Case 3

Since last night, and it really hurts when I move my eyes, and sometimes I see flashing lights with movement.

Not really, everything else is okay. Denies weakness, clumsiness, ataxia, incontinence, nausea, vomiting, and headaches.

Never! And I certainly don’t want it to happen again.

Yes! I have problems seeing out of that eye now. How did you know?

No chronic medical conditions. Asthma as a child, taking OCP and a multivitamin.

None.

Mother has diabetes, father had an MI at age 62. A few relatives on my mother’s side had colon cancer, but no one has had anything like this.

Right eye 20/80; Left eye 20/20

Full to confrontation

Yes, right pupil

Normal with direct ophthalmoscopy

Incorrect: Ischemic optic neuropathy presents with a swollen optic nerve in older patients. It can be associated with giant cell arteritis.

Incorrect: Central retinal vein occlusion presents with an abnormal direct ophthalmoscopy exam and shows hemorrhages throughout the retina classically described as “blood and thunder.”

Incorrect: Papilledema would present with bilateral optic nerve swelling and normal visual acuity until late in the disease.

Correct: This patient has a normal fundus examination with pain on eye movement, decreased central vision, and a relative afferenct pupillary defect. Optic neuritis can present with a swollen (1/3 of the time) or normal (2/3 of the time) appearing optic nerve.

Correct: MRI is commonly ordered in cases of optic neuritis in order to help discern the possibility of the patient developing multiple sclerosis in the future. This should be coupled with referral to a Neurologist since not all patients with optic neuritis and an abnormal MRI will develop multiple sclerosis.

Incorrect: CT is not routinely used in the diagnosis of MS, as demyelinating lesions show up better on MRI.

Less Likely: Unlikely to yield any useful information in a young otherwise healthy woman with no CV risk factors. Also, carotid stenosis not usually associated with optic neuritis.

Incorrect: Lumbar puncture is not needed for the diagnosis of optic neuritis. It may be helpful in the future for diagnosis of multiple sclerosis.

Not Likely: Senilin gene mutations are found in Alzheimer’s disease, not MS. Currently, diagnosis of MS is made clinically, with MRI support.

Correct: This patient has findings consistent with optic neuritis, and needs to be evaluated and treated by a neurologist given the association of optic neuritis and multiple sclerosis.

Incorrect: While intravenous steroids may help an acute presentation of optic neuritis, this patient needs a thorough work up, and close follow up to monitor disease course, and adequately treat her disease. Intravenous steroids are used in the treatment of patients with optic neuritis. Oral steroids alone have been shown to increase the risk of recurrence.

Incorrect: This patient needs a thorough work up, and close follow up to monitor disease course, and adequately treat disease. This is best managed by a neurologist and ophthalmologist. While immunosuppressants may have some role in the treatment of MS at later stages, they are not indicated for the first presentation.

Incorrect: There is no surgical treatment for MS at this time. The patient is best followed up by Neurology. She is medically stable at this time and requires no heroic measures.

Incorrect: While this patient is medically stable, her symptoms warrant work-up and initiation of care by a neurologist