Case Analysis I- Lecture 7

Liana Al-Labadi, O.D.

If you hear hoof beats, think horses—not

zebras

CC: Dr. I see a black curtain over my

eyes

QUESTIONS???

“Dr. I See All Black” Frequency: Constantly (all the time, everyday) @ D&N Onset: Suddenly10 days ago, but has noticed it more

over the past 2 days Location: Both eyes Duration: Lasts for a short time but I feel it’s there all

the time Associated Factors:

Blurry vision A lot of headaches Headaches

Relief: Headaches get better with parcetamol but I still see a

black curtain Severity:

The blacking out is pretty bad, I just can’t stand it anymore. The headaches are there all the time.

DIFFERENTIAL DIAGNOSIS????

“Dr. I See All Black” Migraine DES / Keratitis/ Blepharitis/ Iritis /AACG Vitreous detachment /Retinal break Angiospasm/ vasospasm Optic disc drusen/ Orbital tumor Papilledema ON / MS/ SLE Embolic/ Carotid emboli / Cardiac emboli IV drug use Hypoperfusion Coagulation disorders /Inflammatory arteritis Carotid stenosis /Ophthalmic artery stenosis Cardiac failure or arrhythmia Increased blood viscosity Intraocular hemorrhage Intracranial tumor Psychogenic

Any Other Questions???

POH: (+) Near sightedness Negative for asthenopia, surgery, pain, & flashes Negative for AMD, DR, Cats & Glc (+) DIPL-?????? (+) Trauma- 14 years ago?????

LEE: 6 months ago (unknown doctor)- Status????? FOH: Negative for AMD, DR, Glc, Cat LPE: Does not remember PMH:

(+) stress (+) ENT (+) Respiratory Negative for HTN/DM/Cancer/Neuro

FMH: (+) HTN- Father; (+) DM- Parents; Migraines- Parents MED: None Allg: NKDA; No seasonal allergies SH: Reading Occupation: Student No alcohol consumption ; (+) smoking- Argeeleh

“Dr. I See All Black”

Entrance Testing????

Entrance Testing: DVA (c):

OD: 20/50 PH: ??????????? OS: 20/30 PH: ???????????

Motility: S&F OD, OS Pupils: 4mm/4mm RRL OD, OS; No APD Confrontations:

OD: Slight inferior constriction OS: Full

“Dr. I See All Black”

Additional Testing????

Additional Tests: Lensometry:

OD: -3.75 -0.50x 153 OS: -3.75 -0.50x 153

Manifest Refraction: OD: -4.00 -0.50x 165 VA: “All black” OS: -3.75 -0.50x 153 VA: “All black”

“Dr. I See All Black”

Additional Testing????

SLE: L/L: trace MGD OD, OS Conj: No injection OD, OS K: Clear OD, OS Iris: Flat & brown OD, OS AC: No cell & no flare/ D&Q OD, OS Lens: Clear OD, OS

IOP (TA): ??????????

“Dr. I See All Black”

Additional Testing????

“Dr. I See All Black” Assumption:

Patient is 20/20 OD, OS Confrontations full OD, OS Sx: Headaches + “black-out” DFE unremarkable OD, OS

What would be your FINAL DIAGNOSIS????

“Dr. I See All Black” Assessment:

Transient visual distortion Probably 2˚ Migraines (+) Family history of migraines

Plan:Pt re-assurance Recommend pt sees GP/internist for

pharmacological treatment RTC ASAP if no improvement/worsening of sxRTC for DFE in 2-3 months

Amaurosis Fugax- Definition Transient vision obstruction (TVO) or transient

vision loss is the preferred terminology Amaurosis comes from a Greek word & it

means to “darken or obscure” i.e. “blindness” . Fugax is also from the greek and means “fleeting” i.e. “Fleeting blindness”

Sudden, temporary, partial or total loss of vision

Vision loss typically lasts from a few seconds to several minutes before returning to normal

Clinical Goal: Determine etiology of transient vision loss Important b/c underlying causes of TVO could range

from life threatening conditions to simply dry eyes.

Amaurosis Fugax- Etiology Three causes of TVO:

Circulatory Embolic Hypoperfusion

Ocular Neurological

Amaurosis Fugax- Differnetial Diagnosis

http://ijahsp.nova.edu/articles/vol4num2/Bacigalupi.pdf

Keep in mind that if TVO is found to be associated with CAD, there is a significant increased risk of death from a myocardial infarction (MI)

Amaurosis Fugax- Work Up Case History- The Important Questions

Frequency: How frequently do the sx occur? How quickly do the sx arise?

Onset: Are the sx in one eye or both eyes? Location: Both eyes Duration: How long do the visual disturbances last? Associated Factors:

Is there any pain assoc c visual disturbance? Does blinking or rubbing eyes modify the sx? Are the sx worse with eyes movements? Does the exercise alter or cause visual disturbances? Scalp tenderness, jaw claudication, malaise? Fever? Weight loss? Numbness or tingling of extremities? Slurred Speech? Weakness on one side of the body? Is motion sickness experienced? Is there a long Hx of HA? Family history of HA? Oral contraceptive use? Smoker?

