Transient visual loss linked to elevated cardiovascular and stroke risk for up to a decade

A study published in the British Journal of Ophthalmology¹ found that patients who experience transient visual loss (TVL) have an increased risk of short- and long-term major adverse cardiovascular events, stroke, myocardial infarction, arrhythmia, and hospitalization, warranting prompt systemic evaluation and long-term monitoring, according to the authors led by Tasha Miller, MD, from the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. She was joined in this study by colleagues from the Department of Ophthalmology and Vision Sciences and the Division of Neurology, Department of Medicine, both in the University of Toronto.

TVL has been considered a benign condition, but increasing evidence suggests it may reflect underlying systemic vascular instability, Dr. Miller and colleagues explained.

Monocular TVL most often results from impaired retinal or optic nerve perfusion² and occurs more often in men older than 50 years.³ Ischemic causes such as carotid artery stenosis, thromboembolism (eg, retinal transient ischemic attacks), and inflammatory vasculopathies (eg, giant cell arteritis) are associated with high risks of visual and systemic vascular complications.⁴ “Given its established association with ischemic stroke and myocardial infarction, TVL may represent a critical window for vascular risk reduction,”⁵ they explained.

They also pointed out that the long-term risks have been poorly characterized in large cohorts;⁴ previous studies have had small TVL sample sizes, short follow-up periods (<3 years), and insufficient adjustment for cardiovascular or socioeconomic confounders.^6,7 The long-term risks of arrhythmia, venous thromboembolism, hospitalization, or cause-specific mortality have not been evaluated because the existing studies have focused on myocardial infarction, stroke, and cardiovascular death.^8,9

TVL study methodology and results

Because of these gaps, Dr. Miller and colleagues undertook a multinational, matched cohort study to assess the cardiovascular outcomes after TVL using an electronic health record network.

Patients with TVL were retrospectively identified and matched to controls with dry eye syndrome. The primary outcomes included the occurrence of major adverse cardiovascular events, stroke, myocardial infarction, ventricular arrhythmias, venous thromboembolism, hospitalization, and all-cause mortality.

A total of 37,750 patients were included in both the TCL and control cohorts.

The investigators reported, “Within 14 days, the stroke risk increased over 21-fold (hazard ratio [HR] 21.7; 95% confidence interval [CI], 13.4-37.4), major adverse cardiovascular events nearly 10-fold (HR 9.80; 95% CI 7.19-13.34), arrhythmia over 4-fold (HR 4.01; 95% CI 2.72-5.90), myocardial infarction 5-fold (HR 5.00; 95% CI 1.92-12.06), and hospitalization nearly 4-fold (HR 3.83; 95% CI, 3.52-4.17) compared with controls.”

They also found that the risk of venous thromboembolism was modest and transient, with no elevation past 5 years, and all-cause mortality was not elevated at any time point. Among the patients who remained event-free at 90 days or 1 year, the elevated long-term risk persisted up to 10 years for major adverse cardiovascular events, stroke, arrhythmia, and hospitalization, they reported.

Miller and colleagues concluded, “This study establishes TVL as an ocular emergency associated with highly elevated short-term cardiovascular risk, comparable to cerebral ischemic syndromes. We highlight the first 90 days as a critical window in which the risk of stroke, major adverse cardiovascular events, myocardial infarction, and arrhythmia is greatest and urgent intervention is most impactful. Although risk declines over time, it remains persistently higher than in controls for up to a decade, supporting the need for continued cardiovascular surveillance.”

References

1. Miller T, Xie JS, Tao BK, Margolin E. Cardiovascular risk following transient vision loss. Br J Ophthalmol. 2026;110;published online May 20. doi: 10.1136/bjo-2026-330162

2. Pula J, Yuen C, Kattah J, et al. Update on the evaluation of transient vision loss. Clin Ophthalmol. 2016;297. doi:10.2147/OPTH.S94971

3. Andersen CU, Marquardsen J, Mikkelsen B, et al. Amaurosis fugax in a Danish community: a prospective study. Stroke.1988;19:196-9. doi:10.1161/01.str.19.2.196

4. Biousse V, Trobe JD. Transient monocular visual loss. Am J Ophthalmol. 2005;140:717–21. doi:10.1016/j.ajo.2005.04.020

5. Benavente O, Eliasziw M, Streifler JY, et al. Prognosis after transient monocular blindness associated with carotid-artery stenosis. N Engl J Med. 2001;345:1084–90. doi:10.1056/NEJMoa002994

6. Volkers EJ, Donders RCJM, Koudstaal PJ, et al. Transient monocular blindness and the risk of vascular complications according to subtype: a prospective cohort study. J Neurol. 2016;263:1771–7. doi:10.1007/s00415-016-8189-x

7. Wai KM, Loube DK, Pham NH, et al. Cardiovascular morbidity and mortality after amaurosis fugax. JAMA Ophthalmol. 2025;143:446–8. doi: 10.1001/jamaophthalmol.2025.0249

8. Wai KM, Ludwig CA, Koo E, et al. Risk of stroke, myocardial infarction, deep vein thrombosis, pulmonary embolism, and death after retinal vein occlusion. Am J Ophthalmol. 2024;257:129–36. doi:10.1016/j.ajo.2023.08.022

9. Chu Y-Y, Ho C-H, Chen Y-C, et al. Stroke risk following nonarteritic anterior ischemic optic neuropathy. JAMA Netw Open. 2024;7:e2444534. doi:10.1001/jamanetworkopen.2024.44534