Download Optic Neuritis

Problem Solving
Case 1
History
22 years old female presents to ER
physician with history of sudden redless
decrease in vision in the rt. eye 10 days
ago with mild headaches and pain on eye
movement. Her past medical history is
insignificant of any ophthalmic or
systemic illness.
Examination
• On examination she showed the following
Vitals:
–
–
–
–
Pulse:72/regular
Temp. 37
Resp:14
B.P 120/80
Eye Examination
VA OD 20/100 OS 20/20
Pain on abduction of Rt. eye
EOM: full
Red reflex: normal
Fundus ex.: normal disc, vessels, maculae
Case Management
1. Summarize the case (+ve and -ve)
2. Any further information you needs to know in
history?
3. Any further information you need to know in
the examination
4. What is your provisional diagnosis?
5. What is your role as an ER physician in this
case??? Who treats such a case
6. How does the ophthalmologist manage such a
case?
Case Summary
Positive
Negative
22 years old (Young not old
PMH insignificant
Female ( Not male)
Normal Vitals
Sudden (Not gradual) decrease in Vision Decreased vision
in one eye
Headaches
Normal Red Reflex
Pain on Eye Movement (Symptom)
Normal Fundus
Decreased vision OD
Pain on Eye Movement (sign)
Further History
• Onset: how? When? What
• Progression of vision, headaches, pain
• Headaches Relieving & PPT factors
• Uhthoff’s Phenomenon
• Diplopia/ Oscillopsia /Dizziness
• Parasthesia and weakness
• Bowl symptoms
Further History
•
•
•
•
Onset of Visual loss: How? When? What
Progression of vision, headaches, pain
Relieving & PPT factors
Social History
– Smoking
– Alcohol
– Others
• Family History
• Drug History
Further Examination
• Proptosis
• Ptosis
• Tenderness over sinuses
• Multiple pinhole
• Pupil examination
• Visual field
Diseases Onset & Progress
Acute
Ischemia-Hge. Infections
Inflammation
Minutes24hours
Subacute
Infections
Inflammations
24 hours to
several days
Chronic
Compressive
Infections
4 weeks to
years
Provisional Diagnosis
Optic Neuritis
Differential Diagnosis
Differential Diagnosis
• Other causes of Optic Neuropathies
Ischemia
Infections
Nutritional
Compressive
Hereditary
Traumatic
Differential Diagnosis
• Other causes of acute visual loss
Sinus disease
CRVO
CRAO
Retinal Detachment
Vitreous Hge.
Why???
22 years
Female
Sudden
Pain on eye
movement
Unlikely ischemic but could be
any other process
Demylination or any other
process
Ischemia/Inflam./Infection/
Sudden discovery
Sinusitis- Myositis- CellulitisOptic neuritis-Acute Grave’s
Scleritis & rules out vascular
event (CRAO/CRVO/ION)
Why???
Normal Vitals
Unlikely infectious
Regular Pulse
Unlikely shooting emboli
Unlikely Grave’s
Unlikely Cellulitis or myosiitis
or Grave’s
Absence of
proptosis & Lid
Signs
Absent tenderness Unlikely sinusitis
over sinuses
Why???
Vision
MPH no
improvement
Sluggish Pupil
reaction with
RAPD
Visual Field
Central Scotoma
Refractive Error/ Media
Problem / Retina /Neurological
Psychological
Not refractive
Disease affecting visual
pathway anywhere from ON
to lateral geniculate body
ON disease or macular disease
Why???
Visual Field
Central Scotoma
ON disease or macular disease
Fundus Normal
Not retinal disease but can not
rule out ON or visual pathway
disease.
Differential Diagnosis
• Other Causes of ON Disease
• Sinus Disease
• CRAO +CRVO
• Retinal Detachment