Case #10 (03-31-2004) - Presented by Tim Johnson, MD, PhD

[Andrew_Doan]

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CC: 51 year old woman referred for consideration of cataract surgery.

HPI: 51 year old woman referred for consideration of cataract surgery. Poor vision OS since childhood, and patient having more difficulty with distance vision.

PMH: hypertension, ?borderline? diabetes, bipolar disorder, schizophrenia, "glaucoma" .

MEDS: seroquel, sonata, trazodone, lexapro, valium, furosemide, zaroxylyn, travoprost.

ALLERGIES: none.

FH: cataracts, arthritis, diabetes, thyroid disease.

EXAM
Best corrected visual acuities: 20/40 OD (20/60 before mRx) (mRx -6.00+3.50X115), HM OS.
Pupils: 2.7 log unit RAPD OS; VF: full to CF OD, LP OS all quadrants
EOM: large left exotropia
IOP: normal OU
DFE: see below.
SLE: anterior segments normal with 1+ nuclear sclerosis cataracts OU (mild).

Stereo photos of the right optic nerve.

Stereo photos of the left optic nerve.

Feel free to discuss the following:

What tests should you order (I'll post labs when asked for them)?

What's the differential diagnosis?

What's the diagnosis?

What is the treatment of choice, surgically and/or medically?

 

[Redhawk]

First, I would like to say that I have no idea....

Is anything else known about her "poor vision since childhood" OS? Has she always been hand motion, or has this been progressing? If she has had HM since childhood, did it result from strabismus, or did the exotropia result from the poor vision? H/o congenital glaucoma? Any past ocular procedures?

The left disc appears to exhibit nasalization of vessels. Does she use the travaprost in both eyes? She currently has normal IOP OU....are the changes seen OS old? Normal tension glaucoma vs. controlled pressures? Gonioscopy? Has she had further visual field testing? Do we have any idea about her past pressures? Who put her on the travaprost, by the way?

The right eye seems to manifest some hypertensive changes such as attenuation of vessels, maybe some AV nicking and copper wiring.

Mmmmm.....I still don't know. Any further details of her history might be helpful.

Anyone else have any bright ideas?

 

[Kalel]

The vessel walls do look "thickened" consistent with hypertensive changes, and there may be some papilledema present in the left eye. Unfortunately, I think that the key to this diagnosis lies in interpreting those photos which I'm not certain that I can do. Anyways, I might begin the w/u with an MRI, to see if the patient may have suffered some sort of a CVA that would account for her exotropia. I also might ask the patient if she had a dog or draw an ELISA and serology to Toxicariasis since I read that this may be a cause of exotropia and she may be considered immunodeficient secondary to her diabetes. The RAPD is curious, I'm not certain what the units next to it mean. I suppose that may have to do with whatever pathophysiology she is experiencing (eg lesion in optic tract), or it could be secondary to her cataract. Anyways, besides the imaging, I'd also like to see the standard labs and vitals:
chem 7, CBC, HbA1C

 

[TomOD]

My first impression is that this is a pretty clear retinal photo and it doesn't appear that the cataract is dense enough to reduce her to 20/40 (but it's possible I suppose).

Second thought: Just about all of her meds will list "blurred vision" as a side effect (I love trying to explain that to patients).

Third thought: She has a chuck of astigmatism I have to convert to minus cylinder form for my optometric-oriented mind:
-2.50 - 3.50 x 025. That by itself might be enough to reduce the acuity if she didn't have a "perfect" refraction.

The photos don't look too bad to me. I don't think there is arterial narrowing as much as there is venuous dilation without tourtuosity. Both nerves look compact with pallor on the left and maybe some nerve drusen??

The left eye, with strabismus and long-term poor vision, is probably not to be concerned with (acuity wise).

Venous dilation is seen in early diabetes.

I'd like to see her HbA1C and a fluorescein angiography.

 

[Eyesore]

I can't really tell with the magnification of the photos, but is there an optic nerve pit on the left eye?

 

[Andrew_Doan]

Originally posted by Eyesore
I can't really tell with the magnification of the photos, but is there an optic nerve pit on the left eye?

The left optic nerve looks strange, which is the key in this case.

I wouldn't worry about diabetic retinopathy without signs of diabetes: cotton wool spots, hemorrhages, microaneurysms, exudates, or edema. The retina was normal except for both optic nerves.

What test can you do in the clinic to analyze the optic nerve head better?

 

[Kalel]

Examination of the optic nerve head:
slit lamp combined with a 60-D, 78-D, or 90-D Hruby lens or a posterior pole lens through a dilated pupil

 

[Redhawk]

Perhaps confocal laser scanning microscopy?

