CNS/HN - Blurring of Vision Flashcards
Differential Diagnosis - Gradual Visual loss
- Amaurosis Fugax - TIA
- Myopia
- Multiple Sclerosis
- Acute angle Glaucoma
- Macular Degeneration
Probability diagnosis Cataract Chronic glaucoma ‘Dry’, age-related macular degeneration Gradual retinal detachment Diabetic retinopathy
Serious disorders not to be missed
Vascular:
•hypertensive retinopathy
•cerebromacular degeneration
Infection:
•syphilis
•onchocerciasis (filariasis)
Cancer/neoplasia:
•intraorbital tumours
•intracranial tumours
•choroid melanoma
Other:
•optic neuritis (multiple sclerosis)
•Paget disease of skull
Pitfalls (often missed)
Retinitis pigmentosa
Drug toxicity
(e.g. quinine, methanol, arsenic)
Rarities:
•choroid retinitis
•vitamin A deficiency
•Leber hereditary optic atrophy
BOV - Key history
Key history Past history including risk factors for - cardiovascular disease - family history - drug history - associated symptoms or problems.
BOV - Key Examination
Key examination
- Visual acuity
- ophthalmoscopic examination
- tonometry
- Cardiovascular including carotid arteries (especially for Amaurosis fugax)
- early ophthalmological referral is recommended
BOV - Key Investigation
Key investigations Initial tests are: •FBE •ESR/CRP •blood sugar •syphilis serology (if clinically indicated)
BOV - Key Diagnostic tip
Diagnostic tips •Keep the big three causes in mind— -cataract, - chronic glaucoma and - age-related macular degeneration—
refer for shared care.
•In the older patient whose cataract is not significantly improved with the pinhole test consider macular degeneration
Differential Diagnosis - Amaurosis Fugax
SUDDEN VISUAL LOSS
Eye, acute and subacute painless loss of vision
Probability diagnosis Amaurosis fugax Migraine Retinal detachment Acute glaucoma ‘Wet’ macular degeneration
Serious disorders not to be missed Cardiovascular: •central retinal artery occlusion •central retinal vein occlusion •hypertension (complications) •CVA
Neoplasia: •intracranial tumour •intraocular tumour: o— primary melanoma o— retinoblastoma o— metastases
Vitreous haemorrhage AIDS Temporal arteritis Acute glaucoma Benign intracranial hypertension
Pitfalls (often missed) Acute glaucoma Papilloedema Optic neuritis Uveitis Intraocular foreign body
Masquerades checklist
Diabetes (diabetic retinopathy)
Drugs (e.g. quinine, alcohol)
Thyroid disorder (hyperthyroidism)
Is the patient trying to tell me something?
Consider ‘hysterical’ blindness, although it is uncommon
Management - Amaurosis Fugax
Management
Investigation: Basic Blood Lipid profile Clotting profile FBE ESR CRP BSL ECG
Imaging
o UTZ of Carotid arteries in the neck
o MRA - Magnetic resonance Angiography of head and neck
o Echocardiogram of heart or angiogram
Treatment:
- Admit
- Refer to specialist - neurologist and cardiologist
- Check and order certain imaging to find where the clot is
- ASA
- Surgical procedure: Carotid Endarterectomy - remove plaque from vessel
- Antihypertensive drugs
- SNAP
Management - Multiple Sclerosis
Management:
Investigation:
- MRI
- CSF Analysis
Treatment:
- Refer to neurologist
o Acute attacks:
§ Corticosteroids (methylprednisolone 1gm over 5 days) and plasma exchange Disease-modifying therapy
§ Severe: immunosuppresants (MTX, AZT, Cladribine, fingolimod)
o Prevention of relapse:
§ Interferon
§ Glatiramer (mimic myelin)
§ Natalizumab
§ Prednisolone 75mg once a day for 4 day or 50mg for 4 days.
