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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”. 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

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Clinical Case Challenges In Neuro-Optometry I

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  1. Clinical Case Challenges In Neuro-Optometry I Thomas J. Landgraf, O.D., F.A.A.O.

  2. “Clinical Case Challenges inNeuro-Optometry” Thomas Landgraf, O.D., F.A.A.O. Clinical Associate Professor, UMSL College of Optometry

  3. 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

  4. My Background • At SCO…Chief of Ocular Disease • Goals for this lecture • Not an expert • Share patient care experiences • Share “optometric legal consultant” experiences

  5. Resources • Journals and Internet • Review of Optometry • Review of Ophthalmology • Handbook of Ocular Disease Management • Clinical Guide To Ophthalmic Drugs

  6. Neuro-Optometry • Why spend 3 hours on it? • Conditions are both: • Vision threatening • Life threatening • “True” ocular emergencies

  7. Case #1: ONH Edema? • Always A Tough DDx (Differential Diagnosis) • S: • 52 yo Caucasian male referred to me • Tentative diagnosis of CRVO OS

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Case #1: ONH Edema? • Always a Tough DDx • Follow-up 4 months later • Resolving Malignant Hypertensive Retinopathy • Improved Blood Pressure • Educated on compliance

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. PTC: Diagnosis • Signs • Optic disc edema • Unilateral, bilateral, asymmetric • VA, pupils, EOM’S usually normal • VF: blind spot enlargement, inferonasal loss, generalized constriction

  22. 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

  23. 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

  24. PTC: Ancillary Tests • Optometric In-Office: • VF • B scan ultrasound • Photos or optic nerve imaging

  25. 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

  26. Neuroimaging • Major Scans Used To Evaluate Neuro-Eye Disease • CT (Computerized tomography) • MRI (Magnetic Resonance Imaging)

  27. Neuroimaging • CT • Good to view bony abnormalities, calcifications, acute hemorrhages • Valuable to diagnosis of orbital processes • Test of choice for thyroid eye disease

  28. 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

  29. PTC: Ancillary Tests • Lumbar Puncture • Required for the diagnosis of PTC • Neurologist, radiologist or ER physician • Usually > 200 mm

  30. 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

  31. Lumbar Puncture • Opening pressure • Normal: 60-80 mm of H20 • Borderline elevated: 180-210 mm of H20

  32. 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

  33. 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

  34. PTC: Management • “Comanage” with neurologist • Other options for some persistent signs and sxs • CAI’s : acetazolamide • Other diuretics • Weight loss • HA management

  35. 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

  36. 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

  37. PTC: Management • For signs and symptoms unresponsive to LP, severe vision loss • Corticosteroids • Surgery • Optic nerve sheath fenestration • CSF diversion (shunt)

  38. 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

  39. 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

  40. 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

  41. Case #2: Golden Girl • O: • DFE: pallid swelling of the optic nerve OD • Othewise normal retina and posterior pole OU

  42. 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

  43. 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

  44. Case #2: Golden Girl • One week later….. • Right temporal artery biopsy • Ear pain and temporal HA resolved

  45. Case #2: Golden Girl • Two weeks later….. • ESR: 4 • Plan: • Monitor with ESR • And for prednisone side effects

  46. Case #2: Golden Girl • Eventually….. • VA did not improve OD • But remained stable OS

  47. Anterior Ischemic Optic Neuropathy (AION) Arteritic • Or….. • Giant Cell Arteritis • Nomenclature following vision loss • Temporal Arteritis

  48. AION-artertic • Background • Granualomatous vasculitis of medium-sized arteries • “True” ocular emergency • The Goal: Prevention of contralateral vision loss

  49. AION-arteritic • Background • Contralateral vision loss • 2/3 if untreated • Within weeks if untreated

  50. AION-arteritic • Why • Granulomatous vasculitis of temporal artery  • Occlusion of short posterior ciliary arteries (supply anterior optic nerve)  • AION-artertic

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