Professional Documents
Culture Documents
The Basics
Madhu R. Agarwal, M.D.
California Orbital Consultants
Redlands,, California
Redlands
Skin Cancer
Time course:
Review of Systems
Fatigue
Malaise
Jaw claudication
Weight loss
Anorexia
Scalp tendersness
Very important
HTN
DM
Heart Disease
Medications
Ethambutol
Exam
Pressure
Pupils
Anisocoria
Afferent Pupillary Defect
Pupils!
Beast of itself!
Orbital Exam
Is there proptosis?
Is there a bruit?
Motility Exam
Ductions?
Versions?
Comitant?
Visual Field
Confrontation
HVF 3030-2
TEMPORAL ARTERITIS
TEMPORAL ARTERITIS
OPHTHALMIC MANIFESTATIONS
Ischemic optic neuropathy (AION,
PION)
Choroidal ischemia
Central retinal artery occlusion
Stroke of CNS visual pathways
Ischemic cranial n/EOM dysfunction
Is it temporal arteritis?
AION: IS IT TEMPORAL
ARTERITIS?
Age
Associated symptoms
Associated signs
g
Severity of visual loss
Bilateral simultaneous or rapid sequential onset
Disc appearance
Choroid appearance
ARTERITIC
Mean age 70
Systemic symptoms:
Sy
y p
headache,, jjaw
claudication,, temporal tenderness, weight loss
claudication
Erythrocyte sedimentation rate mean 70 mm/hr
Severe visual loss (< 20/200 in 65%)
Caucasians most commonly affected
TEMPORAL ARTERITIS
HEADACHE
Most common symptom (up to 90%)
Often severe,, constant
Localized or generalized
Associated scalp/temporal tenderness
TEMPORAL ARTERITIS
CLAUDICATION
Jaw well
well--known, but also neck, ear, pharynx
(facial artery occlusion)
Differentiate from TMJ, other causes of pain
High level of suspicion
ARTERITIC
ARTERITIC
ARTERITIS: LATE
CUPPING OPTIC
NERVE
Rare in NAION
If fellow eye
excavated, consider
AAION
ARTERITIC
Hayreh et al (1998): 21.2% of eyes with
AAION had associated cilioretinal artery
occlusion
CILIORETINAL ARTERY OCCLUSION IS
RARE IN NAION
ARTERITIC
10
ARTERITIC: PATHOGENESIS
Granulomatous inflammation of SPCAs with
thrombotic occlusion
Ischemia/infarct of optic nerve head + adjacent
choroid
ARTERITIC FA
ARTERITIC FA:
CHOROIDAL
ISCHEMIA
11
ARTERITIC FA:
CHOROIDAL
ISCHEMIA
Widespread choroidal
nonfilling; disc fills
normally, peripapillary
retinal leakage
AION: IS IT TEMPORAL
ARTERITIS?
Fluorescein angiography
Blood tests
ARTERITIC: ERYTHROCYTE
SEDIMENTATION RATE (ESR)
12
ARTERITIC:
TEMPORAL
ARTERY BIOPSY
False negatives:
Skip lesions
Insufficient sample
Uni (contra) lateral lesions
Inadequate sectioning
Inexperienced interpretation
13
Options:
Frozen section 1st side, biopsy 2nd if negative
Permanent section 1st side, biopsy 2nd if negative
and clinical suspicion high
Bilateral biopsy initially all cases
ARTERITIC: THERAPY
Systemic steroids
IV methylprednisolone 1 gm/day
Oral prednisone > 1mg/kg/day
ARTERITIC: THERAPY
Improvement in affected eye not common
Breakthrough
g on therapy
py 1010-15%
%
Risk of recurrence on steroid taper 7%
14
AION: IS IT TEMPORAL
ARTERITIS?
Age
Associated symptoms
Associated signs
g
Severity of visual loss
Bilateral simultaneous or rapid sequential onset
Disc appearance
Choroid appearance
AION: IS IT TEMPORAL
ARTERITIS?
Fluorescein angiography
Blood tests
Case
Va 20/20 OU
PF 10, 3: previously 6 mm OS
15
EOM: Worsening!
MRI negative
MRA negative
16
Myasthenia gravis
MS
Graves disease
17
Myasthenia Gravis
Eye
y muscles: pptosis, diplopia
p p
How to check
Bienfangs
18
Testing
Treatment
Case
19
Eyelid:
Palpebral fissure 10 mm OD, 4mm OD
Levator Function, 18 mm OD, 7mm OS
SLE: unremarkable
EOM: OS no adduction,
adduction otherwise full
Photo
20
CN 3 palsy
Oculomotor Nerve
Medial Rectus
Inferior Rectus
Superior Rectus
Inferior Oblique
Levator Muscle
21
Work-up
If isolated
isolated, Pupil involvement?
Testing
Treatment
If aneurysm,
y
clip
p or coil
22
Case
Diabetes
Hypertension
A bit obese
Pupils
IOP
No proptosis, tenderness
EOM: 10 PD ET
18 PD ET in left gaze
3 mm abduction deficit in left gaze
23
Photo
MRI
24
Meningiomas
Vascular abnormalities
Case
25
Exam
Vision 20/20 OU
IOP nl OU
Orbital exam nl
26
27
28
Case
PMH: Hepatitis C
Meds: Interferon
PSH: HEAVY drugs and alcohol x 25
years, clean for the last 12 years.
1+ APD OS
29
Optic Nerves
Is this tobacco
tobacco--alcohol amblyopia
Is this AION??
30
Visual Fields
MRI
MRI
31
Large Meningioma!
Headache
Decreased libido
Galactorrhea
Gynecomastia
Signs
Vision loss
Bitemporal hemianopsia!!
32
Treatment
Surgical resection
Case
Optic neuritis
Infectious Optic neuropathy
Autoimmune optic neuropathy
33
No PSH
Va CF OU
Sluggish pupils
pupils, no APD
Nl orbital exam
Optic Nerves
34
Our Patient
20mg/kg/day
Treatment
35
Case
No medications
Va 20/20 OU
2mm p
pupil
p OD, 4mm OS
Dark 3mm OD, 8mm OS
No APD
36
Lymphedema
37
Horners Syndrome
38
Cluster headache
Carotid artery dissection
Nasopharyngeal tumors
Cavernous sinus mass ((or inflammation,, ie.
Tolosa--Hunt syndrome)
Tolosa
Herpes Zoster (HZO)
Otitis media
Trauma or postpost-surgical damage
Raeder paratrigeminal syndrome
39
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