clinical case challenges in neuro optometry i l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Clinical Case Challenges In Neuro-Optometry I PowerPoint Presentation
Download Presentation
Clinical Case Challenges In Neuro-Optometry I

Loading in 2 Seconds...

play fullscreen
1 / 64

Clinical Case Challenges In Neuro-Optometry I - PowerPoint PPT Presentation


  • 341 Views
  • Uploaded on

Clinical Case Challenges In Neuro-Optometry I. Thomas J. Landgraf, O.D., F.A.A.O. “Clinical Case Challenges in Neuro-Optometry”. Thomas Landgraf, O.D., F.A.A.O. Clinical Associate Professor, UMSL College of Optometry. My Background. Graduate of ICO…Chicago Residency at PCO…Philadelphia

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Clinical Case Challenges In Neuro-Optometry I' - lalasa


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
clinical case challenges in neuro optometry i

Clinical Case Challenges In Neuro-Optometry I

Thomas J. Landgraf, O.D., F.A.A.O.

clinical case challenges in neuro optometry
“Clinical Case Challenges inNeuro-Optometry”

Thomas Landgraf, O.D., F.A.A.O.

Clinical Associate Professor, UMSL College of Optometry

my background
My Background
  • Graduate of ICO…Chicago
  • Residency at PCO…Philadelphia
  • SCO x 15 years…Memphis
  • Now at UMSL College of Optometry
  • In terms of Neuro-Eye…
    • Dr. Lawrence Gray at ICO & PCO
my background4
My Background
  • At SCO…Chief of Ocular Disease
    • Goals for this lecture
    • Not an expert
    • Share patient care experiences
    • Share “optometric legal consultant” experiences
resources
Resources
  • Journals and Internet
    • Review of Optometry
    • Review of Ophthalmology
    • Handbook of Ocular Disease Management
    • Clinical Guide To Ophthalmic Drugs
neuro optometry
Neuro-Optometry
  • Why spend 3 hours on it?
  • Conditions are both:
    • Vision threatening
    • Life threatening
  • “True” ocular emergencies
case 1 onh edema
Case #1: ONH Edema?
  • Always A Tough DDx (Differential Diagnosis)
  • S:
    • 52 yo Caucasian male referred to me
    • Tentative diagnosis of CRVO OS
case 1 onh edema8
Case #1: ONH Edema?
  • Always a Tough DDx
  • S:
    • Painless vision loss OS x 2 weeks
    • Prosthetic OD due to trauma
    • No significant medical or ocular conditons
      • Low daily dosage of methadone
      • Nicotine patch
case 1 onh edema9
Case #1: ONH Edema?
  • Always a Tough DDx
  • O:
    • BVA OS: 20/400
    • OS pupil round and reactive to light
    • Normal SLX
    • Tonometry 17 mm Hg
    • BP: 280/170 RAS: not done at previous visit
case 1 onh edema10
Case #1: ONH Edema?
  • Always a Tough DDx
  • O:
    • DFE OS:
      • Optic nerve head edema
      • Accompanied by flame hemes, exudates, cotton wool spots, and macular edema
      • Normal peripheral retina
case 1 onh edema11
Case #1: ONH Edema?
  • Always a Tough DDx
  • A: Malignant Hypertension and Resultant Retinopathy OS
  • P:
    • Immediate referral to medical center
    • For lowering of BP
    • Referral to retinal specialist
      • Level Of Comfort
      • Confirmation
case 1 onh edema12
Case #1: ONH Edema?
  • Always a Tough DDx
  • Follow-up 4 months later
    • Current meds: minoxidil, norvasc, coumadin
    • HTN and its complications
    • Noted improved vision
      • But some glare, distortion, “wavy lines” in central vision
case 1 onh edema13
Case #1: ONH Edema?
  • Always a Tough DDx
  • Follow-up 4 months later
    • BVA OS: 20/20
    • BP: 160/85
    • DFE OS: exudative macular star, healthy ONH (.2/.2), normal peripheral retina
case 1 onh edema14
Case #1: ONH Edema?
  • Always a Tough DDx
  • Follow-up 4 months later
    • Resolving Malignant Hypertensive Retinopathy
