
• Real-world data suggests that anticoagulation therapy after CAS may be suitable for patients with nonvalvular atrial fibrillation, with a combination of antiplatelet and anticoagulation agents potentially reducing mortality and vascular events 5.