Case Analysis I- Lecture 7

1. Case Analysis I- Lecture 7 Liana Al-Labadi, O.D.

2. If you hear hoof beats, thinkhorses—not zebras

3. CC: Dr. I see a black curtain over my eyes

4. QUESTIONS???

5. “Dr. I See All Black” • Frequency: Constantly (all the time, everyday) @ D&N • Onset: Suddenly10 days ago, but has noticed it more over the past 2 days • Location: Both eyes • Duration: Lasts for a short time but I feel it’s there all the time • Associated Factors: • Blurry vision • A lot of headaches Headaches • Relief: • Headaches get better with parcetamol but I still see a black curtain • Severity: • The blacking out is pretty bad, I just can’t stand it anymore. The headaches are there all the time.

6. DIFFERENTIAL DIAGNOSIS????

7. “Dr. I See All Black” • Migraine • DES / Keratitis/ Blepharitis/ Iritis /AACG • Vitreous detachment /Retinal break • Angiospasm/ vasospasm • Optic disc drusen/ Orbital tumor • Papilledema • ON / MS/ SLE • Embolic/Carotid emboli / Cardiac emboli • IV drug use • Hypoperfusion • Coagulation disorders /Inflammatory arteritis • Carotid stenosis/Ophthalmic artery stenosis • Cardiac failure or arrhythmia • Increased blood viscosity • Intraocular hemorrhage • Intracranial tumor • Psychogenic

8. Any Other Questions???

9. “Dr. I See All Black” • POH: • (+) Near sightedness • Negative for asthenopia, surgery, pain, & flashes • Negative for AMD, DR, Cats & Glc • (+) DIPL-?????? • (+) Trauma- 14 years ago????? • LEE: 6 months ago (unknown doctor)- Status????? • FOH: Negative for AMD, DR, Glc, Cat • LPE: Does not remember • PMH: • (+) stress (+) ENT (+) Respiratory • Negative for HTN/DM/Cancer/Neuro • FMH: (+) HTN- Father; (+) DM- Parents; Migraines- Parents • MED: None • Allg: NKDA; No seasonal allergies • SH: Reading • Occupation: Student • No alcohol consumption ; (+) smoking- Argeeleh

10. Entrance Testing????

11. “Dr. I See All Black” • Entrance Testing: • DVA (c): • OD: 20/50 PH: ??????????? • OS: 20/30 PH: ??????????? • Motility: S&F OD, OS • Pupils: 4mm/4mm RRL OD, OS; No APD • Confrontations: • OD: Slight inferior constriction • OS: Full

12. Additional Testing????

13. “Dr. I See All Black” • Additional Tests: • Lensometry: • OD: -3.75 -0.50x 153 • OS: -3.75 -0.50x 153 • Manifest Refraction: • OD: -4.00 -0.50x 165 VA: “All black” • OS: -3.75 -0.50x 153 VA: “All black”

14. Additional Testing????

15. “Dr. I See All Black” • SLE: • L/L: trace MGD OD, OS • Conj: No injection OD, OS • K: Clear OD, OS • Iris: Flat & brown OD, OS • AC: No cell & no flare/ D&Q OD, OS • Lens: Clear OD, OS • IOP (TA): • ??????????

16. Additional Testing????

17. “Dr. I See All Black” • Assumption: • Patient is 20/20 OD, OS • Confrontations full OD, OS • Sx: Headaches + “black-out” • DFE unremarkable OD, OS • What would be your FINAL DIAGNOSIS????

18. “Dr. I See All Black” • Assessment: • Transient visual distortion • Probably 2˚ Migraines • (+) Family history of migraines • Plan: • Pt re-assurance • Recommend pt sees GP/internist for pharmacological treatment • RTC ASAP if no improvement/worsening of sx • RTC for DFE in 2-3 months

19. Amaurosis Fugax- Definition • Transient vision obstruction (TVO) or transient vision loss is the preferred terminology • Amaurosis comes from a Greek word & it means to “darken or obscure” i.e. “blindness” . Fugax is also from the greek and means “fleeting” • i.e. “Fleeting blindness” • Sudden, temporary, partial or total loss of vision • Vision loss typically lasts from a few seconds to several minutes before returning to normal • Clinical Goal: • Determine etiology of transient vision loss • Important b/c underlying causes of TVO could range from life threatening conditions to simply dry eyes.

20. Amaurosis Fugax- Etiology • Three causes of TVO: • Circulatory • Embolic • Hypoperfusion • Ocular • Neurological

21. AmaurosisFugax- Differnetial Diagnosis • Keep in mind that if TVO is found to be associated with CAD, there is a significant increased risk of death from a myocardial infarction (MI) http://ijahsp.nova.edu/articles/vol4num2/Bacigalupi.pdf

22. Amaurosis Fugax- Work Up • Case History- The Important Questions • Frequency: How frequently do the sx occur? How quickly do the sx arise? • Onset: Are the sx in one eye or both eyes? • Location: Both eyes • Duration: How long do the visual disturbances last? • Associated Factors: • Is there any pain assoc c visual disturbance? • Does blinking or rubbing eyes modify the sx? • Are the sx worse with eyes movements? • Does the exercise alter or cause visual disturbances? • Scalp tenderness, jaw claudication, malaise? • Fever? Weight loss? • Numbness or tingling of extremities? • Slurred Speech? • Weakness on one side of the body? • Is motion sickness experienced? • Is there a long Hx of HA? Family history of HA? • Oral contraceptive use? • Smoker? • Relief: Anything makes the symptoms better? • Severity: On a scale of 1-10 how bad is it?

