What is the best course of action for an adult patient with recurring episodes of unprovoked blurred vision, lasting a couple of minutes, that have been increasing in frequency over the past year?

Urgent Neurological and Ophthalmological Evaluation Required

This patient requires immediate comprehensive ophthalmological examination with urgent neuroimaging to rule out life-threatening causes of transient visual obscurations, particularly raised intracranial pressure with papilledema or transient ischemic attacks.

Critical Diagnostic Distinction

The key to managing this patient lies in determining whether these episodes represent:

• Transient visual obscurations (TVOs) - lasting seconds, indicating optic nerve head ischemia from raised intracranial pressure 1
• Transient monocular vision loss (TMVL/amaurosis fugax) - lasting minutes with "shade descending" description, indicating retinal vascular ischemia requiring urgent stroke workup 1
• Exercise-induced or physiologic corneal edema - lasting minutes to hours with "blurring/fogging" description 1

The duration of "a couple of minutes" and increasing frequency over one year raises serious concern for either TMVL (stroke risk) or evolving papilledema (intracranial pressure). 1

Immediate Evaluation Protocol

History Details to Establish Urgently

• Exact duration: Seconds (TVOs/papilledema) versus minutes (TMVL/stroke) versus minutes-to-hours (corneal edema) 1
• Description of vision loss: "Dimming/darkening" (optic nerve ischemia), "shade descending" (retinal ischemia), or "blurring/fogging" (corneal pathology) 1
• Unilateral versus bilateral: Unilateral TMVL requires immediate stroke center referral 1
• Associated symptoms: Headache, pulsatile tinnitus (suggests idiopathic intracranial hypertension), eye pain, periorbital pain (acute angle closure glaucoma) 1, 2
• Positional triggers: Worse with postural changes or Valsalva (papilledema) 1
• Vascular risk factors: Diabetes, hypertension, hyperlipidemia, smoking (increases stroke/TMVL risk) 3
• Medication history: Topiramate causes acute myopia with secondary angle closure glaucoma within 1 month of initiation 2

Mandatory Examination Components

Comprehensive adult medical eye examination is required, not routine screening. 3

• Visual acuity with pinhole testing: Improvement with pinhole suggests refractive error rather than serious pathology 4
• Intraocular pressure measurement: Essential to identify acute angle closure glaucoma or elevated IOP from topiramate 1, 2
• Pupillary examination: Relative afferent pupillary defect indicates optic nerve pathology 4
• Slit-lamp biomicroscopy: Identifies corneal edema, anterior chamber shallowing, guttae suggesting Fuchs dystrophy 1
• Dilated fundus examination: Critical to identify papilledema (optic disc edema), retinal emboli, or retinal whitening 1
• Visual field testing by confrontation: Visual field deficits with blurred vision suggest stroke or intracranial pathology 5
• Extraocular motility: Diplopia with strabismus suggests cranial neuropathy from raised intracranial pressure or vascular event 3

Management Algorithm Based on Findings

If Papilledema Identified on Fundus Exam

• Urgent brain MRI with gadolinium and MR venography to evaluate for idiopathic intracranial hypertension, venous sinus thrombosis, or mass lesion 3
• Immediate neurology or neuro-ophthalmology referral 1
• TVOs with papilledema indicate raised intracranial pressure requiring urgent treatment to prevent permanent vision loss 1

If Normal Fundus Exam But TMVL Suspected (Minutes Duration, "Shade" Description)

• Immediate referral to stroke center with brain DWI-MRI, vascular imaging (carotid ultrasound, CTA, or MRA), cardiac evaluation, and full stroke protocol workup 1
• TMVL represents retinal vascular ischemia and is a stroke warning sign requiring urgent intervention 1

If Acute Myopia With Angle Closure (Eye Pain, Elevated IOP, Myopia)

• Discontinue topiramate immediately if patient is taking it - this is the primary treatment 2
• Topiramate causes acute myopia with secondary angle closure glaucoma, typically within 1 month of starting therapy 2
• Symptoms include acute decreased visual acuity, ocular pain, myopia, anterior chamber shallowing, and elevated IOP 2
• Avoid miotics in topiramate-induced angle closure - treatment is drug discontinuation, not the usual angle closure management 2

If Refractive Error Suspected (Improves With Pinhole, No Red Flags)

• Cycloplegic refraction is indicated when symptoms are inconsistent with manifest refraction or accommodation cannot be relaxed 3
• Presbyopia beginning around age 40-45 years causes difficulty with near vision but would not cause transient episodes 3, 6
• However, isolated refractive error does not explain transient, episodic symptoms lasting minutes 3

If Examination Completely Normal

• This does not exclude serious pathology - excellent visual acuity does not preclude serious eye disease 3
• Recurrent transient visual symptoms with normal examination require provocative testing or extended monitoring 1
• Consider 24-hour ambulatory blood pressure monitoring, hypercoagulability workup, and cardiac evaluation for embolic sources 1

Critical Pitfalls to Avoid

Do not attribute transient visual symptoms to refractive error or "eye strain" without excluding serious pathology. 3

• Small refractive changes in asymptomatic patients generally do not require correction and would not cause episodic symptoms 3
• A suddenly acquired refractive change may signal systemic or local disease 3
• The increasing frequency over one year suggests progressive pathology, not stable refractive error 3

Do not delay neuroimaging if papilledema is present or if TMVL is suspected. 1

• TVOs with papilledema can lead to permanent vision loss if raised intracranial pressure is not treated urgently 1
• TMVL requires immediate stroke workup as it represents retinal ischemia 1

Do not miss medication-induced causes, particularly topiramate. 2

• Topiramate causes acute myopia and secondary angle closure glaucoma, with symptoms of acute vision loss and eye pain 2
• Elevated IOP from any cause, if untreated, can lead to permanent vision loss 2

Recommended Examination Frequency Going Forward

Once serious pathology is excluded, the American Academy of Ophthalmology recommends comprehensive medical eye examinations at intervals based on age for asymptomatic patients without risk factors 3:

• Under 40 years: every 5-10 years 3
• 40-54 years: every 2-4 years 3
• 55-64 years: every 1-3 years 3
• 65 years or older: every 1-2 years 3

However, this patient is symptomatic with increasing frequency of episodes, requiring immediate evaluation rather than routine screening intervals. 3