    • Improved Blood Pressure
    • Educated on compliance
case 1 onh edema15
Case #1: ONH Edema?
  • Always a Tough DDx
  • Bottom Lines
    • Primary Care OD’s need to take BP’s
      • Especially on those with retinal vascular disease
    • Consider typically bilateral retinal conditions
      • In monocular patients
case 1 onh edema16
Case #1: ONH Edema?
  • Always a Tough DDx
    • Timely diagnosis for malignant HTN
      • Can significantly reduce morbidity and mortality
    • Like Neuro-Eye Disease: sight and life threatening
pseudotumor cerebrii ptc
Pseudotumor Cerebrii (PTC)
  • Background
    • “false brain tumor”
    • Increased intracranial pressure without an intracranial mass
    • Major diagnosis of exclusion: a true intracranial tumor
      • All patients with papilledema must have neuro-imaging studies
ptc why
PTC: Why?
  • Poor CSF absorption
    • By meninges surrounding brain and spinal cord
    • Increased intra-abdominal pressure
      • From obesity
      •  elevated intrathoracic pressure
      •  decreased venous drainage from the brain
ptc diagnosis
PTC: Diagnosis
  • Who?
    • Obese women of childbearing age
    • Secondary
      • Obstruction to venous drainage: cerebral venous thrombosis
      • Exongenous agents: tetracycline, vitamin A, corticosteroids, BCP’s
      • Medical conditons: lupus, sarcoidosis, anemias, blood dyscrasias
ptc diagnosis20
PTC: Diagnosis
  • Symptoms
    • Bad HA’s: frontal, around the eyes, pressure-like, throbbing
    • Transient visual loss
    • Intracranial noises: heartbeat or whooshing sound in ears, tinnitus
    • Vision loss: blur, temporal VF defect
ptc diagnosis21
PTC: Diagnosis
  • Signs
    • Optic disc edema
      • Unilateral, bilateral, asymmetric
    • VA, pupils, EOM’S usually normal
    • VF: blind spot enlargement, inferonasal loss, generalized constriction
ptc differential diagnosis
PTC: Differential Diagnosis
  • Intracranial mass
  • Meningitis: abrupt onset, fever and chills, stiff neck
  • Bilateral inflammatory optic neuropathy: early and central vision loss, pain on eye movement, retrobulbar
ptc differential diagnosis23
PTC: Differential Diagnosis
  • Pseudopapilledema: optic disc drusen or tilted discs, ultrasound may aid
  • Neuroretinitis: macular exudate, early central vision loss
  • Bilateral ION: older, vascular risk factors, painless, early vision loss
ptc ancillary tests
PTC: Ancillary Tests
  • Optometric In-Office:
    • VF
    • B scan ultrasound
    • Photos or optic nerve imaging
ptc ancillary tests25
PTC: Ancillary Tests
  • Neurologist or neuro-eye doc referral
    • Neuroimaging before lumbar puncture
      • Standard MRI of the brain
      • CT scan with contrast if patient markedly obese
neuroimaging
Neuroimaging
  • Major Scans Used To Evaluate Neuro-Eye Disease
    • CT (Computerized tomography)
    • MRI (Magnetic Resonance Imaging)
neuroimaging27
Neuroimaging
  • CT
    • Good to view bony abnormalities, calcifications, acute hemorrhages
    • Valuable to diagnosis of orbital processes
    • Test of choice for thyroid eye disease
neuroimaging28
Neuroimaging
  • MRI
    • Far better at characterizing soft tissues
    • Preferable for most intracranial processes
    • Not subject to bone artifact
    • Contrast media and special studies can sharpen
      • Gadolinium is a contrast material that can increase signal intensity
ptc ancillary tests29
PTC: Ancillary Tests
  • Lumbar Puncture
    • Required for the diagnosis of PTC
    • Neurologist, radiologist or ER physician
    • Usually > 200 mm
lumbar puncture
Lumbar Puncture
  • Procedure
    • Patient positioned on side in fetal position with back fully flexed
    • 18 g needle inserted at L4-L5 interspace
