What is the appropriate work‑up and acute management for an 80‑year‑old woman who experienced a brief episode of unilateral visual blurring lasting several hours that resolved spontaneously?

Transient Monocular Vision Loss in an 80-Year-Old Woman

This patient requires immediate referral to an emergency department affiliated with a stroke center for urgent stroke workup, as transient monocular vision loss lasting hours represents a retinal vascular ischemic event (ocular TIA) with maximum stroke risk in the first few days. 1

Critical Initial Distinction

The duration and description of visual loss are diagnostically crucial:

• Transient monocular vision loss (TMVL) lasting minutes to hours with a "shade descending" description indicates retinal arterial ischemia requiring urgent stroke evaluation 1, 2
• Transient visual obscurations lasting only seconds (dimming/darkening) suggest optic nerve head ischemia from raised intracranial pressure, not vascular retinal ischemia 2
• Blurring lasting minutes to hours that resolves spontaneously may represent exercise-induced corneal edema from endothelial dysfunction 2

In this 80-year-old patient with symptoms lasting "few hours," the most likely diagnosis is TMVL from retinal vascular ischemia, which mandates immediate stroke workup regardless of spontaneous resolution. 1

Immediate Management Algorithm

Step 1: Ophthalmologic Confirmation (Same-Day)

• Perform dilated fundus examination to identify retinal emboli, retinal whitening, or optic disc changes 2
• Measure intraocular pressure to exclude acute angle closure 2
• Perform slit-lamp examination to exclude corneal pathology 2
• Once vascular TMVL is confirmed, immediately refer to ED—do not perform further testing yourself 1

Step 2: Emergency Department Evaluation (Within Hours)

The patient should be sent immediately to the nearest ED affiliated with a certified stroke center with a note stating "Ocular TIA" or "Ocular Stroke," and the center should be called ahead to warn them "a stroke patient is on the way." 1

The ED workup includes:

• Brain DWI-MRI to detect acute ischemic stroke 1, 2
• Vascular imaging (carotid ultrasound, CTA, or MRA) to identify carotid stenosis ≥50% requiring intervention 1
• Cardiac evaluation including ECG, telemetry monitoring, and echocardiography to identify embolic sources 1
• Laboratory testing as part of standard stroke protocol 1

Step 3: Observation and Disposition (23-Hour Protocol)

• Cardiac monitoring over 23-hour observation period in ED observation unit or stroke unit 1
• If embolic source requiring immediate treatment is identified (carotid stenosis ≥50% or cardiac emboli), admit to stroke unit 1
• If no cause identified after 24 hours, discharge with secondary stroke prevention measures 1

Mandatory Secondary Prevention at Discharge

All patients must be discharged with the following, regardless of whether a source is identified: 1

• Antiplatelet agent (start immediately, even if seen days after the event) 1
• Statin therapy for hyperlipidemia 1
• Blood pressure control 1
• Neurology follow-up with stroke expertise within 2 weeks 1

Critical Pitfalls to Avoid

Do Not Dismiss Based on Spontaneous Resolution

The stroke risk is maximum within the first few days after visual loss onset, making prompt diagnosis and triage mandatory even when symptoms have resolved. 1 Patients seen days after the episode still require urgent stroke workup, which can be obtained by a neurologist with stroke expertise as an outpatient if ED evaluation is delayed. 1

Do Not Attribute to Benign Causes Without Excluding Vascular Ischemia

• Do not attribute transient visual symptoms to refractive error or "eye strain" without excluding serious pathology 2
• Do not assume corneal edema or other benign causes in an 80-year-old with vascular risk factors without completing stroke workup 2

Rule Out Giant Cell Arteritis

In all patients with suspected vascular TMVL, inquire about systemic symptoms of giant cell arteritis (jaw claudication, scalp tenderness, temporal headache, polymyalgia rheumatica symptoms). 1 If present, this requires immediate high-dose corticosteroids and temporal artery biopsy, as this represents a different emergency pathway.

Special Considerations in the Elderly

At age 80, this patient has elevated baseline stroke risk, and the combination of age with transient monocular vision loss creates a medical emergency. 1 The presence of vascular risk factors (diabetes, hypertension, hyperlipidemia, smoking) further increases stroke risk and reinforces the need for urgent evaluation. 2

Even if the ophthalmologic examination is completely normal at presentation, the history of transient monocular vision loss lasting hours in an 80-year-old mandates full stroke workup. 1, 2