Relief: Anything makes the symptoms better? Severity: On a scale of 1-10 how bad is it?

Amaurosis Fugax- Work UpCase History- The Important Questions Ask the patient to describe the visual

disturbance? Does the vision blur, fog, dim or black out?

i.e Negative visual phenomenon

Do you see zigzag lines & colorful patterns? i.e Positive visual phenomenon

Pay special attention to the patient’s medical history Look for the presence of

HTN Previous MI DM

Orthostatic hypotension in DM pts can cause BF in ophthalmic artery to decrease by almost 100% when simply moving from supine to seated position. This dramatic loss of perfusion will cause significant TVO. Thus any signs of DR could be linked to TVO.

Prior cerebrovascular accidents Hypercholesterolemia Long-standing migraine history Peripheral vascular disease

Amaurosis Fugax- Work UpConsiderations In The Differential

Diagnosis Age of patient- very important factor

If over 45 years Ischemic attacks are the more common causes of TVO MUST R/O carotid disease & GCA esp in v. old pts

If under 45 years Benign migrainous TVO’s are the most frequent cause

41% of TVO pts under 45yo will have an accompanying HA to help solidify a diagnosis of migraine

MUST R/O sickle cell disease, hyperviscosity syndromes & cardiac valve disease

Amaurosis Fugax- Work UpConsiderations In The Differential Diagnosis Frequency of TVO:

Repeated events more likely caused by: Hypoperfusion secondary to arterial stenosis

Isolated events May be due to an ambolism

Increasing frequency of sx: May be suggestive of an impending cerebral infarct

Onset of transient visual disturbance: Less rapid onset more likely a hypoperfusion event

Hypoperfusion events will develop over a matter of minutes, not seconds

Brief onsetembolic or vasospastic attack

Amaurosis Fugax- Work Up

Considerations In The Differential Diagnosis

Duration of transient visual disturbance If lasts for minutes migraines If lasts for only seconds

Papilledema or vitreous traction or retinal breaks If permanent

Artery/vein occlusion Ischemic optic neuropathy

Amaurosis Fugax- Work Up

Considerations In The Differential Diagnosis

Monocular or binocular symptoms: Monocular Sx

Occlusive retinal /Carotid artery condition GCA

Binocular Sx Vertebro-basilar circulatory condition Or Posterior circulatory problems Papilledema Migraine prodrome

Is vision followed by HA? Yes- Classic migraine No- Acephalic Migraine

Amaurosis Fugax- Work UpConsiderations In The Differential

Diagnosis Negative or Positive TVO?

Negative TVO Ischemic etiology Positive TVI Migrainous or ocular etiology

Nature of vision loss: Transient blur

If resolves c blinking ocular surface disease Complete black out of vision

Embolic Transient occlusion of embolic or central retinal artery

Graying or dimming of vision Vascular stagnation Papilledema Postural changes, HAs, Tinnitis

Amaurosis Fugax- Work UpConsiderations In The Differential

Diagnosis Pain With TVO:

Common in cases of hypoperfusion & vasospasm Severe pressure & pain that lasts for extended

period of time Migraines Chronic ocular or retrobulbar aching pains

More likely to suffer from carotid stenosis or ON/MS

Improvement in symptoms with blinking & rubbing DES Or Blepharitis

Worse symptoms with eye movement Vitreous traction Orbital tumor ON

Amaurosis Fugax- Work UpConsiderations In The Differential

Diagnosis Increase in symptoms with exercise

Demyelinating disease Vasospasm

Symptoms of scalp tenderness/ jaw claudication TA/ GCA

Motion sickness & history of HA Migrainous cause

Amaurosis Fugax- Work Up

Entrance Tests: VA (pinhole) EOM Pupils if APD consider color vision or red desaturation Confrontations

Refraction??? SLE

Examine lid margins, tear film, K & AC Gonio R/O AACG Automated VF R/O altitudinal defects DFE to R/O

RD, retinal tears ONH edema

BP measurement

Amaurosis Fugax- Work Up

Laboratory testing CBC for pts > 45yo

To R/O anemia or hematological disorders Complete chemistry panel

Provides info on DM, electrolytes & liver enzymes Thyroid screening Coagulation profile ESR & CRP & platelet count

If suspect TA If monocular sx of TVO

Order non-invasive evaluation of carotid circulation such as carotid duplex

If binocular sx of TVO Order a CT scan or MRI

In area of occipital lobe & along the optic pathways If hx suggests cardiogenic emboli as an etiology

Consider echocardiogram as a secondary test

Amaurosis Fugax- Management

Management: Long lecture!

Based on etiology!!!