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Case JRD

Case JRD. Juan G. Santiago, MD Ophthalmology Department University of Puerto Rico. Chief Complaint. “Perdí la visión del ojo izquierdo hace 2 días”. Present History.

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Case JRD

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

  2. Chief Complaint • “Perdí la visión del ojo izquierdo hace 2 días”

  3. Present History • JRD is a 51 y/o male with history of DM, HTN in his usual state of health that complaints of left eye visual loss since 2 days ago. Patient refers a cloud in front of his eye. Denies improvement or worsening of vision since event. Patient refers (-) eye pain, (-) photophobia, (-) flashlights, (-) diplopia, (-) secretions, (-) redness, (-) pain with eye movements, (-) headaches, (-) extremity weakness, (-) trauma, or (-) recent illness.

  4. History • Eye history: None • Surgeries: None • Childhood: (+)VZV • Systemic history: DM, HTN • Family history: BA, DM, HTN

  5. Exam

  6. Exam CBC: WNL ESR: 12 Orbit CT: Normal study

  7. Follow-up • Patient return to OPH Clinics for follow up. • Pt with new complaints of mild headaches, (+) pain with eye movements, (+) perioral numbness??? • Patient send to ER for new workup!!!

  8. Differential Diagnosis • Nonarteritic Anterior ION • Idiopathic Optic Neuritis • Inflammatory Optic Neuropathy • Infectious Optic Neuropathy • Arteritic Anterior ION • Compressive Optic Neuropathy

  9. Infarction of optic nerve Acute painless visual loss Unilateral disc edema Flame shaped hemorrhages Usually > 50 yrs DM / HTN +RAPD Contralateral small C/D ratio ↓ Color vision VF loss (altitudinal) No associated symptoms Normal ESR and C-RP Treatment: NONE Nonarteritic Anterior ION

  10. Nonarteritic Anterior ION

  11. Optic Neuritis • Inflammation of optic nerve • Younger (20-40 yrs) • Unilateral • Women > Men

  12. Acute unilateral visual loss Ocular pain exacerbated by eye movements (92%) + RAPD ↓ Color vision ↓ Contrast sensitivity Visual Field Diffuse (50%) Central scotoma (20%) Optic disc 2/3 Normal 1/3 Swollen Usually no flame shaped hemorrhages Optic Neuritis

  13. Optic Neuritis • Isolated • Associated to MS

  14. Multiple Sclerosis • Autoimmune disease • Myelin • Women > Men • 20-40 years old • Symptoms • Visual complaints • Extremities muscle weakness • Poor coordination and/or balance • Speech impediments, tremors, dizziness

  15. What to think if… • 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

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

  17. 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

  18. Arteritic Anterior ION Associated symptoms • Scalp tenderness • Jaw claudication • Fever • Malaise • Anorexia • Weight loss • Anemia • Headache • Tender temporal artery

  19. Diagnosis: ↑ ESR ↑ C-RP ↓ HCT / ↑ PLT Temporal artery biopsy Inflammation in artery wall with disruption of internal elastica lamina Arteritic Anterior ION

  20. Slow progressive visual loss ↓ Color vision + RAPD VF defect Proptosis Disc Normal Pale Swollen Etiologies ON tumor Pituitary tumor or apoplexy TRO Diagnosis Orbit CT/MRI Compressive Optic Neuropathy

  21. Brain MRI Left optic nerve enhancement No brain lesions Labs RPR  Non-Rx ACE  N/A HIV  Non-Rx Chest X-rays Normal No hilar adenopathies Treatment Solumedrol IV Improve VA and symptoms Our patient…

  22. Literature Review • Optic Neuritis Treatment Trial (ONTT) • Visual recovery • No significant difference between the 3 treatment groups at 1 year in mean VA, color vision, contrast sensitivity, or visual field. • IV methyprednisolone  Recover VA faster • Oral prednisone  Increase rate of recurrent attacks • Cumulative Risk of Development of MS • 13% - normal MRI • 35% - 1-2 lesions > than 3 mm • 50% - with more than 2 lesions > than 3 mm • IV methylprednisolone  reduced rate of MS during the first 2 years only in patients who had abnormal brain imaging

  23. Literature Review • Controlled High-risk Avonex Multiple Sclerosis Prevention Study (CHAMPS) • Once weekly intramuscular interferon beta-1a initiated at the time of a first clinical demyelinating event may be benificial in patients who have MRI evidence prior subclinical demyelination, reducing the risk of CDMS by approximately half

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