'Ocular Stroke (Central Retinal Artery Occlusion) a me Temporal Arteritis¶

ʻO ka makapō hikiwawe, ʻeha ʻole a i ʻole ka pōʻeleʻele ʻike nui i ka maka hoʻokahi, he manawa koʻikoʻi ka neuro-ophthalmic vascular ulia pōpilikia e like me ka lolo ischemic acute. hahau. Ke hoʻopaʻa ʻia ka hāʻawi ʻana o ke koko i ka ** retina** (Central Retinal Artery Occlusion [CRAO] a i ʻole Branch Retinal Artery Occlusion [BRAO]) a i ʻole optic nerve head (Anterior Ischemic Optic Neuropathy [AION] i kumu ʻia e Giant Optic Neuropathy [AION] ma muli o ka Giant Optic Arteritis/AION]. E hoʻomaka ana nā pūnaʻi aʻalolo e make hiki ʻole ke hoʻihoʻi ʻia i loko o 90 a 240 mau minuke. ʻOiai ʻo ka ʻeleʻele ma ka maka hoʻokahi wale nō 2 a 15 mau minuke a laila hoʻomaʻemaʻe loa (Amaurosis Fugax, he retinal transient ischemic attack), a hiki i ka 25 pākēneka o nā maʻi i loaʻa i ka concurrent silent cerebral infarctions ma ka lolo MRI a ke alo nei i kahi pilikia koke o ka hōʻeha hemispheric a i ʻole makapō bilateral. Kāhea koke aku i nā lawelawe ulia pōpilikia, e lawe pololei ana i kahi Kulawaena Stroke i koho ʻia (ʻaʻole e kali i kahi koho optometrist maʻamau), a me ka hoʻomaka koke ʻana i ka thrombolysis intravenous a i ʻole nā ​​corticosteroids intravenous kiʻekiʻe i loko o nā hola e hoʻoholo ai inā mālama ʻia ka hana o ka ʻike a me ka lolo.

E hana i kēia i kēia manawa¶

1. **E uhi i kekahi maka i ka manawa e hōʻoia inā aia ka ʻeleʻele ʻike i ka maka hoʻokahi (monocular) a i ʻole nā ​​maka ʻelua (binocular), a kākau i lalo i ka minuke pololei i hoʻololi ʻia ka hihiʻo (manawa "Last Known Well").
2. ʻeleʻele Monocular (ʻo ka maka hema a i ʻole ka maka ʻākau wale nō ka pōʻeleʻele/nalo ka hapalua ke uhi ʻia ka maka ʻē aʻe): E hōʻike ana i kahi paʻa ʻana o ke aʻa ** i mua o ka chiasm optic** (Central Retinal Artery Occlusion, Branch Retinal Artery Occlusion, Ophthalmic Artery Occlusion, or Giant Cell Arteritis Optic Neuropathy).
3. Binocular half-field loss (ka maka hema ʻelua a ʻaʻole hiki i ka maka ʻākau ke ʻike i ka ʻaoʻao hema a i ʻole ʻaoʻao ʻākau o ka lumi): Hōʻike i kahi occipital lobe lolo maʻi (homonymous hemianopia) ma hope o ka optic chiasm.
4. E nānā koke i kēlā me kēia maʻi ma mua o 50 makahiki a ʻoi paha no ka "Giant Cell Arteritis (Temporal Arteritis) Red Flag Triad": E nīnau i ka mea maʻi i kēia manawa:
5. "Ua loaʻa anei iā ʻoe kahi maʻi poʻo hou, ʻeha heiau, a i ʻole ka ʻili poʻo i ka wā e kāhili ai i kou lauoho a i ʻole ka hoʻomaha ʻana i ka uluna?"
6. "E ʻeha paha kou ʻāʻī, alelo, a maka paha, ʻeha, a luhi paha ma hope o ka nau ʻana i ka meaʻai no hoʻokahi minute (jaw claudication)?"
7. " Ua loaʻa anei iā ʻoe nā poʻohiwi ʻoʻoleʻa a ʻeha paha i ke kakahiaka (polymyalgia rheumatica), luhi i wehewehe ʻole ʻia, ka wela i ka pō, a i ʻole nā manawa pōkole o ka ʻike pālua a i ʻole ka ʻemi ʻana o ka ʻike maka?"
8. Inā ʻae he pane i loko o kahi kanaka makua \(\ge 50\text{makahiki}\): E haʻi koke aku i ka poʻe lapaʻau a me ke kahu hoʻāʻo ʻana o ka lumi ulia pōpilikia e manaʻo ʻoe ʻo Artitic Ischemic Optic Neuropathy mai Giant Cell Arteritis no laila e lawelawe lākou i ka **high-dose intravenous methylprednisolone ($500\text{ i } 1,0}00 i ke koko ma mua o ke kali ʻana i ke koko ma mua o ke kali ʻana i ke koko ma mua o ke kali ʻana i ke koko. e hoola i ka hoa maka.
9. E kelepona koke i kāu helu ulia pōpilikia a noi aku i ka lawe ʻana i ka Halemaʻi Centerated Stroke Center me kahi Oihana Hoʻopilikia. Kāhea iā 911 ma United States a me Kanada, 112 ma waena o ka European Union, 999 ma United Kingdom, a i ʻole e ʻike i nā mea āpau helu pilikia. E ʻōlelo akaka: "Ua nalo koke ka ʻike maka ʻeha ʻole ma ka maka hoʻokahi; manaʻo mākou he Ocular Stroke (Central Retinal Artery Occlusion) a i ʻole Giant Cell Arteritis."
10. E hoʻonoho pono i ka mea maʻi i ke kali ʻana i ke kaʻa kaʻa:
11. No ka CRAO / Embolic Eye Stroke i manaʻo ʻole ʻia (ʻaʻohe ʻeha poʻo a i ʻole ʻeha puʻuwai koʻikoʻi): E hoʻomoe i ka mea maʻi palaha loa ma ko lākou kua (ma ke kua, \(0\text{ degrees}\)) me ke poʻo palahalaha. Hoʻonui ka moe palahalaha i ke kaomi ʻana o ke aʻa o ka ophthalmic a me ke aʻa retina waena, e kōkua ana i ka hoʻokuke ʻana i ke koko ma mua o ka ʻōpū a i ʻole ma o nā kīʻaha liʻiliʻi cilioretinal collateral.
12. Inā loaʻa i ka mea maʻi i ka manawa pōkole o ka hanu a i ʻole i manaʻo ʻia he hemorrhage lolo: E hoʻokiʻekiʻe iki i ke poʻo i \(15\text{ a i }30\text{ degrees}\).
13. E nānā i nā hōʻailona ʻeha o ka lolo FAST a me nā hōʻailona hōʻailona carotid. alakaʻi hahau). Inā loaʻa i kahi maʻi ʻōpio (ma lalo o 50 mau makahiki) i ka nalowale ʻana o ka ʻike maka hoʻokahi i hui pū ʻia me ka ** ʻeha hou ma kekahi ʻaoʻao o ka ʻāʻī a i ʻole ka maka a me kahi lihilihi hāʻule liʻiliʻi me kahi haumāna liʻiliʻi ma kēlā ʻaoʻao hoʻokahi (Horner syndrome) ma hope o ka ʻeha ʻāʻī, ka hoʻomaʻamaʻa chiropractic, ka hāpai kaumaha, a i ʻole ka ʻū ʻana, manaʻo ʻoe he ** Internal Carotid Artery Dissection**.
14. Mai kaomi ikaika a lomilomi paha i ka pōpō maka, mai hanu i loko o ka ʻeke pepa, a mālama i ka mea maʻi Nothing by Mouth (NPO). ʻOiai ʻo nā puke lapaʻau kahiko i ʻōlelo ʻia i ka hoʻomaʻamaʻa ʻana i ka maka maka a i ʻole ka hanu hou ʻana o ka ʻeke pepa, ʻōlelo ka American Heart Association (AHA) e kūʻē i ka mea i hoʻomaʻamaʻa ʻole ʻia i ka ocular compression a i ʻole hypercarbia no ka mea hiki iā lākou ke hōʻino i ka maʻi o ka maka a i ʻole ka maʻi pilikia. hahau-waena thrombolysis.

