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Technicians and Visual Fields in Usher Patients – Are You Missing the Clues?

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Technicians and Visual Fields in Usher Patients – Are You Missing the Clues? 4/2/2019 What Processes Can Cause Technicians and Tough Visual “Tough” Fields ? Fields: Are You Missing The • Clues? RED FILTER FIELDS (Toxic vs MS): Plaquenil Hydroxychloroquine Ethambutol Multiple Sclerosis • Pituitary Tumor – Junctional Scotoma • Retinitis Pigmentosa /USHER’s Syndrome • “I cant find anything – go do a field” Eyesoncambodia.wordpress FRIDAY AM 800 AM ADD ON The front desk person came back to say we had an At 8:10 I walked out, called her name and this is what add on from the ER. greeted me….”You’re late “. 38 y.o. woman, c/o She didn’t want an exam, she didn’t feel decreased vision in her right eye and any questions were pertinent – weakness that comes and she wanted the doctor – not me. and goes. Wanted to be seen and done by 930 Vision sc: 20/40 OD, 20/20 OS. AM as she had an Refraction: -0.50 sph (20/30-2) important meeting -0.50 sph (20/20+) she was leading. Do CX to see if she has any fundus problems (plaque, hypertension changes???) Pupils: No APD OD, but not as brisk as OS. (MD agreed) Retrobulbar Neuritis: History Red Filter Visual Fields Noticed her vision changes x 1 week. No other remarkable history. But when I pushed her regarding any other changes - she stated that she noticed when she ran she would feel really spent afterwards, and her foot would drag a little. Same thing happened happened after the hot tub - and sex. I checked her color vision – and she did poorly. So…… I did a RED FILTER GVF. Warnerbrothers.com 1 4/2/2019 Retrobulbar Optic Neuritis – Signs and Symptoms MS? Multiple sclerosis (MS) * Mainly women (3:1) is an auto immune, * Onset 3rd or 4th decade * Associated with MS in demylenating 85% of cases disease that * Vision loss is usually at the 20/40 level for first attack affects the * Decreased color vision nerve sheathings * 90% have pain near eye with 50% having pain on movement in the brain and * Vision will improve – but will spinal cord. eventually relapse contactlenses.co.uk Symposcium.com Optic Neuritis vs. Papilledema Toxic/Nutritional Neuropathies Optic Neuritis Papilledema “papillitis” “choked disc syndrome” loss of vision normal vision pupils sluggish normal pupils central scotomas enlarged blind spots unilateral bilateral Less elevation ↑ nerve head elevation of nerve head When to Do Red Filter Visual Fields Plaquenil Retinopathy • Plaquenil fields Plaquenil (hydroxychloroquine) & Chloroquine are anti-inflammatory and antimalarial. They • Hydroxychloroquine fields can be used alone or in combination • Ethambutol with other medications for • IF patient is suspected of having MS rheumatoid arthritis. It helps to reduce pain, • If patient is suspected of having optic stiffness, and swelling in neuritis or retrobulbar neuritis the joints. It can also be used for Lupus. webeye.ophth.uiowa.edu 2 4/2/2019 Chloroquine or Toxic Macular Disorders Hydroxychloroquine Amblyopia Bull’s Eye Maculopathy with Ethambutol (TB med) or Antimalarial drugs that are also used in Plaquenil the treatment of Lupus and Rheumatoid Abnormal ERG with loss of cone function. Arthritis. Your doctor may see a “mottling “ of the fovea area. Defects are large, central Important to do scotomas. Use Red Filter COLOR VISION TESTING as well as Test ! VF 10-2. IF do a GVF – do a red filter test to hyper check the cones.. retinalphysician.com Ethambutol Amblyopia Lead Amblyopia * Ethambutol is used in the • Often associated with children of lower socio- treatment of tuberculosis economic means living in cities • Defects will be central • Also seen with painters or centrocecal scotomas and gasoline attendants (leaded gas) of various depths • Fumes or paint are absorbed • Decreased color vision ! through the skin • Can eventually cause papilledema • Do RED VISUAL FIELDS and optic atrophy due to chronic exposure Pituitary Gland Classic Field Defect: (Hypophysis) Tear Shaped CentrocecalScotoma Hangs by a “stalk” from under the