Grand Rounds Conference Juan P. Fernandez de Castro, MD University of Louisville Department of Ophthalmology and Visual Sciences June 05, 2015

Subjective CC: Refraction re-check HPI: 76 yo M presents to clinic because of poor vision even with his new glasses; refracted six weeks ago. Previous visit he complained of right sided intermittent headache with associated flashes. No changes in vision.

History Past Medical History Past Medical History DM, newly diagnosed. HbA1C 5.9 DM, newly diagnosed. HbA1C 5.9 Hyperlipidemia Hyperlipidemia Meds: Oral DM meds, statin Meds: Oral DM meds, statin NKDA NKDA

History Past Ocular History Past Ocular History Cataracts OU, not visually significant Cataracts OU, not visually significant Glaucoma suspect Glaucoma suspect C/D: 0.65 / 0.4 C/D: 0.65 / 0.4 Tmax: 20mmHg / 20mmHg Tmax: 20mmHg / 20mmHg Central Corneal Thickness: 578 / 550μ Central Corneal Thickness: 578 / 550μ Neg Family Hx Neg Family Hx Migraine with ocular aura Migraine with ocular aura

Objective ODOS VAcc20/2020/ x x165 VAcc20/2020/ x x165 M Rx20/2020/20 M Rx20/2020/ x x169

Objective OD OS OD OS Pupils5→2 mm 5→2 mm Pupils5→2 mm 5→2 mm NO rAPD NO rAPD IOP15 mmHg 16 mmHg IOP15 mmHg 16 mmHg EOMFullFull EOMFullFull

Objective External/LidsWNL OU External/LidsWNL OU Conj/ScleraWhite OU Conj/ScleraWhite OU CorneaClear OU CorneaClear OU Ant ChamberDeep and Quiet OU Ant ChamberDeep and Quiet OU IrisWNL IrisWNL Lens+1 NS OU Lens+1 NS OU Vitreous Clear Vitreous Clear

Objective DFE DFE OD: C/D 0.65 Sharp, No pallor OD: C/D 0.65 Sharp, No pallor Macula WNL Vessels WNL Periphery WNL OS: C/D 0.4 Sharp, No pallor OS: C/D 0.4 Sharp, No pallor Macula WNL Vessels WNL Periphery WNL

Upon further questioning… “While driving I have missed a bridge in my property twice in the past month. It has never happened in 30 years” “While driving I have missed a bridge in my property twice in the past month. It has never happened in 30 years” CVFOSOD CVFOSOD

Neurologic Exam Mental status: Alert and oriented x3 Mental status: Alert and oriented x3 Fluid, appropriate speech Fluid, appropriate speech No cranial nerve deficit No cranial nerve deficit No limb weakness or numbness No limb weakness or numbness No gait abnormalities No gait abnormalities

Humphrey Visual Fields 24-2 OS OD

Assessment 76 year old white male who presents with a bilateral homonymous visual field deficit. 76 year old white male who presents with a bilateral homonymous visual field deficit. Differential Diagnosis Differential Diagnosis Occipital lobe ischemic event, unknown timing Occipital lobe ischemic event, unknown timing Occipital lobe tumor Occipital lobe tumor Plan: Emergency Department for CNS imaging and neurology evaluation Plan: Emergency Department for CNS imaging and neurology evaluation

CT Head

Hemorrhagic mass surrounded with large edema or acute ischemic injury with a foci of parenchymal heme located mainly in the right temporal and parietal lobe. Hemorrhagic mass surrounded with large edema or acute ischemic injury with a foci of parenchymal heme located mainly in the right temporal and parietal lobe. Recommend MRI Recommend MRI Pt transferred to UofL Hospital for further evaluation and treatment Pt transferred to UofL Hospital for further evaluation and treatment

MRI Brain

Heterogeneously-enhancing right occipital lobe mass measures up to 3.1 cm in maximal diameter, with extensive peritumoral infiltration into the subcortical and periventricular white matter of the right occipital, parietal, temporal, and to a lesser extent, frontal lobes. Heterogeneously-enhancing right occipital lobe mass measures up to 3.1 cm in maximal diameter, with extensive peritumoral infiltration into the subcortical and periventricular white matter of the right occipital, parietal, temporal, and to a lesser extent, frontal lobes.

Brain tumor resection Pre-opPost-op Pre-opPost-op

Pathology Right Occipital Dural Base Tumor Biopsy: Right Occipital Dural Base Tumor Biopsy: Metastatic carcinoma, consistent with renal cell carcinoma

Postoperative CT Head Postoperative changes from posterior occipital craniotomy are noted with resection of the previously noted enhancing right cuneus mass with no residual enhancement noted to suggest residual enhancing tumor, consistent with gross total resection. Postoperative changes from posterior occipital craniotomy are noted with resection of the previously noted enhancing right cuneus mass with no residual enhancement noted to suggest residual enhancing tumor, consistent with gross total resection.