ʻO ka lāʻau hoʻoholo hoʻoholo pilikia pilikia: Pohō ʻike ʻole ʻeha ʻole a me Temporal Arteritis¶

E hoʻohana i kēia papa kuhikuhi holoʻokoʻa no ka hoʻokaʻawale ʻana i ka nalo ʻike monocular vs. binocular ischemic a hoʻāla i ka maʻi maʻi maʻi a i ʻole ka lāʻau steroid i loko o nā minuke.

flowchart TD
    Start["Pohō ʻEha Hiki ʻole, <br/> ʻEleʻele Māhele Hiʻohiʻona, a i ʻole ka Dimming Transient"] --> CoverTest{"E uhi kaʻawale i kēlā me kēia maka:<br/>Ua nalowale ka ʻike ma ka maka hoʻokahi a i ʻole nā maka ʻelua?"}

    CoverTest -->|"Ua nalowale nā maka ʻelua<br/>Hapa hema a i ʻole Hapa ʻākau o ka hihio"| Occipital["HOMONYMOUS HEMIANOPIA<br/>(Acute Postterior / Occipital Brain Stroke):<br/>E kelepona iā 911 / 112 / 999 koke no Stroke Center"]

    CoverTest -->|"Hookahi Maka WALE (Monocular Vision Loss):<br/>Aia ka Lesion i ka Retina, Optic Nerve,<br/>a Ipsilateral Carotid/Ophthalmic Artery"| AgeCheck{"E nānā i ka makahiki & Giant Cell Arteritis<br/>(Temporal Arteritis) Nā Hae ʻulaʻula:<br/>ʻO ka makahiki maʻi >= 50 Makahiki ME<br/> ʻO ke poʻo o ka luakini, ka ʻeha o ke poʻo, <br/> ʻeha ʻeha i ka wā e nahu ai, a i ʻole ʻoʻoleʻa poʻohiwi?"}

    AgeCheck -->|"ʻAe (makahiki >= 50 + KEKAHI GCA Symptom,<br/>a i ʻole Chalky/Altitudinal Vision Loss):<br/>SUPECT GIANT CELL ARTERITIS<br/>(Arteritic AION or Arteritic CRAO)"| GCAProtocol["KĀKĀWAI 'E HOʻOLOHE I KA MAKA Elua':<br/>1. Kāhea iā 911 / 112 / 999 -> Oihana Hoʻopilikia i kēia manawa<br/>2. Hoʻoponopono i ka Stat High-Dose IV Methylprednisolone<br/> (500 i ka 1,000 mg IV / lā x 3 mau lā) KOWAI<br/> (Mai hoʻopaneʻe i nā steroids no nā labs ESR / CRP a iʻole biopsy) <br/>3. Kauoha Stat ESR, CRP, Platelets + Temporal Ultrasound/Biopsy"]

