Swollen Optic Disc PresentationNortheastern University10/31/12
• 58yo WM with type II DM and HTN is anestablished patient with one swollen opticdisc and spots in his vision when he woke...
Proceed by:1. GCA and Increased Intracranial Pressurequestions (HA, Jaw/scalp/NECK, Tinnitus, N/V,TVO)2. Cranial Nerve Exa...
Valerie Biousse’s Neuro-OphthalmologyAnterior Optic Neuropathy PapilledemaOCULAR SIGNS:decrease in VAdecrease in colorCent...
Grant Liu’s NeuroOphthamologyTable 6–1 Differentialdiagnosis of a swollen opticdisc: causes according tofrequencyMost comm...
Grant Liu’s NeuroOphthamologyTable 6–1 Differentialdiagnosis of a swollen opticdisc: causes according tofrequencyMost comm...
Grant Liu’s NeuroOphthamologyTable 6–1 Differentialdiagnosis of a swollen opticdisc: causes according tofrequencyMost comm...
Differential Diagnosis• AION – Most Common• In order search for NEOPLASIA  IMAGINGWHICH YOU MUST PURSUE YOURSELF---------...
1. GCA• is the most common form ofsystemic vasculitis in adults• its most feared complicationis irreversible loss of visio...
three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.Vasculitis PLUS any 3of 5 gets Dx of GCA1....
three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.Vasculitis PLUS any 3of 5 gets Dx of GCA1....
three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.Vasculitis PLUS any 3of 5 gets Dx of GCA1....
1. GCA–this pt in this case had no GCA symptoms andthe ESR/CRP were not elevated – so GCA notsuspected in this case–MUST R...
GCA (Purvin) BOTH OIS(Glaser-Mendrinos)● Ischemic opticneuropathy● Homonymoushemianopia● Cortical blindness(NECK PAIN)● Re...
2. NAION
NAION• Pathogenesis: unknown• majority 60-70yo but could be any age• Caucasian>African American or HispanicAmerican• Incre...
Hypertensive THERAPY as a POSSIBLEPRECIPITATING Risk factor for NAION• Nocturnal Hypotension–vision loss noticed in the mo...
Other possible risk factors• Disc at Risk / crowded disc–If you look at the fellow eye and it iscupped – question NAION as...
Symptoms of NAION• IONDT: 40% noticed monocularvision loss upon awakening• Maximal when noted and usually does notprogress...
Signs of NAION• IONDT:50% see better than 20/6467% see better than 20/200• +APD; +red cap test• Any VF Defect including in...
Education of NAION pt• Can improve or worsen in 1st month• IONDT: 43% IMPROVE with no tx• IONDT: 14.7% is the risk of fell...
The Case03/16/12 – As previously stated the pt woke upwith bunch of black spots in left eye’s vision…History of microvascu...
Brief Mention about……VA’s20/20 OU throughout…Macula’s:No macular edema throughout…IOP’s:IOP was unremarkable throughout
Brief Mention about……Optic Nerve:No pallor or APD or red desat wasnoted throughout…motilities:After initial CN 6 palsy res...
-18-16-14-12-10-8-6-4-200 1 2 3 4 5 6 7 8 9 10RIGHT EYELEFT EYEMONTHS in 2012MDOfVF~Altitudinal defectsW/ CENTRAL SPARING
0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10OCT thickness measures of RIGHT EYEumInferior rimSuperior rimSECTORAL DIS...
0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10OCT thickness measures of LEFT EYEumInferior rimSuperior rimSECTORAL DISC...
Superior rimright eye0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10SUSPECTEDInferior rimof left eye4-5 mos
0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10Inferior rimof left eyeSuperior rimright eye-18-16-14-12-10-8-6-4-200 1 2...
NAION NAION Kanski’sNAIONKanski’s P’edema Kanski’s Arteritic AION
NAION NAION K’sAcuteEst.P’edemaKanski’s Bur. Drusen Kanski’s Hypoplastic
References• Liu: NeuroOphthalmology• Biousse: NeuroOphthalmology Illustrated• Dr. Richard Castillo Northeastern State Univ...
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Swollen optic nerve_presentation_last_revision 103112 disregard all others

  1. 1. Swollen Optic Disc PresentationNortheastern University10/31/12
  2. 2. • 58yo WM with type II DM and HTN is anestablished patient with one swollen opticdisc and spots in his vision when he woke up.There are no other significant abnormalfindings.
