Swollen optic nerve_presentation_last_revision 103112 disregard all others

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Swollen optic nerve_presentation_last_revision 103112 disregard all others

  1. 1. Swollen Optic Disc Presentation Northeastern University 10/31/12
  2. 2. • 58yo WM with type II DM and HTN is an established patient with one swollen optic disc and spots in his vision when he woke up. There are no other significant abnormal findings.
  3. 3. Proceed by: 1. GCA and Increased Intracranial Pressure questions (HA, Jaw/scalp/NECK, Tinnitus, N/V, TVO) 2. Cranial Nerve Exam (Dr. Castillo) -cover test in multiple positions of gaze (Keane) 3. Vital Signs 4. Image posterior pole 5. schedule the VF and F/U appt 6. Educate “Swollen Optic Disc”/ER visit possible 7. Get release of information for PCP’s note/etc 8. ESR/CRP within a few hours
  4. 4. Valerie Biousse’s Neuro-Ophthalmology Anterior Optic Neuropathy Papilledema OCULAR SIGNS: decrease in VA decrease in color Central/Arcuate/Altitudinal Disc edema more often unilateral ____________________________ SYSTEMIC SIGNS: Often isolated (or associated with symptoms/signs related to underlying disease – like GCA symptoms) OCULAR SIGNS: Normal VA’s til late Normal color Enlarged blindspot, nasal defect, constriction Disc edema almost always bilateral ____________________________ SYSTEMIC SIGNS: Other symptoms or signs of increased ICP, HA, Nausea, Vomiting, Dip lopia, 6th nerve palsy, Pulsatile Tinnitus, TVO’s,(Fever,Seizure, Stiffness) (OR >1 CN DAMAGED)
  5. 5. Grant Liu’s NeuroOphthamology Table 6–1 Differential diagnosis of a swollen optic disc: causes according to frequency Most common Papilledema BILATERAL Optic neuritis PAINMRI Anterior ischemic optic neuropathy (GCAPAIN) Pseudopapilledema Common Central retinal vein occlusion? Diabetic papillopathy Uncommon Ocular hypotony Intraocular inflammation (uveitis) Malignant hypertension Optic perineuritis PAIN MRI Papillitis Intrinsic optic disc tumors Leber’s hereditary optic neuropathy -YOUNG Optic nerve infiltration by sarcoidosis PAIN MRI lymphoma leukemia plasma cell dyscrasia ADDRESSED BY HISTORY
  6. 6. Grant Liu’s NeuroOphthamology Table 6–1 Differential diagnosis of a swollen optic disc: causes according to frequency Most common Papilledema Optic neuritis Anterior ischemic optic neuropathy Pseudopapilledema CHARACT Common FINDINGS Central retinal vein occl-RET Diabetic papillopathy-RET Uncommon Ocular hypotony-IOP Intraocular inflammation (uveitis) - CELLS Malignant hypertension BP Optic perineuritis Papillitis BILATERAL Intrinsic optic disc tumors Leber’s hereditary optic neuropathy Optic nerve infiltration by sarcoidosis lymphoma ? CELLS (Kanski) leukemia ? RET (Kanski) plasma cell dyscrasia RETINAL ADDRESSED BY EXAM
  7. 7. Grant Liu’s NeuroOphthamology Table 6–1 Differential diagnosis of a swollen optic disc: causes according to frequency Most common Papilledema Optic neuritis Anterior ischemic optic neuropathy Pseudopapilledema Common Central retinal vein occlusion? Diabetic papillopathy Uncommon Ocular hypotony Intraocular inflammation (uveitis) Malignant hypertension Optic perineuritis Papillitis Int. optic D. tum. Fast;NO IMP. Leber’s hereditary optic neuropathy Optic nerve infiltration sarcoidosis lymphoma leukemia Meningioma—Slow ; NO IMP. Paraneoplastic –Slow; NO IMP.
  8. 8. Differential Diagnosis • AION – Most Common • In order search for NEOPLASIA  IMAGING WHICH YOU MUST PURSUE YOURSELF ------------------------------------------------------- LOOKING AT AION: 1. GCA 2. NAION
  9. 9. 1. GCA • is the most common form of systemic vasculitis in adults • its most feared complication is 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 GCA 1. 50yrs or older 2. New onset or new type of localized pain in the head 3. ESR ≥50 mm/hr by the Westergren method 4. Temporal artery tenderness to palpation or decreased pulsation, unrelated to arteriosclerosis of cervical arteries 5. Biopsy specimen with artery showing vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated 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 GCA 1. 50yrs or older 2. New onset or new type of localized pain in the head 3. ESR ≥50 mm/hr by the Westergren method 4. Temporal artery tenderness to palpation or decreased pulsation, unrelated to arteriosclerosis of cervical arteries 5. Biopsy specimen with artery showing vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells when ESR is normal, systemic symptoms are almost always present.