    AgeCheck -->|"ʻAʻohe hōʻailona GCA<br/>(a i ʻole ka mea maʻi ma lalo o 50 makahiki)"| DurationCheck{"Ua hoʻi hou ka ʻike i ka 100% maʻamau<br/>Ma loko o 2 a 15 mau minuke,<br/>a i ʻole ʻo ka ʻike ʻike STILL/Nalo?"}

    DurationCheck -->|"Ua Hoʻi Loaʻa ʻia ka ʻike ma ka 2 a i ka 15 min<br/>('Huki ʻia ka malu o ka puka makani i lalo a hāpai ʻia i luna'):<br/>AMAUROSIS FUGAX (Retinal TIA)"| TIAProtocol["KAHIKI TIA RETINAL ACUTE:<br/>1. Mai noho i ka home (Ke pilikia nui o ka lolo ma 24-72h)<br/>2. E hele i ke Keʻena ʻEpekema Koho ʻia ʻo Stroke Center NOW<br/>3. Pono ka stat Brain MRI (DWI), Carotid CTA/Ultrasound,<br/> ECG/Holter no AFib, Dual Antiplatelets, & Statin"]

    DurationCheck -->|"Noho Pōʻeleʻele ka ʻike (Peleʻele piha)<br/>a i ʻole ka ʻāpana luna/lalo:<br/>SUPECT CENTRAL OR BRANCH RETINAL<br/>ARTERY OCCLUSION (CRAO / BRAO)"| CRAOProtocol["ACUTE OCULAR STROKE ('CODE STROKE'):<br/>1. Kāhea iā 911 / 112 / 999 -> Koho ʻia ʻo Stroke Center NOW<br/>2. E hoʻomoe i ka mea maʻi FLAT ma ke kua (0 degere) no ka hoʻonui ʻana i ka wai<br/>3. E nānā pono i ka minuke o ka hoʻomaka ʻana (<4.5 hola IV tPA pukaaniani)<br/>4. Inā ʻeha ka ʻāʻī + pupil liʻiliʻi / poʻi maloʻo -> E nānā i ka ʻāpana Carotid"]

Pathophysiology: Pehea ka hana ʻana o ke koko ʻelua o ka maka a me ke kumu o nā minuke¶

Hāʻawi ʻia ka maka e ka ophthalmic artery, ʻo ia ka lālā nui mua loa mai ka artery carotid internal e like me kona komo ʻana i ka iwi poʻo mai ka ʻāʻī. No ka mea, ua lala pololei ke a'a ophthalmic mai ke a'a carotid i loko, kekahi mea e hana ana i loko o ke aa o ka maka he puka aniani ia i loko o ke a'a o ka lolo a me ka pu'uwai.

I loko o ka maka maka, ua māhele ʻia ke aʻa ophthalmic i ** ʻelua ʻōnaehana moku kaʻawale loa** e hānai ana i nā papa ʻokoʻa o ka retina a me ke aʻalolo optic:

1. Ka Pūnaehana Retinal Artery (CRA) (Hanai i ka Retina Iloko):
2. ʻO ke aʻaʻa retinal waena e hou i ke kikowaena o ke aʻalolo optic a me nā lālā ma ka ʻili o loko o ka retina i ʻehā quadrants (ke kino kino, ke kino haʻahaʻa, ka ihu kiʻekiʻe, a me nā lālā ihu haʻahaʻa).
3. He anatomical end-artery me ka pili ole collateral ma 70 a 85 pakeneka o na kanaka.
4. *(Anatomical exception: Ma kahi o 15 a hiki i ka 30 pakeneka o na kanaka i hanauia me kekahi moku komo hou i kapaia he cilioretinal artery e hele mai ana mai ka choroidal circulation e hanai ana i ke kikowaena macula. I ka ma'i laki me ka cilioretinal artery i loa'a i ka CRAO, hele eleele ko lakou mau hi'ona peripheral holo'oko'a, ** aka, he 20/2 wahi heluhelu ke ola o ka piko.
5. Ka Pūnaehana Ciliary Arteries (SPCAs) Pōkole (Hanai i ke Poʻo Nerve Optic & Outer Retina):
6. ʻElua a ʻekolu mau kumu ciliary hope loa e māhele ʻia i 10 a 20 liʻiliʻi ** pōkole hope ciliary arteri ** e hana i ke apo vascular a puni ke poʻo o ke aʻalolo optic a hānai i ka choroid (e hānai ana i nā koʻokoʻo photoreceptor waho a me nā cones, me ke kikowaena fovea).
7. No ke aha i makemake nui ai ka Giant Cell Arteritis i ka Short Posterior Ciliary Arteries: ʻO ka lamina elastic i loko o nā ʻaʻaʻa ciliary hope pōkole a me nā ʻaʻaʻaʻaʻai kino papa ka pahuhopu #1 o ka autoimmune giant-cell attack ma Temporal Arteritis, e wehewehe ana i ke kumu o ka Giant Cell Arteritis e hoʻopōʻino ai i ka optic nerve head infarction (**Arteri Optic nerve head infarction) 80 pākēneka o nā hihia ʻike maka a me Arteritic CRAO ma 10 a 15 pākēneka.

