Kelly Eye 2016 copy - NC · PDF file• Medications: insulin, losartan • Allergies...
Transcript of Kelly Eye 2016 copy - NC · PDF file• Medications: insulin, losartan • Allergies...
Neuro-ophthlamologyCasesSyndeeJGivre,MD,PhD
RaleighNeurologyAssociates
AdjunctProfessorOphthalmology,UNCChapelHill
Case1• 34yearoldmansentfor
consultationforchangeinvisionOS
• awokewith"glare"inthetemporalfieldOSabout1.5weekspriorandithadn'tchangedsince
• noeyepainorheadache
• nootherchangeinhealth
• PMH:eczema
• SH:none
• POH:none
• FH/FOH:none
• Medications:none
• Allergies:none
• Tobacco:none
• EtOH:3drinksperweek
Case1
• Pupils:noanisocoria,noRAPD
• Motility:fullOU
• SLE:normalODandOS
• IOP(mmHg):17OD,18OS
• Fundus:normaldisc,vessels,maculaandperiphery
ODandOS
Case2
• 37yearoldwomansentforconsultationforchangeinvisionOD
– for9daysnoticedaspotofglare,liketheafterimageofabrightlightOD,inthelowernasalcornerofvision
– spotisintheshapeofadiagonalline
– noeyepain/headache
– visionOSfine
• PMH:migraine,sinusinfections,eczema
• POH:none
• SH:orthopedic
• FH:DM,HTN
• FOH:none
• Medications:ExcedrinMigraineprn
• Allergies:PCN
• Tobacco:10cigarettesperdayX25years
• EtOH:onedrinkperday
Case2
• SLE:normalOD&OS
• IOP:12OD,11OS
• Pupils:noanisocoria,noRAPD
• Motility:fullOU
• IOP(mmHg):18OD&18OS
• Fundus
– Normaldisc,vessels,macula,peripheryOD
– OS
Case3
• 17yearoldyoungmansentforconsultationforpapilledema
• neckpainX2months-(evalby
orthonegative)
• doubleandblurredvisionX1month
• infrequentheadaches
• noiseof“drumbeat”inears
• PMH:ADD
• POH:none
• FH:DM,HTN
• FOH:none
• SH:neckcystremovedage2
• 11thgrade,notobacco
• Medications:Adderall
• Allergies:none
Case3
• Pupils:noanisocoria,noRAPD
• Motility:fullOU
• SLE:normalODandOS
• IOP(mmHg):9OD,12OS
• Fundus
Case3
• bilateralopticdiscedemawithgoodvisual
functionandsymptomsofhighICPin250lb
youngman(whosnoresheavilypermom)
Case3
• hadpartialresectionwithpathology“inconclusive”
• presumedtobebenigndermoidorepidermoid
cyst
• symptoms,hydrocephalusresolvedwithbiopsy
Case4
• 66yearoldmansentforconsultationforpapilledema
• incidentalfindingonroutineeyeexam(wantednewglasses)
• PMH:prostatecancer(surgery),acidreflux,HTN
• POH:none
• SH:prostate
• FH:none
• FOH:none
• Medications:sildenafil,loperamide
• Allergies:Septra
• Tobacco:none
• EtOH:2drinkspermonth
Case4
EXAM
• Height:70inches
• Weight:184lbs
• Bloodpressure:150/89mmHg
• BCVA:20/20OD&OS
• CVF:fullOD&OS
Case4
• Pupils:noanisocoria,noRAPD
• Motility:fullOU
• SLE:normalOD&OS
• IOP(mmHg):16OD&12OS
• Fundus
Case4
• incidentallyfoundoptic
discedema,bilateralwith
goodopticnervefunction
• onquestioning,no
headaches,neckpainor
pulsatiletinnitus(no
symptomshighICP)
• MRIbrainnormal
• MRVbrainnormal
Case4
• Nextstep?
