ON/ Neuro dx Flashcards
in a healthy eye, there is a pressure gradient that exists bw eye and the brain. The pressure is higher in the ___ compared to the ___ allowing axoplasmic flow to occur in ___ direction
in a healthy eye, there is a pressure gradient that exists bw eye and the brain. The pressure is higher in the eye compared to the brain allowing axoplasmic flow to occur in orthograde direction
if the pressure gradient is reversed anterior to the opt. chiasm, retrograde axoplasmic flow will occur, resulting in ______
if the pressure gradient is reversed anterior to the opt. chiasm, retrograde axoplasmic flow will occur, resulting in unilateral disc edema
if the pressure gradient is reversed posterior to the optic chiasm due to inc intracranial pressure, retrograde axoplasmic flow will occur in both eyes, resulting in ____________
if the pressure gradient is reversed posterior to the optic chiasm due to inc intracranial pressure, retrograde axoplasmic flow will occur in both eyes, resulting in papilledema
optic nerve damage can be detected via ___, _____, and ____
optic nerve damage can be detected via pupil testing, brightness comparison test, red cap desaturation.
unilateral disc edema is due to _________
unilateral disc edema is due to pre-chiasmal disruption of axoplasmic flow.
clinical signs of unil disc edema
– decr visual acuity
–APD
–vis field defect
–rim tissue and retinal nerve fiber layer elevation
-can have hemorrhages or CWS on rim tissue
presence of ____ rules out optic disc edema has to be previously noted before though
presence of SVP rules out optic disc edema, has to be previously noted before though
most common causes of optic disc edema:
- Arteritic 2’ to GCA
2.Non-arteritic NAION inc DM papillopathy - ophthalmic causes
- inflammatory causes
- optic neuritis
- compressive lesion anterior to opt chiasm
ophthalmic causes of optic dis edema
CRVO
hypotony
optic disc drusen
uveitis (rare)
inflammatory causes of opt. disc edema
non infection: sarcoidosis, collagen vascular disease, papillophlebitis
infectious: syphilis,TB, neuroretinits
compressive lesions causing optic disc edema (lesion anterior to optic chiasm)
–thyroid related ophthalmopathy
–optic nerve glioma
–optic nerve sheath meningioma
–orbital cavernous hemanigoma
rDx: Arteritic ischemic op.neuropathy
epid/hx: _ age
pthphys:
symptoms:
Dx: Arteritic ischemic op.neuropathy
epid/hx: >55YO age
pathophysiology: GCA, systemic vasculitis of med/large bv/** secondary to occlusion of the SPCA causing decreased perfusion to anterior ON**
symptoms: amaurosis fugax, sudden loss of vision in the eye, temporal HA, jaw claudication, neck pain, anorexia, scalp tenderness, malaise, fever
Dx: AAION
signs:
Diagnosis:
Dx: AAION
signs: unilateral disc edema w. APD and reduced vision in affected eye
Diagnosis: evaluate suspected pt STAT.
- CBC w/ differential: elevated platelets
- erythrocyte sedimentation rate (ESR)
–C-reactive protein (CRP)
– temporal artery biopsy to confirm granulomatous inflammation with the bv wall
ESR - inflam in body, CSR - acute/faster for inflamm, CBC: wbc,rbc,infec
what are less common causes of AAION
polyarteritis nodosa, SLE, herpes zoster
for AAION, list ESR diagnosis criteria
elevated platelets
elevated CRP
abnormal lab results
elevated ESR: >age/2 in men or >(age+10)/2 in women
elevated platelets >400,000
elevated CRP >2.45mg/dL
Treatment/management for AAION
systemic steroids should be started IMMEDIATELY
refer pt to rheumatology promptly for long term care for GCA
IV methylprednisolone followed by oral prednisone. slow taper 3-6months
why is AAION due to GCA considered an ocular emergency?
risk of sudden vision loss in fellow eye in as early as 2 weeks
Dx: NAAION
epid/hx:
pathophysiology:
symptoms:
epid/hx: >50YO age w/ hx of HTN, DM, high chol. 90% have small crowded ON (disc@risk)
pathophysiology: 2’ to irreversible ischemia of anterior ON due to unknown etiology
– nocturnal HTN resulting in poor perfusion to ON can contribute
symptoms: sudden, painless, non-progressive unilateral vision loss upon awakening. Vision rarely improved after onset
weak link between NAION and pt taking what drug?
NAION and Viagra, Levitra, Cialis
what are the signs and diagnostic tools for NAAION
Signs: decreased vision, APD, unilateral disc edema, VF loss: inferior altitudinal defect common
Diagnosis: normal ESR, CRP, platelet count
–Diagnosis of exclusion: Pt must be thoroughly investigated for possible GCA by careful case hx, and blood work (STAT) before making NAAION diagnosis.
treatment/management for NAION
No treatment
–pt referred to PCP for proper control of blood press, blood sugar, high cholesterol to reduce risk of NAAION in fellow eye.