ʻO ka Retinal Ischemic Survival Clock (No ke aha 90 a 240 mau minuke ka paepae)¶

ʻO nā hoʻokolohua neuro-ophthalmology primate kahiko (Hayreh et al.) a me nā hoʻokolohua hahau kanaka e hoʻokumu i ka uaki ola ola maoli o nā pūnaewele ganglion retinal i ka wā e hoʻopaʻa ʻia ai ke aʻa o ka retina waena. - 0 a hiki i 90 mau minuke o ka hoʻopaʻa ʻia ʻana: ʻAi ʻia ka ʻiʻo o ka retina (ischemic penumbra), akā hiki ke hoʻihoʻi ʻia ka ʻike piha a kokoke paha ke hoʻihoʻi koke ʻia ke kahe koko. - 90 a 240 mau minuke (1.5 a 4 mau hola): Hoʻomaka ʻia ka hoʻoneʻe ʻana o ka ʻāʻī o ka ʻāpana o ka ganglion retinal i loko; Hiki ke ho'ōla hapa me ka reperfusion pilikia. - Ma mua o 240 mau minuke (4+ hola) o ka hoʻopau piha ʻana: Hiki mai ka necrosis nui a hiki ʻole ke hoʻihoʻi hou ʻia o ka retina i loko, e waiho ana i ka nalowale ʻike hohonu (ʻo ka maʻamau ** helu ʻana i nā manamana lima [CF], neʻe lima [HM], a i ʻole ** ʻike māmā [LP] wale nō) ke ʻole ke aʻa cilioretinal a paʻa ʻole paha.

ʻO ka hoʻohālikelike piha ʻana o nā 5 mau pilikia ocular ischemic nui¶

E hoʻohana i kēia papa lāʻau lapaʻau e hoʻokaʻawale i ka CRAO embolic, ka lālā retinal artery occlusion, amaurosis fugax, arteritic optic neuropathy (Giant Cell Arteritis), a me non-arteritic optic neuropathy:

Kūlana 1: Hoʻopiʻi ʻia nā ʻaʻa ʻaʻa ʻāʻī waena a me ka lālā (CRAO & BRAO)¶

No ke aha i kauoha ai ka ʻAhahui Puʻuwai ʻAmelika i kahi "Code Stroke" no CRAO¶

Ma ka mōʻaukala, ua hele mua nā poʻe maʻi i nalowale ka ʻike ma ka maka hoʻokahi i ka optometrist a i ʻole ke keʻena maka, kahi i hoʻohana ʻia ai nā hola a i ʻole mau lā i ka nānā ʻana i nā maka ma mua o ka nānā ʻana o kekahi i ko lākou lolo a i ʻole nā aʻa ʻāʻī. I ka makahiki 2021, ua hoʻopuka ka American Heart Association (AHA) a me American Stroke Association (ASA) i kahi ʻōlelo Scientific Statement e hoʻololi ana i ka mālama CRAO ma ke ao holoʻokoʻa: 1. CRAO he Acute Ischemic Stroke: No ka mea, ʻo ka retina he ʻāpana embryologically o ka ʻōnaehana nūnū waena a hānai ʻia e ke aʻa carotid kūloko, ʻo kahi occlusion o ke aʻaʻa retinal waena he ʻano ** ischemic stroke o ka retina**. 2. 1 i loko o 4 mau maʻi CRAO i loaʻa i ka maʻi maʻi lolo malū i kēia manawa: Ua hōʻike nā haʻawina MRI (DWI) o ka lolo diffusion-weighted he 19 i ka 25 pākēneka o nā maʻi e loaʻa ana i ka CRAO a i ʻole BRAO i loaʻa i nā maʻi ischemic acute i ka manawa like ma ka cerebral hemisphere kumu ʻia e ka ua o nā clots i haki ʻia ka lima a i ʻole ka puʻuwai hoʻokahi. pilikia. 3. Intravenous Thrombolysis Window (\(\le 4.5\text{ Hours}\)): Ke hiki mai ka mea ma'i me ka CRAO non-arteritic i kahi Storke Center i kohoia i loko o 4.5 hola o ka ho'omaka 'ana o ka ma'i, ma hope o ke po'o like 'ole 'o CT e ho'oku'u i ke koko o ka lolo a me nā labs e ho'oku'u aku i ka Giant Cell Arteritis a me ka hiki ke ho'oku'u i ka ma'i ma'i ma'i ma'i. mea hoʻoulu plasminogen (alteplase a i ʻole tenecteplase)**. Hōʻike nā meta-analyses i ka IV thrombolysis i hāʻawi ʻia i loko o 4.5 mau hola e hoʻonui nui i ka helu o ka hoʻihoʻi ʻana i ka ʻike kūpono e hoʻohālikelike ʻia me ka nānā conservative.

He aha ka "Cherry-Red Spot" ma ka nānā maka?¶

Ke nānā aku ke kauka ulia pōpilikia a i ʻole ka ophthalmologist i ka maka me CRAO me ka hoʻohana ʻana i ka ophthalmoscope a i ʻole ka pahu kamera fundus i loko o nā hola o ka hoʻouka ʻana: - ʻO nā ʻaoʻao o loko o ka retina (hānai ʻia e ke aʻaʻa retina waena i hoʻopaʻa ʻia) e pehu me ka wai intracellular (cytotoxic edema), e hoʻololi i ka opaque milky white. - Eia naʻe, ʻo ka bullseye make-center o ka macula (ka foveola) he ʻano lahilahi pepa a loaʻa ʻole ** ʻaʻohe ʻāpana ganglion retinal i loko **, hānai ʻia ʻo ia e ka choroid lalo (hānai ʻia e nā aʻa ciliary hope). - Ma muli o ka ʻālohilohi ʻana o ka choroid vascular ʻulaʻula ʻulaʻula ma waena o ke kikowaena ʻālohilohi lahilahi ʻoiai e hoʻopuni ʻia ana e ka halo o ka retina infarcted milky-white, hana ia i ka "Cherry-Red Spot" o Central Retinal Artery Occlusion.