  3. 3. Proceed by:1. GCA and Increased Intracranial Pressurequestions (HA, Jaw/scalp/NECK, Tinnitus, N/V,TVO)2. Cranial Nerve Exam (Dr. Castillo)-cover test in multiple positions of gaze (Keane)3. Vital Signs4. Image posterior pole5. schedule the VF and F/U appt6. Educate “Swollen Optic Disc”/ER visit possible7. Get release of information for PCP’s note/etc8. ESR/CRP within a few hours
  4. 4. Valerie Biousse’s Neuro-OphthalmologyAnterior Optic Neuropathy PapilledemaOCULAR SIGNS:decrease in VAdecrease in colorCentral/Arcuate/AltitudinalDisc edema more often unilateral____________________________SYSTEMIC SIGNS:Often isolated (orassociated withsymptoms/signs related tounderlying disease – likeGCA symptoms)OCULAR SIGNS:Normal VA’s til lateNormal colorEnlarged blindspot, nasal defect,constrictionDisc edema almostalways bilateral____________________________SYSTEMIC SIGNS:Other symptoms or signs ofincreased ICP, HA, Nausea,Vomiting, Diplopia, 6th nervepalsy, Pulsatile Tinnitus,TVO’s,(Fever,Seizure,Stiffness)(OR >1 CN DAMAGED)
  5. 5. Grant Liu’s NeuroOphthamologyTable 6–1 Differentialdiagnosis of a swollen opticdisc: causes according tofrequencyMost commonPapilledema BILATERALOptic neuritis PAINMRIAnterior ischemic opticneuropathy (GCAPAIN)PseudopapilledemaCommonCentral retinal vein occlusion?Diabetic papillopathyUncommonOcular hypotonyIntraocular inflammation(uveitis)Malignant hypertensionOptic perineuritis PAIN MRIPapillitisIntrinsic optic disc tumorsLeber’s hereditary opticneuropathy -YOUNGOptic nerve infiltration bysarcoidosis PAIN MRIlymphomaleukemiaplasma cell dyscrasiaADDRESSED BY HISTORY
  6. 6. Grant Liu’s NeuroOphthamologyTable 6–1 Differentialdiagnosis of a swollen opticdisc: causes according tofrequencyMost commonPapilledemaOptic neuritisAnterior ischemic opticneuropathyPseudopapilledema CHARACTCommon FINDINGSCentral retinal vein occl-RETDiabetic papillopathy-RETUncommonOcular hypotony-IOPIntraocular inflammation(uveitis) - CELLSMalignant hypertension BPOptic perineuritisPapillitis BILATERALIntrinsic optic disc tumorsLeber’s hereditary opticneuropathyOptic nerve infiltration bysarcoidosislymphoma ? CELLS (Kanski)leukemia ? RET (Kanski)plasma cell dyscrasia RETINALADDRESSED BY EXAM
  7. 7. Grant Liu’s NeuroOphthamologyTable 6–1 Differentialdiagnosis of a swollen opticdisc: causes according tofrequencyMost commonPapilledemaOptic neuritisAnterior ischemic opticneuropathyPseudopapilledemaCommonCentral retinal vein occlusion?Diabetic papillopathyUncommonOcular hypotonyIntraocular inflammation(uveitis)Malignant hypertensionOptic perineuritisPapillitisInt. optic D. tum. Fast;NO IMP.Leber’s hereditary opticneuropathyOptic nerve infiltrationsarcoidosislymphomaleukemiaMeningioma—Slow ; NO IMP.Paraneoplastic –Slow; NO IMP.
  8. 8. Differential Diagnosis• AION – Most Common• In order search for NEOPLASIA  IMAGINGWHICH YOU MUST PURSUE YOURSELF-------------------------------------------------------LOOKING AT AION:1. GCA2. NAION
  9. 9. 1. GCA• is the most common form ofsystemic vasculitis in adults• its most feared complicationis irreversible loss of vision(like Pseudo. Cerebri)
  10. 10. three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.Vasculitis PLUS any 3of 5 gets Dx of GCA1. 50yrs or older2. New onset or new type of localized pain in the head3. ESR ≥50 mm/hr by the Westergren method4. Temporal artery tenderness to palpation or decreasedpulsation, unrelated to arteriosclerosis of cervicalarteries5. Biopsy specimen with artery showing vasculitischaracterized by a predominance of mononuclear cellinfiltration or granulomatous inflammation, usually withmultinucleated giant cells
  11. 11. three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.Vasculitis PLUS any 3of 5 gets Dx of GCA1. 50yrs or older2. New onset or new type of localized pain in the head3. ESR ≥50 mm/hr by the Westergren method4. Temporal artery tenderness to palpation or decreasedpulsation, unrelated to arteriosclerosis of cervicalarteries5. Biopsy specimen with artery showing vasculitischaracterized by a predominance of mononuclear cellinfiltration or granulomatous inflammation, usually withmultinucleated giant cellswhen ESR is normal, systemicsymptoms are almost alwayspresent.
