1. Problem Solving Case 1

2. History  22 years old female presents to ER physician with history of sudden redless decrease in vision in the rt. eye 10 days ago with mild headaches and pain on eye movement. Her past medical history is insignificant of any ophthalmic or systemic illness.

3. Examination On examination she showed the following Vitals: –Pulse:72/regular –Temp. 37 –Resp:14 –B.P 120/80

4. Eye Examination  VA OD 20/100 OS 20/20  Pain on abduction of Rt. eye  EOM: full  Red reflex:normal  Fundus ex.: normal disc, vessels, maculae

5. Case Management 1.Summarize the case (+ve and -ve) 2.Any further information you needs to know in history? 3.Any further information you need to know in the examination 4.What is your provisional diagnosis? 5.What is your role as an ER physician in this case??? Who treats such a case 6. How does the ophthalmologist manage such a case?

6. Case Summary Positive Negative 22 years old (Young not oldPMH insignificant Female ( Not male)Normal Vitals Sudden (Not gradual) decrease in Vision in one eye Decreased vision HeadachesNormal Red Reflex Pain on Eye Movement (Symptom)Normal Fundus Decreased vision OD Pain on Eye Movement (sign)

7. Further History Onset: how? When? What Progression of vision, headaches, pain Headaches Relieving & PPT factors Uhthoff’s Phenomenon Diplopia/ Oscillopsia /Dizziness Parasthesia and weakness Bowl symptoms

8. Further History Onset of Visual loss: How? When? What Progression of vision, headaches, pain Relieving & PPT factors Social History –Smoking –Alcohol –Others Family History Drug History

9. Further Examination Proptosis Ptosis Tenderness over sinuses Multiple pinhole Pupil examination Visual field

10. Diseases Onset & Progress AcuteIschemia-Hge. - Infections Inflammation SubacuteInfections Inflammations ChronicCompressive Infections Minutes- 24hours 24 hours to several days 4 weeks to years

11. Provisional Diagnosis Optic Neuritis

12. Differential Diagnosis

13. Other causes of Optic Neuropathies  Ischemia  Infections  Nutritional  Compressive  Hereditary  Traumatic

14. Differential Diagnosis Other causes of acute visual loss  Sinus disease  CRVO  CRAO  Retinal Detachment  Vitreous Hge.

15. Why??? 22 yearsUnlikely ischemic but could be any other process FemaleDemylination or any other process SuddenIschemia/Inflam./Infection/ Sudden discovery Pain on eye movement Sinusitis- Myositis- Cellulitis- Optic neuritis-Acute Grave’s Scleritis & rules out vascular event (CRAO/CRVO/ION)

16. Why??? Normal VitalsUnlikely infectious Regular PulseUnlikely shooting emboli Unlikely Grave’s Absence of proptosis & Lid Signs Unlikely Cellulitis or myosiitis or Grave’s Absent tenderness over sinuses Unlikely sinusitis

17. Why??? VisionRefractive Error/ Media Problem / Retina /Neurological Psychological MPH no improvement Not refractive Sluggish Pupil reaction with RAPD Disease affecting visual pathway anywhere from ON to lateral geniculate body Visual Field Central Scotoma ON disease or macular disease

18. Why??? Visual Field Central Scotoma ON disease or macular disease Fundus NormalNot retinal disease but can not rule out ON or visual pathway disease.

19. Differential Diagnosis Other Causes of ON Disease Sinus Disease CRAO +CRVO Retinal Detachment