LP
• OP=15(normal)
• RBC=3(normal)
• WBC=38(0-5)
• Glucose=normal
• Protein=47.4mg/dL(0-44)
• Gramstainandculturenegative
• VDRL:1:2(<1:1)
• Subsequent
– RPR:reactive,1:256
– TPPA:positive
Case5
• 86yearoldsentforconsultationforpainlessvisionlossOS
• visiongettingworseforacoupleofweeksandthenabout5daysagoarapiddecline
• noeyepain,neckpain,scalptendernessortroublechewing
• occasionalheadaches(norecentchangepatternofthis)
• visionODisfine
• alreadysawretina-someAMD,nothingacute
Case5
• PMH:breastcancer(lumpectomy,XRT,tamoxifen),thyroidproblems,DM,HTN,dyslipidemia,onefunctioningkidney
• POH:cataractoperationOU
• SH:R&Lcarotidendarterectomy,thyroid,lumpectomy
• FH:DM,HTN,stroke
• FOH:none
• Tobacco:none/EtOH:none
• Medications:zocor,ASA,metformin,norvasc,metoprolol,benazipril,synthroid
• Allergies:sulfa
Case5
• Exam:
• BCVA:20/40OD&CFOS
• CVF:fullOD&canseeHMinallquadrantsOS
• Pupils:noanisocoria,+RAPDOS
• Motility:tracelimitationleftabductionotherwise
fullOU
Case5
• SLE:PCIOLOU
• IOP(mmHg):19OD&19OS
• Fundus:normaldisc,vessels,peripheryOU;
changesofAMDinmaculaOU,noDR
Case5
• immediatelystartedPrednisoneand
underwentendoscopicorbitaldecompression
withinaweek
• within2weeksaftersurgeryvisionOS
improvedto20/40
Case5
• 8monthslatercomesinforregularfollowup
sayingvisionODhasbeengettingworsefora
fewweeks
• OSisstable
Case6
• 56yearoldmansentforpossibleNA-AIONOS
• noticedsuddenvisionlossabout3weeksprior
• nochangesince
• somepaininandbehindtheeyewhenthevisionlossfirstoccurredbutthat
wentawaywhenheresumedtakingBPandcholesterolmedication.
• ODisfine
• wifesayshesnoresheavily
• PMH:HTN,dyslipidemia
• POH:none
• SH:none
• FOH:none
• FH:DM
• Tobacco:none/EtOH:none
• Medications:HCTZ,amlodipine,crestor
• Allergies:none
Case6
• EXAM
• BCVA:20/15OD,HMOS
• CVF:fullOD
• Pupils:noanisocoria,+RAPDOS
• Motility:fullOU
• SLE:normalOU
• IOP(mmHg):12OD,13OS
Case6
• ForAION
– suddenvisionloss,not
progressive
– riskfactors-HTN,
dyslipidemia,heavysnoring
(probablesleepapnea)
• AgainstAION
– ?painatonset
– other(right)discnotcrowded
Case7
• 47yearoldmanforconsultationforincidentallyfoundleftopticdiscedema.
• inforaroutinecheckfornewglasseswhenthiswasnoted
• PMH:DM,HTN,OSAdiagnosedbutnevertreated
• POH:none
• SH:appendectomy
• FH:DM
• FOH:glaucoma
• Tobacco:none/EtOH:2drinksperday
• Medications:insulin,losartan
• Allergies:none
Case7
• SLE:normalOD&OS
• Pupils:noanisocoria,noRAPD
• Motility:fullOU
• IOP(mmHg):18OD&17OS
• Fundus
opticdiscedema
• inflammation/neuritis/infectious
• ischemia
• retrobulbarcompression
• asymmetricpapilledema
• trauma
• toxic
• hereditary/LHON
• diabeticpapillitis
• papillophlebitis
Case7
• normalMRIandMRV
• LP
– OP17
– CSFcompositionnormal
• retrobulbar
compression
• asymmetric
papilledema
• diabeticpapillitis
• papillophlebitis
Case7
• patientseenmultipletimeswithnochangeinexam
• onscheduledf/uabout4monthsafterinitialexam
complainsof4daysofblurrinessOD,painless
• repeatsleepstudy
confirmedOSAandpatientusingCPAPregularly
• bloodsugarsunderbestcontrolsincediagnosis
• otherwisenochangein
medicalhistory
Case7
• bilateralsequentialdiscedema
– initialeyeimprovingwithoutvisuallos
– secondeyepresentingwithinferiorfieldloss
• ?sequentialAIONwithfirsteyeaborting
withoutinfarct
Help!• ClinicaltrialofQPI-1007inimprovingvisualoutcome
inAION
• QPI-1007isacustom-designed,small-interfering
RNAthatbindstothemessengerRNAofcaspase2
andpreventsthemessengerRNAfrombeing
translatedintoaprotein
Help!
• apoptosisisonecellularprocessbelievedtounderlieretinalganglioncelldeath(opticnervedeath)inAION
• caspase2isaninitiatorofapoptosis
• byinterferingwiththeproductionofcaspase2,QPI-1007mayinhibitapoptosisanddecreasecelldeath(=preservevision)inAION
Help!
• multicenter,double-blind,placebocontrolledstudy
• patientswithin14daysofonsetofsymptomsofAIONwillreceiveintravitrealinjectionofeitherQPI-1007orashaminjectionandwillbefollowed
• measuredvisualoutcomeswillbeBCVAandautomatedperimetry(SITA)
Case8• 28yearoldwomansentbyneurologyforconsultationforbilateral
opticneuritisseenonMRI12/2015
• senttoneurologyforfurtherworkupandmanagementin3/2015
• bythetimeIsawhershehadbeentreatedwithsteroidsandpain
medicationandsaidvisionwasbacktobaselinebutshewasstillhavingsevereheadaches3timesperweek.
