Flashcards in Optic Neuropathis Part II Deck (50):
If you see bilateral optic nerve head swelling you can't just say its papilledema until you get a ____ _____
NAION is ischemic but NOT ______. Its due to a vascular insult to preliminar and retro laminar optic nerve. It presents as the most common cause of unilateral optic nerve swellig and optic neuropathy in patients over 50 yoa.
What is clinical presentation of NAION
- acute painless vision loss: mild to severe
- typically older pt with cardiovascular risk factors
- disc at risk (tiny nerve)
what is the pathophysiology of NAION
Chronic HTN causes alteration in auto regulatory response. Vasodilation fails to occur in decresed BP. Nocturnal hypotension occurs in the morning hours. Ischemia to SPCA results in decreased optic nerve perfusion
optic nerve appearance of NAION includes
1. hyperemic edema
2. flame hemorrhages
3. +/- macular star
NAION visual field defects include
3. central scotoma
NAION risk factors includes HTN, DM, age >55, atherosclerotic disease, glaucoma, small optic nerves, and ______ in 14-73% of patients. Some Visual recovery is possible, or may have mild improvement/deterioation
bilateral; they typically have no eye pain, diplopia or neurological symptoms. EOMS are normal, but they do have + RAPD.
How do you monitor patients with NAION
1. monitor in 2-4 weeks
2. If VA or VF is still worsening, diagnosis is suspect and pt needs workup. If stable, reexamine in 3-4 months.
with NAION, same eye recurrence is ____ to ___ %, fellow eye involvement is _____% and VF remains poor
3; 5; 25
AION is ischemic and inflammatory which leads to vessel occlusion. Predilection for ___, vertebral, ophthalmic, and posterior ciliary arteries
Epidemiology of AION is women usually over 65, 75% bilateral, fellow eye involved in 1-2 days and has decreased . Decreased likelihood of fellow eye involvement after 6-8 weeks of initial insult. 50% of patients have polymyalgia rhuematica which is:
pain and stiffness of shoulders, pelvic girdle, and torso
Symptoms of AION include
1. Severe VA loss preceded by episodes of transient vision loss.
2. scalp tenderness
3. jaw claudication
4. mild fever
5. weight loss
What are signs of AION
1. pallid optic nerve swelling (no blood getting to eye)
2. extensive CWS
3. preceded by episodes of TIA (mini strokes)
How do you manage AION
1. STAT hospital admission and IV steroids for 3-5 days, then oral taper x 1 + year
2. Temporal artery biopsy
3. Labwork: ESR, CRP, platelets. (Use ESR and CRP levels to guide steroid taper)
AION is usually secondary to _____ which is systemic vasculitis of medium and large arteries, self limiting but may persist for years. Steroids may be discontinued after 12-18 months unless symptoms or blood inflammatory markers persist
T/F AION will have normal size nerves unlike NAION.
What do you have to rule out in NAION in patients less than 40 years old
1. early onset DM, HTN, and hyperlipidemia
2. Elevated homocysteine levels ( inflammation)
3. Vasculitides: SLE, wegeners
4. coagulpathy: clotting
What blood work do you order in patients less than 40 yoa
5. RPR- VDRL
posterior ischemic optic neuropathy is insult to the _____ _____ optic nerve blood supply and is usually post surgical or spontaneous.
post surgical surgeries that deal with the pt lying down for a long time. (less blood is getting into brain)
spontaneous: vasculitis (GCA)
atherosclerosis, or radiation
Symptoms of posterior ischemic optic neuropathy include patient discovering poor VA in one/both eyes. What do signs of it include?
initially optic disc is normal, pallor develops in 4-6 weeks, and RAPD. If RAPD absent and both pupils respond briskly then you are suspecting bilateral posterior cerebral artery infarction (cortical blindness)
T/F LGN and posterior lesions have no APD
What are steps you have to take to make sure its posterior ischemic optic neuropathy
1. ESR, CRP, platelets to rule out GCA
2. Carotid Doppler to rule out ICA stenosis
3. Review of intraoperative BP measurements and blood loss estimations
4. Full CBC with electrolytes to rule out anemia
How do you treat ICA stenosis? what about hypotension?
1. carotid endarterectomy
2. increase BP
Diabetic papillopathy is a diagnosis of exclusion and could be unilateral or bilateral. Vision is typically unaffected, and may be a mild form of NAION. Hyperemic disc swelling is also present due to dilated _____vessels. VF will show an enlarged blind spot, disc swelling resolves within 2-10 months.
_______ is optic nerve edema caused by raised ICP. Elevated CSF causes axoplasmic stasis (waste products getting stuck) in the ______ ONH
CSF enters dural venous sinusus via arachnoid granulations and drains via internal jugular veins. Where is CSF present in?
