As shown by Drs Brown and Vasudevan’s letter, the management of transient ischemic attacks (TIAs) remains controversial. The debate regarding the work-up and its ideal timing and location is mostly based on wide differences in access to care among various locations and institutions. The most important point made by Drs Brown and Vasudevan is in their last paragraph, where they emphasize the need for a prompt work-up. I agree that whether this work-up is done as an outpatient, in a TIA clinic, or in the hospital is not relevant; this specific point is already the subject of numerous studies and reviews. The only thing that really matters is that it be done promptly and by expert physicians.
Unfortunately, patients with retinal TIAs and permanent retinal ischemia often receive delayed care because of inappropriate referrals by eye care providers; it is important to recognize that patients with acute retinal ischemia are relatively uncommon in general ophthalmology, and that simple recommendations such as those suggested in my editorial are likely the best way to ensure that all such patients receive immediate appropriate care. These recommendations follow those from the National Stroke Association and the American Heart Association, which emphasize the need to immediately and aggressively evaluate and manage all patients with acute cerebral and ocular ischemia.
Although the study by Lee and associates indeed did not include patients with isolated transient retinal ischemia, my editorial also commented on another study from Boston published in 2012, which showed that retinal arterial ischemia (both transient and permanent) carries the same overall poor vascular prognosis as cerebral ischemia. Not surprisingly in the Boston study, the probability of abnormal magnetic resonance imaging (MRI) was higher in permanent visual loss patients than in retinal TIA patients (33% vs 18%). However, patients with transient retinal ischemia and an abnormal MRI had a high risk of having a major etiology as the cause of retinal TIA and, therefore, had a worse prognosis.
The practice of medicine is difficult, and access to care is becoming more challenging for many patients, who often choose to present to local walk-in optometry clinics in shopping centers or to urgent care centers where non-specialists have to make rapid triage decisions and often have difficulty obtaining urgent outpatient tests and consultations. Additionally, most academic ophthalmology departments are “opting out” of the systematic measurement of vital signs on their ophthalmology patients. As specialists with expertise in vascular diseases, it is our duty to facilitate emergent evaluations of patients with presumed retinal TIAs or permanent retinal ischemia. The details of how such evaluations should be performed vary greatly depending on patient characteristics and local resources, and I am pleased to see that Drs Brown and Vasudevan already have a strategy in place to handle such patients.