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 Mrs JC
 76 years old
 LTG diagnosed 2010 IOP R15 L17
 Treated with Xalatan
 Nov 19 2013 RVA 6/9 LVA 6/9
 IOP R13 L17
 PHx PMR
 Mentioned in passing “ eyes were
playing up” with visual disturbance on
Left side 2 days previously and a “heavy”
head
 Complained to the Field Tester that she
was having trouble with LE and felt Left
field was worse.
 Didn’t mention any other symptoms
 Represented via GP 6 days later
(25/11/13)
 RVA NLP LVA vague HM
 R RAPD
 Mrs JC
 Admitted immediately to Gosford
Hospital
 3 days IV 1gm Methyl Prednisolone
 ESR and CRP elevated
 26/11/13 TABx: Positive Giant Cell Arteritis
 Bilateral AAION with R CRAO
 Prognosis.....
 Anterior Ischaemic Optic Neuropathy
 CRAO
 CN palsies
 Plus AMI, Dermal ischaemia, Mesenteric
ischaemia
 Beware to Stoic Little Old Lady with any of
these 4
› Amaurosis Fugax
› New Headache
› New Diplopia
› Facial/Neck/ Mouth/Jaw Pain
 Amaurosis Fugax
 Fleeting (seconds to mins)painless
significant loss of vision in one eye
 Severe dimming/Blackout/curtain(partial
field loss)
 No aura and no neuro symptoms
 No persistence
 Exact nature of the symptoms and
associated symptoms
 Normal examination with no emboli
 Monocular vision loss
 Recent onset of Diplopia
 New Headache
 Unwell, loss of appetite or weight or night
sweats or fever, muscle aches and pains
 Face/mouth/tongue/jaw/ throat/ear
eye/scalp ache
 Scalp tenderness
 Other recent illness
 Temporal
 Scalp and Temporal artery tenderness
 Can be diffuse and bifrontal
 New in character
 Monocular vision loss
 Recent onset of Diplopia
 New Headache
 Unwell, loss of appetite or weight or night
sweats or fever, muscle aches and pains
 Face/mouth/tongue/jaw/ throat/ear
eye/scalp ache
 Scalp tenderness
 Other recent illness
 Jaw claudication is only the classic
symptom
 Any ache from scalp to ear to neck
 Tongue pain with talking
 Throat with swallowing
 Ocular ischaemic pain with orbit or eye
pain on standing
 Monocular vision loss
 Recent onset of Diplopia
 New Headache
 Unwell, loss of appetite or weight or night
sweats or fever, muscle aches and pains
 Face/mouth/tongue/jaw/ throat/ear
eye/scalp ache
 Scalp tenderness
 Other recent illness
 A new symptom
 Can be fleeting or persistent
 Vertical or Horizontal
 Monocular vision loss
 Recent onset of Diplopia
 New Headache
 Unwell, loss of appetite or weight or night
sweats or fever, muscle aches and pains
 Face/mouth/tongue/jaw/ throat/ear
eye/scalp ache
 Scalp tenderness
 Other recent illness
 Ocular exam usually normal
 Tender swollen Temporal artery
 Carotid auscultation
 Rarely signs of ocular ischaemia
› Dilated veins, retinal haemorrhages,uveitis
› Corneal oedema
 What do you do if someone over 6o says in
passing
› Lost vision in one eye
› New Headache
› New Diplopia
› Facial/Neck/ Mouth/Jaw Pain/orbital
pain
 Ask your questions
 One confirming symptom
 Normal or suggestive ocular examination
› GP or Ophthalmologist urgently
Request exclusion of GCA
› Yes you will be wrong more often than
not. The price of vision is eternal vigilance
In AION caused by GCA the time course to
2nd eye blindness is usually
a. Hours
b. Days
c. Weeks
d. can be any of above
A new diffuse headache in the elderly is
a. unlikely to be GCA due to poor
localization
b. Requires urgent clinical assessment
c. Can be referred for GP assessment in a
few days.
d. probably migraine
Why is aggressive investigation and
treatment required in possible GCA
a. to prevent haemorrhagic stroke
b. to prevent permanent bilateral
blindness
c. to avoid steroid complications
d. to reduce unnecessary osteoporosis

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Neuro-ophthalmology - A cautionary tale

  • 1.