hypothalamus. Two parts: Anterior pituitary (glandular tissue) and the posterior pituitary Tear shape points at (nervous tissue). fixation in one eye. IF Called the there is optic nerve damage “master gland” due to chronic papilledema, because it controls the defects will be so many other permanent ! endocrine glands. vivo.colostate.edu 3 4/2/2019 A pituitary adenoma is a benign (not cancerous) tumor found of your pituitary gland. Patients c/o of headaches and changes in vision among other things. The “change of vision”? Loss of side vision – listen to their complaints! quazoo.com en.wikipedia.org Progression of the Defects Right Eye Left Eye This is a CHIASM visual field defect that occurs in the temporal visual field of each eye. The classic visual field defect is a bitemporal hemianopsia, but… it can progress clockwise in the right eye and Defect progresses in a Defect progresses counterclockwise in clockwise fashion. When tumor counterclockwise. When the or bleed resolves, the damage tumor or bleed resolves, the the left eye. will reverse itself to some damage will reverse itself to degree some degree. neec.com So….. What is this ?! Junctional Scotoma Whenever you are doing a field, and the • “Blind” one eye patient has one “blind” eye, always check very • Temporal defect in the other eye carefully superior temporally in the fellow eye ! I consider “blind” an eye with a dense central scotoma ( 20/80 VA or worse). Junctional scotoma studyblue.com 4 4/2/2019 Retinitis Pigmentosa A genetic disorder of the eyes that Findings in the retina causes loss of peripheral vision due to ROD dystrophy. Usually occurs in have been young males. characterized as the Symptoms include: difficulty with night vision and decreased peripheral vision. "ophthalmic triad". This includes : Onset is generally gradual. As peripheral * a “mottled” appearance of the vision worsens, patients may experience “tunnel vision". retinal pigment epithelium (RPE) Complete blindness * bony spicule formation is uncommon, but central vision • can be affected due to cone a waxy look to the optic nerve “drop out” as well . • weakening of blood vessels in the retina herbal-care-products.com rpcure.net Wikipedia.com Normal vs. RP Fundus Layers of the Retina dxline.info webeye.ophth.uiowa.edu 101proofsforgod.blogspot.co m Basic ERG in a normal patient A contact lens electrode to the eye is used - a bright light is flashed. Patients with the RP trait would show decreased /delayed electrical response in the photoreceptors (rods & cones). If a dim flash ERG is performed on a dark-adapted eye, the response is primarily from the rods. Flash ERGs will reflect the activity of the cones. Bright flashes will show ERGs with an a-wave (initial negative deflection) webvision.umh.es followed by a b-wave (positive deflection). ( Wikipedia) 5 4/2/2019 When doing a GVF, it is important to NOT start too far “in” or you may miss islands. Very often fields appear “gun barrel” for this very reason – islands were missed because the tech started in too close. Slideshare.net webeye.ophth.uiowa.edu “Gun Barrel “ (Tunnel Vision) What The Patient May See webmd.com healio.com Non Pigmented RP Usher’s Syndrome Atypical cases of A rare genetic disorder caused by a mutation in the genes RP are common and resulting in a combination often occur when you of hearing loss and visual impairment. It is a do not see the leading cause of deaf/blindness and is incurable at this time. usual pigment The progressive blindness of changes in Usher syndrome results from the retinitis pigmentosa. the fundus. Testing is the same. retinagallery.com omnieyesurgery.com Webeye.com 6 4/2/2019 Usher’s occurs in roughly 1 deaf person in 23,000 in the United States. People with Usher syndrome represent roughly 1/6th of people with retinitis pigmentosa. People with Usher are born profoundly deaf and begin to lose their vision in the first 1-2 decades. First visual complaints are often night blindness (nyctalopia) (Wikipedia) Slideshare.net Nyctalopia Slideplayer.com What Is This ?! Scotomatous Hemianopsia…….. CHIASM…..temporal! [email protected] 7 .
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