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Case JHC

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  1. Case JHC Juan G. Santiago, MD Ophthalmology Department University of Puerto Rico

  2. Chief Complaint • “Veoborrosopor el ojoizquierdohace 4 semanas”

  3. Present History • JHC is a 58 y/o male with history of HTN, heart disease in his usual state of health that complaints of left eye visual loss since 4 weeks ago. Patient refers a gray cloud in front of his eye, that does not move. Denies improvement or worsening of vision since event. Patient refers (-) eye pain, (-) photophobia, (-) flashlights, (-) diplopia, (-) secretions, (-) redness, (-) pain with eye movements, (-) headaches, (-) jaw claudication, (-) extremity weakness, (-) trauma, or (-) recent illness.

  4. History • Eye history: None • Surgeries: None • Childhood: None • Systemic history: HTN, Heart Disease • Family history: BA, DM, HTN

  5. Exam

  6. Exam

  7. Exam BP: 170/92

  8. Exam

  9. Visual Fields

  10. Differential Diagnosis • Nonarteritic Anterior ION • Pseudo Foster-Kennedy Syndrome • Compressive Optic Neuropathy • True Foster-Kennedy Syndrome • Malignant Hypertension • Inflammatory Optic Neuropathy • Infectious Optic Neuropathy • Arteritic Anterior ION

  11. Pseudo Foster Kennedy Syndrome Bilateral sequential infarction of optic nerve Sudden and painless visual loss Unilateral disc edema + Optic atrophy Flame shaped hemorrhages Usually > 50 yrs Nonarteritic Anterior ION

  12. Nonarteritic Anterior ION • DM / HTN • Contralateral small C/D ratio • ↓ Color vision • VF loss (altitudinal) • No associated symptoms • Normal ESR and C-RP • Treatment: NONE

  13. Nonarteritic Anterior ION

  14. True Foster Kennedy Syndrome Large mass lesion compressing the atrophic optic nerve and elevating intracranial pressure, to cause disc swelling in the other nerve Slow progressive visual loss ↓ Color vision Visual field defect Compressive Optic Neuropathy

  15. Etiologies ON tumor Pituitary tumor or apoplexy Diagnosis Orbit CT/MRI Compressive Optic Neuropathy

  16. Malignant Hypertension • Very high blood pressure (>200/130) with papilledema • Accompanied by • Heart failure • Kidney failure • Hypertensive encephalopathy

  17. Flame-shaped hemorrhages Cotton-wool spots Exudative edema Vessel sheathing Vessel tortuosity Malignant Hypertension

  18. Inflammatory and Infectious Optic Neuropathies • History is atypical • Atypical clinical course • Ongoing pain • Lack of visual recovery • Recurrence on steroid taper • Associated signs of intraocular infection • Optic disc appearance is not typical • Imaging is not typical • Patient has other systemic illness

  19. Sarcoidosis Infectious Viral Syphilis Lyme disease Bartonella TB Autoimmune Wegener’s SLE Devic’s syndrome Inflammatory and InfectiousOptic Neuropathies

  20. Arteritic Anterior ION • Infarction of optic nerve 2ry to temporal arteritis • Acute painful visual loss • Female > male (2:1) • Aged >65 yrs • ↓ Color vision • VF loss • Unilateral OD edema • Amaurosis fugax or diplopia

  21. Arteritic Anterior ION Associated symptoms • Scalp tenderness • Jaw claudication • Fever • Malaise • Anorexia • Weight loss • Anemia • Headache • Tender temporal artery Diagnosis: • ↑ ESR • ↑ C-RP • ↓ HCT / ↑ PLT • Temporal artery biopsy • Inflammation in artery wall with disruption of internal elastica lamina

  22. Our patient…

  23. Our patient… • Head and Orbit CT • Preliminar report: Enlarged left optic nerve??? • Labs • CBC  WNL • RPR  Non-Rx • ANA Screen  Neg • HIV  Non-Rx • Chest X-rays • Normal • No hilaradenopathies • CSF  WNL • ESR  8 • CRP  0.252 • Vit B12  446

  24. Our patient… • Head and Orbit CT • WNL • No evidence of enlarged optic nerves, no masses • Brain MRI • WNL

  25. Our diagnosis… • Pseudo Foster Kennedy Syndrome • Bilateral Sequential NAAION