  • 2.  Mrs JC  76 years old  LTG diagnosed 2010 IOP R15 L17  Treated with Xalatan  Nov 19 2013 RVA 6/9 LVA 6/9  IOP R13 L17
  • 3.
  • 4.
  • 5.  PHx PMR  Mentioned in passing “ eyes were playing up” with visual disturbance on Left side 2 days previously and a “heavy” head  Complained to the Field Tester that she was having trouble with LE and felt Left field was worse.  Didn’t mention any other symptoms
  • 6.
  • 7.  Represented via GP 6 days later (25/11/13)  RVA NLP LVA vague HM  R RAPD
  • 9.
  • 10.  Admitted immediately to Gosford Hospital  3 days IV 1gm Methyl Prednisolone  ESR and CRP elevated  26/11/13 TABx: Positive Giant Cell Arteritis  Bilateral AAION with R CRAO  Prognosis.....
  • 11.
  • 12.  Anterior Ischaemic Optic Neuropathy  CRAO  CN palsies  Plus AMI, Dermal ischaemia, Mesenteric ischaemia
  • 13.  Beware to Stoic Little Old Lady with any of these 4 › Amaurosis Fugax › New Headache › New Diplopia › Facial/Neck/ Mouth/Jaw Pain
  • 14.  Amaurosis Fugax  Fleeting (seconds to mins)painless significant loss of vision in one eye  Severe dimming/Blackout/curtain(partial field loss)  No aura and no neuro symptoms  No persistence  Exact nature of the symptoms and associated symptoms  Normal examination with no emboli
  • 15.  Monocular vision loss  Recent onset of Diplopia  New Headache  Unwell, loss of appetite or weight or night sweats or fever, muscle aches and pains  Face/mouth/tongue/jaw/ throat/ear eye/scalp ache  Scalp tenderness  Other recent illness
  • 16.  Temporal  Scalp and Temporal artery tenderness  Can be diffuse and bifrontal  New in character
  • 17.  Monocular vision loss  Recent onset of Diplopia  New Headache  Unwell, loss of appetite or weight or night sweats or fever, muscle aches and pains  Face/mouth/tongue/jaw/ throat/ear eye/scalp ache  Scalp tenderness  Other recent illness
  • 18.  Jaw claudication is only the classic symptom  Any ache from scalp to ear to neck  Tongue pain with talking  Throat with swallowing  Ocular ischaemic pain with orbit or eye pain on standing
  • 19.  Monocular vision loss  Recent onset of Diplopia  New Headache  Unwell, loss of appetite or weight or night sweats or fever, muscle aches and pains  Face/mouth/tongue/jaw/ throat/ear eye/scalp ache  Scalp tenderness  Other recent illness
  • 20.  A new symptom  Can be fleeting or persistent  Vertical or Horizontal
  • 21.  Monocular vision loss  Recent onset of Diplopia  New Headache  Unwell, loss of appetite or weight or night sweats or fever, muscle aches and pains  Face/mouth/tongue/jaw/ throat/ear eye/scalp ache  Scalp tenderness  Other recent illness
  • 22.  Ocular exam usually normal  Tender swollen Temporal artery  Carotid auscultation  Rarely signs of ocular ischaemia › Dilated veins, retinal haemorrhages,uveitis › Corneal oedema
  • 23.
  • 24.  What do you do if someone over 6o says in passing › Lost vision in one eye › New Headache › New Diplopia › Facial/Neck/ Mouth/Jaw Pain/orbital pain
  • 25.  Ask your questions  One confirming symptom  Normal or suggestive ocular examination › GP or Ophthalmologist urgently Request exclusion of GCA › Yes you will be wrong more often than not. The price of vision is eternal vigilance
  • 26. In AION caused by GCA the time course to 2nd eye blindness is usually a. Hours b. Days c. Weeks d. can be any of above
  • 27. A new diffuse headache in the elderly is a. unlikely to be GCA due to poor localization b. Requires urgent clinical assessment c. Can be referred for GP assessment in a few days. d. probably migraine
  • 28. Why is aggressive investigation and treatment required in possible GCA a. to prevent haemorrhagic stroke b. to prevent permanent bilateral blindness c. to avoid steroid complications d. to reduce unnecessary osteoporosis