2. central canal of SC
3. subarachnoid space
The frisen scale is used to grade papilledema. Stage 0 is a normal optic nerve. Stage 1 is blurring of S, I, and N aspects. There is incomplete peripapillary halo like a "C." stage 2 includes blurring of all borders, elevation of nasal border, and complete peripapillary halo. Stage 3 is partial obscuration of vessel at disc margin, and peripapillary halo with fingerlike extensions. Swelling extends into the retina. Stage 4 includes _____ of the entire nerve head. Near total obscuration of major blood vessels on the disc. Stage 5 includes dome shaped protrusion of disc, obliteration of cup, and total obscuration of blood vessels on the disc
Other findings with papilledema include _____ folds, macular edema, macular star, ONH hemes, and peripapillary hemes
After you think your pt has papilledema, measure bp in office (to rule out malignant hypertension), immediate near imaging to rule out intracranial mass. Clinical features are that its _____, optic nerve function preserved early in its course, VA can be compromised from macular edema. VF include an enlarged blind spot with absent ______ _____ pulsation
bilateral ; spontaneous venous
what are symptoms of papilledema
1. headache; worsens with valsalva maneuver
2. transient visual obscuration; precipitated by postural changes
3. pulsatile tinnitus: whooshing sound in ears
what is the diagnostic work up of a papilledema
1. MRI to rule out mass lesion
2. lumbar puncture to confirm increased ICP and analyze CSF constituents.
3. MRV to rule out inflammatory/infectious etiology
4. Labs to rule out inflammatory/infectious etiology
which labs rule out inflammatory/infectious etiology
7. Lyme titers
mechanisms of increased ICP include a ____ occupying lesion usually due to a tumor or hemorrhage. It can also include cerebral edema due to trauma or metabolic disease. Other mechanisms include reduced CSF drainage which is seen in hydrocephalus, meningitis, subarachnoid hemorrhage, venous sinus thrombosis, or extra cranial venous outflow obstruction.
what are known medical disorders that can cause peudotumor cerebri
2. Malignant HTN
3. Sleep apnea
4. Renal failure
what are some meds that can cause known causes of pseudotumor cerebri
1. tetracycline antibiotics
2. excessive vitamin A
4. BC pills
______ obstruction aka venous senous thrombosis is another known cause to cause pseudo tumor cerebri. What is this?
occlusion of major dural sinus (saggital, transverse, or sigmoid) which causes increased ICP and seizures. It is usually due to infections, pregnancy related, malignancies, or coagulopathis. You treat it with an anticoagulant like heparin or coumadin. You HAVE to order an MRI and MRV (looks at blood vessels)
An unknown cause of a pseudo tumor cerebri is referred as _____ _______ hypertension
what is the modified dandy criteria which helps diagnose IIH?
1. signs and symptoms of increased ICP
2. no localizing neurological sign except CN 6 palsy. (can be unilateral/bilateral)
3. pt is awake and alert
4. no evidence of intracranial mass on MRI/CT
5. Normal MRV
6. LP opening pressure of >25 cmH20 with normal CSF composition
what are typical neurological signs seen in a patient with venous obstruction
tremor, motor weakness, ataxia, brainstem signs, cerebellar signs
Which tests need to be negative for IIH?
1. MRI of brain and orbits with contrast
2. MRV: to rule out venous sinus thrombosis
3. CSF microbiology, biochem, and cytology
4. BP, temp and chest X ray
5. CBC, electrolytes, glucose, liver function, ESR, CRP, ACE, ANA, RPR-VDRL
venous sinus thrombosis happens in _____ states. can also be due to infection or neoplasm.
what are conditions which can cause a hyper coagulable state
1. oral contraceptive use
3. bechets disease
4. antiphopolipid antibody syndrome
6. Antithrombin III deficiency
7. Factor V Leiden mutation
8. Elevated Factor VIII
whats the politically incorrect way to describe patients with IIH
fat, fertile, female 18-40's
How do you treat IIH
1. 6% reduction in weight loss
2. Acetazolamide (Diamox)
3. oral diuretics
5. surgical intervention
-Lumbo peritoneal shunt
-optic nerve sheath fenestration
Malignant hypertension is a medical emergency and may lead to _____ infarction, cerebrovascular accident, or renal failure
What are signs of malignant hypertension
bilateral optic nerve swelling in the setting of extremely elevated blood pressure (180/120)
what are possible etiologies of unilateral optic nerve edema
1. papillophlebitis: idiopathic inflammation of peripapillary retinal vessels.
2. Diabetic papillopathy
Infiltrative optic neuropathy is infiltration of one or both optic nerves by:
1. leukemia (report weight loss)
3. breast, lung, bowl metastases
4. sarcoid granuloma (report breathing problems)
what are symptoms of infiltrative optic neuropathy
patients usually have known malignancy - acute, subacute or slowly progressive VA and VF loss