The Thrill of Victory, The Agony of Defeat: Lessons from 35 Years - PDF document

10/29/2012 The Thrill of Victory, The Agony of Defeat: Lessons from 35 Years of Neuro-Ophthalmic Practice William T. Shults, MD Portland, Oregon “ Experience is just the name we give our mistakes” Oscar Wilde “Some people make the same mistake over and over again and call it experience” Herb Fred, MD 1

10/29/2012 “Listen to the patient, he’s trying to tell you what’s wrong with him.” Eugene Stead, MD “The final diagnosis is often as dependent on an accurate history as on a clinical examination” Sir Gordon Holmes Iatrogenic Papilledema MT, 43 yr-old Latino, 10 yr hx of peptic ulcer  9/2/71 : Surgery for obstruction → stormy post- op course requiring hyperalimentation via catheter in R subclavian vein  Developed headaches, diplopia and blurred vision soon afterwards → cerebral edema 2 ° water retention!  “This is all due to that thing they stuck in my chest” Iatrogenic Papilledema 1/27/72 : Readmitted 4 mos later with TVO’s and bilateral papilledema 1/27/72 Ophthalmology Consult:  Acuity : OD 20/30, OS 20/20  Color : Normal OU  EOMs : Full OU  Fields and Fundi : see next slides 2

10/29/2012 Iatrogenic Papilledema Iatrogenic Papilledema Iatrogenic Papilledema 2/1/72 : 4 vessel arteriogram: NI 2/8/72 : Pneumoencephalogram: NI 2/9/72 : Discharged 4/3/72 : Readmitted to Neurology with persistent papilledema, LP→ 220 OP, 2 nd angio nl  Recommended repeat pneumo → Patient “Adios” 3

10/29/2012 Iatrogenic Papilledema 10/9/72 : Over 1 year after illness began → readmitted with increasing blur  Repeat LP → OP now 375  Repeat angio: R transverse and sigmoid sinus occlusion (next slides) Iatrogenic Papilledema Iatrogenic Papilledema 10/27/72 : LP shunt 12/28/72 : Acuity OD 20/30 OS 20/40 -1  Fields and Fundi : see next slides 4

10/29/2012 Iatrogenic Papilledema Iatrogenic Papilledema Measles and a Broken Leg The Neuro-Ophthalmic Patient with Multiple Diagnosis 5

10/29/2012 Data Overload KM, 31 year-old secretary  8/77 : Developed transient visual obscurations, OS with headaches  Headaches cleared after chiropractic manipulation, TVOs persisted Data Overload No history of exposure to steroids, nalidixic acid, lithium, tetracycline or excess vitamin A Normal weight Neurologically healthy Long-standing right exotropia and amblyopia Iris colobomas (see next slides) Data Overload 6

10/29/2012 Data Overload Examination ( 8/78 ):  Acuity : OD HM; OS 20/30  Color : OD nil; OS 10/10 correct HRR  Pupils : Right RAPD  Fields and Fundi : see next slides Data Overload Data Overload 7

10/29/2012 Data Overload What’s going on here? What would you do next? Data Overload “ Disease will sometimes peer up over the hedge of health with only its eyes showing” John Stone, MD 8

10/29/2012 Post Traumatic Vision Loss? 55 year old waitress  8/15/90 Rear-ended in MVA  Struck forehead but no LOC  Lost all vision in OD immediately after accident  VA gradually recovered over several days but inferior nasal field defect persisted Post Traumatic Vision Loss? Examination ( 8/23/90 ):  Acuity : OD 20/25 +2 , OS 20/20 -2  Color : Normal  Pupils : No RAPD!  Fields and Fundi : see next slides Post Traumatic Vision Loss? 9

10/29/2012 Post Traumatic Vision Loss? Post Traumatic Vision Loss? Post Traumatic Vision Loss? MRI SCANS 10

10/29/2012 Post-traumatic Diplopia DR, 58 year old housewife  2/8/89 : Involved in MVA with severe facial trauma → right zygomatic fracture, bilateral orbital ecchymoses  Blepharoptosis noted OS sometime thereafter  3/89 : Noted diplopia → Ill-defined impaired ocular motility  Tensilon test neg → referred Post-traumatic Diplopia Examination  External : Narrowed palpebral aperture OS, 2mm enophthalmos on left  Afferent package : Intact  EOMs : Limited adduction, abduction, elevation  Forced ductions : Restricted Post-traumatic Diplopia 11

10/29/2012 Post-traumatic Diplopia Post-traumatic Diplopia Post-traumatic Diplopia Original CT scan review:  Poor scan quality, showed altered tissue behind left globe compatible with post- traumatic scarring  MRI Scan: Next slides 12

10/29/2012 Post-traumatic Diplopia Post-traumatic diplopia 8/89 : Orbital biopsy by card carrying orbital surgeon.  Biopsy negative Now what? Post-traumatic diplopia Patient followed with stable motility findings 3/90 developed “woody” firmness beneath left eye MRI repeated 13