CT Abdomen Large heterogeneously enhancing lesion arising from the upper pole of the right kidney, consistent with renal cell carcinoma. Large heterogeneously enhancing lesion arising from the upper pole of the right kidney, consistent with renal cell carcinoma.

BONE SCINTIGRAPHY No convincing scintigraphic evidence of underlying osseous metastatic disease No convincing scintigraphic evidence of underlying osseous metastatic disease Injection site Bladder

Nephrectomy 1 month later, patient undergoes 1 month later, patient undergoes Right laparoscopic radical nephrectomy 4.3 x 4.7 x 5.3 cm mass 4.3 x 4.7 x 5.3 cm mass No complications No complications

Current Treatment Brain: Stereotactic Radiotherapy x1 completed Brain: Stereotactic Radiotherapy x1 completed Kidney: adjuvant chemotherapy (Pazonib) Kidney: adjuvant chemotherapy (Pazonib)

Follow up with ophthalmology Follow up 2 months Follow up 2 months VA 20/20 OU VA 20/20 OU Vision is subjectively better Vision is subjectively better

HVF 24-2 Improvement

7 ways to do Confrontational Visual Fields Description of examiner’s face Description of examiner’s face Finger counting Finger counting Finger comparison Finger comparison Red comparison Red comparison Static finger wiggle Static finger wiggle Kinetic finger wiggle Kinetic finger wiggle Kinetic red target Kinetic red target

Description of examiner’s face 20cm Patients to examiner distance 30 cm Patients to examiner distance 30 cm (test 20 degrees) (test 20 degrees) Are any parts missing OR distorted Are any parts missing OR distorted

Finger counting Use 1 or 2 fingers Use 1 or 2 fingers 20 °eccentric 20 °eccentric 90cm 20° 60cm 22cm

Finger comparison Are both fingers equally sharp? Are both fingers equally sharp? 20° 22cm 20° 22cm

Red comparison Use atropine bottle caps Use atropine bottle caps Aprox 20mm Aprox 20mm Are both caps equally red? Are both caps equally red? 20° 22cm 20° 22cm

Static finger wiggle Wiggle 1 finger Wiggle 1 finger Less than 5°oscillation Less than 5°oscillation Ask which finger is wiggling Ask which finger is wiggling 20° 22cm 20° 22cm

Kinetic finger wiggle When is the finger first visible? When is the finger first visible?

Kinetic red target When is the red target first visible? When is the red target first visible? 5mm

-6

Best 5 Combinations

Conclusion Detection of field loss may be the first sign of sight-threatening or potentially life-threatening disease. Detection of field loss may be the first sign of sight-threatening or potentially life-threatening disease. CVF has limited sensitivity compared with Goldmann or Humphrey VF CVF has limited sensitivity compared with Goldmann or Humphrey VF Even the best combination of CVF tests will fail to detect more than 20% of lesions, so it is important to use an appropriate technique to maximize sensitivity. Even the best combination of CVF tests will fail to detect more than 20% of lesions, so it is important to use an appropriate technique to maximize sensitivity.

References Kerr NM, Chew SS, Eady EK, Gamble GD, Danesh-Meyer HV. Diagnostic accuracy of confrontation visual field tests. Neurology Apr13; 74(15): Kerr NM, Chew SS, Eady EK, Gamble GD, Danesh-Meyer HV. Diagnostic accuracy of confrontation visual field tests. Neurology Apr13; 74(15): Elliott DB, North I, Flanagan J. Confrontation visual field tests. Ophthalmic Physiol Opt 1997;17 suppl 2:S17–S24. Elliott DB, North I, Flanagan J. Confrontation visual field tests. Ophthalmic Physiol Opt 1997;17 suppl 2:S17–S24. Pandit RJ, Gales K, Griffiths PG. Effectiveness of testing visual fields by confrontation. Lancet 2001;358:1339 –1340. Pandit RJ, Gales K, Griffiths PG. Effectiveness of testing visual fields by confrontation. Lancet 2001;358:1339 –1340. Johnson LN, Baloh FG. The accuracy of confrontation visual field test in comparison with automated perimetry. J Natl Med Assoc 1991;83:895– 898. Johnson LN, Baloh FG. The accuracy of confrontation visual field test in comparison with automated perimetry. J Natl Med Assoc 1991;83:895– 898.