neuro-ophthalmology - a cautionary tale

A Cautionary Tale

Dr Phillip HayesGOSFORD AND WYONG EYE SURGERYD

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

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

Represented via GP 6 days later (25/11/13)

RVA NLP LVA vague HM R RAPD

Mrs JC

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.....

Bilateral Blindness happens

Giant Cell Arteritis

Anterior Ischaemic Optic Neuropathy CRAO CN palsies Plus AMI, Dermal ischaemia,

Mesenteric ischaemia

Beware to Stoic Little Old Lady with any of these 4› Amaurosis Fugax› New Headache› New Diplopia› Facial/Neck/ Mouth/Jaw Pain

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

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

New Headache

Temporal Scalp and Temporal artery tenderness Can be diffuse and bifrontal New in character

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

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

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

Recent onset Diplopia

A new symptom Can be fleeting or persistent Vertical or Horizontal

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

Examination

Ocular exam usually normal Tender swollen Temporal artery Carotid auscultation Rarely signs of ocular ischaemia

› Dilated veins, retinal haemorrhages,uveitis› Corneal oedema

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

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

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

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 

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