10/29/2012 Post-traumatic diplopia Post-traumatic diplopia Rebiopsy Dx: Metastatic Carcinoma of breast Post-traumatic diplopia References  Mottow-Lippa L, Jakoblec FA, Iwamoto T: Pseudoinflammatory metastatic breast carcinoma of the orbit and lids, Ophthalmology 88:575-580, 1981.  Manor RS, Enophthalmos caused by orbital metastatic breast carcinoma; ACTA Opthalmologica 52:881-884,1974.  Cline RA, Rootman J: Enophthalmos: a clinical review. Ophthalmology 91:229-237, 1984. 14

10/29/2012 “Hindsight is an exact science.” Fagan’s Rule on Past Prediction Papilledema: True or False? FD, 57 year old tool and dye maker  Saw cornea consultant on 3/23/93 for RK pre- op assessment Noted to have asymptomatic bilateral disc edema →referred for neuro-ophthalmic consultation  No history of visual complaints of any kind Papilledema: True or False? No history of headache, obesity, intracranial bruits or exposure to pseudotumorigenic drugs Past history: Hypertensive for 10 years Habits:  Smokes 2 packs of cigarettes/day  Recovering alcoholic 15

10/29/2012 Papilledema: True or False? Examination:  Acuity : OD 20/20, OS 20/20 with moderate myopic Rx  Color : OD 9/10, OS 9/10 correct with AOHRR  Contrast : OD 1.50, OS 1.65, Pelli-Robson  Pupils : no RAPD  Fields and fundi : see next slides Papilledema: True or False? Papilledema: True or False? 16

10/29/2012 Papilledema: True or False? MRI scan : Normal Neurology consult: No localizing abnormalities Lumbar puncture : OP 140mm H 2 O Now what? Papilledema: True or False? RK performed mid-April with 20/20 result OU About 1 month later noted abrupt loss of central vision OS Examination on 6/2/1993 :  Acuity : OD 20/20 -1 , OS 20/50 -3  Color : OD 10/10, OS 9/10 correct, AOHHR  Contrast : OD 1.65, OS 1.35  Pupils : 0.3 log unit RAPD, OS  Fields and fundi : see next slides Papilledema: True or False? 17

10/29/2012 Papilledema: True or False? Papilledema: True or False? ANTERIOR ISCHEMIC OPTIC NEUROPATHY WITH PRESYMPTOMATIC DISC SWELLING Hayreh SS: Anterior ischemic optic neuropathy: V. Optic disc edema an early sign, Arch Ophthalmology 99: 1030-1040, 1981. “Symptomless optic disc edema may precede the vision loss in AION and could constitute the earliest sign of the disease.” “The Second Cranial Nerve is Ours” Henry J. L. Van Dyk, MD 18

10/29/2012 Meningiomas: Importance of Proper Neuro-Imaging BC, 35 year old woman  3/97 : “Smudged” area superonasal field, reduced light brightness and color, OD Visual acuity : OD 20/20 -1 , OS 20/20 Disc pallor noted OD, no RAPD  6/97 : Acuity now OD 20/25, OS 20/20 Visual fields : see next slide Meningiomas: Importance of Proper Neuro-Imaging Meningiomas: Importance of Proper Neuro-Imaging MRI Scan:  Done with standard angulation (rather than reverse angulation in plane of the optic nerve)  Thick slices  Without Gadolinium 19

10/29/2012 Meningiomas: Importance of Proper Neuro-Imaging BRAIN MAGNETIC RESONANCE IMAGING Scans were done with 2 second rep time transversely, 1.5 second coronally and sagittal images done near midline with 0.5 second rep time for maximal differentiation of CSF and neural tissue. Additional fat suppressed T, weighted axial and T, weighted coronal images are obtained through the orbits using thin sections obtained with the 1.5 tesla Siemens Magnetom. Ventricle size and position are normal. The signal intensity of the brain parenchyma is unremarkable. Visualized cranial nerves and vascular structures are within normal limits. No calvarial abnormalities are identified. No sinus mucosal disease is seen. Mild mucosal thickening is seen in the ethmoid sinuses. The globe, optic nerves and muscle cones are normal. No abnormal fat is seen in the orbits. IMPRESSION No significant abnormality. Meningiomas: Importance of Proper Neuro-Imaging Meningiomas: Importance of Proper Neuro-Imaging 20

10/29/2012 Meningiomas: Importance of Proper Neuro-Imaging Meningiomas: Importance of Proper Neuro-Imaging 9/97 : Referred for neuro-ophth consult  Acuity : 20/15, OU  Color : OD 4/10, OS 10/10, HRR  Contrast : OD 1.35, OS 1.65  Pupils : 1.8 log unit RAPD, OD  Fundus : Atrophic OD, Normal OS  Repeat MRI : see next slides 21

10/29/2012 Meningiomas: Importance of Proper Neuro-Imaging Meningiomas: Importance of Proper Neuro-Imaging Meningiomas: Importance of Proper Neuro-Imaging 22

10/29/2012 Meningiomas: Importance of Proper Neuro-Imaging The Definition of Neuro- Ophthalmology RR, 78 year old man  Three months of diplopia and one month of dim vision in the left eye  CT scan with contrast “normal”  Referred for neuro-ophthalmology evaluation  Visual fields, CT, MRI: see next slides The Definition of Neuro- Ophthalmology 23

10/29/2012 The Definition of Neuro- Ophthalmology CT SCANS The Definition of Neuro- Ophthalmology MRI SCANS The Definition of Neuro- Ophthalmology MRI SCANS 24