No ke aha ʻaʻole ʻoe e hilinaʻi i ka home "Ocular Massage" a i ʻole "Paper-Bag Breathing"¶

Manaʻo nā puke kahiko e kaomi ikaika i ka pōpō maka i pani ʻia (digital ocular massage) a i ʻole ka hanu ʻana i loko o kahi ʻeke pepa ʻeleʻele (carbogen therapy) no CRAO. - Ka Manaʻo Hoʻonaʻauao Hou (AHA & AAO): ʻAʻole i hoʻonāwaliwali ʻia nā hana ʻelua no ka poʻe e kū ana . ʻO ke kaomi ʻana i ka pōpō maka hiki ke haki i ka maka me ka hana hou ʻana, hoʻomāhuahua i ka wehe ʻana o ka retina, a i ʻole e hoʻoulu i kahi vagal bradycardia reflex (oculocardiac reflex). ʻO ka hanu ʻana i loko o kahi ʻeke pepa ke kumu o ka systemic hypoxia i nā poʻe maʻi kahiko me ka hoʻomaikaʻi ʻole ʻana i ke ola retinal. ** ʻO ka hana hoʻokahi ma mua o ka haukapila e hoʻomoe ana i ka mea maʻi ma ko lākou kua a kāhea aku iā 911 / 112 / 999 no ka lawe koke ʻana i ka Stroke Center.

Ke Kumu Kūikawā i loko o nā mākua ma lalo o 50 makahiki: ʻO ka hoʻokaʻawale ʻana i ke aʻaʻa carotid kūloko¶

Inā loaʻa i kahi kanaka ʻōpio (20 a 50 mau makahiki) ka nalo ʻana o ka ʻike monocular a i ʻole amaurosis fugax, e nīnau inā he ** ʻeha ʻāʻī, ʻeha ʻaoʻao ʻaoʻao, a ʻeha paha ka maka**, a nānā i ko lākou mau lihilihi a me nā haumāna i ka mālamalama pohihihi: - ʻO ka haehae ma ka ʻaoʻao o loko o ke aʻa carotid kūloko ma ka ʻāʻī (Internal Carotid Artery Dissection), i hoʻoulu pinepine ʻia e ka ʻāʻī ʻāʻī, yoga hyperextension, chiropractic manipulation, hoʻokiʻekiʻe kaumaha, a i ʻole ka ʻū ʻana, e hohola i nā ** sympathetic nerve fibers ** i ʻōwili ʻia ma waho o ka paia o ke aʻa carotid. - Hoʻopuka kēia i ka ipsilateral Horner Syndrome (he lihilihi lihi iki o luna [ptosis] a me kahi haumāna liʻiliʻi [miosis] ma ka ʻaoʻao like me ka ʻeha ʻāʻī) ma ka ʻaoʻao o ka retinal a i ʻole ka cerebral emboli. ʻO ka CT angiography (CTA) koke o ke poʻo a me ka ʻāʻī i ka keʻena pilikia e hōʻoia i ka wehe ʻana.

Kūlana 2: Amaurosis Fugax (Transient Monocular Vision Loss / Retinal TIA)¶

No ke aha "e hoʻi ana ka hihiʻo i ka maʻamau i loko o 5 mau minuke" he pilikia 911/112/999¶

Amaurosis fugax ("pouli lele") hiki mai ke wehe 'ia kahi'āpana o ka cholesterol (a Hollenhorst plaque) a i 'ole ka platelet-fibrin micro-clot mai kahi plaque i loko o ke a'a carotid o loko o ka ai (a mai ka pu'uwai i ka atrial fibrillation), e moe pokole i loko o ke a'a o ka retina waena, a laila he 5 mau minuke. - Hōʻike ka poʻe maʻi iā ia he "he malu puka aniani ʻeleʻele e huki mālie ana ma luna o hoʻokahi maka" a hina a ʻeleʻele paha ka maka, lōʻihi 3 a 10 mau minuke, a laila hoʻāla hou a hiki i ka 100 pakeneka maʻamau. - Ka Pahele: Ma muli o ka hoʻi ʻana o ka ʻike i ka mea maʻamau ma hope o 5 mau minuke me ka ʻeha ʻole, nui ka poʻe e hoʻomaʻemaʻe iā ia ma ke ʻano he maʻi maka a he migraine paha a noho i ka home. - Ka ʻOiaʻiʻo: ʻO Amaurosis fugax he Retinal Transient Ischemic Attack (TIA). Me ka loaʻa ʻole o ka loiloi halemai ulia pōpilikia, dual antiplatelet therapy (aspirin + clopidogrel), high-intensity statin therapy, a me ka carotid endarterectomy a stenting (inā he \(70\%\text{ a hiki i }99\%\)), ʻo ka ʻōpū aʻe e hemo ana i nā hola.