• shehadalreadyhadMRIbrainX2,MRIspine(cervicalandthoracic)andalumbarpuncture-allnegativeexcepttheopticnervefindings
onMRI
Case8• PASTMEDICALHISTORY:headaches,h/ochildhoodleukemia
successfullytreated10yearsprior
• SURGICALHISTORY:cholecystectomy,myringotomytubes,benigngrowthleftear
• PASTOCULARHISTORY:congenitalptosisOD,h/ograduallyworseningvisionODoverpastfewyearstoldduetoastigmatism
• SOCIALHISTORY:neversmoker,1drinkpermonh
• FAMILYMEDICALHISTORY:heartdisease
• FAMILYOCULARHISTORY:glaucoma,AMD
• Medications:birthcontrol
• Allergies:none
Case8
• SLE:mildRULptosis(unchangedperpatient)
otherwisenormalOD&OS
• Pupils:noanisocoria,0.6logunitRAPDOD
• Motility:fullOU
• IOP(mmHg):9OD,11OS
Case8
• DILATEDFUNDUSEXAM
• OpticDiscs
• OD:pale,noedema,c/d0.1
• OS:nopallororedema,c/d0.1
•
• Vitreous:clearOU
•
• Retina
• Macula:normalOU
• Vessels:normalOU
• Periphery:normalOU
Case8
• DATA
• MRIbrainandorbits-
• MRIthoracicandcervicalspine(lookingforevidenceMS)-negative
• Labs
– blood:ACE,ANA,NMO,CBC,anticardiolipinantibodiesallnegativeornormal
– CSF:cellcount,protein,glucose,cytology,MSmarkersallnegativeornormal
Case8
• patienthadbeensenttouniversityeyeclinicJanuary2013forabnormaldiscandVFdefectOD
• discwasthoughttobeeitherpaleoranomalousanditwasrecommendedtothePCPtoorderan
MRIbutthisnevergotdone(until12/2015-patientwentintoPCPwithcomplaintofheadaches)
Case8
Timeline
• 1/2013:abnormalVFanddiscOD,MRIrecommended
• 12/2014:presentstoPCPwithheadaches,MRIshows
bilateralopticnerveenhancement(“opticneuritis”)
• 3/2015:lab,CSF,MRIspineworkupforcausesoptic
neuritisnegative
• 6/2015repeatorbitMRIunchanged
Case8
• Whyisn’tthis(bilateral)opticneuritis?
– Progressionveryslow-20/30ODafter>2years
– Painless(presumingtheintermittentheadaches
areunrelated)
– VisualfunctionOSisnormaldespitethatnerve
lookingjustasbadasODontheMRI
Case9
• 69yearoldwomansentneurologistfortroublewithperipheralvision
• milddementia,accompaniedbysonwhohelpswiththehistory.
• sonsaysthepatient’seyedoctordidaperipheralvisiontestandmom“failed”
• Whenaskedwhathenoticessayshas
difficultyseeingifthelightisdimordarkX1yearorso
• PMH:COPD,depression,GERD,RA,neuropathy,seizures,OSA,dementia,
hypothyroid
• POH:cataractoperations
• SX:hysterectomy,orthopedic
• FH/FOH:negative
• Tobacco:neversmoked
• EtOH:onedrinkperweek
• Medications:aricept,gabapentin,
synthroid,fluoxetine,pantoprazole,requip,celexa,lamictal,trazedone
• Allergies:sulfa
Case9
EXAM
• BCVA:20/40OD&20/40OS
• CVF:couldseefingerwigglinginall4quadrantsOD&OS
• Pupils:noanisocoria,noRAPD
• Motility:fullOD&OS
• SLE:PCIOLOD&OSotherwisenormal
• IOP(mmHg):14ODand17OS
• Fundus:
Case10
• 59yearoldwomansentforseeingflashesoflight
• noticedabout14-16monthsagowhileonHerceptintreatmentforbreastcancer
• initiallynoticedasquare"windowoflight"thatmovedaroundinthe
peripheryoflefteyeforafewsecondsthendisappears
• afterafewmonthsshebegantonoticethesymptomODbut“notasbad”
• PMH:breastcancer(sx,xrt,chemo),
HTN,IBS
• POH:refractivesurgeryOU,CEOU
• SX:carpaltunnel,hysterectomy,mastectomy,orthopedic
• FH:DM,thyroiddisease
• FOH:retinaldetachment
• Tobacco/EtOH:never
• Meds:quinapril,tamoxifen
• Allergies:PCN
Case10
• Pupils:noanisocoria,noRAPD
• Motility:fullOU
• SLE:normalODandOS
• IOP(mmHg):14OD&14OS
• Fundus: