eMedicine Specialties > Ophthalmology > Ophthalmology for the General Practitioner
Sudden Visual Loss: Treatment & Medication
Updated: Mar 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Medical care for patients with sudden visual loss includes the following:
- Aspirin is believed to be beneficial in patients with no hemodynamically significant disease of the carotid artery (ie, greater than 1 mm residual lumen) or those who are poor surgical candidates.
- In general, aspirin together with modification of risk factors (eg, decreasing serum cholesterol level, controlling systemic hypertension) reduces the likelihood of myocardial infarction. It is also very effective in reducing the risk of stroke.
- Aspirin was once believed to be most effective in high doses, but recent evidence has shown that similar benefits can be achieved with low-dose aspirin at 81 mg a day.
- Advise patients with frequent or severe headaches to stop smoking. Women who smoke and take birth control pills are at increased risk for stroke.
- Clopidogrel (Plavix) has been shown to be effective in reducing the risk of stroke and, in a study comparing its efficacy to aspirin, was shown to be only minimally better. It can be used easily in patients who are aspirin intolerant. Whether the combination of clopidogrel plus aspirin is better than either medication alone is currently unknown.
- Aggrenox (aspirin plus dipyridamole) has been shown to be effective in reducing stroke risk. In a comparison with either agent alone, it was found to be significantly more effective.
- The recent results of the PROFESS trial showed that aspirin plus dipyridamole and clopidogrel were equivalent in efficacy. Either medication is an acceptable starting medication for the patient at risk for future stroke.
- Inferior retinal detachment is treated with the patient sitting up. Superior detachment is treated with the patient lying prone.
Surgical Care
- Carotid artery stenosis increases the risk of hemispheric stroke. This risk is greater after hemispheric ischemic symptoms than after retinal ischemic symptoms. Amaurosis fugax with a carotid stenosis of 70% or greater definitely increases a person's risk of stroke, but not as high as the risk if the ischemic symptoms were cerebral.
- Carotid endarterectomy subsequent to episodes of transient cerebral or retinal ischemia is known to reduce the risk of cerebral infarction. This effect is seen after cerebral ischemia with stenosis greater than 50%. It is seen after retinal ischemia only if stenosis is 70% or greater. Therefore, endarterectomy is advocated in the retinal patient only if the stenosis is 70% or greater while advocated for hemispheric events with stenosis of 50% or greater.
- Recommendations for this procedure must be individualized.
- It should be considered for patients with TMB or amaurosis fugax only if the surgical complication rate is less than 2%.
- For patients with cerebral transient ischemic attacks (TIAs), a complication rate of 3% or less is acceptable.
- Local arterial fibrinolysis for the treatment of central retinal artery occlusion (CRAO): A nonrandomized, single center, interventional study by Aldrich et al demonstrated improved visual acuity in patients who received local intra-arterial aliquots of tissue plasminogen activator (tPA). In this small study, 21 patients received 3 mg aliquots of intra-arterial tPA and 76% of these patients had improved visual acuity compared with 33% of the patients in the standard therapy group. The authors cautioned that because of the nonrandomized nature of this and previous studies, local arterial fibrinolysis cannot be recommended as standard therapy in daily clinical practice pending the publication of randomized clinical trials.3
Consultations
- Ophthalmic consultation is prudent in any case of sudden visual loss that cannot be easily and confidently explained and managed by emergency department physicians.
- Cardiac and neurologic consultation is recommended. A complete cardiac and neurologic examination, including murmurs and carotid bruits, should be performed.
Medication
The goals of pharmacotherapy in sudden visual loss are to reduce morbidity and prevent complications.
Antiplatelet agents
Inhibit platelet function perhaps by blocking cyclooxygenase and subsequent aggregation. Antiplatelet therapy has been shown to reduce mortality by reducing the risk of fatal strokes, fatal myocardial infarctions, and vascular death in patients at risk.
Aspirin (Anacin, Ascriptin, Bayer Aspirin)
Irreversibly inhibits the formation of cyclooxygenase, thus preventing the formation of thromboxane A2, a platelet aggregator and vasoconstrictor. Platelet inhibition lasts for the life of the cell (approximately 10 d).
Adult
65-325 mg PO qd
Pediatric
Not established
Antacids and urinary alkalinizers may decrease effects; corticosteroids decrease serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increase bleeding time; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome, do not use in children (<16 y) with flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Asthma, nasal polyps, severe carditis, hemophilia, telangiectasis, G-6-PD deficiency (since hemolysis can occur), preexisting hypoprothrombinemia, vitamin K deficiency, renal or hepatic dysfunction, patients receiving anticoagulants, and third trimester pregnancy
Clopidogrel (Plavix)
Selectively inhibits ADP binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation.