– raising bp at night might be considered
Diag: Diabetic papillopathy
Epid/hx:
pathophysiology:
symptoms:
signs:
diagnosis:
Trx/Mgmt:
Diag: Diabetic papillopathy
Epid/hx: young pt <50YO with Type 1 DM. Also elderyl with DM Type II
pathophysiology: mild form of NAION w/ reversivle ischemia of anterior optic nerve.
symptoms: mild to no decrease in vision,
signs:mild APD, optic disc edema (unil), mild depression on visual field(no altitudinal defect), DM retinopathy (mac edema)
diagnosis: diagnosis of exclusion. Investigate to rule out AAION 2’ to GCA or for causes of papilledema if bilat. disc edema including malig. HTN
Trx/Mgmt: no treatment . Refer to PCP to ensure proper management of blood glucose levels
Central retinal vein occlusion
review in Retina/vitreous
Hypotony
epid/hx:
pathophys:
signs/symp
Hypotony
epid/hx: pt hx of trabeculectomy, blunt ocular trauma, intraocular inflammation
pathophysiology: hypotony occurs with IOP <6mmHg, anatomical and physiological changes ensue.
– over-filtering bled after trabeculectomy, wound leak, cyclodialysis cleft
signs:
– folds in descement membrane, corneal edema, shallow AC, catarct formation, optic disc edema in presence of low IOP
symptoms: decreased vision & pain esp w/ ocular inflammation.
how to trx/manage hypotony with disc edema
– as hypotony resolves, optic disc edema also resolves.
– if hypotony is a result of a wound leak, use large bandage CL, topical opthalmic antibiotics, aqueous suppressants
if due to over-filtering bleb, faster taper of topical ophthalmic corticosteroid and potential laser, and other techniques to stimulate inflammation and partial closure of open wound
optic disc drusen
epid/hx
pathophysiology
signs/symptoms
trx/management
epid/hx: 3.4-24 person per 1000 people
pathophysiology/diagnosis: optic drusen are hyaline bodes in the optic disc.
– hereditary
– hyper-reflective on Bscan, even if gain is reduced
– fundus autofluorescence photos and OCT raster scan though ON to confirm drusen presence.
signs/symptoms: rarely causes symptoms. buried when pt young, and evident with age.
– can potentially compress retinal GC fibers in ON, causing VF defect that mimic glaucoma
– cause psuedo-disc edema where rim tissue and RNFL look elevated due to bumps of the optic disc drusen
–can cause CNVN w/break in bruch’s membrane within area of ppa
trx/management: none. Good prognosis
Sarcoid
etiol/hx
pathophysiology
signs/symp
trx/mgmt
etiol/hx: idiopathic condition affecting middle age AA females. non-causeating granulomatous inflammation throughout body. 90% lung involvement
Diagnosis:
–Serum ACE (angiotensin converting enzyme) elevated
(40% active sarcoid cases have normal ACE)
–chest x-ray
–chronic dacryoadenitis, dry eye disease, chronic/bilateral anteiror granulomatous uveitis
–post seg: vasculitis (candle wax dripping), diffuse vitritis (cotton ball opacities)
Trx/mgmt: with disc edema
– MRI w/ and w/o contrast to look for granulomatous compression of ON.
–refer to rheumatology or pulmonology for systemic management
collagen vascular disorders
collagen vascular disorders including: RA, SLE, granulomatosis w/ polyangitis
– occurs mainly in pt with SLE// females// 20-30s
– systemic symptoms include: butterfly rash, discoid lupus, photosensitivity
Diagnosis: produce ANA
– pt with optic disc edema due to suspected SLE
- ANA and refer to rheumatology for additional management
syphilis + unilateral disc edema
– etiology
– signs/symptoms
– diagnosis
–trxt/mgmt
– etiology: sexually transmitted, by spirochete Treponema pallidum
– signs/symptoms:
- optic disc edema, CN neuropathies, uveitis, Argyll Robertson pupil (tertiary syphilis)
– diagnosis:
–trxt/mgmt: hospitalization for IV penicillin G
TB & unil optic disc edema
etiol:
sign/sym
Trx/management
etiol: infectious diease of lungs caused by airborn droplet: mycobacterium tuberculosis
sign/sym: fver, chronic cough, night sweats.
