JCAHPO and ATPO Continuing Education Webinar Series. Sunrise on the Serengeti. Are you a gazelle or a lion? 6/6/ Group A CE Credit

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1 JCAHPO and ATPO Continuing Education Webinar Series 1 Group A CE Credit Tonight s Presentation: Five Triage Decisions That Can Save a Life Presented by: Andrew G. Lee, MD 1 2 Copyright 2011 Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO ). All rights reserved Five neuro-ophthalmic triage decisions that can save a life Sunrise on the Serengeti Andrew G. Lee, MD Chairman of Ophthalmology, The Methodist Hospital, Houston Professor of Ophthalmology, Weill Cornell Medical College Adjunct Professor of Ophthalmology, University of Iowa Clinical Professor of Ophthalmology, UTMB Galveston Are you a gazelle or a lion? I have no financial interest in the contents of this talk Gazelle Quiet Agile, responsive to change Quick & fleet footed On the move, graceful But also alert for activity On the look out for danger in front & behind Lion Roaring & loud Hungry Aggressive On the hunt Forward looking (no one is chasing me) On the look out for opportunity *I will give you my answer at the end so stay tuned 1

2 I will not be discussing any off label uses of drugs At conclusion of this lecture the learner will be able to: 1) Recognize life threatening acute symptoms conditions in neuro ophthalmology 2) Identify the distinctive sign for selected emergencies in neuro-ophthalmology 3) Describe best acute imaging study for selected conditions above 4) Develop triage list for phone & ancillary staff to use for above conditions Overview List five potentially life threatening diagnosis in neuro-op Define rule of the pupil Define best imaging study for the 5 dx Show key clinical or radiographic features for the above 5 dx Overview: Lee s A s: The five chances to save a life 1. Arteritis (Giant cell) 2. Apoplexy (Pituitary) 3. Abscess (Mucor) 4. Aneurysm (pupil involved third nerve palsy) 5. Arterial (carotid or vertebral) dissection *At the end I want to give you an additional important take home message Overview: Lee s A s: The five chances to save a life Women in audience close your eyes.men: What do you see (keep it to yourself for now)? 1. Arteritis (Giant cell) 2. Apoplexy (Pituitary) 3. Abscess (Mucor) 4. Aneurysm (pupil involved third nerve palsy) 5. Arterial (carotid or vertebral) dissection 2

3 OK, now men cover your eyes. Women: What do you see (keep to yourself for now)? What did you see? Men? Women? How much would you bet that the other person is wrong? How strongly would you argue the point? Dad s definition of a great lecture Bad Great Good lecture: lecture: lecture: You You make You make make a list a list of a list things of of patients things you have you to to need do pick differently to up call at back the next store week clinic laterin clinic It s ok to ask for help but you have to be able to read the signs Five triage pearls in neuroophthalmology 1. Have the triage list in ADVANCE not ad hoc 2. Beware red flag: acute painful (insert any neuro-ophthalmic sign!) 3. How long has it been there? (this is your time clock for working it up) 4. How bad is your pain or visual loss? (worst HA of life, LP or NLP vision = Come now! ) 5. Are your pupils different sizes (Go look in the mirror now!) 3

4 The 7 Must Call triage list (Give to your techs tomorrow) 1. Acute painful ophthalmoplegia 2. Acute painful bitemporal hemianopsia 3. Acute painful anisocoria (big or small) 4. Acute painful visual loss in elderly 5. Acute painful (HA) bilateral optic disc edema (papilledema) 6. Acute no light perception vision 7. Acute painful severe HA ( worst pain of my life) Who s fault is it if the resident/fellow/technician doesn t triage patient properly? Uh-Oh PS: My Neuro-ophthalmic Do not call list Walking on the beach in Oahu Monocular diplopia Eye pain with normal eye exam Dizzy patient Visual snow (static) This patient is nuts only Dr. Lee can help you now. The beautiful Sunday syndrome Story of a beautiful Sunday morning Army Pvts Lockard & Elliot Detected aircraft at 7:02am practicing with new equipment (RADAR) Reported findings to Fort Shafter but staff had gone to pancake breakfast Lt. Tyler received message & told them that it was scheduled flight of B-17s Advised radar crew not to worry 4

5 They should have worried because that Sunday was a date that will live in infamy December 7, 1941 The first use of wartime radar in US Beautiful Sunday.but what if it had been Monday 8 AM instead Pattern recognition Pattern recognition Is the pattern emerging? It is easy now. 5

6 Giant cell arteritis: What everyone knows. Elderly patient (often female) Acute onset headache, jaw claudication, temporal artery pain, neck or ear pain Loss of vision (typically due to ischemic optic neuropathy) Elevated erythrocyte sedimentation rate (ESR) & C-reactive protein Patients do not come in with the diagnosis written on their forehead (but sometimes they do) I have temporal arteritis The artery on the side of my head hurts Delay in GCA diagnosis common Br J Rheumatol Feb;36(2): Clinical features in patients with permanent visual loss due to biopsy-proven giant cell arteritis. Font et al. I have GCA 146 biopsy + GCA 23 (16%) lost vision GCA Sx for average of 1.3 months 35% PMR x 10.8 months 65% premonitory visual Sx for 8.5 days Clear delay in diagnosis in 65% (15) Some things you don t know about things you know well (GCA) Which is worse AION or PION of elderly? Anterior ischemic optic neuropathy Posterior ischemic optic neuropathy Transient visual loss Transient diplopia in the elderly The distinctive hx = premonitory visual symptoms & constitutional S/Sx Swollen disc in anterior ischemic optic neuropathy Normal appearing disc in posterior ischemic optic neuropathy 6

7 Beware pallid edema Big Red Flags in GCA Severe visual loss (e.g. LP or NLP) Bilateral simultaneous visual loss Transient visual loss (not seen in nonarteritic form of ischemic optic neuropathy) PMR with visual symptoms Giant cell arteritis can kill people. Aortitis Systemic vasculitis Crow et al. J Gerontol A Biol Sci Med Sci Mortality in GCA: 5-year survival: 67% for controls vs 35% for GCA cases (p <.001) There are five things to remember about acute visual loss in the elderly One is GIANT CELL ARTERITIS. And the other four are Giant Cell Arteritis 75 year old woman with acute loss of vision OD Beware ischemic loss of vision without disc edema Multifocal cotton wool patches can be GCA 7

8 FFA: Peripapillary choroidal perfusion delay Biopsy proven GCA Beware of Unusual Ocular Presentation of GCA Multifocal cotton wool patches Posterior ischemic optic neuropathy (normal appearing optic nerve) Non-embolic central retinal artery occlusion Transient visual loss (amaurosis fugax) Transient diplopia Simultaneous choroidal or retinal artery occlusion with AION 8

9 Beware non-embolic CRAO in elderly Unilateral vs. Bilateral TAB Danesh-Meyer: 91 bilateral TAB (WILLS) & concordance rate = 98% 4 additional studies: pooled concordance rate = 96% (95% confidence interval) Pless: 60 TAB (Mass. Eye & Ear) & histopathologic discordant = 13% 4-5% + TAB after negative contralateral TAB Danesh-Meyer et al: J Neuro-ophthalmol 2000; How many TABs should I be doing? What % are positive? Like appendectomies (If you have 100% positive results, you have missed some) Smith (Arthur Rheum 1983; 26:1214-9) 23% Huston (Ann Int Med 1978; 88:162-7) 42% Liu (Ophthalmol 6:1147-9, 2001): 17% Pless M et al; J Neuro-ophthalmo 2000; 20: Intravenous steroids: indications in GCA No head to head evidence that IV is superior to oral steroids Monocular or bilateral visual loss Severe visual loss Transient visual loss Less than 1 week duration of visual loss No contraindications Avoid common errors in treatment of GCA Dont taper too fast (No Medrol dose pack ) Don t use too small an initial dose ( mg/d) Don t taper too soon (danger period = 1st month) Don t use alternate day steroids Don t stop Rx too early (median = yrs not wks) Don t taper just for mild or even moderate side effects (warn patient and primary doctor) Don t forget Vitamin D and calcium or bisphosphonates (DEXA bone density) 9

10 The triage decision. Elderly patient with ANY neuroophthalmic complaint (visual loss, diplopia, ptosis, anisocoria, headache/eye pain) Is it giant cell arteritis? A true ophthalmic emergency Which of the following is the most likely diagnosis for new onset HA & visual loss in the elderly? A) Posterior communicating a. aneurysm B) Pituitary apoplexy C) Chiasmal glioma D) Optic neuritis E) Giant cell arteritis Which of the following is the acute imaging study for the prior dx? A) CT orbit B) MR orbit C) MR or CT sella D) MRA E) NONE of the ABOVE Holiday Headache 22 y/o woman Severe headache 20/50? Effort (blurred vision) Fundus normal OU HVF: unreliable Friday 4:45 PM Perform a confrontation field Beware acute bitemporal field loss Unreliable HVF = I have no visual field on this patient! Life threatening diagnosis? 10

11 Pituitary tumors common Incidence of pituitary tumors = 7 per 100K population per year As high as 1 in 500 > 65 years The average ophthalmologist should see about one pituitary tumor per year.are you missing your quota? ----B. Katz MD Pituitary apoplexy Acute onset Usually severe headache Bitemporal hemianopsia Apoplexy can kill (8%) Hypopituitarism (cortisol) Emergent scan biocomp.stanford.edu Pituitary apoplexy Semple et al. Neurosurgery. 56(1):65-73, patients (Average age 51.1 years) Average time presentation: 14 days after ictus 81% no previous history of pituitary tumor Headache (87%) with diminished visual acuity in 56% (bitemporal hemianopia 34%) 73% hypopituitarism; 8% diabetes insipidus Which of the following is the life threatening cause of an acute painful bitemporal hemianopsia? A) Posterior communicating a. aneurysm B) Pituitary apoplexy C) Chiasmal glioma D) Optic neuritis Which of the following is the acute imaging study for the prior dx? A) CT orbit B) MR orbit C) MR or CT sella D) MRA The triage decision. Acute painful visual loss Is there a bitemporal hemianopsia? Could this be pituitary apoplexy? 11

12 Acute ophthalmoplegia in a diabetic 35 y/o WM with diabetes History of diabetic ketoacidosis Complete left ptosis Acute onset almost complete left sided ophthalmoplegia What should be the evaluation? Life threatening diagnosis? Don t procrastinate on seeing ophthalmoplegia if. Acute painful ophthalmoplegia The ICU or post-surgical cases Cancer patients on chemotherapy Long term immunosuppression or corticosteroid use Chronic renal dialysis Chronic antibiotic treatment Bone marrow or organ transplant Cavernous sinus lives close to other structures From: Mucor Does not have to show black eschar Can be Aspergillus too! 12

13 How could a fungal orbital apex lesion be missed on MRI? Aspergillosis of orbital apex Need contrast to see enhancement Fungi are dark on MRI No fat suppression can miss lesion Super-dangerous because tempting to give steroids to Presumed retrobulbar optic neuritis Presumed Tolosa Hunt syndrome YOU NEED CONTRAST. DISTINCTIVE SIGN = SINUS ENHANCEMENT! What happens if you don t give contrast?... My house at NIGHT!!! What is Fat suppression ( fat-sat )? technique T1 weighted signal Increase contrast (light and dark) between structures Fat is too bright on T1 No fat suppression 13

14 Polar bear in a snowstorm Can you tell if this nerve is enhancing? Complementary roles for CT & MR in fungal orbital apex disease (T2 dark) The triage decision. Proptosis, pain, ophthalmoplegia in a diabetic patient Could this be MUCORMYCOSIS? What s wrong with this picture? 60 y/o diabetic man New onset ptosis right Right adduction, elevation, & depression deficit 45 exotropia (XT) Diagnosis: Ischemic third nerve palsy Plan: Return 6 weeks Tell your technicians. If the patient s complaint is diplopia or ptosis or. If you have to lift a ptotic lid to put in the dilating drops then. STOP, come get the doctor before dilating 14

15 Rule of the pupil Acute pupil involved third n. palsy Life threatening diagnosis? A pupil involved third nerve palsy Aneurysm of posterior communicating artery until proven otherwise Highest stakes encounter an eye doctor will see Vasculopathic LIVE Third nerve palsy Aneurysm DIE Which of the following is the life threatening cause of an acute painful third nerve palsy? A) Aneurysm B) Adenoma C) Allergic aspergillosis D) Amyloid 15

16 Choice of imaging strategy in third nerve palsy CT/CTA first to look for SAH/aneurysm in pupil involved third nerve palsy MRI/MRA first to look for non-aneurysmal etiologies or do MRI second if CTA negative first Catheter angiography if MRI/MRA and CTA not of sufficient quality or insufficient confidence level to rule out aneurysm Which of the following is the first line imaging to evaluate the prior diagnosis? A) CT orbit B) MR head C) MRA D) CTA The triage decision. Amaurosis fugax Acute third nerve palsy? Could this be an aneurysm? 70 year old woman judge Curtain over vision RE x 10 resolved Normal eye exam Dx: ocular migraine Life threatening diagnosis? High grade stenosis ICA 16

17 The triage decision. Transient visual loss Could it be transient ischemic attack (TIA) i.e., amaurosis fugax Should we call the stroke team? Acute painful anisocoria after car accident Life threatening diagnosis? As if death weren t enough. Carotid dissection History of trauma Neck pain Ipsilateral Horner syndrome Transient visual loss Branch or central retinal artery occlusion Don t waste time localizing just image (drops not available anyway) 17

18 Which of the following is the life threatening cause of an acute painful Horner syndrome? A) Adenoma B) Arterial dissection C) Aspergillosis D) Acute multiple sclerosis Which of the following is the acute imaging study for the prior dx? A) MR head B) MR orbit C) MR sella D) MR head and neck The triage decision. Is this an acute painful Horner syndrome? Could it be a carotid dissection? Summary Texas Palm Pilot List five potentially life threatening diagnosis in neuro-op Define rule of the pupil Define best imaging study for the 5 dx Show key clinical or radiographic features for the above 5 dx 18

19 What does your list look like? 1. Acute HA in elderly with visual loss: Arteritis 2. Acute orbital apex syndrome in DM: Abscess 3. Acute painful anisocoria (3 rd n.): Aneurysm 4. Small pupil: (Horner) Arterial dissection 5. Acute painful bitemporal loss Apoplexy The buzz words to get the attention of your local friendly neuro-op. Acute painful.. I am worried about. Arteritis, apoplexy, aneurysm, abscess, arterial dissection You have my attention now Bottom line: Its your job No matter how you see yourself Back to the Serengeti Thanks for your attention 19

20 Thanks for giving me the opportunity to run with you today QUESTIONS and ANSWERS 116 Thank you for attending tonight s Webinar. We hope it was a beneficial and productive experience. Next Scheduled Webinar Event: Entering a History in EHR Presented by: Heather Bush, Senior Training Specialist for Compulink Business Systems Tuesday, June 21, :30 PM CDT