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Neurology Case Presentation

Neurology Case Presentation. March 23, 2012 Lori Noorollah. Chief Complaint. Double Vision HPI: 53 yo F who reports that during the first week in December she woke up with blurry vision and pain in her right eye Week before Xmas – woke up with double vision

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Neurology Case Presentation

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  1. Neurology Case Presentation March 23, 2012 Lori Noorollah

  2. Chief Complaint • Double Vision • HPI: • 53 yo F who reports that during the first week in December she woke up with blurry vision and pain in her right eye • Week before Xmas – woke up with double vision • Binocular, vertical and horizontal • Worse on right gaze • First week in February – woke up with blurry vision in left eye and left orbital pain

  3. More History • PMH: • HTN, Anxiety, chronic pain, GI bleed due to diverticulosis • Meds: • Clonidine 0.2mg qHS • Metoprolol 50mg BID • Diazepam prn • DiltiazemqAM • Losartan 100mg qHS • hydrocodoneprn • SH: • Smokes 3-4 cigarettes daily for 25 years • No EtOH or illicit drug use

  4. General Exam • Alert, oriented, no acute distress • CV: RRR, no carotid bruit • Chest: CTAB • Visual Acuity: • OD: 20/60 • OS: 20/25 • +relative APD on right • red-green dyschromatopsia on right

  5. Neurological Exam • Mental status and speech normal • CN: • PERRL • APD on right • Visual Fields – • Inferior arcuate defect on Right • Enlarged blind spot on Left • normal facial sensation and movement, symmetric palate elevation, tongue midline • EOM:Limited abduction and slightly limited upgaze bilaterally • Motor, Sensory, Reflexes, Coordination – within normal limits

  6. Visual Fields • Inferior arcuate defect in right eye Enlarged blind spot in left eye

  7. ?Where? ?What?

  8. Differential Diagnosis • Anterior Ischemic Optic Neuropathy (AION) + cranial nerve infarcts • AAION vs. NAION • Optic Neuritis • Ocular Myasthenia gravis • Acetylcholine receptor antibodies negative

  9. NAION Non-arteritic Anterior Ischemic Optic Neuropathy is an “idiopathic” ischemic insult of the optic nerve head • Most common optic neuropathy • Annual incidence for people > age 50 is 2.3 – 10.2 /100,000 • 95% of cases occur in Caucasian population

  10. NAION • Clinical presentation: • Sudden monocular visual loss • Blurring or cloudiness • Often noticed upon awakening (73%) • Most often painless • 12% have ocular pain or headache • A lot of pain more suggestive of optic neuritis or AION • Exam: • Reduced visual acuity to varying degrees • Not ruled out by normal visual acuity • Dyschromatopsia proportional to reduction in visual acuity • Afferent pupillary defect • Fundoscopic Exam: • Optic disc swelling • Disc hyperemia with splinter or flame hemorrhages • Small optic cup (nerve fiber crowding) in unaffected eye • Visual field defect – relative inferior altitudinal defect and absolute inferior nasal defect

  11. NAION – Fundoscopic Exam Hayreh SS (2009) Ischemic optic neuropathy. Progress in retinal and eye research 28: 34-62

  12. NAION • Vascular supply to optic nerve head • 15-20 short posterior ciliary arteries, supplied by ophthalmic artery

  13. NAION • Pathogenesis: • Different than Ischemic CVA • No clear relationship with HTN, HLD, smoking • Not associated with embolism or large vessel occlusion • Transient hypoperfusion of posterior ciliary arteries • Vasospasm vs. nocturnal hypotension vs. impaired autoregulation of microvasculature vs. vasculopathic occlusion vs. venous insufficiency • Hypoxia/Ischemia  optic disc swelling (in setting of physiologically crowded optic nerve head)  infarction • Treatment = Modify risk factors, vision therapy • Early therapy shown to have better recovery • Questionable role for steroids

  14. NAION and OSA • Nocturnal Hypotension • Normal physiologic occurrence • Autoregulation • OSA • Loss of autoregulation • Non-dipping status • Hypoxic-ischemic insult to optic nerve head • Anti-hypertensive medications at night may also disrupt autoregulation

  15. OSA and NAION • Stein, 2011 – American Journal of Ophthalmology • Retrospective cohort study • Review from managed care database looking at patients > 40 with at least 1 eye-care visit • N=2,259,061 • Compared incidence of NAION in population with and without OSA • Compared NAION in treated vs. untreated OSA

  16. OSA and NAION • Results: • After adjusting for confouding variables: • Untreated OSA patients had 16% increased hazard of experiencing NAION (HR 1.16, CI 1.01-1.33) compared with non-OSA patietns • Treated OSA patients had no difference in hazard (HR 1.38, CI 0.76-2.5) compared with non-OSA patients

  17. NAION – Future Studies • Implications: • Do patients with NAION need screening for OSA? • Do patients with OSA need evaluation? • Consider avoiding anti-hypertensive medications at night, especially in patients “at risk” for NAION • Future Studies: • Treatment options/Intervention/Prevention • Further investigation into the pathophysiology of NAION

  18. References Anterior Ischemic Optic Neuropathy:Part II: a discussion for physicians. Sohan Singh Hayreh, MD, MS, PhD, DSc, FRCS, FRCOphthhttp://webeye.ophth.uiowa.edu/component/content/article/118-aion-part2 Atkins, EJ Nonarteritic Anterior Ischemic Optic Neuropathy. Current Treatment Options in Neurology. 2011; 13: 92-100 Hayreh SS (2009) Ischemic optic neuropathy. Progress in retinal and eye research 28: 34-62 Kerr NM, Etal. Non-arteriticischaemic optic neuropathy: A review and update. Journal of Clinical Neuroscience. 2009; 16: 994-1000. Stein JD, Etal. The Association between Glaucomatous and other causes of Optic Neuropathy and Sleep Apnea. Am J Ophthalmol. 2011; 152: 989-998. Up To Date Online

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