 

[jonnyboy]

i agree with andrew, the optic disc looks like it has a little papilledema, which would explain the RAPD. From what i've been taught, cataracts don't cause RAPD--the only thing that can cause RAPD is optic nerve problems (correct me if i'm wrong). i would be interested to know the progression of the RAPD.

any history of previous MS episodes in her life?

any recent head scans? r/o optic nerve sheath meningioma, MS lesions (not likely unless previous question is yes)

 

[TomOD]

Differentials for an APD include: Ischemic optic neuropathy (retrobulbar) , optic neuritis, tumors, lesion of the optic chiasm or tract (and others).

The "poor vision OS since childhood" has me stumped a bit. I just can't tell too much from the 2-D photo. Looks like some blurred disc margins (edema) but I'm not sure.

Color vision?

Even though the CF fields were listed as normal, I'd still get as good an automated field as I could.

Just for my curiousity, I'd like to see what an autorefraction (or retinoscopy) would show on that left eye.

Mostly I'd try my best to get a copy of any previous eye records to see how she was doing in the past. 20/50 in the left eye last year would surely raise my suspicions.

Tough case

 

[Eyesore]

Originally posted by jonnyboy
i agree with andrew, the optic disc looks like it has a little papilledema, which would explain the RAPD. From what i've been taught, cataracts don't cause RAPD--the only thing that can cause RAPD is optic nerve problems (correct me if i'm wrong). i would be interested to know the progression of the RAPD.

any history of previous MS episodes in her life?

any recent head scans? r/o optic nerve sheath meningioma, MS lesions (not likely unless previous question is yes)

Originally posted by TomOD
Differentials for an APD include: Ischemic optic neuropathy (retrobulbar) , optic neuritis, tumors, lesion of the optic chiasm or tract (and others).

The "poor vision OS since childhood" has me stumped a bit. I just can't tell too much from the 2-D photo. Looks like some blurred disc margins (edema) but I'm not sure.

The left optic nerve does not look edematous to me. (By the way, the term papilledema is reserved for optic nerve swelling secondary to increased intracranial pressure). It does look anomalous. I stand by my original statement that with this photo it is difficult to tell, but I would look closely at the nerve. Is there a pit? or a small coloboma? hypoplasia? severe cupping? It appears excavated to me, probably affecting the papillomacular bundle. An OCT would help. I would lean more towards a developmental anomaly. The vessels look funny. The way they are coming off the disc does not look typical. It' s possible that she had a developmental anomaly on the left eye which somebody down the line thought was cupping and started treating her for glaucoma (unless, of course, it is cupping and I just can't tell from the photos).

Nevertheless, that is not why she came to see you. She came to see you for cataract evaluation. Given her monocular status, and her improvement in vision with a better refraction, I would encourage her to wait. If the cataract is consistent with a 20/40 cataract and she is symptomatic (BAT?), and she really, really, really wants it, then go ahead with the surgery.

 

[Redhawk]

I don't think it looks edematous either. There appears to be some kind of chorioretinal change (?) vs. soft edudate (?) vs. something else at the inferior edge of the disc.

Has she had exotropia since childhood. I've read that can be associated with neurologic problems. She does have an apparent h/o psych disorders. I'm wondering whether the "anomalous disc", the exotropia, and the psych h/o are linked.

How the heck do you add a picture in this thing? I click on add image and it wants me to "enter the text to be formatted".

 

[Andrew_Doan]

Originally posted by Eyesore
An OCT would help. I would lean more towards a developmental anomaly. The vessels look funny. The way they are coming off the disc does not look typical. It' s possible that she had a developmental anomaly on the left eye which somebody down the line thought was cupping and started treating her for glaucoma (unless, of course, it is cupping and I just can't tell from the photos).

Great observation! Dr. Johnson did OCT and the findings are posted here:

http://webeye.ophth.uiowa.edu/eyeforum/case10.htm

 

[TomOD]

This was a good case. But it would surely have been easier by being able to compare each nerve side by side in real life.

As an aside, one of the big unexpected benefits for me, since I began using a HRT II, 2 years ago, is the ability to quickly measure nerve size and compare OD to OS (in addition to cupping/elevation). And anyone contemplating purchasing, the new retinal software on the HRT, while not near as good as the OCT, is pretty sweet, now allowing 3-D viewing.

The OCT is nice but just can't afford ALL the toys

 

[Redhawk]

Dang it. You know, I did initially think the discs looked a little small, but I didn't really see the "double ring sign" which seemed more prominent in Kanski. Is that what I'm seeing at the lower edge of the disc OS?

 

[Andrew_Doan]

Originally posted by Redhawk
Dang it. You know, I did initially think the discs looked a little small, but I didn't really see the "double ring sign" which seemed more prominent in Kanski. Is that what I'm seeing at the lower edge of the disc OS?

Actually you see the double ring sign in both discs. On the left, it's harder to see it because the pale halo takes up the majority of the area where the optic nerve should be. If you look carefully, there's only a stump of an optic nerve on the left, and you know this because all the retinal vessels travel from that stump.