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Systemic Disease with a Twist of Neuro 6/14/2021 Systemic Disease Straight Up…. AOA’s definition of Optometry approved Sept 2012 with a Twist of Neuro! Doctors of optometry (ODs) are the independent primary health care Beth A. Steele, OD, FAAO professionals for the eye. Optometrists examine, diagnose, treat, and [email protected] manage diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identify related systemic conditions affecting the eye. PREVENTION Not just this… TREATING THE WHOLE PATIENT But also this… MEDICAL OPTOMETRY …..where do we fit in? 1 6/14/2021 29 AA F Hx ESRD, on dialysis Blood Pressure Classifications and Referral Guidelines (adapted from the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure –JNC 7, no symptoms, visual or systemic 2003) Hypotension normal Pre‐ HTN Stage 1Stage 2 Critical High Point Systolic < 90 < 120 120‐139 140‐ 159 ≥160 >180 Diastolic < 60 < 80 80 ‐ 89 90‐99 ≥100 >110 Refer Refer Evaluate or refer From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members within 2 within 1 immediately or BP 159/116 Appointed to the Eighth Joint National Committee (JNC 8) months month within 1 week JNC vs. ACC/AHA Guidelines All values ~10mmHg lower than JNC • 2017 ACC/AHA Clinical Practice Guidelines lowered thresholds by 10mmHg for diagnosis and treatment goals! • 26% increase in US prevalence HTN • Very controversial 2 6/14/2021 Atherosclerotic cardiovascular disease (ASCVD) risk calculator • 10‐year risk of CVD • http://tools.acc.org/ASCVD‐Risk‐Estimator/ • age >65 • atherosclerosis or risk of developing it (e.g. total cholesterol, HDL, LDL; smoking history), • chronic kidney disease • diabetes Number of deaths and age‐adjusted death rates for hypertension‐related and all Prevalence of Hypertension other causes of death combined: United States, 2000–2013 Overall 29.1 Sex Men 29.7 Women 28.5 Age (years) 18‐39 7.3 40‐59 32.4 60 and over 65 Race and Hispanic origin Non‐Hispanic white 28 Non‐Hispanic black 42.1 Non‐Hispanic Asian 24.7 Hispanic 26 0 10203040506070 Percent Nwankwo. T., Yoon. S.S., Burt. V., Gu. Q. (2013). Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011–2012. NCHS data brief, no 133. Hyattsville, MD: National Center for Health Statistics. CDC.gov 3 6/14/2021 “Hypertensive Crisis” • URGENT vs. EMERGENT Systolic >180 • JNC 7 “Evaluate and treat immediately or within 1 week depending on clinical Diastolic >110 situations and complications.” • Systemic symptoms • Ocular findings Meetz RE, Harris TA. The optometrist's role in the management of hypertensive crises. Optometry. 2011 Feb;82(2):108-16. Hypertensive Crisis Emergencies – indicated Same BP –2 different situations end organ damage BP 190/112 BP 190/112 • Feeling “fine” • (+) “migraine” since yesterday • 1‐year death rate is >79% • Forgot his medicine • DFE: disc • today median survival is 10.4 months if edema, the emergency is left untreated • Denies H/A, etc flame • actual BP level may not be as heme • DFE: crossing important as the rate of BP rise changes 4 6/14/2021 Causes of Hypertensive Crisis • Most have known Hx HTN • Compliance • Recent medication changes • Drug interactions • Pregnancy • Recreational Drug Use (cocaine, amphetamines) • Head Trauma Acute focal RPE lesions Vs…. Hypertensive leak on IVFA 32 year old with Hx kidney transplant Choroidopathy • Young patients • Acute HTN • Elschnig Spots • Focal choriodal infarctions • Sign of past acute HTN episodes • Siegrist Streaks • Linear areas of infarction and subsequent necrosis 5 6/14/2021 Diagnosis – Management 17 year old with adrenal carcinoma HTN Choroidopathy Choroidal Thickness • SD‐OCT with EDI or SS‐ • SS‐OCT or SD‐OCT with OCT EDI • Choroidal thickening M. Rahhal‐Ortuño, A.S. et al. Archivos de la Sociedad initially Española de Oftalmología, 2019 Manjunath V, Am J Ophthalmol. 2010 • SRDs • vertical distance from RPE • Inner retinal thinning over ischemic areas and inner surface of the • OCT‐A : moth‐eaten sclera appearance of the • Subfoveally + parafoveally choriocapillaris • FAF: hypo of Elschnig spots Tsukikawa M, Stacey AW. A Clin Optom 2020 SRDs, PEDs, can lead to RPE Tear 9 days after admission, BP lowering on board Natsuki Matsubara, et al. AJOpht, 2019 6 6/14/2021 85 WM, HTN, Smoker • Black circle over vision x 2 days Indirect manifestations of HTN: • FB vision Are we educating our Patients? • Pupils normal NAION Retinal Vein Occlusion Retinal Macroaneurysm 7 6/14/2021 • 52 Caucasian male • Never had an eye exam • No regular health care • Vision goes “out” when he turns his head Vascular Supply Systems to Brain •≥70% blockage before ocular 1. Internal Carotid system manifestations Supplies anterior and lateral portions of brain Unilateral visual