Fall 2014: Week 10: ION

Question 1

What’s the MOST common cause of Disc edema in Pts over 50?

Answer 1

1. NA-AION

Question 2

When does Optic Neuritis tend to occur? (age)

Answer 2

1. Around 20-30s

Question 3

Which of the following is the main blood supply to the Anterior part of the Optic Nerve?

a. CRA
b. ACA
b. LPCA
d. SPCA

Answer 3

1. Short Posterior Ciliary Arteries

Question 4

Which of the following Decrease BF to the Optic Nerve (MR)?

a. HBP
b. LBP
c. Very High IOP
d. Very low IOP
e. Dilation of terminal Aterioles
f. Constriction of Terminal Arterioles

Answer 4

1. LBP;Very High IOP, and Constriction of Terminal Arterioles

Question 5

1. NA-AION is due to what?

2. A-AION is due to what?

Answer 5

1. Non Perfusion of the Optic Nerve Head (Ischemia)

2. GCA (most common cause). (Inflammatory)

Question 6

Pathophysiology of NA-AION

1. Starts with ISCHEMIA of the ONH –> (4 more steps)

Answer 6

Axoplasmic Flow Stasis in the ON Fibers –> Axonal Swelling –> Optic Disc Edema –> Compression of the intervening Capillaries by Swollen Axons in the Crowded Disc

which then starts the whole process over…causing more Ischemia of the ONH.

Question 7

NA-AION: Epidemiology

1. US?
2. More common in what age group?
3. More common in what race?
4. M >F?

Answer 7

1. 2.3 to 10.2 per 100,000
2. Middle-Aged and Elderly
3. Caucasians
4. No gender predisposition

Question 8

Which of the following are risk factors for NA-AION?

1. Nocturnal Hypotension
2. Nocturnal Drop in IOP
3. Small Optic nerve cup
4. Lg. ON Cup
5. Myopia
6. Diabetes
7. HTN
8. Sleep Apnea

Answer 8

1, 3, 6, 7, 8.

Question 9

NA-AION: “Disc at Risk”

1. It’s well established that what cup size is a contributing factor in the pathogenesis of NA-AION?
2. Eyes w/NA-AION have a HIGHER PREVALENCE of what than the general population?

Answer 9

1. Absent or Small cup

2. Small cups

Question 10

NA-AION: Symptoms

1. Vision Loss: Acute, or slowly progressive? Painful?
2. What else?

Answer 10

1. Sudden, PAINLESS VISION LOSS (usually discovered upon awakening)
2. VF Loss, and Decreased Color Vision

Question 11

T/F: If a Pt w/a U/L NA-AION has a VA of 20/20 in the affected eye, they most likely will not have an RAPD

Answer 11

FALSE

Question 12

What’s the most common type of VF Defect with NA-AION?

2. What’s the Second most common VF Defect?

Answer 12

1. INFERIOR ALTITUDINAL

2. Central Scotoma

Question 13

NA-AION: ON Appearance

1. Optic Disc Edema: Becomes pallid over what amt of time?
2. What kind of Hemes are commonly seen?

Answer 13

1. Over 4-6 wks. (Diffuse or Segmental).

2. Peripapillary Splinter Hemes

Question 14

NA-AION: Diagnostic Criteria

1. Age?
2. Risk Factors?
3. 1 or both eyes affected at a time?
4. VA, and VF loss?
5. Other CN involvement or Systemic Symptoms?
6. c/d ratio in Contralateral eye?
7. Stable vision loss at what time?
8. GCA Labs?

Answer 14

1. 50 or over
2. Vasculopathic Risk Factors
3. just one EYE
4. Sudden VA and VF Loss w/no Progression beyond one week.
5. None
6. Small
7. at one month
8. NORMAL

Question 15

NA-AION: Prognosis

About what % of eyes w/NA-AION show spontaneous improvement in VA?

2. What is the chance that a pt with an NA-AION in one eye will develop an NA-AION in the fellow eye?

Answer 15

1. 40%

2. 15-25%

Question 16

NA-AION: Management

1. Reduction of what?
2. Manage what?

Answer 16

1. Risk factors

2. Nocturnal Hypotension

Question 17

A-AION: GCA:

1. GCA is what kind of disease that INVOLVES the medium and Large Arteries?
2. A-AION in Pts w/GCA is the result of what?