  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 GCA 1. 50yrs or older 2. New onset or new type of localized pain in the head 3. ESR ≥50 mm/hr by the Westergren method 4. Temporal artery tenderness to palpation or decreased pulsation, unrelated to arteriosclerosis of cervical arteries 5. Biopsy specimen with artery showing vasculitis characterized by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells In the 16-26% WITHOUT systemic symptoms the ESR is almost always elevated
  13. 13. 1. GCA –this pt in this case had no GCA symptoms and the ESR/CRP were not elevated – so GCA not suspected in this case –MUST RULE OUT GCA WITH STAT ESR AND CRP
  14. 14. GCA (Purvin) BOTH OIS(Glaser-Mendrinos) ● Ischemic optic neuropathy ● Homonymous hemianopia ● Cortical blindness (NECK PAIN) ● Retinal ischemia ● Anterior segment ischemia ● Eye pain ● Transient visual loss ● Abnormal ocular Motility – diplopia ● Retinal Embolus (IF you see it in a GCA suspect, look for Carotid Artery Disease) FULL SPECTRUM OF GCA’s VISION FINDINGS (NAION)
  15. 15. 2. NAION
  16. 16. NAION • Pathogenesis: unknown • majority 60-70yo but could be any age • Caucasian>African American or Hispanic American • Increased Risk in DM, high Cholesterol, HTN
  17. 17. Hypertensive THERAPY as a POSSIBLE PRECIPITATING Risk factor for NAION • Nocturnal Hypotension –vision loss noticed in the morning in NAION –as well as progressive vision loss in NAION
  18. 18. Other possible risk factors • Disc at Risk / crowded disc –If you look at the fellow eye and it is cupped – question NAION as the dx • Sleep Apnea? • Smoking? • Viagra?
  19. 19. Symptoms of NAION • IONDT: 40% noticed monocular vision loss upon awakening • Maximal when noted and usually does not progress • Not other ocular or systemic symptoms •Pain is rare.
  20. 20. Signs of NAION • IONDT: 50% see better than 20/64 67% see better than 20/200 • +APD; +red cap test • Any VF Defect including inferior altitudinal • Classically Sectoral or Diffuse Hyperemic or 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 eye involvement within 5 years • Take Evening dose of BP meds earlier • Avoid Viagra
  22. 22. The Case 03/16/12 – As previously stated the pt woke up with bunch of black spots in left eye’s vision… History of microvascular CN 6 palsy ‘07 that resolved within two months
  23. 23. Brief Mention about… …VA’s 20/20 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 was noted throughout …motilities: After initial CN 6 palsy resolved; No diplopia; no restriction in eye movement …overall changes in health: No symptoms other than black spots No HA, scalp tenderness, jaw claudication, or new onset neurological deficit
  25. 25. -18 -16 -14 -12 -10 -8 -6 -4 -2 0 0 1 2 3 4 5 6 7 8 9 10 RIGHT EYE LEFT EYE MONTHS in 2012 MD Of VF ~Altitudinal defects W/ CENTRAL SPARING
  26. 26. 0 50 100 150 200 250 300 350 400 450 0 1 2 3 4 5 6 7 8 9 10 OCT thickness measures of RIGHT EYE um Inferior rim Superior rim SECTORAL DISC INVOLVEMENT HYPEREMIC SWELLING (HEMES)
  27. 27. 0 50 100 150 200 250 300 350 400 450 0 1 2 3 4 5 6 7 8 9 10 OCT thickness measures of LEFT EYE um Inferior rim Superior rim SECTORAL DISC INVOLVEMENT HYPEREMIC SWELLING/HEMES
  28. 28. Superior rim right eye 0 50 100 150 200 250 300 350 400 450 0 1 2 3 4 5 6 7 8 9 10 SUSPECTED Inferior rim of left eye 4-5 mos
  29. 29. 0 50 100 150 200 250 300 350 400 450 0 1 2 3 4 5 6 7 8 9 10 Inferior rim of left eye Superior rim right eye -18 -16 -14 -12 -10 -8 -6 -4 -2 0 0 1 2 3 4 5 6 7 8 9 10 Mean Deviation of VF RIGHT SUDDEN (NOT COMPLETE) LOSS OF VISION WITH IMPROVEMENT A PROLONGED/POOR COURSE WOULD NOT BE CONSISTENT WITH NAION (THINK IMAGING)
  30. 30. NAION NAION Kanski’sNAION Kanski’s P’edema Kanski’s Arteritic AION
  31. 31. NAION NAION K’sAcuteEst.P’edema Kanski’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: Kelley's 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 Pathways Mendrinos: “Ocular Ischemic Syndrome” 2010
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