1. Case Analysis I- Lecture 7 Liana Al-Labadi, O.D.

2. If you hear hoof beats, think horses—not zebras

3. CC: Dr. I see a black curtain over my eyes

4. QUESTIONS???

5. “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.

6. DIFFERENTIAL DIAGNOSIS????

7. “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

8. Any Other Questions???

9. 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”

10. Entrance Testing????

11.  Entrance Testing:  DVA (c):  OD: 20/50PH: ???????????  OS: 20/30PH: ???????????  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”

12. Additional Testing????

13.  Additional Tests:  Lensometry:  OD: -3.75 -0.50x 153  OS: -3.75 -0.50x 153  Manifest Refraction:  OD: -4.00 -0.50x 165VA: “All black”  OS: -3.75 -0.50x 153VA: “All black” “Dr. I See All Black”

14. Additional Testing????

15.  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”

16. Additional Testing????

17. “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????

18. “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 sx  RTC for DFE in 2-3 months

19. 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.

20. Amaurosis Fugax- Etiology  Three causes of TVO:  Circulatory  Embolic  Hypoperfusion  Ocular  Neurological

21. 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)

22. 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?

23. Amaurosis Fugax- Work Up Case 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

24. Amaurosis Fugax- Work Up Considerations 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

25. Amaurosis Fugax- Work Up Considerations 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 onset  embolic or vasospastic attack

26. 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

27. 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

28. Amaurosis Fugax- Work Up Considerations 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

29. Amaurosis Fugax- Work Up Considerations 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

30. Amaurosis Fugax- Work Up Considerations 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

31. Amaurosis Fugax- Work Up  Entrance Tests:  VA (pinhole)  EOM  Pupils  if APD consider c olor 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

32. 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

33. Amaurosis Fugax- Management  Management:  Long lecture!  Based on etiology!!!