Case 3

A 28-year-old with eye pain

Q1

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What additional history do you want to obtain?

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[accordion-item title=”How long has the pain been there? (click to show/hide)”]

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

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[accordion-item title=”Do you have any associated symptoms? (click to show/hide)”]

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

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[accordion-item title=”Has this ever happened before? (click to show/hide)”]

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

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[accordion-item title=”Visual changes? (click to show/hide)”]

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

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[accordion-item title=”Medical history? (click to show/hide)”]

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

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[accordion-item title=”Neurological history? (click to show/hide)”]

None.

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[accordion-item title=”Family history (click to show/hide)”]

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.

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Q2

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What physical examinations would you like to perform?

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[accordion-item title=”VA (click to show/hide)”]

Right eye 20/80; Left eye 20/20

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[accordion-item title=”Visual fields (click to show/hide)”]

Full to confrontation

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[accordion-item title=”RAPD? (click to show/hide)”]

Yes, right pupil

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[accordion-item title=”Fundoscopy (click to show/hide)”]

Normal with direct ophthalmoscopy

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Q3

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What is your leading diagnosis?

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[accordion-item title=”Ischemic optic neuropathy (click to show/hide)”]

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

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[accordion-item title=”Central retinal vein occlusion (click to show/hide)”]

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

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[accordion-item title=”Papilledema (click to show/hide)”]

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

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[accordion-item title=”Optic neuritis (click to show/hide)”]

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.

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Q4

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What is the most likely diagnostic modality?

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[accordion-item title=”MRI (click to show/hide)”]

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.

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[accordion-item title=”CT (click to show/hide)”]

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

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[accordion-item title=”Carotid US (click to show/hide)”]

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.

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[accordion-item title=”LP (click to show/hide)”]

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

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[accordion-item title=”Genetic testing for senilin genes (click to show/hide)”]

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

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Q5

A 28 yo woman presents to your office complaining of eye pain in her right eye.

What is your treatment plan for this patient?

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[accordion-item title=”Refer to neurology for management & workup if possible MS (click to show/hide)”]

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.

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[accordion-item title=”Start steroids (click to show/hide)”]

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.

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[accordion-item title=”Start immunosuppresants (click to show/hide)”]

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.

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[accordion-item title=”Immediate NSG intervention (click to show/hide)”]

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.

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[accordion-item title=”Reassure and allow home with follow up in 6 months. (click to show/hide)”]

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

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Summary

Optic neuritis is an important cause of acute visual loss. It can be associated with multiple sclerosis, and is the presenting symptom in 20% of MS patients. It is most common in women aged 20-40 yo, and follows the geographical distribution of MS (more common in temperate climates compared to tropical), more common in Caucasians. It is caused by acute demyelination of the optic nerve which leads to axon loss. Histologic features are typical of MS plaques including perivascular cuffing, myelin breakdown, and nerve sheath edema. These changes are thought to be T-cell mediated vs. a yet unknown target. B-cell activation vs. myelin basic protection has also been noted.

Clinically, the presentation is usually monocular (90%), and vision loss occurs over hrs to days, peaks in 1-2 weeks, and usually affects central vision. Eye pain is present in 92% of patients and is worse on eye movement. There should be a RAPD if other eye uninvolved. If there is no RAPD, it is possible that the patient has a nonorganic cause of visual loss. Other features include a loss of color vision out of proportion to visual acuity loss, papillitis in 1/3 of patients, (which means that 2/3 of patients present with normal appearing optic nerve), and photopsias (flashes of light with eye movement) in 30% of patients.