Pehea e haʻi aku ai iā Amaurosis Fugax ma waho o kahi Visual Migraine Aura a i ʻole Papilledema¶

Kūlana 3: Giant Cell Arteritis (GCA / Temporal Arteritis) i nā mākua he 50 a ʻoi aku.¶

No ke aha ʻo Giant Cell Arteritis ke kumu hiki ke pale ʻia o ka makapō holoʻokoʻa bilateral¶

ʻO Giant Cell Arteritis (GCA), i ʻike ʻia hoʻi ʻo Temporal Arteritis, he autoimmune granulomatous vasculitis o nā ʻaʻa ʻaʻa waena a me nā aʻa nui e ulu ** wale nō i loko o nā poʻe mākua he 50 makahiki a keu aku** (ke piʻi nei ma waena o nā makahiki 70 a me 85).

I loko o GCA, hoʻopili nā pūnae T immune a me nā pūnana nunui i ka paia o nā lālā extracranial o ke aʻa carotid a me vertebral. - Pehu ka paia o ke aʻa i loko (intimal hyperplasia) a hiki i ka pani ʻana o ke awāwa waena. - Ke hahau keia occlusion inflammatory i ka short posterior ciliary arteries or central retinal artery, make ke poo nerve optic i ka pololi hikiwawe o ka oxygen (Arteritic Anterior Ischemic Optic Neuropathy [A-AION]), e waiho ana i ka pouli loa ma ka 50 pakeneka o na hihia. - Ka Uaki "Hoa Maka": Ke nalowale ka maka mua mai GCA, ʻaʻole hiki ke loaʻa ka ʻike nui i kēlā maka mua. **Akā naʻe, inā hoʻopaneʻe ʻia ka lāʻau corticosteroid kiʻekiʻe, 30 a 50 ka nui o nā maʻi e loaʻa i ka hoʻouka like ʻana i ko lākou maka SECOND (koe) i loko o 24 mau hola a i 7 lā, e waiho mau ana iā lākou ma nā maka ʻelua. ʻoki ʻana o ka ʻāʻī).

Hoʻopiha piha i ka papa inoa hōʻailona hōʻailona ʻulaʻula no Giant Cell Arteritis (makahiki \(\ge 50\))¶

No ka 20 pakeneka o nā mea maʻi me ka pohō ʻike mai GCA he "GCA huna" (ka liʻiliʻi o ke poʻo, me ka ʻāwae maʻalahi a i ʻole nā hōʻailona ʻōnaehana), e nānā i kēlā me kēia mea ma kēia papa inoa i kēlā me kēia kanaka makua ma mua o 50 me ka loli ʻike.

• 1. ʻO ka Jaw Claudication (Maikaʻi Kūikawā o GCA, aia ma -50%): E nīnau i ka mea maʻi: *"I ka wā e nahu ai ʻoe i ka meaʻai maʻa e like me ka ʻiʻo a i ʻole ka berena ʻūlū no 1 a 2 mau minuke, e hoʻomaka anei kou ʻiʻo a me kou alelo e ʻeha, ʻeha, a luhi paha no laila pono ʻoe e hoʻōki a hoʻomaha?" ua hōʻemi ʻia e ka arteritis, e hoʻoulu ai i ka ischemia muscle i hoʻoikaika ʻia.
• 2. ʻO ka ʻeha poʻo i hoʻokumu ʻia i ka ʻāina hou (e loaʻa ana ma 70% a i 80%): He ʻeha hou, ʻeha, a ʻeha paha ma luna o hoʻokahi a i ʻole nā hale ʻelua **, ka lae, a i ʻole ke kua o ke poʻo i kahi kanaka makua.
• 3. ʻO ka ʻili o ke poʻo a me ka ʻaʻaʻa kino ʻē aʻe: ʻO ka holoi ʻana i ka lauoho, hoʻomaha i ke poʻo ma luna o ka uluna, a i ʻole ke komo ʻana i nā makaaniani e ʻeha ma ke poʻo. ʻO ka holo mālie ʻana i ka manamana lima ma luna o ka ** aʻaʻa kino maʻamau** (ma ke alo o ka pepeiao a ma luna o ka luakini) e hōʻike ʻia he aʻaʻa mānoanoa, nodular, palupalu me ka puʻuwai nāwaliwali a ʻaʻole paha.
• 4. ʻO nā hōʻailona hoʻolaha ʻike mua: Pōkole 5 mau minuke dimming spells (amaurosis fugax) a i ʻole ** transient diplopia (ʻike pālua, aia ma 10% a 15%)** ma muli o ka ischemia o nā ʻiʻo maka.
• 5. ʻO ka Polymyalgia Rheumatica (PMR) a me nā hōʻailona Kumukānāwai (Ke kū nei ma 40% a 50%): ʻO ka ʻoʻoleʻa a me ka ʻeha o ke kakahiaka ma waena o ** nā poʻohiwi, ka ʻāʻī, a me ka pūhaka** ʻoi aku ka lōʻihi ma mua o 45 mau minuke ma hope o ke ala ʻana, i hui pū ʻia me ** ka wela haʻahaʻa, ka wela o ka pō, ke kaumaha ʻole o ke kaumaha, a i ʻole.

