Painful Vision Loss

Question 1

DiffDx for painful vision loss: cornea

Answer 1

Abrasion and ulcers

Question 2

DiffDx for painful vision loss: AC

Answer 2

Uveitis

Question 3

DiffDx for painful vision loss: lens

Answer 3

Subluxation d/t trauma

Question 4

DiffDx for painful vision loss: vit

Answer 4

Vitritis

Question 5

DiffDx for painful vision loss: Mac

Answer 5

Choroidal rupture from trauma

Question 6

DIffDx for painful vision loss retina

Answer 6

RD from trauma

Question 7

DiffDx of painful vision loss: ONH

Answer 7

Optic neuritis, GCA

Question 8

Things that cause pain on eye movement

Answer 8

DED
Scleritis
Optic neuritis

Question 9

Classic example of optic neuritis

Answer 9

Young female patient with sudden onset, unilateral vision loss (2/20 to NLP) and pain on EOMs

Question 10

What is optic neuritis

Answer 10

Primary inflammation of the optic nerve. Will present with an APD, decreased perceived brightness on brightness comparison test, decreased contrast sensitivity, and VF defects

Question 11

Vision after initial episode of optic neuritis

Answer 11

VA returns to near normal or normal over the course of 2-4 weeks, although most patients will have reduced contrast sensitivity and optic nerve pallor

Question 12

Brightness comparison test

Answer 12

Often abnormal with unilateral or asymmetric optic neuropathies

Question 13

What is optic neuritis associated with

Answer 13

MS. The 15 year risk of developing MS after an isolated episode of optic neuritis is appx 50% (75% if one or more white matter lesions are present on an MRI and 25% if there are no white matter lesions on an MRI

Question 14

What is the ONTT

Answer 14

A study that says an MRI should be considered for patients who present with acute optic neuritis in order to determine the patient’s risk of developing MS, as well as the need for treatment with IV steroids and/or interferon beta

Question 15

Is an MRI necessary to confirm the diagnosis of MS

Answer 15

No

Question 16

Symptoms suggestive of MS

Answer 16

Uhthoffs phenomenon
Lhermittes phenomenon
INO

Question 17

Uhtoffs

Answer 17

Transient vision loss that occurs in response to an increase in body temperature (after exercise); although it only occurs in 6% of patients, it is considered highly characteristic of MS

Question 18

Lhermittes phenomenon

Answer 18

The sensation of an electric chock that quickly travels down the back and into the limbs with flexure of the neck; occurs in 30-40% of MS patients

Question 19

INO

Answer 19

Characterized by a lack of adduction on the affected side with contralateral nystagmus on abduction. It occurs due to an MS lesion in the MLF

R INO=R adduction problem with L nystagmus

Question 20

Bialteral INO

Answer 20

Considered highly suggestive of MS; an estimated 15-30% of patient with MS present with bilateral INO

Question 21

Overview of optic neuritis

Answer 21

• sudden painful vision loss
• VA can range from 20/20 to HM
• vision usually gets better over 3 week period
• Be aware of others (ex atypical optic neuritis) where VA does not improve
• order MRI to evaluate risk of MS
• Tx is IV steroids

Question 22

Things other than MS that can cause optic neuritis

Answer 22

Idiopathic 
Syphilis 
Cat scratch 
Lyme 
Meningitis 
Sarcoidosis 
SLE 
Devics

Question 23

Devic’s disease (neuromyelitis optica)

Answer 23

Bialteral demyelinating disease characterized by optic neuritis and transverse myelitis; commonly found in children, and will not have white matter lesions prestn on an MRI

MS meds actually make this worse

Question 24

Types of optic neuritis with MS

Answer 24

Papillitis
-secondary to inflammation of the anterior optic nerve and will present with disc edema (1/3 of cases)

Retrobulbar optic neuritis
-secondary to posterior inflammation of the optic nerve (2/3 of cases); the optic nerve will appear normal, but the patient will still have an APD, decreased VA, and decreased contrast sensitivity

Question 25

AAION

Answer 25

Secondary to occlusion of the SPCA, most commonly due to GCA, a systemic vasculitis of the medium and large blood vessels. Recall that AAION occurs in patietns >55. Will likely have an elevated ESR and CRP and elevated platelets

Question 26

Normal ESR for females

Answer 26

< (age+10)/2

Question 27

Normal ESR for men

Answer 27

< age/2

Question 28

Normal CRP

Answer 28

0-1 mg/dL CRP?2.45 is associated with a 3x greater risk of GCA

Question 29

Normal platelets

Answer 29

<400,000

Question 30

Lebers optic neuropathy

Answer 30

Hereditary condition that occurs from mutations in the mitochondrial DNA that are inherited from the mother. 85% are males, with an onset in the late teens to early 20s. The condition most commonly begins in one eye with a sudden onset decreased VA, before occurring in the other eye. - early signs include: optic disc edema, disc hyperemia, and telangiectatic vessels on the surface of the ONH - late signs include optic disc atrophy The condition may spontaneously improve in appx 35% of cases. There is no treatment.

Question 31

Optic nerve sheath meningioma

Answer 31

Most common in young to middle aged women; they are generally benign, unilateral tumors that restful in compression of the optic nerve with resulting optic disc edema, followed by optic atrophy and progressive vision loss. Treatment includes observation, radiation, and/or surgery. An MRI will detect the presence of an optic nerve cheats meningioma

Question 32

ONTT and treatment for MS

Answer 32

IV steroids = oral taper | -oral pred does not improve final VA or speed up recovery and is associated with a higher risk of recurrence

Question 33

CHAMPs study

Answer 33

Treatment with IV steroids + Avenova reduces the risk of development of MS from 50-35% over 3 years

Question 34

Treatment based on ONTT and CHAMPS

Answer 34

Consider IV steroids (followed by an oral taper) + Avenova in patients with an acute episode of unilateral optic neuritis with at least 2 white matter lesions on a baseline MRI in order to reduce the risk of progression to MS

Question 35

Optic nerve pallor in MS associated optic neuritis

Answer 35

Becomes pale 4-6 weeks after initial incident

Question 36

Why might someone with MS complain of diplopia

Answer 36

INO