Adult
75 mg PO qd
Pediatric
Not established
Naproxen associated with increased occult GI blood loss; safety of coadministration with warfarin not established
Documented hypersensitivity; active pathological bleeding, such as peptic ulcer or intracranial hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolongs bleeding time; caution in patients at increased risk of bleeding from trauma, surgery, or other pathological conditions; caution in patients with lesions with propensity to bleed (such as ulcers)
Aggrenox (aspirin and dipyridamole)
Aspirin irreversibly inhibits formation of cyclooxygenase, thus preventing formation of thromboxane A2, a platelet aggregator and vasoconstrictor. Platelet-inhibition lasts for life of cell (approximately 10 d).
Dipyridamole is a platelet adhesion inhibitor that possibly inhibits RBC uptake of adenosine, itself an inhibitor of platelet reactivity. In addition, may inhibit phosphodiesterase activity leading to increased cyclic-3', 5'-adenosine monophosphate within platelets and formation of the potent platelet activator thromboxane A2.
Each tablet contains 25 mg aspirin and 200 mg dipyridamole for total of 50 mg aspirin and 400 mg dipyridamole per day.
Adult
1 tab PO bid
Pediatric
Not established
Aspirin: Antacids and urinary alkalinizers may decrease effects; corticosteroids decrease serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increase bleeding time; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Dipyridamole: Theophylline may decrease hypotensive effects; antiplatelet activity may increase heparin toxicity
Aspirin: Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association with Reye syndrome, do not use in children (<16 y) with flu
Dipyridamole: Documented hypersensitivity; active pathological bleeding, such as peptic ulcer or intracranial hemorrhage
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Aspirin: Asthma, nasal polyps, severe carditis, hemophilia, telangiectasis, G-6-PD deficiency (since hemolysis can occur), preexisting hypoprothrombinemia, vitamin K deficiency, renal or hepatic dysfunction, patients receiving anticoagulants, and third trimester pregnancy
Dipyridamole: Caution in hypotension; medication has peripheral vasodilating effects
More on Sudden Visual Loss |
| Overview: Sudden Visual Loss |
| Differential Diagnoses & Workup: Sudden Visual Loss |
 Treatment & Medication: Sudden Visual Loss |
| Follow-up: Sudden Visual Loss |
| References |
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References
Hedges TR. The terminology of transient visual loss due to vascular insufficiency. Stroke. Sep-Oct 1984;15(5):907-8. [Medline].
Wray SH. Visual aspects of extracranial internal carotid artery disease. In: Bernstein EF, ed. Amaurosis Fugax. New York: Springer-Verlag; 1988:72-80.
Aldrich EM, Lee AW, Chen CS, et al. Local intra-arterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience. Stroke. Jun 2008;39(6):1746-50. [Medline].
Bruno A, Corbett JJ, Biller J, Adams HP Jr, Qualls C. Transient monocular visual loss patterns and associated vascular abnormalities. Stroke. Jan 1990;21(1):34-9. [Medline].
Burde RM. Amaurosis fugax. An overview. J Clin Neuroophthalmol. Sep 1989;9(3):185-9. [Medline].
Carter JE. Chronic ocular ischemia and carotid vascular disease. In: Bernestein EF, ed. Amaurosis Fugax. New York: Springer-Verlag; 1988:118-134.
FDA. US Food and Drug Administration Center for Drug Evaluation and Research [Web site]. Available at http://www.fda.gov/cder/. Accessed November 2008.
Fisher CM. Observations of the fundus oculi in transient monocular blindness. Neurology. May 1959;9(5):333-47. [Medline].
Pfaffenbach DD, Hollenhorst RW. Morbidity and survivorship of patients with embolic cholesterol crystals in the ocular fundus. Am J Ophthalmol. Jan 1973;75(1):66-72. [Medline].
Further Reading
Keywords
sudden visual loss, sudden vision loss, acute visual dysfunction, transient visual loss, eye ischemia, transient visual obscuration, TVO, papilledema, increased intracranial pressure, amaurosis fugax, monocular blindness, partial blindness, total blindness, transient monocular visual loss, TMVL, transient monocular blindness, TMB, transient bilateral visual loss, TBVL, ocular infarction, ischemic damage to the eye, internal carotid artery disease, ICA disease, angle-closure glaucoma, central retinal artery occlusion, CRAO, branch retinal artery occlusion, BRAO, ischemia of the optic nerve, anterior ischemic optic neuropathy, AION, ruptured globe, decreased vision, nonarteric anterior ischemic optic neuropathy, NAION, migraine, scintillating scotoma, intraocular foreign body, cardiac disease, stenotic vascular disease, carotid or vertebral artery atherosclerotic disease, fibromuscular dysplasia, arteritis, carotid artery dissection, vertebral artery dissection, platelet-containing emboli,antiphospholipid syndrome, anemia, hypercoagulable states