    • Opening pressure measured when needle penetrates subarachnoid space
    • HA is most common complication
lumbar puncture31
Lumbar Puncture
  • Opening pressure
    • Normal: 60-80 mm of H20
    • Borderline elevated: 180-210 mm of H20
lumbar puncture32
Lumbar Puncture
  • CSF evaluation
    • Color
      • Clear and colorless is normal
      • Cloudy: infection
      • Xanthochromic (yellow): subarachnoid hemorrhage
    • Cell count and differential, cytology, chemical analysis, serologic analysis, microscopy, culture
ptc management
PTC: Management
  • “Comanage” with neurologist
    • Initial LP  improved signs and sxs
    • VF, DFE, photos or optic nerve imaging every month x 3 months
    • Every 2-3 months thereafter for about a year
    • Individual case variability
ptc management34
PTC: Management
  • “Comanage” with neurologist
    • Other options for some persistent signs and sxs
      • CAI’s : acetazolamide
      • Other diuretics
      • Weight loss
      • HA management
ptc management35
PTC: Management
  • Diamox
    • Not just for angle closure
    • Decreased CSF production up to 50%
    • 1-3 grams qd
      • 500 mg bid, tid, qid
    • Side effects: taste alteration, nausea, fatigue, diarrhea, tingling
    • Not with sulfa allergies, kidney disease
ptc management36
PTC: Management
  • Headache management
    • Topamax (topiramate)
      • Migraine prophylaxis and epilepsy
      • PTC: HA relief and mild inhibition of carbonic anhydrase, also causes weight loss
      • Recently: development of angleclosure glaucoma from choroidal expansion
ptc management37
PTC: Management
  • For signs and symptoms unresponsive to LP, severe vision loss
    • Corticosteroids
    • Surgery
      • Optic nerve sheath fenestration
      • CSF diversion (shunt)
ptc my clinical experience
PTC: My Clinical Experience
  • Relatively rare condition?
    • Not at SCO
  • “Comanagement” turns into MANAGEMENT
    • Optometrists take the time
    • Need to be familiar with ancillary diagnostic tests and treatment options
case 2 monocular acute vision loss in a golden girl
Case #2: Monocular Acute Vision Loss In A Golden Girl
  • S:
    • 85 yo Caucasian female
    • Cx: acute vision loss OD
    • 2 weeks earlier
      • Earache
      • Sore temporal veins
      • Jaw claudication
    • Past medical hx: non-contributory
case 2 golden girl
Case #2: Golden Girl
  • O:
    • BVA
      • LP OD, 20/30 OS
    • +APD OD
    • BP: 150/100
    • No carotid bruits
    • SLX: NS consistent with 20/30 VA
case 2 golden girl41
Case #2: Golden Girl
  • O:
    • DFE: pallid swelling of the optic nerve OD
    • Othewise normal retina and posterior pole OU
case 2 golden girl42
Case #2: Golden Girl
  • A:
    • Provisional Diagnosis: Giant Cell Arteritis OD
  • P:
    • FLAN:
      • increased arterial filling time OD
      • Choroidal nonfilling defect OD
    • 80 mg Prednisone po daily
case 2 golden girl43
Case #2: Golden Girl
  • P: R/O all causes of Anterior Ischemic Optic Neuropathy
    • CBC:
      • Elevated monocyte and platelet counts
    • ESR: 44
    • FTA-ABS and VDRL non-reactive
case 2 golden girl44
Case #2: Golden Girl
  • One week later…..
    • Right temporal artery biopsy
    • Ear pain and temporal HA resolved
case 2 golden girl45
Case #2: Golden Girl
  • Two weeks later…..
    • ESR: 4
    • Plan:
      • Monitor with ESR
      • And for prednisone side effects
case 2 golden girl46
Case #2: Golden Girl
  • Eventually…..
    • VA did not improve OD
      • But remained stable OS
anterior ischemic optic neuropathy aion arteritic
Anterior Ischemic Optic Neuropathy (AION) Arteritic
  • Or…..
  • Giant Cell Arteritis
    • Nomenclature following vision loss
