1. Never a dull moment…….. Leland Carr, O.D. Oklahoma College of Optometry CarrLW@nsuok.edu

2.  E.R. visit #1: “Horrible headache x 2 days. Worsening.”  “Something’s not right with my vision.”  Seen in another E.R. two days prior  Dx: MIGRAINE HEADACHE  (+) for Tick Bite “about two weeks ago”

4.  Poorly-controlled Type 1 Diabetic  History of Major Depressive Disorder  History of Obstructive Sleep Apnea  Meds:  Insulin  Gabapentin  Fenofibrate  Omeprazole

5.  Temperature: 99.8  Blood pressure: 132/88  Random/Manifest Glucose: 247  Complete Blood Count: Elevated W.B.C. slightly reduced platelet count  C-reactive Protein: 8.3  Rapid Plasma Reagin: (-)  Tick Panel ordered  H.I.V. ordered  OPTOMETRY RESIDENT CALLED IN  C.T. Scan (without contrast) of Head, Ordered

6.  C.T. results: “No acute intracranial pathology noted.”  Optometry Resident assessment: “Papilledema. Bilateral swollen disks.”  PATIENT ADMITTED TO HOSPITAL  Following Day:  Tick Panel (+) for Rocky Mountain Spotted Fever, (-) for Lyme Disease and Tularemia  Lumbar Puncture performed  Opening pressure of 24  Clear C.S.F. sample  M.R.I. Order Placed

7.  Intramuscular Rocephin  100mg. Doxycycline b.i.d. x 14 days  Phenergan tabs as needed for nausea

8.  RETURNS TO E.R. ONE DAY LATER  C/O: “Front of my head feels like it’s going to explode.”  C/O: “My headaches worse and I’m sick to my stomach.”  Given morphine i.v. x 3  CONSULT REQUESTED OF OPTOMETRY BY E.R. PHYSICIAN: “Please re check eye pressure, visual disturbance, and headache.”  Patient to be seen 24 hours later in eye clinic.

9.  VA’s: 20/50 20/40  Motilities: Full. Pain increase on rotations.  (+) for intermittent “bright flickers of light”  Clear anterior chamber  I.O.P. 14mmHg 15mmHg  DISSOCIATED PUPIL RESPONSE  NO relative afferent pupillary defect  Weak responses to Direct & Consensual  Strong response to Near pupil testing

11.  Consult Report back to Hospitalist:  M.R.I. of Brain  M.R.I. of Orbits  Advise re-check in Optometry in 1 week  Visual Fields  O.C.T. of nerve and nerve fiber layer (RNFL)  Consider oral prednisone, starting at 60mg. Daily  What about the Optic Neuritis clinical trials ????  What about the Diabetes ????

13.  Headpain “Back of my head and neck. But kind of all over…”  “Pounding pain. Annoying.”  “Vision getting worse over about 6 weeks.”  CONSULT REQUESTED BY URGENT CARE CLINIC  History of intramuscular steroid injections  Dexamethasone and Triamcinolone  For painful lower back sprain  Given weekly for 3 weeks

14.  Type 2 Diabetic, “Pretty good control. Yes, my doctor’s happy.”  Systemic Hypertension, “Pretty well controlled. Happy doctor.”  No prior records at facility.  OUR EXAM:  VA’s: 20/200 20/400  Pinhole: No improvement OD or OS  DISSOCIATED PUPIL RESPONSE  Sluggish to Light, OU. 1(+) A.P.D., OS  Motilities: Full, Pain-free, Convergence intact  External Exam: Mild “watery eye” without hyperemia  Anterior: Corneas clear. Anterior Chambers clear.  I.O.P.: 23mmHg. 25mmHg.  Dilated with Tropicamide and Phenylephrine