disturbances •5 year mortality rate – 40% 2. Vertebrobasilar system • MI is mc Provides posterior brain Bilateral visual symptoms • 4/5 strokes are causes by atherosclerosis at carotid bifurcation 8 6/14/2021 …as many diseases as she pleases…. Dr. Leo Semes • Moderate NPDR –tough call Carotid Artery Occlusion • Associated with up to 20% of strokes • 4/5 strokes are causes by atherosclerotic disease at carotid bifurcation • Risk factors: • HTN • Smoking • Diabetes • High cholesterol (high LDL/triglyc) • Obesity • Sleep Apnea • Stroke • FHx • leading causes of death in US • 44WM, Type 1, A1C 8.3 • Age • 1/3 of cases are fatal Hb: 12.7 ‐ low • Lack of exercise • Survivors usually have irreversible • An easier call, but… damage HCT: 38% ‐ borderline Platelets: 157 –low 9 6/14/2021 • X 2 hours ago Intra‐arteriolar emboli • 62 year old white male “Vision went out, but • Heavy smoker, hx now it’s back” hypercholesterolemia, +HTN • Increased risk of stroke, mortality, co‐morbidity • 25% have carotid stenosis >40% (Bakri 2013) • Symptoms? Ocular signs of carotid • Often transient – plaques are pliable artery disease • Correlated with degree of occlusion? • Not predictive of future retinal events 1. Amaurosis Fugax – TMVL • Doppler 2. RAO 3. Hollenhorst Plaque • EKG/Angiography 4. Ocular Hypoperfusion Only 10% of emboli from ICA end up in OA .. ! (Kaufmann 2012) 81 Caucasian retinal heme and intra‐ And then there’s… female arteriolar plaque • Atrial fibrillation • 60 year old male longhaul trucker • Recent falls – due to TIA • Smoker, hx CVD • Sudden unilateral decrease vision • 2 hours of event Most common cardiac arrhythmia • Your staff suggests he come in Increased risk of mortality immediately TIA, stroke (x5) and MI • Hx of 20/50 amblyopia in other Screen for with RAO patients eye risk of stroke • LPO OS need for anticoagulant 10 6/14/2021 tPA for CRAO New Guidelines • Dissolves embolism • Oral or IV • Some studies have shown tPA to be effective in improving VA for up • National Stroke Association, 2011 to 60‐70% cases • Other studies find no difference • American Heart Association, 2013 • Tx within 6 hours –better outcomes • Adverse events with tPA • Strokes of major arteries = must be sent immediately to an • Cerebral stroke and hemorrhage (10%) ER with stroke center • RAO • Transient monocular vision loss 3 categories of stroke 1. Ischemic (85%) All are medical 2. Hemorrhagic emergencies! 3. Transient Ischemic Attack • Temporary disruptions in blood flow ‐‐ no permanent damage • Symptoms last 30 min to 2 hrs ‐‐ often same symptoms as stroke • Risk of stroke if untreated • 10‐15% in 3 months – 50% of these within next 48 hours Take home: Spend the time to determine if most likely vascular….. • CDC 2015 33% in the next year AHA 2015 History, presentation, risk factors. Johnston WC, et al. Lancet. 2007; 369: 283‐ 292. 11 6/14/2021 • 48 WM 48 WM C/c: blurry vision, bumping into things C/c: blurry vision, bumping into things • Significance of Macular Sparing? • Never worn glasses • LEE, LPE: “over 10 years ago” • VA: 20/30 OD, 20/30‐2 OS • Pupils: normal, ‐APD • Confrontations: left field restricted OD, OS • Refraction: • OD +1.00 ‐0.50 x 175 20/15 • OS +1.25 –0.75 x 008 20/15 Kline L. Neuro-Ophthalmology Review • Normal IOP and ant/post seg exam Manual. 5th Edition. 50 Imaging considerations for this patient… And what about this one? • CT vs. MRI • ±contrast • ±angiography • Location to scan • ±urgency • CT with Diffuse Weighted Imaging (DWI) if acute And… expect eventual structural loss 12 6/14/2021 Unexplained VF Loss 66 year old AA FM • Left eye: NLP due to old RD • Right eye: MRA of Brain – Clear Silent Migraine ? • Migraine VF Loss – Anything and Everything • Small peripheral scotomas, constricted fields, total loss…… • Can last up to 75 days • Progressive cortical depression – associated with vascular changes • Leads to vasoconstriction, • Then vasodilation • Brief neuronal excitation, followed by prolonged inhibition • Triggers headache phase • RNFL thinning around ONH , and faster progression of VF loss in NTG 13 6/14/2021 VF Loss – Migraine vs. Tension H/A Benign Episodic Pupillary Mydriasis • women with migraines • last minutes to one week; usually 12 hours • may or may not react to light http://www.nature.com/eye/journal/v21/n1/f ull/6702422a.html Yener. Neuro‐Ophthalmology, 2017. 76 Caucasian male Unexplained vascular changes.. ? 30% carotid occlusion, kidney disease “Blood work‐up”….tests driven by differentials CBC with differential Chem 7 Lipid Profile ESR C‐Reactive Protein 14 6/14/2021 CBC Index Clinical Significance Red Blood Count (RBC) Anemia and classification Platelet Count (PLT) Clotting disorders Mean Platelet Volume (MPV)
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