Acute visual disturbance 2 - optic neuropathies

Question 1

optic neuropathy is

Answer 1

abnormality or damage to the optic nerves from any cause

Question 2

symptoms of optic neuropathy

Answer 2

visual blurring or loss
or a change in colour vision

Question 3

disc swelling looks like

Answer 3

Question 4

is optic neuropathy common

Answer 4

no its not common but its not rare either

Question 5

optic disc elevation may be

Answer 5

psuedopapilloedema or optic nerve head swelling

Question 6

optic nerve head swelling may be categorised into

Answer 6

elevated ICP and Normal ICP

Question 7

elevated ICP causes

Answer 7

papilloedema
which is bilateral optic nerve head swelling from elevated intracranial pressure

Question 8

ONH swelling with normal ICP - is this unilateral or bilateral?

Answer 8

more commonly unilateral

Question 9

is elevated ICP usually unilateral or bilateral

Answer 9

bilateral

Question 10

Hx of optic nerve head swelling

Answer 10

variable visual change
pain (retro- or periocular)
systemic (paraesthesia, weakness etc)
headache, TVOs, diplopia -> raised ICP

Question 11

age Hx

Answer 11

young - optic neuritis (+/- demyelination)
middle aged - non arteritic ischaemic optic neuropathy NAION (tends to happen in vasculopaths)
elderly - GCA

Question 12

acute onset minutes/hours

Answer 12

NAION, GCA, trauma

Question 13

subacute onset hours/days

Answer 13

optic neuritis

Question 14

gradual onset (months/years)

Answer 14

toxic/nutritional/compressive

Question 15

examination of papillodaema

Answer 15

loss of clarity of the margin of the optic nerve

Question 16

drusen looks like

Answer 16

speckles
looks similar to hard exudate
age related

Question 17

aetiology of GCA

Answer 17

systemic vasculitis of medium/large arteries
causes ischaemia of the optic nerve head

Question 18

presentation of GCA

Answer 18

> 60 years
temporal pain, jaw claudication, discomfort when chewing food, TVOs/diplopia
fatigue, weight loss, myalgia
chalky white disc swelling, cotton wool spots (infarcts of the retina), may also see central artery occlusion
‘cord like’ tender temporal artery with reduced pulse - palpate this as part of the examination

Question 19

management of GCA

Answer 19

FBC, ESR, CRP
high-dose steroids
time critical condition, they will lose vision is not treated
temporal artery biopsy to confirm diagnosis

Question 20

prognosis of giant cell arteritis

Answer 20

if untreated, one third patients will develop contralateral vision loss over days
may involve the aorta, causing aneurysm, dissection or rupture
threat to sight and life

Question 21

aetiology of papilloedema

Answer 21

bilateral optic disc swelling secondary to raised ICP

Question 22

prsentation of papilloedema

Answer 22

headache (postural), vomiting, visual disturbance, pulsatile tinnitus

Question 23

DDx of papilloedema

Answer 23

tumour, malignant HTN, venous sinus thrombosis, meningitis, idiopathic intracranial hypertension

Question 24

management of papilloedema

Answer 24

BP, full neurological exam
MRI/CT head
LP (when SOL excluded)

Question 25

idiopathic intracranial hypertension is a cause of

Answer 25

a cause of papilloedema

Question 26

aetiology og idiopathic intracranial hypertension

Answer 26

elevated ICP without identifiable cause
usually female of child bearing age, high BMI, may or may not be on the OCP

Question 27

management of idiopathic intracranial hypertension

Answer 27

MRI/MRV (exclude SOL/venous sinus thrombosis), then LP
medical: weight loss, salt restriction, acetazolamide, topiramate
surgical: nerve fenestration, neurosurgery (stent), bariatric

Question 28

prognosis of idiopathic intracranial hypertension

Answer 28

variable depending on management of ICP, BMI

Question 29

sectoral optic nerve oedema

Answer 29

Question 30

non-arteritic ischeamic optic neuropathy aetiology

Answer 30

crowded optic nerve head configuration and small vessel arteriosclerosis

Question 31

presentation of non-arteritic ischameic optic neuropathy

Answer 31

> 50 years
vascular risk factors, sleep apnoea, symptoms felt on waking caused by nocturnal hypotension
sectoral disc swelling and altitudinal field loss (top or bottom field loss)

Question 32

management of non-arteritic ischaemic optic neuropathy

Answer 32

vascular risk factors, avoid BP meds nocte (this may cause nocturnal hypotension)

Question 33

prognosis of non-arteritic ischameic optic neuropathy

Answer 33

VA remains status or improves slightly in majority
15% risk to fellow eye within 5 years

Question 34

optic neuritis on MRI

Answer 34

unilateral optic nerve looks thicker, wider, enhanced on MRI

Question 35

optic neuritis aetiology

Answer 35

immune mediated inflammation +/- demyelination (risk factor for multiple sclerosis)
younger patient
often preceding viral illness with neuropathic presentations

Question 36

presentation of optic neuritis

Answer 36

20-45 yo, recent viral illness
+/- neurological symptoms
known MS

Question 37

DDx of optic neuritis

Answer 37

idopathic, infective, inflammatory, autoimmune/demyelination

Question 38

management of optic neuritis

Answer 38

MRI brain/spine (T2 hyper intense lesions)
bloods +/- LP after neuroimaging to rule out infection
high dose steroids hasten recovery
immunomodulatory treatment

Question 39

prognosis of optic neuritis

Answer 39

90% improve to near normal VA in weeks
risk of development of MS (38% of MRI- and 56% of MRI+ at 10y)

Question 40

compressive tumours

Answer 40

gradual, progressive
Ddx: meningioma, pituitary adenoma, aneurysm, thyroid eye disease

Question 41

infiltrative issues

Answer 41

subacute - weeks/months
Ddx: lymphoma, leukaemia, multiple myeloma, carcinoma

Question 42

toxic/nutritional issues

Answer 42

gradual onset; social history is relevant
ethambutamol, amiodarone, alcohol, methanol, methotrexate, cyclosporine

Question 43

summary of conditions

Answer 43