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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 Thomas J. Landgraf, O.D., F.A.A.O.
“Clinical Case Challenges inNeuro-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 • SCO x 15 years…Memphis • Now at UMSL College of Optometry • In terms of Neuro-Eye… • Dr. Lawrence Gray at ICO & PCO
My Background • At SCO…Chief of Ocular Disease • Goals for this lecture • Not an expert • Share patient care experiences • Share “optometric legal consultant” experiences
Resources • Journals and Internet • Review of Optometry • Review of Ophthalmology • Handbook of Ocular Disease Management • Clinical Guide To Ophthalmic Drugs
Neuro-Optometry • Why spend 3 hours on it? • Conditions are both: • Vision threatening • Life threatening • “True” ocular emergencies
Case #1: ONH Edema? • Always A Tough DDx (Differential Diagnosis) • S: • 52 yo Caucasian male referred to me • Tentative diagnosis of CRVO OS
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
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
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
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
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
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
Case #1: ONH Edema? • Always a Tough DDx • Follow-up 4 months later • Resolving Malignant Hypertensive Retinopathy • Improved Blood Pressure • Educated on compliance
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
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
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
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
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
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
PTC: Diagnosis • Signs • Optic disc edema • Unilateral, bilateral, asymmetric • VA, pupils, EOM’S usually normal • VF: blind spot enlargement, inferonasal loss, generalized constriction
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
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
PTC: Ancillary Tests • Optometric In-Office: • VF • B scan ultrasound • Photos or optic nerve imaging
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
Neuroimaging • Major Scans Used To Evaluate Neuro-Eye Disease • CT (Computerized tomography) • MRI (Magnetic Resonance Imaging)
Neuroimaging • CT • Good to view bony abnormalities, calcifications, acute hemorrhages • Valuable to diagnosis of orbital processes • Test of choice for thyroid eye disease
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
PTC: Ancillary Tests • Lumbar Puncture • Required for the diagnosis of PTC • Neurologist, radiologist or ER physician • Usually > 200 mm
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
Lumbar Puncture • Opening pressure • Normal: 60-80 mm of H20 • Borderline elevated: 180-210 mm of H20
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
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
PTC: Management • “Comanage” with neurologist • Other options for some persistent signs and sxs • CAI’s : acetazolamide • Other diuretics • Weight loss • HA management
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
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
PTC: Management • For signs and symptoms unresponsive to LP, severe vision loss • Corticosteroids • Surgery • Optic nerve sheath fenestration • CSF diversion (shunt)
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
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
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
Case #2: Golden Girl • O: • DFE: pallid swelling of the optic nerve OD • Othewise normal retina and posterior pole OU
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
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
Case #2: Golden Girl • One week later….. • Right temporal artery biopsy • Ear pain and temporal HA resolved
Case #2: Golden Girl • Two weeks later….. • ESR: 4 • Plan: • Monitor with ESR • And for prednisone side effects
Case #2: Golden Girl • Eventually….. • VA did not improve OD • But remained stable OS
Anterior Ischemic Optic Neuropathy (AION) Arteritic • Or….. • Giant Cell Arteritis • Nomenclature following vision loss • Temporal Arteritis
AION-artertic • Background • Granualomatous vasculitis of medium-sized arteries • “True” ocular emergency • The Goal: Prevention of contralateral vision loss
AION-arteritic • Background • Contralateral vision loss • 2/3 if untreated • Within weeks if untreated
AION-arteritic • Why • Granulomatous vasculitis of temporal artery • Occlusion of short posterior ciliary arteries (supply anterior optic nerve) • AION-artertic