Neurology Case Presentation
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Transcript of Neurology Case Presentation
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MARCH 23 , 2012LORI NOOROLLAH
Neurology Case Presentation
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Chief Complaint
Double Vision
HPI: Middle aged woman who reports that she woke up
with blurry vision and pain in her right eye Two week later– woke up with double vision
Binocular, vertical and horizontal Worse on right gaze
Three months later– woke up with blurry vision in left eye and left orbital pain
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PMH: HTN, Anxiety, chronic pain, GI bleed due to
diverticulosisMeds:
Clonidine 0.2mg qHS Metoprolol 50mg BID Diazepam prn Diltiazem qAM Losartan 100mg qHS hydrocodone prn
SH: Smokes 3-4 cigarettes daily for 25 years No EtOH or illicit drug use
More History
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General Exam
Alert, oriented, no acute distressCV: RRR, no carotid bruitChest: CTABVisual Acuity:
OD: 20/60 OS: 20/25
+relative APD on right red-green dyschromatopsia on right
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Neurological Exam
Mental status and speech normalCN:
PERRL APD on right Visual Fields –
Inferior arcuate defect on Right Enlarged blind spot on Left
normal facial sensation and movement, symmetric palate elevation, tongue midline
EOM:Limited abduction and slightly limited upgaze bilaterally
Motor, Sensory, Reflexes, Coordination – within normal limits
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Visual Fields
Inferior arcuate defect in right eye Enlarged blind spot in left eye
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?Where?
?What?
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Differential Diagnosis
Anterior Ischemic Optic Neuropathy (AION) + cranial nerve infarcts AAION vs. NAION
Optic NeuritisOcular Myasthenia gravis
Acetylcholine receptor antibodies negative
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NAION
Non-arteritic Anterior Ischemic Optic Neuropathy is an
“idiopathic” ischemic insult of the optic nerve head
Most common optic neuropathy Annual incidence for people > age 50 is 2.3 – 10.2
/100,000 95% of cases occur in Caucasian population
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NAION
Clinical presentation: Sudden monocular visual loss Blurring or cloudiness Often noticed upon awakening (73%) Most often painless
12% have ocular pain or headache A lot of pain more suggestive of optic neuritis
or AION Exam:
Reduced visual acuity to varying degrees Not ruled out by normal visual acuity
Dyschromatopsia proportional to reduction in visual acuity Afferent pupillary defect Fundoscopic Exam:
Optic disc swelling Disc hyperemia with splinter or flame hemorrhages Small optic cup (nerve fiber crowding) in unaffected eye
Visual field defect – relative inferior altitudinal defect and absolute inferior nasal defect
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Hayreh SS (2009) Ischemic optic neuropathy. Progress in retinal and eye research 28: 34-62
NAION – Fundoscopic Exam
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NAION
Vascular supply to optic nerve head 15-20 short posterior ciliary arteries, supplied by ophthalmic artery
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NAION
Pathogenesis: Different than Ischemic CVA
No clear relationship with HTN, HLD, smoking Not associated with embolism or large vessel occlusion
Transient hypoperfusion of posterior ciliary arteries Vasospasm vs. nocturnal hypotension vs. impaired
autoregulation of microvasculature vs. vasculopathic occlusion vs. venous insufficiency
Hypoxia/Ischemia optic disc swelling (in setting of physiologically crowded optic nerve head) infarction
Treatment = Modify risk factors, vision therapy Early therapy shown to have better recovery Questionable role for steroids
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NAION and OSA
Nocturnal Hypotension Normal physiologic occurrence Autoregulation
OSA Loss of autoregulation Non-dipping status Hypoxic-ischemic insult to optic nerve head
Anti-hypertensive medications at night may also disrupt autoregulation
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OSA and NAION
Stein, 2011 – American Journal of Ophthalmology
Retrospective cohort study Review from managed care database looking at
patients > 40 with at least 1 eye-care visit N=2,259,061 Compared incidence of NAION in population with and
without OSA Compared NAION in treated vs. untreated OSA
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OSA and NAION
Results:After adjusting for confouding variables:
Untreated OSA patients had 16% increased hazard of experiencing NAION (HR 1.16, CI 1.01-1.33) compared with non-OSA patietns
Treated OSA patients had no difference in hazard (HR 1.38, CI 0.76-2.5) compared with non-OSA patients
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NAION – Future Studies
Implications: Do patients with NAION need screening for OSA? Do patients with OSA need evaluation? Consider avoiding anti-hypertensive medications at
night, especially in patients “at risk” for NAION
Future Studies: Treatment options/Intervention/Prevention Further investigation into the pathophysiology of
NAION
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References
Anterior Ischemic Optic Neuropathy:Part II: a discussion for physicians. Sohan Singh Hayreh, MD, MS, PhD, DSc, FRCS, FRCOphthhttp://webeye.ophth.uiowa.edu/component/content/article/118-aion-part2
Atkins, EJ Nonarteritic Anterior Ischemic Optic Neuropathy. Current Treatment Options in Neurology. 2011; 13: 92-100
Hayreh SS (2009) Ischemic optic neuropathy. Progress in retinal and eye research 28: 34-62
Kerr NM, Etal. Non-arteritic ischaemic optic neuropathy: A review and update. Journal of Clinical Neuroscience. 2009; 16: 994-1000.
Stein JD, Etal. The Association between Glaucomatous and other causes of Optic Neuropathy and Sleep Apnea. Am J Ophthalmol. 2011; 152: 989-998.
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