Download - Neuro-ophthalmology - A cautionary tale
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A Cautionary Tale
Dr Phillip HayesGOSFORD AND WYONG EYE SURGERYD
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Mrs JC 76 years old LTG diagnosed 2010 IOP R15 L17 Treated with Xalatan Nov 19 2013 RVA 6/9 LVA 6/9 IOP R13 L17
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PHx PMR Mentioned in passing “ eyes were
playing up” with visual disturbance on Left side 2 days previously and a “heavy” head
Complained to the Field Tester that she was having trouble with LE and felt Left field was worse.
Didn’t mention any other symptoms
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Represented via GP 6 days later (25/11/13)
RVA NLP LVA vague HM R RAPD
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Mrs JC
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Admitted immediately to Gosford Hospital
3 days IV 1gm Methyl Prednisolone ESR and CRP elevated 26/11/13 TABx: Positive Giant Cell
Arteritis Bilateral AAION with R CRAO Prognosis.....
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Bilateral Blindness happens
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Giant Cell Arteritis
Anterior Ischaemic Optic Neuropathy CRAO CN palsies Plus AMI, Dermal ischaemia,
Mesenteric ischaemia
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Beware to Stoic Little Old Lady with any of these 4› Amaurosis Fugax› New Headache› New Diplopia› Facial/Neck/ Mouth/Jaw Pain
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Transient Monocular Vision Loss
Amaurosis Fugax Fleeting (seconds to mins)painless
significant loss of vision in one eye Severe dimming/Blackout/curtain(partial
field loss) No aura and no neuro symptoms No persistence Exact nature of the symptoms and
associated symptoms Normal examination with no emboli
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History History History Monocular vision loss Recent onset of Diplopia New Headache Unwell, loss of appetite or weight or
night sweats or fever, muscle aches and pains
Face/mouth/tongue/jaw/ throat/ear eye/scalp ache
Scalp tenderness Other recent illness
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New Headache
Temporal Scalp and Temporal artery tenderness Can be diffuse and bifrontal New in character
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History History History Monocular vision loss Recent onset of Diplopia New Headache Unwell, loss of appetite or weight or
night sweats or fever, muscle aches and pains
Face/mouth/tongue/jaw/ throat/ear eye/scalp ache
Scalp tenderness Other recent illness
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Facial Pain Jaw claudication is only the classic
symptom Any ache from scalp to ear to neck Tongue pain with talking Throat with swallowing Ocular ischaemic pain with orbit or eye
pain on standing
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History History History Monocular vision loss Recent onset of Diplopia New Headache Unwell, loss of appetite or weight or
night sweats or fever, muscle aches and pains
Face/mouth/tongue/jaw/ throat/ear eye/scalp ache
Scalp tenderness Other recent illness
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Recent onset Diplopia
A new symptom Can be fleeting or persistent Vertical or Horizontal
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History History History Monocular vision loss Recent onset of Diplopia New Headache Unwell, loss of appetite or weight or
night sweats or fever, muscle aches and pains
Face/mouth/tongue/jaw/ throat/ear eye/scalp ache
Scalp tenderness Other recent illness
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Examination
Ocular exam usually normal Tender swollen Temporal artery Carotid auscultation Rarely signs of ocular ischaemia
› Dilated veins, retinal haemorrhages,uveitis› Corneal oedema
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Be Suspicious!!!
What do you do if someone over 6o says in passing› Lost vision in one eye› New Headache› New Diplopia› Facial/Neck/ Mouth/Jaw Pain/orbital pain
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Be Suspicious!!!
Ask your questions One confirming symptom Normal or suggestive ocular examination
› GP or Ophthalmologist urgently Request exclusion of GCA› Yes you will be wrong more often than
not. The price of vision is eternal vigilance
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Question 1
In AION caused by GCA the time course to
2nd eye blindness is usually
a. Hoursb. Days c. Weeksd. can be any of above
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Question 2
A new diffuse headache in the elderly is
a. unlikely to be GCA due to poor localization
b. Requires urgent clinical assessmentc. Can be referred for GP assessment in
a few days.d. probably migraine
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Question 3
Why is aggressive investigation andtreatment required in possible GCA
a. to prevent haemorrhagic strokeb. to prevent permanent bilateral
blindnessc. to avoid steroid complicationsd. to reduce unnecessary osteoporosis