ON/ Neuro dx

Question 1

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

Answer 1

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

Question 2

if the pressure gradient is reversed anterior to the opt. chiasm, retrograde axoplasmic flow will occur, resulting in ______

Answer 2

if the pressure gradient is reversed anterior to the opt. chiasm, retrograde axoplasmic flow will occur, resulting in unilateral disc edema

Question 3

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 ____________

Answer 3

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

Question 4

optic nerve damage can be detected via ___, _____, and ____

Answer 4

optic nerve damage can be detected via pupil testing, brightness comparison test, red cap desaturation.

Question 5

unilateral disc edema is due to _________

Answer 5

unilateral disc edema is due to pre-chiasmal disruption of axoplasmic flow.

Question 6

clinical signs of unil disc edema

Answer 6

– decr visual acuity
–APD
–vis field defect
–rim tissue and retinal nerve fiber layer elevation
-can have hemorrhages or CWS on rim tissue

Question 7

presence of ____ rules out optic disc edema has to be previously noted before though

Answer 7

presence of SVP rules out optic disc edema, has to be previously noted before though

Question 8

most common causes of optic disc edema:

Answer 8

1. Arteritic 2’ to GCA
   2.Non-arteritic NAION inc DM papillopathy
2. ophthalmic causes
3. inflammatory causes
4. optic neuritis
5. compressive lesion anterior to opt chiasm

Question 9

ophthalmic causes of optic dis edema

Answer 9

CRVO
hypotony
optic disc drusen
uveitis (rare)

Question 9

inflammatory causes of opt. disc edema

Answer 9

non infection: sarcoidosis, collagen vascular disease, papillophlebitis

infectious: syphilis,TB, neuroretinits

Question 10

compressive lesions causing optic disc edema (lesion anterior to optic chiasm)

Answer 10

–thyroid related ophthalmopathy
–optic nerve glioma
–optic nerve sheath meningioma
–orbital cavernous hemanigoma

Question 11

rDx: Arteritic ischemic op.neuropathy
epid/hx: _ age
pthphys:
symptoms:

Answer 11

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

Question 12

Dx: AAION
signs:
Diagnosis:

Answer 12

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

Question 13

what are less common causes of AAION

Answer 13

polyarteritis nodosa, SLE, herpes zoster

Question 14

for AAION, list ESR diagnosis criteria

elevated platelets

elevated CRP

abnormal lab results

Answer 14

elevated ESR: >age/2 in men or >(age+10)/2 in women

elevated platelets >400,000

elevated CRP >2.45mg/dL

Question 15

Treatment/management for AAION

Answer 15

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

Question 16

why is AAION due to GCA considered an ocular emergency?

Answer 16

risk of sudden vision loss in fellow eye in as early as 2 weeks

Question 17

Dx: NAAION
epid/hx:

pathophysiology:

symptoms:

Answer 17

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

Question 18

weak link between NAION and pt taking what drug?

Answer 18

NAION and Viagra, Levitra, Cialis

Question 19

what are the signs and diagnostic tools for NAAION

Answer 19

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.

Question 20

treatment/management for NAION

Answer 20

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

Question 21

Diag: Diabetic papillopathy
Epid/hx:
pathophysiology:
symptoms:
signs:
diagnosis:
Trx/Mgmt:

Answer 21

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

Question 22

Central retinal vein occlusion

review in Retina/vitreous

Question 23

Hypotony

epid/hx:

pathophys:

signs/symp

Answer 23

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.

Question 24

how to trx/manage hypotony with disc edema

Answer 24

-- 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

Question 25

optic disc drusen epid/hx pathophysiology signs/symptoms trx/management

Answer 25

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

Question 26

Sarcoid etiol/hx pathophysiology signs/symp trx/mgmt

Answer 26

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

Question 27

collagen vascular disorders

Answer 27

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

Question 28

syphilis + unilateral disc edema -- etiology -- signs/symptoms -- diagnosis --trxt/mgmt

Answer 28

-- 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

Question 29

TB & unil optic disc edema etiol: sign/sym Trx/management

Answer 29

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

Question 30

Neuroretinitis etiol/hx pathophysiology signs/symp Diagn trx/mgmt

Answer 30

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

Question 31

optic neuritis epid/hx pthaophysiology/diag sympt: signs trx/mgmt

Answer 31

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.

Question 32

signs of optic neuritis symptoms of optic neuritis

Answer 32

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

Question 33

why is INO seen for pt with MS

Answer 33

-- white matter lesion in medial longitudinal fasciculus that causes poor conduction from contralateral CN 6 nucleus to ipsilater CN 3

Question 34

list compression lesions of the optic nerve

Answer 34

--thyroid eye disease --optic nerve sheath meningioma --optic nerve glioma --orbital cavernous hemangioma

Question 35

thyroid eye disease

Answer 35

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

Question 36

what are exophthalmometry norms for adults: what is anormal

Answer 36

12-22 mm caucasians 12-18 mm asians 12-24 mm AA abnormal if higher than norms or >3mm between eyes

Question 37

optic nerve sheath meningioma

Answer 37

-benign tumor from optic nerve shear -young women -unilateral

Question 38

optic nerve glioma

Answer 38

- most common intrinsic tumor -- sympoms within 1st decade of life --neurofibormatosis type 1 benign if present during childhood.

Question 39

when are optic nerve gliomas malignant

Answer 39

if they present in adulthood

Question 40

most common benign orbital neoplasm in adults

Answer 40

orbital cavernous hemangioma

Question 41

orbital cavernous hemangioma

Answer 41

- 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

Question 42

optic nerve tumors or orbital tumors that compress ON are characterized by

Answer 42

painless, slowly progressive vision loss, proptosis, unilateral disc edema followed by 2' optic atrophy