–bilateral anterior granulomatous uveitis, CME
–optic disc edema less common
Diagnosis: chest X ray
–Latent TB: positive PPD or quantiFERON TB gold – shows negative chext xray
–Active TB: positive test results and positive chest Xray
Trx/management: combo of: rifampin, isoniazid, pyrazinamide, ethambutol (RIPE). treatment will also resolve swollen opt. nerves
Neuroretinitis
etiol/hx
pathophysiology
signs/symp
Diagn
trx/mgmt
etiol/hx: anterior optic neuritis
– 30s-40s, or any age
–preceded by viral illness
–cat scratch fever
assoc w/ spirochete infections (syphilis, lyme disease), histoplasmosis, toxoplasmosis
pathophysiology: leakage of superficial vasculature on optic disc; retinal vessels near macula are normal without leakage on fluorescein angiography
signs:
– optic disc edema and macular edema + hard exudates (macular star)
–cells in vitreous and AC
–cecocentral most common VF defect
symp: mild to severe vision loss and aching sensation behind affected eye that may worsen with eye movement.
trx/mgmt: – depends on underlying etiology. trx usually resolves disc edema
optic neuritis
epid/hx
pthaophysiology/diag
sympt:
signs
trx/mgmt
epid/hx: young ot 24-45YO, females?male
pthaophysiology/diag: primary inflammation of ON; demyelinating opt. neuritis assoc mainly with MS. if MS: optic neuritis is initial presenting symptoms)
sympt: sudden onset unilateral vision loss
–pain on eye movement (90%)
–vision improves over course of weeks
signs: with or without disc edema. depend on location of inflammation within ON
– APD
– decr. visual acuity, decreased contrast sensitivity, decreased color vision, variable VF defect
–ON becomes pallid 4-6 weeks after acute episode of optic neuritis
Diagnosis: MRI to assess for white matter lesions
trx/mgmt: Iv steroids for speed up recovery of visual acuity, followed by oral steroids.
signs of optic neuritis
symptoms of optic neuritis
signs:
–papillitis: inflammation of anterior optic nerve with optic disc edema. 1/3 of cases
–retrobulbar optic neuritis : inflammation of posterior ON. no disc edema. normal ON (+) APD
symptoms:
-Uthoff’s phenomenon: transient vision loss b/c inc body temp
-Lhermitte’s phenomenon: electric shock sensation traveling down back and limbs w. neck flexure
– bilateral internuclear ophthalmoplegia (INO): adduction deficit on both sides and convergence may not be in tact
why is INO seen for pt with MS
– white matter lesion in medial longitudinal fasciculus that causes poor conduction from contralateral CN 6 nucleus to ipsilater CN 3
list compression lesions of the optic nerve
–thyroid eye disease
–optic nerve sheath meningioma
–optic nerve glioma
–orbital cavernous hemangioma
thyroid eye disease
etiolg/hx: autoimmune disorder, thyroid stimulating receptor antibodies (TSH) act against the EOMS and orbital tissue.
-cause fribroblast proliferation, and inflammation of EOM
- smoking is strong risk factor
-antibodies can affect thyroid gland, causing hyperthyroidism
TED ~ graves thyroid disease
-middle age pt
sign: inflamm of EOM and orbital adipose tissue, causing opt nerve compression
– unil optic disc edema
–APD
–reduced color vision, variable VF loss
-proptosis, upper lid retraction, eyelid erythema & edema
–IR, MR affected 1st
symptoms: decreased vision, color vision loss, prominent eyes, fb sensation, tearing
–diplopia (worse in AM b/c of fludi retention within EOM overnight when laying down)
diagnosis: exophthalmometry, VF, forced ductions.
– orbital CT or MRI shows enlargement of EOM, with tendon spared
–blood work: T3/T4/TSG, TSI,TSAb,TRAb, to measure thyroid function and determine presence of autoantibodies
trx/mgm: lubrication w/ ATs or gels, eyelid taping, patching at bedtime
– Tepezza IV infusion every 3 weeks for 8 total infusions
systemic steroids: prednisone 100mg daily for 2-14 days
smoking cessation counseling
– fresnel prism for DV 2’ to strabismus
what are exophthalmometry norms for adults:
what is anormal
12-22 mm caucasians
12-18 mm asians
12-24 mm AA
abnormal if higher than norms or >3mm between eyes
optic nerve sheath meningioma
-benign tumor from optic nerve shear
-young women
-unilateral
optic nerve glioma
- most common intrinsic tumor
– sympoms within 1st decade of life
–neurofibormatosis type 1
benign if present during childhood.
when are optic nerve gliomas malignant
if they present in adulthood
most common benign orbital neoplasm in adults
orbital cavernous hemangioma
orbital cavernous hemangioma
- females, in 4th to 6th decade of life
–collection of vascular channels and fibrous tissue
–within muscle cone posterior to glove
– compression of ON causing optic disc edema
–diplopia
optic nerve tumors or orbital tumors that compress ON are characterized by
painless, slowly progressive vision loss, proptosis, unilateral disc edema followed by 2’ optic atrophy
