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“Clinical Case Challenges in Neuro -Optometry”

“Clinical Case Challenges in Neuro -Optometry”. Thomas Landgraf, O.D., F.A.A.O. Clinical Associate Professor, UMSL College of Optometry. Neuro -Optometry. Why spend time on it? Conditions are both: Vision threatening Life threatening “True” ocular emergencies. Case #1: ONH Edema?.

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“Clinical Case Challenges in Neuro -Optometry”

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

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

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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

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

  11. 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

  12. 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

  13. Case #2 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”

  14. Case #2: 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?

  15. Case #2: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

  16. Case #2: BWI • Exam • SLX essentially normal OU • IOP: 27, 25 • DFE: • .4/.4 with healthy rim OU • Macula clear OU • Periphery clear OU

  17. Case #2: BWI • Photos

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

  19. Case #2: BWI • VF OD

  20. Case #2: BWI : “The Clincher” • VF OS

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

  22. Case #2: 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?

  23. Case #2: 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

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