ʻO ke kaʻina hana pilikia o ka haukapila no ka mea i manaʻo ʻia ʻo Giant Cell Arteritis¶

Wahi a nā alakaʻi hoʻomaʻamaʻa hoʻomaʻamaʻa hui o ka American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), a me British Society for Rheumatology (BSR): 1. E hoʻomaka koke i nā corticosteroids kiʻekiʻe ma luna o ka hoʻopiʻi kino (ma mua o ka hoʻi ʻana o Biopsy a i ʻole Labs): - Inā loaʻa kekahi mau hōʻailona ʻike maka (nānā ʻike, amaurosis fugax, a i ʻole ʻike pālua): Hoʻohana intravenous methylprednisolone \(500\text{ a i }1,000\text{ mg}\) IV i kēlā me kēia lā no 3 mau lā mau, a ukali ʻia e ka prednisone waha kiʻekiʻe (\(1\text{mg/kg/day}\),\text{mg/kg/day}\(,\text{mg/kg/day} mg}\) i kēlā me kēia lā) a me ka noʻonoʻo ʻana o tocilizumab. - Inā loaʻa nā hōʻailona GCA cranial ME OLE nā hōʻailona ʻike maka: E hoʻomaka koke i ka ** prednisone waha \(40\text{ a i }60\text{ mg}\) i kēlā me kēia lā**. 2. Mai hoʻopaneʻe i nā Steroid e kali ana i kahi Biopsy Temporal Artery a i ʻole Ultrasound: Ke hoʻomau nei nā hoʻololi a me nā cell pilikua i loko o ka pā aʻa kino no **10 a i 14 mau lā ma hope o ka hoʻomaka ʻana i nā steroid kiʻekiʻe **, ʻoiai ke hoʻopaneʻe nei i nā steroid i nā hola 12 hiki ke uku i ka mea maʻi i ko lākou mau maka. 3. Kakau ʻia nā hoʻāʻo koko ma ka ER: Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), a me Complete Blood Count (CBC) (e nānā ana i ka reactive thrombocytosis me nā platelets \(>400,000/\mu\text{L}\)).

Palapala kamaʻilio pololei no 911/112/999 a me ka hoʻāʻo ʻana i ka haukapila¶

Ma muli o ka nalo ʻole ʻana o ka ʻike maka ʻana i waho o ka maka he 100 pakeneka maʻamau (keʻokeʻo sclera, clear cornea), hiki i nā limahana hoʻāʻo ma nā halemai ākea ke hoʻohaʻahaʻa i kona wikiwiki ke ʻole ʻoe e hoʻohana i ka ʻōlelo pololei a me ka vasculitis:

• No ka mea i manaʻo ʻia ʻo Central Retinal Artery Occlusion (CRAO) i loko o 4.5 mau hola:

  "Pono au i kahi kaʻa kaʻa kaʻa pilikia ma [Exact Address]. ʻO ka mea maʻi he [Kane/female] makahiki i hoʻomohala i ka makapō koke, piha, ʻeha ʻole i ka maka [hema / ʻākau] ma [Exact Minute of Onset]. Wahi a nā alakaʻi alakaʻi o ka American Heart Association, manaʻo mākou he Ocular Stroke acute (Central Retinal Artery transport Ocmedia) 4.5-hola puka aniani thrombolysis. "

• No ka mea i manaʻo ʻia ʻo Giant Cell Arteritis (Temporal Arteritis) i loko o kahi kanaka makua 50+ makahiki:

  *"Emergency Triage: keia [Age]-makahiki ma'i nalo koke ka hihio [a i ole elua hihio / transient dimming] ma ka [hema/akau] maka hele pu me ka [hou luakini headache / ili poo / eha auwae i ka nau ana i ka meaʻai]. Manaʻo mākou i ka Arteritic Ischemic Optic Neuropathy mai Giant Cell Arteritis a me ka pono i ka stat i ka ulia pōpilikia. methylprednisolone (500 a hiki i 1,000 mg IV) i kēia manawa no ka pale ʻana i ka makapō mau i ka maka.

• No Amaurosis Fugax (Retinal TIA):

  • "He [Age] makahiki ka mea maʻi i ʻike i ka ʻeleʻele piha ʻole ʻeha ('window shade') ma ka maka [hema / ʻākau] mau minuke [Number] i [Manawa] i kēia lā. ʻOiai ua hoʻi hou ka hihiʻo i ka maʻamau, ʻo Amaurosis Fugax kēia, he TIA Retinal acute, a koi koke i ka Stroke Center Emergency Evaluation a me ka MRI imaging, carotid brain.

Nīnau pinepine¶

No ke aha ke ʻano keʻokeʻo a maʻamau ka waho o ka maka i ka wā o ka maʻi ocular (CRAO) a i ʻole ka arteritis kino?¶

ʻO nā kīʻaha koko e ʻulaʻula ai ka ʻili o ka maka i ka wā o ka maka ʻulaʻula a i ʻole ka glaucoma, ʻo ia nā moku conjunctival papa a me nā moku episcleral ma mua o ka pōʻeleʻele. I loko o ka Central Retinal Artery Occlusion a me Giant Cell Arteritis, hiki ke hoʻopaʻa ʻia ke aʻa i loko o ke kua o ka maka i loko o ke aʻaʻa retinal liʻiliʻi a i ʻole nā ​​aʻa ciliary pōkole hope e hānai ana i ka retina a me ke aʻalolo optic, no laila ke keʻokeʻo a me ka ʻeha ʻole ka mua o ka maka i ka wā e pōloli ana ka retina i ka oxygen.

