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Clinical Case Challenges

Clinical Case Challenges . In Neuro-Optometry II Thomas J. Landgraf, O.D., F.A.A.O. Oops Almost Forgot!. My Email landgraft@umsl.edu. Case #3: Instead Of A Case. Sildenafil…Does the “little blue pill” cause big problems? Viagra Erectile Dysfunction: 30 million men Best Seller List

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Clinical Case Challenges

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

  2. Oops Almost Forgot! • My Email • landgraft@umsl.edu

  3. Case #3: Instead Of A Case • Sildenafil…Does the “little blue pill” cause big problems? • Viagra • Erectile Dysfunction: 30 million men • Best Seller List • Association with AION-non-arteritic

  4. Case #3: Instead Of A Case • Viagra • Newer agents • Levitra (vardenafil hydrochloride) • Cialis (tadalfil) • 2 reported cases of NA-AION

  5. Case #3: Instead Of A Case • Viagra • FDA 2005 • Updated labeling for all 3 drugs • Information on possibility of vision loss

  6. Case #3: Instead Of A Case • Viagra: How does it work? • Inhibits phosphodiesterase-5 • Normally degrades cGMP • cGMP normally relaxes smooth muscle and increased blood flow

  7. Case #3: Instead Of A Case • Viagra: dosage • Standard 25-50 mg • 100 mg tabs also available • Once a day at the most • 2-3 x / week

  8. Case #3: Instead Of A Case • Viagra: systemic side effects • Due to effects on phosphodiesterases • Potentiates vasodilation • HA, flushing, dyspepsia, nasal congestion, cardiovascular, cerebrovascular, vascular • Visual disturbances

  9. Case #3: Instead Of A Case • Viagra: ocular side effects • Due to effect on enzyme on photoreceptors and alterates cGMP in the cones • Bluish tinge to vision • Increased light sensitivity • Haloes • Infrequent at low dosages • 50% if > 200 mg • Within hours

  10. Case #3: Instead Of A Case • Viagra and NA-AION • Since 1999, > 20 cases involving ingestion • Blur, altitudinal VF loss, edematous disc • “disc at risk”: small cup, crowded optic nerve head • Ischemia at prelaminar portion of optic nerve

  11. Case #3: Instead Of A Case • Viagra and NA-AION • At risk patients? • Small vessel occlusive cerebrovascular disease • HTN, DM, elevated cholesterol • Smokers • After age 50

  12. Case #3: Instead Of A Case • Viagra and NA-AION • Why? • Perhaps effect via NO-cGMP pathway • Nitric oxide & cyclic gaunosine monophosphate • Interferes with autoregulation of ocular blood flow

  13. Case #3: Instead Of A Case • Viagra: Our Role • Include ED drugs in DDx of NA-AION • Ask all male patients about use of ED meds • Inform about potential risks, especially if already had monocular NA-AION • Annual exam with DFE : keep those patient #’s up

  14. Case #3: Instead Of A Case • Viagra: Bottom Line • All over the news and in the literature • Patients aware, we must be too! • Most recent articles BY FAR • Data will continue to develop

  15. AION-non-arteritic • Background • Most common cause of acute optic neuropathy > 50 • Remains a disease without treatment or prophylaxis • Recently: Ischemic Optic Neuropathy Decompression Trial and Follow-Up Study

  16. AION-non-arteritic • Why? • “a short posterior ciliary artery problem” • Small branches occluded or hypoperfused • Already have an affected vasculature if small C/D • HTN and DM  vaso-occlusion

  17. AION-non-arteritic • Why… per Hayreh • “dysfunctional vascular autoregulatory mechanisms at the level of the optic nerve” • Transient nocturnal hypotension • Overtreatment of systemic hypertension

  18. AION-non-arteritic • Diagnosis: Who? • Men and women > 50 years • Caucasians • 1500-5700 new cases / year • Majority of patients have DM, and / or HTN • Cigarette smokers • C/D < 0.1

  19. AION-non-arteritic • Diagnosis: Symptoms • Vision loss: gradual over weeks • Scotoma or blur • Some more abrupt and without warning • < 20/60 within 30 days • Peri-ocular discomfort in 10% • Usually painless

  20. AION-non-arteritic • Diagnosis: Signs • VA ends up between 20/60-20/200 • Inferior altitudinal VF defect • Inferior nasal and cecocentral too • APD

  21. AION-non-arteritic • Diagnosis: Signs • Optic disc edema needed for diagnosis • With flame hemorrhages • Hyperemic • Dilated and tortuous retinal veins • Contralateral small C/D or “disc-at-risk”

  22. AION-non-arteritic • Differential Diagnosis • Dr. Gray “Diagnosing In The Negative” • Vs. AION-arteritic • Younger • Better VA • Lack of constitutional symptoms • CRP and ESR less likely to be elevated • Lack of cotton wool spots, artery occlusions

  23. AION-non-arteritic • Differential Diagnosis • Optic Neuritis • Inflammatory • Slowly progressive and intraocular inflammation • Infectious • Infiltrative (papilledema)