  12. 12. three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.Vasculitis PLUS any 3of 5 gets Dx of GCA1. 50yrs or older2. New onset or new type of localized pain in the head3. ESR ≥50 mm/hr by the Westergren method4. Temporal artery tenderness to palpation or decreasedpulsation, unrelated to arteriosclerosis of cervicalarteries5. Biopsy specimen with artery showing vasculitischaracterized by a predominance of mononuclear cellinfiltration or granulomatous inflammation, usually withmultinucleated giant cellsIn the 16-26% WITHOUT systemicsymptoms the ESR is almost always elevated
  13. 13. 1. GCA–this pt in this case had no GCA symptoms andthe ESR/CRP were not elevated – so GCA notsuspected in this case–MUST RULE OUT GCA WITH STAT ESR ANDCRP
  14. 14. GCA (Purvin) BOTH OIS(Glaser-Mendrinos)● Ischemic opticneuropathy● Homonymoushemianopia● Cortical blindness(NECK PAIN)● Retinal ischemia● Anterior segmentischemia● Eye pain● Transient visual loss● Abnormal ocularMotility – diplopia● RetinalEmbolus(IF you see itin a GCAsuspect, lookfor CarotidArteryDisease)FULL SPECTRUM OF GCA’sVISION FINDINGS(NAION)
  15. 15. 2. NAION
  16. 16. NAION• Pathogenesis: unknown• majority 60-70yo but could be any age• Caucasian>African American or HispanicAmerican• Increased Risk in DM, high Cholesterol, HTN
  17. 17. Hypertensive THERAPY as a POSSIBLEPRECIPITATING Risk factor for NAION• Nocturnal Hypotension–vision loss noticed in the morning inNAION–as well as progressive vision loss inNAION
  18. 18. Other possible risk factors• Disc at Risk / crowded disc–If you look at the fellow eye and it iscupped – question NAION as the dx• Sleep Apnea?• Smoking?• Viagra?
  19. 19. Symptoms of NAION• IONDT: 40% noticed monocularvision loss upon awakening• Maximal when noted and usually does notprogress• Not other ocular or systemic symptoms•Pain is rare.
  20. 20. Signs of NAION• IONDT:50% see better than 20/6467% see better than 20/200• +APD; +red cap test• Any VF Defect including inferior altitudinal• Classically Sectoral or Diffuse Hyperemicor Pale Disc Edema with hemes
  21. 21. Education of NAION pt• Can improve or worsen in 1st month• IONDT: 43% IMPROVE with no tx• IONDT: 14.7% is the risk of fellow eyeinvolvement within 5 years• Take Evening dose of BP meds earlier• Avoid Viagra
  22. 22. The Case03/16/12 – As previously stated the pt woke upwith bunch of black spots in left eye’s vision…History of microvascular CN 6 palsy ‘07 thatresolved within two months
  23. 23. Brief Mention about……VA’s20/20 OU throughout…Macula’s:No macular edema throughout…IOP’s:IOP was unremarkable throughout
  24. 24. Brief Mention about……Optic Nerve:No pallor or APD or red desat wasnoted throughout…motilities:After initial CN 6 palsy resolved; No diplopia;no restriction in eye movement…overall changes in health:No symptoms other than black spotsNo HA, scalp tenderness, jawclaudication, or new onset neurologicaldeficit
  25. 25. -18-16-14-12-10-8-6-4-200 1 2 3 4 5 6 7 8 9 10RIGHT EYELEFT EYEMONTHS in 2012MDOfVF~Altitudinal defectsW/ CENTRAL SPARING
  26. 26. 0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10OCT thickness measures of RIGHT EYEumInferior rimSuperior rimSECTORAL DISC INVOLVEMENTHYPEREMIC SWELLING (HEMES)
  27. 27. 0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10OCT thickness measures of LEFT EYEumInferior rimSuperior rimSECTORAL DISC INVOLVEMENTHYPEREMIC SWELLING/HEMES
  28. 28. Superior rimright eye0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10SUSPECTEDInferior rimof left eye4-5 mos
  29. 29. 0501001502002503003504004500 1 2 3 4 5 6 7 8 9 10Inferior rimof left eyeSuperior rimright eye-18-16-14-12-10-8-6-4-200 1 2 3 4 5 6 7 8 9 10MeanDeviation ofVF RIGHTSUDDEN (NOT COMPLETE) LOSS OF VISION WITHIMPROVEMENTA PROLONGED/POOR COURSEWOULD NOT BE CONSISTENT WITHNAION (THINK IMAGING)
  30. 30. NAION NAION Kanski’sNAIONKanski’s P’edema Kanski’s Arteritic AION
  31. 31. NAION NAION K’sAcuteEst.P’edemaKanski’s Bur. Drusen Kanski’s Hypoplastic
  32. 32. References• Liu: NeuroOphthalmology• Biousse: NeuroOphthalmology Illustrated• Dr. Richard Castillo Northeastern State University• Kanski: Illustrated Tutorials in Clinical Ophthalmology• Walsh and Hoyt: the Essentials• Daroff: Bradley’s Neurology in clinical practice• Firestein: Kelleys Textbook of Rheumatology• Keane: “Multiple Cranial Nerve Palsies” 2005• Purvin: “Neuro-Ophthalmic Emergencies for the Neurologist” 2005• Glaser in Duane’s: “Topical Diagnosis: Prechiasmal Visual PathwaysMendrinos: “Ocular Ischemic Syndrome” 2010

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