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Swollen Optic Disc Presentation
Northeastern University10/31/12
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• 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.
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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 Signs4. Image posterior pole5. schedule the VF and F/U appt6. Educate “Swollen Optic Disc”/ER visit possible 7. Get release of information for PCP’s note/etc8. ESR/CRP within a few hours
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Valerie Biousse’s Neuro-OphthalmologyAnterior 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, constrictionDisc edema almost always bilateral
____________________________
SYSTEMIC SIGNS:Other symptoms or signs of increased ICP, HA, Nausea, Vomiting, Diplopia, 6th nerve palsy, Pulsatile Tinnitus, TVO’s,(Fever,Seizure,Stiffness)
(OR >1 CN DAMAGED)
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Grant Liu’s NeuroOphthamologyTable 6–1 Differential diagnosis
of a swollen optic disc: causes according to frequency
Most common Papilledema BILATERALOptic neuritis PAINMRIAnterior ischemic optic
neuropathy (GCAPAIN)PseudopapilledemaCommonCentral 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 -YOUNGOptic nerve infiltration by sarcoidosis PAIN MRI lymphoma leukemia plasma cell dyscrasia
ADDRESSED BY HISTORY
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Grant Liu’s NeuroOphthamologyTable 6–1 Differential diagnosis of
a swollen optic disc: causes according to frequency
Most common Papilledema Optic neuritis Anterior ischemic optic
neuropathy Pseudopapilledema CHARACTCommon FINDINGSCentral retinal vein occl-RET Diabetic papillopathy-RET Uncommon Ocular hypotony-IOP
Intraocular inflammation (uveitis) - CELLS
Malignant hypertension BPOptic 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
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Grant Liu’s NeuroOphthamologyTable 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.
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Differential Diagnosis• AION – Most Common• In order search for NEOPLASIA IMAGING WHICH YOU MUST PURSUE YOURSELF
-------------------------------------------------------
LOOKING AT AION: 1. GCA2. NAION
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1. GCA • is the most common form of
systemic vasculitis in adults • its most feared complication
is irreversible loss of vision (like Pseudo. Cerebri)
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three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.
Vasculitis PLUS any 3 of 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
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three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.
Vasculitis PLUS any 3 of 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.
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three or more criteria yields a sensitivity of 93.5% and a specificity of 91.2%.
Vasculitis PLUS any 3 of 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
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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
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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 ArteryDisease)
FULL SPECTRUM OF GCA’s VISION FINDINGS
(NAION)
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2. NAION
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NAION
• Pathogenesis: unknown• majority 60-70yo but could be any age• Caucasian>African American or Hispanic
American• Increased Risk in DM, high Cholesterol, HTN
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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
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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?
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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.
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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
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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
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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
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Brief Mention about……VA’s
20/20 OU throughout…Macula’s:No macular edema throughout…IOP’s:IOP was unremarkable throughout
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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 spotsNo HA, scalp tenderness, jaw claudication, or
new onset neurological deficit
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3 4 5 6 7 8 9 10
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
RIGHT EYE
LEFT EYE
MONTHS in 2012
MDOfVF
~Altitudinal defectsW/ CENTRAL SPARING
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3 4 5 6 7 8 9 100
50
100
150
200
250
300
350
400
450
OCT thickness measures of RIGHT EYE
umInferior rim
Superior rim
SECTORAL DISC INVOLVEMENT
HYPEREMIC SWELLING (HEMES)
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3 4 5 6 7 8 9 100
50
100
150
200
250
300
350
400
450
OCT thickness measures of LEFT EYE
um
Inferior rim
Superior rim
SECTORAL DISC INVOLVEMENT
HYPEREMIC SWELLING/HEMES
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Superior rim right eye
3 4 5 6 7 8 9 100
50
100
150
200
250
300
350
400
450
SUS-PECTEDInferior rim of left eye
4-5 mos
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3 4 5 6 7 8 9 100
50
100
150
200
250
300
350
400
450
Inferior rim of left eye
Superior rim right eye
3 4 5 6 7 8 9 10
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
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)
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NAION NAION Kanski’sNAION
Kanski’s P’edema Kanski’s Arteritic AION
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NAION NAION K’sAcuteEst.P’edema
Kanski’s Bur. Drusen Kanski’s Hypoplastic
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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