Answer 17

1. Vasculitis

2. Thrombotic Occlusion
Inflammation –> increased risk of thrombosis –> risk of blood clotting –> occlusion

Question 18

A-AION: GCA: Epidemiology

1. Annual Incidence in US?
2. Peeps?
   a. Mean Age?
3. M>F?
4. More common in what race?
5. GCA is the cause of AIONs in what % of cases?

Answer 18

1. 0.36 per 100,000
2. Late middle-aged and elderly
   a. 70
3. Females more common than males
4. in Caucasians
5. 5.7% of cases (So that includes all AIONs, Arteritic and Nonarteritic…)…but it’s the most common cause of A-AION

Question 19

What are the most common visual symptoms in GCA (3)

Answer 19

Amaurosis Fugax, Diplopia, and Sudden Vision Loss

Question 20

A-AION: GCA:

Persistent vision loss due to A-AION is preceded by Transient Vision Loss in what % of cases?

Answer 20

7-18% of cases.

Question 21

A-AION: GCA: Systemic Symptoms of GCA

1. Most Common?
2. Most Specific?

Answer 21

1. HA

2. Jaw Claudication

Question 22

A-AION: GCA: Occult GCA

1. What % of Pts w/Vision loss due to GCA have NO SYSTEMIC SYMPTOMS?

Answer 22

1. ~21%

Question 23

A-AION: GCA: VF

1. VF Loss in A-AION is more/less extensive and severe than inNA-AION?

Answer 23

1. MORE

Question 24

A-AION: GCA: ON Appearance

1. Pallor = ?
2. What else is seen?
3. Does A-AION Favor any particular cup size?

Answer 24

1. “Chalky White” Optic Disc Edema
2. Can have peripapillary splinter hemes, CWS
3. Nope.

Question 25

A-AION: GCA: Diagnostic Tests 1. what can be done? 2. Why do we order CRP and ESR together?

Answer 25

1. CRP ESR and CBC (Thrombocytosis) 2. Most sensitive (100%) and more specific (97%) when ordered together than by themselves

Question 26

A-AION: GCA: TAB 1. What is found?

Answer 26

1. Granulomatous inflammation of the Arterial Walls Possible Multinucleated Giant Cells *Skip Lesions

Question 27

A-AION: GCA: What's the most common Tx for Pts w/GCA that present w/VISION LOSS?

Answer 27

High Dose IV steroids followed by Oral Steroids tapered over years

Question 28

A-AION: GCA: Tx 1. Uncomplicated GCA (No jaw claudication or visual symptoms) 2. Evolving visual loss or transient vision loss 3. Established vision loss

Answer 28

1. 40-60 mg oral prednisolone daily 2. IV Methylprednisolone 500-1000 mg daily for 3 days then oral prednisolone 3. At least 60 mg prednisolone daily

Question 29

A-AION: GCA: Which of the following are side-effects of long-term steroid treatment? 1. Wgt Gain 2. Hyperglycemia 3. Cataracts 4. Depression 5. HBP 6. Fatigue 7. Osteoporosis

Answer 29

1. ALL OF THEM

Question 30

A-AION: GCA: Management 1. History 2. Serology 3. Bx?

Answer 30

1. Symptoms of GCA 2. CPR, ESR, CBC (if elevated, start Tx for GCA) 3. TAB w/in 1-2 wks of Steroid Tx

Question 31

KNOW: GCA MUST be on your DDx for the following Conditions (4)

Answer 31

1. AION 2. CRAO 3. TMVL (Transient Monocular Vision Loss) 4. Diplopia

Question 32

PION 1. Common? 2. Dx of what? 3. 3 types.... 4. Optic Nerve appearance?

Answer 32

1. RARE condition that's due to ischemia of the posterior part of the ON 2. of EXCLUSION! 3. Arteritic, Non-Arteritic, and Perioperative PION (This one is due to prolonged general anesthesia, Surgical trauma, massive blood loss, hemodilution) 4. Normal --> Pallor (6-8 wks)