23. Amaurosis Fugax- Work Up Case History- The Important Questions • Ask the patient to describe the visual disturbance? • Does the vision blur, fog, dim or black out? • i.e Negative visual phenomenon • Do you see zigzag lines & colorful patterns? • i.e Positive visual phenomenon • Pay special attention to the patient’s medical history • Look for the presence of • HTN • Previous MI • DM • Orthostatic hypotension in DM pts can cause BF in ophthalmic artery to decrease by almost 100% when simply moving from supine to seated position. This dramatic loss of perfusion will cause significant TVO. Thus any signs of DR could be linked to TVO. • Prior cerebrovascular accidents • Hypercholesterolemia • Long-standing migraine history • Peripheral vascular disease

24. Amaurosis Fugax- Work Up Considerations In The Differential Diagnosis • Age of patient- very important factor • If over 45 years • Ischemic attacks are the more common causes of TVO • MUST R/O carotid disease & GCA esp in v. old pts • If under 45 years • Benign migrainous TVO’s are the most frequent cause • 41% of TVO pts under 45yo will have an accompanying HA to help solidify a diagnosis of migraine • MUST R/O sickle cell disease, hyperviscosity syndromes & cardiac valve disease

25. Amaurosis Fugax- Work Up Considerations In The Differential Diagnosis • Frequency of TVO: • Repeated events more likely caused by: • Hypoperfusion secondary to arterial stenosis • Isolated events • May be due to an ambolism • Increasing frequency of sx: • May be suggestive of an impending cerebral infarct • Onset of transient visual disturbance: • Less rapid onset  more likely a hypoperfusion event • Hypoperfusion events will develop over a matter of minutes, not seconds • Brief onsetembolic or vasospastic attack

26. Amaurosis Fugax- Work Up Considerations In The Differential Diagnosis • Duration of transient visual disturbance • If lasts for minutes migraines • If lasts for only seconds • Papilledema or vitreous traction or retinal breaks • If permanent • Artery/vein occlusion • Ischemic optic neuropathy

27. Amaurosis Fugax- Work Up Considerations In The Differential Diagnosis • Monocular or binocular symptoms: • Monocular Sx • Occlusive retinal /Carotid artery condition • GCA • Binocular Sx • Vertebro-basilar circulatory condition Or • Posterior circulatory problems • Papilledema • Migraine prodrome • Is vision followed by HA? • Yes- Classic migraine • No- Acephalic Migraine

28. Amaurosis Fugax- Work Up Considerations In The Differential Diagnosis • Negative or Positive TVO? • Negative TVO Ischemic etiology • Positive TVI Migrainous or ocular etiology • Nature of vision loss: • Transient blur • If resolves c blinking ocular surface disease • Complete black out of vision • Embolic • Transient occlusion of embolic or central retinal artery • Graying or dimming of vision • Vascular stagnation • Papilledema • Postural changes, HAs, Tinnitis

29. Amaurosis Fugax- Work Up Considerations In The Differential Diagnosis • Pain With TVO: • Common in cases of hypoperfusion & vasospasm • Severe pressure & pain that lasts for extended period of time Migraines • Chronic ocular or retrobulbar aching pains • More likely to suffer from carotid stenosis or ON/MS • Improvement in symptoms with blinking & rubbing • DES Or Blepharitis • Worse symptoms with eye movement • Vitreous traction • Orbital tumor • ON

30. Amaurosis Fugax- Work Up Considerations In The Differential Diagnosis • Increase in symptoms with exercise • Demyelinating disease • Vasospasm • Symptoms of scalp tenderness/ jaw claudication • TA/ GCA • Motion sickness & history of HA • Migrainous cause

31. Amaurosis Fugax- Work Up • Entrance Tests: • VA (pinhole) • EOM • Pupils if APD consider color vision or red desaturation • Confrontations • Refraction??? • SLE • Examine lid margins, tear film, K & AC • GonioR/O AACG • Automated VF R/O altitudinal defects • DFE to R/O • RD, retinal tears • ONH edema • BP measurement

32. Amaurosis Fugax- Work Up • Laboratory testing • CBC for pts > 45yo • To R/O anemia or hematological disorders • Complete chemistry panel • Provides info on DM, electrolytes & liver enzymes • Thyroid screening • Coagulation profile • ESR & CRP & platelet count • If suspect TA • If monocular sx of TVO • Order non-invasive evaluation of carotid circulation such as carotid duplex • If binocular sx of TVO • Order a CT scan or MRI • In area of occipital lobe & along the optic pathways • If hx suggests cardiogenic emboli as an etiology • Consider echocardiogram as a secondary test

33. Amaurosis Fugax- Management • Management: • Long lecture! • Based on etiology!!!