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OCULAR CLUES IN NEUROLOGIC DISEASE
Leonid Skorin, Jr., OD, FAAO, DO, FAAO, FAOCO
Albert Lea Medical Center - Mayo Health System
A. Non-Arteritic Ischemic Optic Neuropathy a. Acute ischemic of the anterior part of the optic nerve (1) arteriosclerosis (2) nocturnal systemic hypotension (3) intensive systemic antihypertensive medication use (4) associated with obstructive sleep apnea (Br J Ophthalmol 90:879-82, 2006) (5) shock induced: i.e. surgery, trauma, blood loss (6) PDE 5 inhibitors (Viagra, Levitra, Cialis) Increased risk: MI, hypertension (Br J Ophthalmol 90:154-7, 2006) a. Optic nerve sheath decompression (Ischemic Decompression Trial – JAMA (1) 43% spontaneous improvement of 3 or more lines (2) 33% ONSD improvement of 3 or more lines (3) 12% no surgery – lost 3 or more lines (4) 24% ONSD – lost 3 or more lines b. 24-month update confirms no benefit of ONSD (Arch Ophthalmol 118:793-8, c. Brimonidine – worse VA at 8-12 weeks (Br J Ophthalmol 87:1193-4, 2003) a. Arteritic anterior ischemic optic neuropathy (40% to 70%) b. Central artery occlusion (5% to 10%) c. Diplopia (2% to 15%) d. Amaurosis fugax e. Unilateral or bilateral vision loss (20% to 50% of all cases) (1) 2nd eye involved – if untreated ½ to 2/3 of patients (2) 1/3 within 24 hours (3) 1/3 within one week c. Polymyalgia rheumatica (50%) d. Weight loss h. Tongue claudication i. Optic disc cupping in end-stage (92%); only 2% of patients with NAION have cupping (Ophthalmology 108:593-8, 2001). Pallor exceeds cupping in AION, while in glaucoma pallor does not extend beyond cup area. a. Elevated ESR – Westergren (can be normal in 10% of cases) (1) combined sensitivity of ESR and CRP = 97% (2) disruption of internal elastic lamina (3) lymphocyte infiltration – macrophages or giant cells (1) delayed or absent filling of choroidal circulation b. IV Methylprednisolone 250 mg q6h for 3-5 days, then taper with p.o. c. Adjunctive therapy: 81mg aspirin. Reduces risk of cranial ischemic events including vision loss (Clin Exp Rheumatol 25:137-41, 2007; Curr Opin Rheumatol e. Treat 6 months to 2 years to more, minimum of 3 months f. Even with treatment, 27% get worse in 1st week. 15% VA improves, 5% VF improves (Ophthalmology 112:1098-103, 2005) (1) Mean weight is at least 38% above ideal weight for height 2. Evolution of disease 3. Signs and symptoms (1) Transient visual obscurations (2) Diplopia – 6th CN (lateral rectus) palsy in up to 30% c. Non-visual disturbances d. Papilledema b. Normal cerebrospinal fluid composition c. CT/MRI normal (1) MRI imaging signs of elevated intracranial pressure (Ophthalmology 105; (a) 80% - posterior scleral flattening (b) 70% - empty sella (c) 50% - prelaminar enhancement of optic nerve (d) 45% - perioptic subarachnoid space distended (e) 40% - vertical tortuosity of orbital optic nerve (f) 30% - intraocular protrusion of prelaminar optic nerve (1) Papilledema resolution with weight loss of 6% of total body weight (2) Neptazane (methazolamide) (3) Lasix (furosemide) (2) Calcium channel blocker (3) Tricyclic antidepressant (b) 35% fail due to postoperative scarring, fibrosis, vascularity,
References
1. Skorin L, Larsen K, Eggers D: Temporal Arteritis. Contemporary Optometry 4(2); 1-8, 2. Holdeman NR, Mahendroo N, Tang RA: Pseudotumor Cerebri. Clinical & Surgical 3. Skorin L, Kassel J: The use of Dermabond in temporal artery biopsy surgery. Clinical & Surgical Ophthalmology 26(9):320-1, 2008 4. Lighthizer N, Skorin L: Giant cell arteritis. Indian Optician 40(231):196-204, 2008 5. Lighthizer N, Skorin L: Pseudotumor cerebri. Indian Optician 40(232):202-6, 2009

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