§ If severe relapses (optic neuritis , brain stem signs): Hospitalized. IV therapy: methyl prednisolone 1 g in 200mL of saline daily for 3-5 days
§ For long term: methotrexate with folic acid or Cyclophosphamide.
o Refer to neurologist
o Refer to psychologist
o Refer to physiotherapist if with spasticity
o Support groups
Diagnosis - Amaurosis Fugax
Condition -
The loss of vision in your eye is a condition called amaurosis fugax is due to temporary lack of blood flow to the retina of your eye it is called TIA. It usually does not result in permanent damage but can lead to future stroke.
Common
Cause
It is most likely due to hard substance called atherosclerotic plaque that is formed from fats and other substances in the wall of your neck vessels. A piece of this plaque can break off and travel to the retinal vessels causing a temporary block to the blood flow.
Clinical feature
symptoms are what you are having. If left untreated you may have further symptoms of slurring of speech, body weakness and paralysis
Complication
Stroke
Diagnosis - Multiple Sclerosis
Condition -
Multiple Sclerosis, it is an autoimmune disorder.
What’s happening is demyelination (Nerve cells covered by sheath and it got destroyed).
Sclerosis - means Scar
Uncommon
More common in women, this disease has classical relapse and remission
Cause
Unknown
Clinical feature These scars occur within the central nervous system and depending on where they develop, manifest into various symptoms. These symptoms are what you are having - Blurring of vision and blurring disturbances - Muscle weakness - Bladder or bowel dysfunction - Sensory loss - Motor incoordination - Pain
Complication
It is a serious condition but don’t worry we will help you. It is not curable but controllable. Our aim is to slow the progression of the disease and increase the period btw relapses.
Physical Examination - Multiple Sclerosis
The findings depend on the site of the lesion or lesions and include opticatrophy, weakness, hyper-reflexia, extensor plantar responses, nystagmus(two types—cerebellar or ataxic), ataxia, incoordination and regionalimpairment of sensation.
Physical Examination - General appearance: She is distress. - VS - Neurological Exam: - No facial abnormality. Facial palsy drooping of eye lids - Eye: Ophthalmoplegia visual acuity is decreased visual fields are normal (+) double vision pupils are normal. Fundoscopy: Optic neuritis/atrophy. - Cranial nerves: I’d also like to check 5 to 12. No abnormality for all other cranial nerve.
- Neurological examination of the upper and lower limbs:
Spastic paraparesis in lower limb
increase reflexes
impaired coordination (Heel and the shin test).
Lower limbs:
There’s impaired sensation.
Gait: ataxic gait. - CVS - Carotid bruit
- RS, ABD
- OT - UDS, BSL
Physical Examination - Myopia
Examination
- Inspection:
- Size alignment/symmetrical
- Eye lid: ptosis
- Conjunctiva: chemosis, redness
- Cornea- ulceration, abrasion.
- Sclera- jaundice
- If there’s any cataract/ pupils (if they are dilated, shape and size of the pupils)
- Anterior chamber- blood, pus.
- Proptosis
- PEARL:
• Ophthalmoscopy: Red reflex, posterior chamber, retina for any detachment, exudates, hemorrhage, DM HTN), Optic disc- Papilledema, optic atrophy, Macula (Exudates),
• Feel the increase of pressure-Glaucoma, Any degeneration
- Visual Acuity: 6m/20ft 6/18
- Visual Fields
- Eye movements: for any weakness of muscles, look for any diplopia. Accommodation
Pin hole test: If the vision is improving?
Management - Myopia
Management - Send the patient to the eye specialist/ optician: Concave lens Driving: 6/12
Glasses with a concave lens
Contact lenses
Consider radial keratotomy or excimer laser surgery
Differential Diagnosis - Chronic Simple Glaucoma
Differential Diagnosis
- Macular degeneration
- Visual defects due to pituitary tumor
- Cataract
- Glaucoma
- Optic neuritis
Risk Factors - Chronic Simple Glaucoma
Risk factors
- FHx of glaucoma
- DM
- Hypertension
- Myopia
- Migraine
- Eye injuries
