Amaurosis Fugax/TIA

Please assess this man with concerns about his vision. PMH: hypertension, diabetes, heart attack


History (3 minutes) – he tells you he lost vision, “like a curtain came down”

  • Timing – when did it happen, sudden/gradual onset of symptoms, how long did the symptoms last for, complete recovery now?, previous similar episodes,
  • 1 or both eyes, painful/painless, blurring/distortion/bits missing/double vision
  • Neuro questions- weakness of face/arm/leg, sensory disturbance, speech, swallow, unsteadiness, headache
  • Cardiovascular questions- Risk factors- hypertension, diabetes, high cholesterol, smoking, MI, stroke, palpitations/AF, claudication, angina, TIA, prosthetic heart valve, blood clots, Fx IHD
  • Giant Cell Arteritis questions- headache, scalp tenderness, jaw pain on chewing, stiff proximal muscles
  • Migraine questions: aura, headache, photophobia, phonophobia, nausea/vomiting
  • Seizure questions: loss of consciousness, drowsy after, urine incontinence, tongue biting
  • Hypoglycaemia questions: palpitations, sweating, hunger prior
  • Dx- including can he tolerate aspirin? Is he on warfarin? OCP in females
  • Fx
  • PMH stroke/TIA
  • Sx- driving, smoking, alcohol, recreational drug use


Examine (3 minutes)

  • VA
  • VF and neglect
  • Palpate the temporal arteries
  • Eye movements
  • CVS exam: Pulse (for AF), Heart sounds, carotid bruits, BP, xanthelasma, corneal arcus
  • Fundoscopy
  • Quick neuro Ax- pronator drift, power, sensation, smile (CN VII), facial sensation (CN V), finger-nose testing, reflexes (if time), speech, gait
  • Eye movements (if time)
  • Pupils (if time)



ICE and Explanation (2 minutes)


Suggested explanation as follows:


“It’s reassuring that your vision is back to normal now. I’m sure it was very frightening.  What has happened I think is you have had a shortlived episode of blindness in that eye caused by blockage in the blood vessel supplying the eye. This is usually due to blood clot breaking off from a larger artery in the head or neck and travelling to the brain/eye. Blood clots form because of risk factors- smoking, diabetes, high blood pressure, high cholesterol.


It’s like a stroke but short lived – a mini stroke – we call it a TIA. It is a warning sign. Need to address your risk factors as this episode suggests you are at increased risk of stroke. But no permanent damage for now.  I need to arrange for you to have an ultrasound scan of your neck arteries, a tracing of your heart, an ultrasound scan of your heart, and blood tests for inflammation and sugar and cholesterol.  I’m going to give you aspirin to help reduce the chance of further clots.  I will check your BP now. It will be important for you to stop smoking, improve diet, lose weight, exercise, reduce alcohol.  You should not drive for 1 month and call for help immediately if further episode/weak/numb face/arm/leg/speech problem”







Bloods- FBC, U+E, LFT, PV/ESR/CRP, glucose/Hba1c, lipid profile, clotting

Ecg +/- 24 hr/48 hr/72 hr tape/reveal device

Carotid dopplers


CT head if on warfarin/ongoing neurological symptoms and signs

MRI+dwi to detect ischaemia



Brain imaging is helpful in the management of TIA for: people being considered for carotid endarterectomy where it is uncertain whether the stroke is in the anterior or posterior circulation; people with TIA where haemorrhage needs to be excluded, for example long duration of symptoms or people on anticoagulants; where an alternative diagnosis (for example migraine, epilepsy or tumour) is being considered.


Know the ABCD2 score: admit for urgent assessment if score 4 or more/crescendo TIAs/AF/taking anticoagulant therapy (need to exclude a bleed)


Score of 4 or above: should have specialist assessment and investigation within 24 hours of symptoms onset


Score of 3 or less: should have specialist assessment and investigation within 1 week of symptoms onset




Aspirin 300mg daily (+PPI cover) for 2 weeks then clopidogrel 75mg OD

Smoking cessation

Reduce alcohol consumption

Diet and exercise

Optimise BP, diabetes, cholesterol

Surgical: carotid endarterectomy within 2 weeks if symptomatic carotid stenosis 70–99% according to the ECST (European Carotid Surgery Trialists’ Collaborative Group) criteria

Anticoagulate if AF

No driving for 1 month


Know the CHA2DS2-VASc score for anticoagulation and HAS-BLED score


Differential Diagnosis TIA/amaurosis fugax:


Hemiplegic migraine




Giant cell arteritis

Deranged electrolytes



Written by Dr Sarah Kennedy


Resources used include those listed in the references section of this webpage and also: