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Snapshot
  • A 33-year-old woman presents to the emergency department for severe eye pain with movement and vision loss in the left eye. Her symptoms began earlier in the morning and she cannot identify a cause. Physical examination is notable for a relative afferent pupillary defect noted on the swinging light test. She is scheduled for a gadolinium-enhanced MRI of the orbit and the globe; she is started on intravenous methylprednisolone.
Introduction
  • Definition
    • an inflammatory demyelinating process affecting the optic nerve
  • Epidemiology
    • incidence
      • most commonly affects women between the ages of 20-40
  • Etiology
    • multiple sclerosis
    • ethambutol
      • discontinue if findings 
    • ischemic optic neuropathy (e.g., diabetes mellitus or giant cell arteritis)
      • considered in the elerly
    • infectious and postinfectious causes
      • considered in young children
    • sarcoid-associated optic neuropathy
    • lupus-associated optic neuropathy
    • Lyme disease
    • syphilis
    • varicella
  • Pathogenesis
    • inflammatory demyelination of the optic nerve
      • there is perivascular cuffing, myelinating nerve sheath swelling, and myelin breakdown
      • believed to be immune mediated
  • Prognosis
    • many patients may have residual visual deficits
Presentation
  • Symptoms
    • typically monocular but can occur in both eyes
    • vision loss
      • typically occurs over the course of hours to days
      • most patients have a decrease in central visual acuity
        • visual acuity decreases have different ranges
    • periocular pain
      • often worsens with movement
  • Physical exam
    • decreased visual acuity, color sensitivity, and contrast sensitivity
    • fundoscopy
      • optic disc pallor and/or optic disc swelling
    • relative afferent pupillary defect
      • detected by the swinging light test
      • in the affected eye, the pupil will dilate with direct illumination after illuminating the normal eye
Imaging
  • Gadolinium-enhanced MRI of the orbit and brain
    • indication
      • when there is clinical suspicion for multiple sclerosis
Studies
  • Dependent on clinical suspicion
    • e.g., antinuclear antibody (ANA) if an autoimmune process is suspected
Treatment
  • Medical
    • high-dose IV corticosteroids
      • indication
        • can hasten visual recovery
Complications
  • Optic nerve atrophy
  • Poor visual recovery

 

 

 

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Questions (1)

(M2.OP.15.10) A 57-year-old woman presents with a cough, hemoptysis, fever, chills, and weight loss that has persisted since she returned from her trip to Thailand. She admits to having sexual contact with several prostitutes. The patient is generally healthy and is not taking any medications. She has a family history of glaucoma, diabetes mellitus, factor V Leiden, and an ischemic stroke. Her temperature is 101°F (38.3°C), blood pressure is 125/84 mmHg, pulse is 99/min, respirations are 19/min, and oxygen saturation is 95% on room air. Physical exam is notable only for some coarse breath sounds. A chest radiograph is performed as seen in Figure A. Treatment for this patient's condition is started. The patient returns to clinic with decreased visual acuity mainly in her right eye. She also reports pain in both eyes with movement. On physical examination, when a penlight is shined into the right eye, there is no pupillary constriction in either eye. The rest of her neurological exam is unremarkable. Which of the following is the most appropriate next step in management? Tested Concept

QID: 105376
FIGURES:
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Change antibiotic therapy

10%

(4/40)

2

CT head

48%

(19/40)

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MRI head

10%

(4/40)

4

Timolol eye drops

10%

(4/40)

5

Ultrasound eye

18%

(7/40)

M 7 E

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