  24. AION-non-arteritic • Differential Diagnosis • Compressive • Slowly progressive • Orbital signs: proptosis • HA • Vision and VF loss • Optic nerve edema • GIT upset • Personality changes • Decreased psychomotor function

  25. AION-non-arteritic • Differential Diagnosis • Don’t forget about the demographics of AION • Everyone’s Level Of Comfort Is Different • Never Be Afraid To Get A Second Opinion • Try and teach the students… • The best O.D.’s know they don’t know it all

  26. AION-non-arteritic • Ancillary Tests • Optometric In-Office • VF’s • Optic Nerve Imaging • Photos • FLAN? • Unless checking for choroidal perfusion defects in arteritic AION

  27. AION-non-arteritic • Ancillary Tests • Referral • CRP • ESR • Probably all that is needed for typical AION-non-arteritic

  28. AION-non-arteritic • Management • Referral to PCP • Diagnosis and management of DM, HTN and atherosclerosis • But not a direct marker for impending stroke or heart event • Stop smoking • 1 month follow-up with you

  29. AION-non-arteritic • Management • No effective medical or surgical treatment • Concentrate on: • DM, HTN, cholesterol • Smoking cessation

  30. AION-non-arteritic • Management • Ischemic Optic Neuropathy Decompression Trial • No role for optic nerve sheath decompression in AION-non-arteritic • Poor efficacy and high risk • Aspirin often recommended • To prevent contralateral involvement • Little supportive data

  31. AION-non-arteritic • Management • Neuroprotective Agents • Menatine benefical in animal models • Brimonidine in human trials: thus far no efficacy

  32. AION-non-arteritic • Management: Patient education • Most patients relatively stable vision-wise • Give or take a few lines • Up to 1/5 develop contralateral disease • ONH edema resolves within a month  • Atrophic

  33. AION-non-arteritic • My Clinical Experience • Not uncommon • See it sometimes after the fact • Complicates glaucoma

  34. Case #4 The BWI Connection • History • 19 yo African-American female • Moderate blur OS • Associated with HA , pain, and pressure OS about 1 month ago • Went to PCP and then referred to eye clinic in DC • Doc did not finding anything wrong…was told it was “sinus-related”

  35. Case #4: BWI • History • Back in Memphis to see family • Mom recommends The Eye Center at SCO • No significant medical or ocular history • Pt is overweight…why mention?

  36. Case #4:BWI • Exam • BCVA: 20/20, 20/25+ • EOM’s: FROM without diplopia • Pupils: grade 1-2 APD OS • Confrontation fields: FTFC OU • Amsler normal OU

  37. Case #4: BWI • Exam • SLX essentially normal OU • IOP: 27, 25 • DFE: • .4/.4 with healthy rim OU • Macula clear OU • Periphery clear OU

  38. Case #4: BWI • Photos

  39. Case #4: BWI • Ancillary tests ordered • Photos • VF’s: Humphrey 24-2 • Why no optic nerve imaging?

  40. Case #4: BWI • VF OD

  41. Case #4: BWI : “The Clincher” • VF OS

  42. Case #4: BWI • Assessment • 1. Retrobulbar Optic Neuritis OS • Eye pain, APD, central scotoma, decreased VA • 2. Glaucoma suspect OU • Increased IOP • 3. CMA OU

  43. Case #4: BWI • Plan…hmmmm • Patient concerned about cost of visit to neurologist • Wanted to see neurologist when she returned to DC in 2 weeks • Insurance coverage through college • Is this OK?

  44. Case #4: BWI • Plan • 1. Refer to neurologist for further management as deemed appropriate • R/O Multiple Sclerosis • Educated patient on possible etiologies, importance of seeing neurologist, and vision prognosis • 2. Recall in 6 months • 3. No new Rx recommended

  45. Optic Neuritis • Background • Acute inflammation of the optic nerve • Vs. “Demyelinating Optic Neuropathy” • Initial presentation of Multiple Sclerosis (MS) • Recognition aids with diagnosis in early course • Available treatments may minimize worse effects

  46. Optic Neuritis • Background: historically • “blindness a divine punishment for sin” • Optic neuritis may have accounted for “miraculous” spontaneous cures

  47. Optic Neuritis • Background: as it relates to MS • 75% of patients • 25% initially • Visual prognosis is good • 12 months, nearly all have 20/20 • 5 years, only 6% < 20/40

  48. MS: Additional Ocular Manifestations • Diplopia • INO or BINO (bilateral internuclear ophthalmoplegia) • CN VI, III, IV palsy • Nystagmus

  49. Optic Neuritis • Background: MS • Chronic inflammatory condition • Affects white matter in CNS • Autoimmune response in genetically predisposed • Prevalence < 1% • Leading cause of disability in “young adults”

  50. Optic Neuritis • Why? MS • Destruction of myelin sheath • Slows nervous conduction • Random patches: plaques • Associated with wide range of neurologic sxs

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