  • Temporal Arteritis
aion artertic
AION-artertic
  • Background
    • Granualomatous vasculitis of medium-sized arteries
    • “True” ocular emergency
    • The Goal: Prevention of contralateral vision loss
aion arteritic
AION-arteritic
  • Background
    • Contralateral vision loss
      • 2/3 if untreated
      • Within weeks if untreated
aion arteritic50
AION-arteritic
  • Why
  • Granulomatous vasculitis of temporal artery 
  • Occlusion of short posterior ciliary arteries (supply anterior optic nerve) 
  • AION-artertic
aion arteritic51
AION-arteritic
  • Diagnosis: Who?
    • Rose Nylen on the Golden Girls
    • Average age of onset = 70 years
    • Female and Scandanavian
    • Lower incidence rates
      • Tennessee & Israel
aion arteritic52
AION-arteritic
  • Diagnosis: symptoms
    • Unilateral decreased VA, temporal HA, scalp tenderness
      • VA usually < 20/200
    • Amaurosis fugax
    • Anorexia, fever, malaise, depression
    • Onset is variable
aion arteritic53
AION-arteritic
  • Clinical Features
    • Vasculitis of coronary arteries: MI, CHF, angina pectoris
    • Neurologic: peripheral neuropathies, ischemic brain damage
    • Polymyalgia Rheumatica: pain and stiffness of the neck, shoulders, hips
aion arteritic54
AION-arteritic
  • Diagnosis: signs
    • AION-arteritic
      • Optic nerve edema, hemes, cotton wool spots
      • APD
      • VF defects: central, altitudinal, arcuate
aion arteritic55
AION-arteritic
  • Diagnosis: signs
    • AION-arteritic
      • Pallor described as chalky white
      • CRAO in up to 10% of patients
      • Disc eventually glaucoma-like with cupping BUT with pallor
aion arteritic56
AION-arteritic
  • Differential Diagnosis
    • Vs. non-arteritic AION
      • Worse VA
      • Worse VF
      • HA and scalp tenderness
      • Constitutional symptoms
      • Older
      • Worse ESR, CRP, CBC variables
aion arteritic57
AION-arteritic
  • Ancillary Tests
    • Optometric In-Office
      • VF
      • Optic nerve imaging
      • Photos
      • FLAN considered to check for choroidal perfusion defects
aion arteritic58
AION-arteritic
  • Ancillary Tests
    • Referral
      • ESR (erythrocyte sedimentation rate)
        • Westergren
        • 15% of GCA patients: normal ESR
      • CRP (C-reactive protein)
        • Elevated in > 91%
      • Also elevated WBC, platelet counts; IgG anticardiolipin antibodies
aion arteritic59
AION-arteritic
  • Ancillary Tests
    • Referral
      • Temporal artery biopsy
        • Should be performed on all suspects
        • > 95% sensitive, 100% specific
        • Can be done shortly after steroid treatment
        • Inflammatory cells in the muscular walls of the artery
aion arteritic60
AION-arteritic
  • Diagnosis: Summary
    • History and clinical impression
    • ESR and CRP
    • Confirm with temporal artery biopsy
aion arteritic61
AION-arteritic
  • Management
    • Referral: neurologist, internist (PCP), rheumatologist
    • For suspects or diagnosed:
      • Systemic steroids
aion arteritic62
AION-arteritic
  • Management
    • Systemic steroids
      • Hospital admission
      • 1-2 gm IV methylprednisone x 2-3 days
      •  60-100 mg of oral prednisone: tapered very slowly
aion arteritic63
AION-arteritic
  • Management
  • Systemic steroids
      • Anecdotal vision recovery?
      • Poor prognosis?
      • No solid support for anti-steroid medications (Rheumatrex aka methotrexate)
aion arteritic64
AION-arteritic
  • My Clinical Experience
    • This is rare?
      • Most important from an educational perspective
    • Presume the worst if suspect
    • Vs. glaucomatous optic neuropathy
      • Combination of AION + OAG in my patients