Evaluation of Sudden Unilateral Vision Loss in a Patient with Diabetes and Hypertension
A 51-year-old male presents with sudden left eye vision loss over the past two days, reporting a cloudiness and no associated pain or photophobia. His medical history includes diabetes and hypertension. Initial examinations reveal normal findings, but follow-up shows new symptoms of mild headaches and perioral numbness, prompting a referral for further evaluation. Differential diagnoses include nonarteritic anterior ischemic optic neuropathy and optic neuritis, along with considerations for various infectious and autoimmune conditions necessitating appropriate imaging and management.
Evaluation of Sudden Unilateral Vision Loss in a Patient with Diabetes and Hypertension
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Presentation Transcript
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 • 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.
History • Eye history: None • Surgeries: None • Childhood: (+)VZV • Systemic history: DM, HTN • Family history: BA, DM, HTN
Exam CBC: WNL ESR: 12 Orbit CT: Normal study
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!!!
Differential Diagnosis • Nonarteritic Anterior ION • Idiopathic Optic Neuritis • Inflammatory Optic Neuropathy • Infectious Optic Neuropathy • Arteritic Anterior ION • Compressive Optic Neuropathy
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
Optic Neuritis • Inflammation of optic nerve • Younger (20-40 yrs) • Unilateral • Women > Men
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
Optic Neuritis • Isolated • Associated to MS
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
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
Sarcoidosis Infectious Viral Syphilis Lyme disease Bartonella TB Autoimmune Wegener’s SLE Devic’s syndrome Inflammatory and InfectiousOptic Neuropathies
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
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 Arteritic Anterior ION
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
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…
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
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
