Improve Your Neuro-Ophthalmology Diagnostic Skill Level with These 7 Tips
Eye care providers of all subspecialties are in one way or the other bound to encounter patients suffering neuro-opthalmic disorders. Patients suffering from neuro-opthalmic disorders are more than likely to experience serious systemic morbidity, rapid loss of eye vision and other conditions that may prove difficult to establish. For these reasons, neuro-opthamology represents a huge challenge to many providers. Below are 7 proven practical techniques, eye care providers can institute to improve neuro-opthamology diagnostic.
Use Color Plates
Color-plate testing procedures such as Ishihara color plates are critical in monitoring and evaluating optic neuropathies and maculopathies, as well as in screening conditions such as simultagnosia. Simultanagnosia is a Visual processing impairment that is often marked by inability to simultaneously process multiple visual stimuli. The disorder is common in elderly patients suffering various visual complaints, even after undergoing normal structural eye exam and visual acuity tests.
Use appropriate neuroimaging
A recent study has shown that approximately 40% of all neuroimaging studies performed by academic neuro-opthamology clinics on patients suffering from visual disorders are ill-chosen. The most common mistakes include; failing to use contrast, ordering the wrong type of neuroimaging; for example, ordering Computed Tomography (CT) instead of Magnetic Resonance Imaging (MRI) and performing incomplete neuroimaging. Insidious symptoms of Simultanagnosia are typically related to those of Alzheimer’s disease or other neurodegenerative diseases.
Avoid Becoming a Victim of Papilledema
Although most ambulating and coherent patient’s suffering from papilledema, rarely represent an emergency. Majority of patients with papilledema should undergo expedite outpatient work-up. The procedure begins with an MRI brain with an option of IV contrast. Patients who do not fit the typical pseudotumor celebri demographic such as overweight women or patient in reproductive age or those with hypercoagulable disorders or rapid onset symptoms should undergo Magnetic Resonance Venography (MRV).
An MRV will help rule out conditions such as venous sinus thrombosis that can be overlooked with an MRI brain scan. Non-emergent patients can be referred to the ER to test papilledema through suboptimal work-up. Critical symptoms or signs of papilledema that require immediate attention include; fever, severe rapid vision loss, changes in the mental status and signs of meningismus.
Use Fluorescein Angiography for GCA
Fluorescein is a powerful GCA diagnostic tool for ascertain the presence of Giant Cell Arteritis (GCA). The good thing is that most eye care providers understand the type of questions to ask and tests to draw from the lab. The tests include; C-reactive protein, complete blood count and erythrocyte sedimentation rate. Patients suffering from GCA related vision loss often suffer patchy choroid or delayed filling on the fluorescein. Choroidal filing time is described as the time it takes to fill the choroid from the initializing state, any timing that goes beyond 20 seconds is highly suggestive of GCA.
Questioning the GCA
It is always important to ask critical screening questions, when it comes to GCA. This is mostly because many cases of GCA are usually missed initially as a result of a sloppy or expedited practice history. Some of the pertinent questions include inquiring about recent cases or onset of temple tenderness, headaches, unintended weight loss, proximal muscle myalgias, jaw claudication, low-grade fevers and neck pain. Jaw jaundice is often considered the most specific symptom of GCA. This symptom should prompt immediate steroid treatment, as well as temporal biopsy to any patient who fits the GCA demographic.
Observe the Twitching of the Eyelid
If a patient’s eyelid cannot remain open or closed, an orbicularis oculi-strength testing is highly recommended. This is critical, especially if an ocular involvement via myasthenia gravis is suspected. Patients who have diplopia or intermittent ptosis with myasthenia gravis may exhibit symptoms such as severe weakness or fatigue of the orbicularis oculi muscles. These patients may not suspect or suggest orbicularis oculi weaknesses as a symptom; as such, it is critical for you to check for these symptoms routinely.
To perform this test, you can request the patient to close his or her eyes firmly. Then use your thumb and index finger to try to open the patient’s eyelids. The eyelids of a patient in myasthenics will open easily, while that of a normally patient will provide some resistance.
Be on the Lookout for Severe Optic Neuritis
Patients with conditions associated with multiple sclerosis such as Demyelinating Optic Neuritis (DON) normally experience painful sub-acute vision loss; however, the pain usually disappears within few months.
Patients with DON may also suffer severe vision loss, although this is rare as it affects less than 20 out of every 200 patients with this condition. Under severe cases, a patient may contract optic neuritis associated with neuromyelitis (NMO). NMO associated with optic myelitis neuritis is typically, painless, bilateral and more severe at the onset; the condition is also less responsive to steroids compared to DON. Visit our LiveJournal and let us know what your thoughts are on this subject.
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