Pehea au e nānā ai ma ka home inā aia ka ʻike pohihihi ma ka maka hoʻokahi (monocular) a i ʻole nā ​​maka ʻelua (binocular)?¶

Ke nalo koke ka maka o kekahi maka a i ʻole ke ulu ʻana i kahi aka ʻeleʻele, e hoʻāʻo ka lolo kanaka e hoʻohui i ke kiʻi maʻamau mai ka maka maikaʻi me ke kiʻi ʻeleʻele mai ka maka ʻino, e manaʻo ai ke kanaka me he mea lā ua pohihihi nā maka ʻelua. E uhi mau i kou maka hema me ka poho lima e hoao ai i kou maka akau wale no, a laila e uhi i kou maka akau e hoao i kou maka hema wale no; hōʻike koke ʻia inā pili ka ʻeleʻele i ka maka hoʻokahi a i ʻole ka pili ʻana i ka hapa hema a ʻākau paha o nā maka ʻelua.

No ke aha e ʻeha ai ka ʻāwae i ka wā e nau ai i ka meaʻai (jaw claudication) ka hōʻailona koʻikoʻi o ka Giant Cell Arteritis?¶

ʻAʻole like me ka arthritis temporomandibular joint (TMJ), ka mea e ʻeha i ka manawa e hāmama ai kou waha a nahu paha i kahi mea paʻakikī, ʻo ka claudication a me Giant Cell Arteritis ma muli o ka mumū autoimmune e hōʻemi ana i nā aʻa e hoʻolako i ke koko i kou mau ʻiʻo a me kou alelo. Ma muli o ka loaʻa ʻole o ka oxygen i nā ʻiʻo i ka wā hoʻomaʻamaʻa hoʻomaʻamaʻa, maikaʻi kou ʻāʻī i ka ʻai mua ʻana o ka meaʻai, hoʻomohala i kahi ʻeha hohonu a luhi paha ma hope o ka nau ʻana no 60 a 90 kekona, a ʻoi aku ka maikaʻi i ka wā e hoʻōki ai ʻoe i ka nau ʻana; ʻo ka ʻike ʻana i kēia hōʻailona a hele i ka ER no nā steroid e pale i ka makapō koke.

Inā pōʻeleʻele koʻu maka ma ka maka hoʻokahi no 5 mau minuke a hoʻi mai 100 pakeneka maʻamau, no ke aha e hiki ʻole iaʻu ke kali e ʻike i koʻu kauka maka i kēia pule aʻe?¶

ʻO ka ʻeleʻele ʻeha ʻole o 5 mau minuke ma ka maka hoʻokahi (amaurosis fugax) ʻo ia hoʻi, ua haʻi ʻia ke koko koko a i ʻole ke aniani cholesterol mai kahi aʻa carotid haiki ma kou ʻāʻī a i ʻole mai kou puʻuwai, hoʻopili i ke aʻa nui o kou maka, a laila nahā. Aia i ka 1 i loko o 4 mau mea maʻi me nā hanana retinal artery ua loaʻa iā lākou nā wahi hahau hou ma ka MRI lolo, a ʻoi aku ka kiʻekiʻe o ka maʻi lolo maʻi paʻa mau loa i nā hola 24 a hiki i 72 mau hola ma hope o kēlā hanana ʻōlelo aʻo, e koi ana i kahi kipa Stroke Center koke.

Nānā ʻia nā kumu¶

• Ahahui Puʻuwai ʻAmelika (AHA) a me American Stroke Association (ASA, United States): Management of Central Retinal Artery Occlusion: He Scientific Statement From the American Heart Association (Mac Grory et al., Stroke 2021; e hoʻokumu ana i ka CRAO ma ke ʻano he Code Stroke emergency, the \(\le 4.5\text {hour,}\) IV t o ka hoʻomaʻamaʻa ʻana i ka protocols o ka discular o ka hoʻomaʻamaʻa ʻana i ka ʻōlelo hoʻomaʻamaʻa hoʻomaʻamaʻa ʻana o ka disc.
• American College of Rheumatology (ACR, United States) and European Alliance of Associations for Rheumatology (EULAR): 2021 ACR/Vasculitis Foundation Guideline a EULAR Recommendations for the Management of Giant Cell Arteritis (IV methylprednisolone koke $500{\text{ i }1,000/lā ma mua o ke kino biopsy a i ʻole ka helu ʻana o ultrasound).
• British Society for Rheumatology (BSR, United Kingdom) a me National Institute for Health and Care Excellence (NICE, United Kingdom): Alakaʻi no ka ʻike a me ka mālama ʻana o Giant Cell Arteritis a me NICE NG128: Stroke and Transient Ischemic Attack in Over 16s (amaurosis fugax urgent TIA ala).
• American Academy of Ophthalmology (AAO, United States): Preferred Practice Pattern (PPP): Retinal and Ophthalmic Artery Occlusions.
• Royal College of Ophthalmologists (RCOphth, United Kingdom): Ophthalmic Services Guidance: Management of Acute Retinal Arterial Occlusion and Giant Cell Arteritis.

Nā alakaʻi pili¶

• ʻO ka nalo ʻana o ka ʻike maka, ka wehe ʻana o ka retinal, a me ka glaucoma pani ʻana i ka ʻokiʻoki
• ʻO ka ʻike ʻana i ka hahau (FAST) a me ka pane ulia pōpilikia
• ʻO ka cellulitis orbital, nā maʻi pehu o ka maka, a me ka thrombosis sinus cavernous
• ʻO ka ʻoki ʻana a me ka ʻeha o ka ʻōpū aortic aneurysm
• Ka ʻike ʻana i ka puʻuwai a me ke kōkua mua