Ophthalmology KFP 1.9 – Sally has a painful eye

by | Jan 23, 2018

Sally is a 25 year old Caucasian woman who presents with loss of vision over a few days in one eye, associated with eye discomfort on movement of the eye, with changes in vision and difficulty focussing directly onto objects, reduced colour perception, flashes in the eye on eye movements. Fundoscopy is only remarkable for an optic disk that looks as shown.

What is the most likely diagnosis given the history described? (1)

  1. Acute Demyelinating Optic Neuritis (ADON)

What are the key features of history in the condition described? (5)

  1. Visual impairment
  2. Pain around the eye
  3. Pain worse on eye movement
  4. Dyschromatopsia
  5. Scotoma
  6. Light flashes with eye movement

NB – in the RACGP KFP it is VERY UNLIKELY you will receive marks for having answers that are already given in the stem.

What are the key features of examination in the condition presented? (5)

  1. VA reduced
  2. Scotoma
  3. Relative Afferent pupil defect on affected side.
  4. Optic disc swollen
  5. Optic nerve atrophy
  6. Disc pallor – occurs 4-6 weeks later
  7. Normal macula and peripheral retina

What are the key investigations in this condition? (5)

  1. MRI
  2. CXR
  3. Optical Coherence Tomography
  4. ANA
  5. CRP
  6. B12
  7. FBC
  8. Lumbar Puncture for CSF analysis

What are the key features of management in this condition? (1)

  1. Refer Ophthalmology

What are the complications of this condition? (4)

  1. May be first presentation of MS
  2. Optic nerve atrophy
  3. Optic neuritis in other eye
  4. Poor visual recovery

What is the most common cause/association of ADON? (1)

  1. Multiple Sclerosis

What are the most common causes of this fundoscopic finding in one eye? (3)

  1. Demyelinating optic neuritis
  2. Non-arteritic anterior ischaemic optic neuropathy
  3. Retinal vein occlusion
  4. Diabetic papillopathy

 

BONUS QUESTIONS

 

What are the most common causes of bilateral presentations of this fundoscopic finding? (3)

  1. Papilloedema
  2. Toxic optic neuropathy
  3. Malignant hypertension

What are some conditions of the optic nerve that could cause the fundoscopic findings seen? (5)

  1. Optic neuritis
  2. Arteritic ischaemic optic neuropathy
  3. Giant cell arteritis
  4. Non-arteritic anterior ischaemic optic neuropathy
  5. Toxic optic neuropathy
  6. Methanol poisoning
  7. Compressive optic neuropathy
  8. Thyroid eye disease
  9. Congenitally anomalous optic discs
  10. Infiltration of the disc by sarcoid
  11. Infiltration of the disc by glioma
  12. Infiltration of the disc by lymphoma

What are some intracranial conditions that could cause the fundoscopic findings seen? (3)

  1. Brain Tumour
  2. Cerebral trauma
  3. Intracerebral haemorrhage
  4. Subdural haemorrhage
  5. Cerebral inflammation/infection
  6. Cerebral abscess
  7. Idiopathic intracranial hypertension
  8. Chiari malformation
  9. Acute mountain sickness
  10. High-altitude cerebral oedema
  11. Lyme disease

What are some medication classes that could cause the fundoscopic findings seen? (4)

  1. Tetracycline
  2. Minocycline
  3. Lithium
  4. Isotretinoin
  5. Nalidixic Acid
  6. Corticosteroids

What are some vascular conditions that could cause the fundoscopic findings seen? (4)

  1. Retinal vein occlusion
  2. Retinal artery occlusion
  3. Malignant hypertension
  4. Acute lymphocytic leukaemia

What are some globe conditions that could cause the fundoscopic findings seen? (5)

  1. Glaucoma
  2. Panuveitis
  3. Posterior uveitis
  4. Posterior scleritis
  5. Sarcoidosis

References

  1. patient.info
  2. Murtaghs
  3. Colour Atlas of Family Medicine
  4. Dynamed