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Kyle Ruff, OD Sudden Onset of Bilateral Hemorrhagic Disk

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Kyle Ruff, OD Sudden Onset of Bilateral Hemorrhagic Disk Kyle Ruff, OD Sudden Onset of Bilateral Hemorrhagic Disk Swelling and Significant Gross Vision Loss in a Newly-controlled Middle-age Diabetic Abstract: This case report of a sudden onset of significant bilateral painless vision loss associated with hemorrhagic disc edema discusses differentiating life-threatening and sight-threatening potential diagnoses through a quick and effective evaluation. I. Case history: •49 year old Native American male •Presented on 6/7/14 with decreased central vision OS and was diagnosed with moderate non-proliferative diabetic retinopathy with possible diabetic macular edema. Two days later, the patient awoke with sudden bilateral painless vision loss. •Medical Hx: Diabetes type II x 8 years (newly controlled), Hypertension Ocular Hx: No previous record or significant ocular Hx per patient •Medications: Insulin Detemir, Linagliptin, Lisinopril, Metformin, Pravastatin. •Other information: No primary care physician for the past 1-2 years. II. Pertinent Findings: •Clinical: - VA: 20/400 OD, 20/25 OS - Significant dot/blot hemorrhages in all four quadrants OU - Peripapillary splinter hemorrhages OU - Significant disc edema OU - HFA 24-2: OD: Severe depression 360 degrees with mild sparing 10 degrees superior to fixation. OS: Severe depression 270 degrees with inferior/temporal sparing including inferior fixation. •Laboratory Studies: - A1C: 11.0 (5/19/14); 6.4 (7/23/14) - Glucose range: 125 to 179mg/dL (7/7/14 to 8/6/14) - CRP: 24.48 mg/L (7/26/13), 22.66 (7/23/14), 40.38 (8/6/14) – (all elevated) - ESR: 70 mm/hr (7/26/13), 66 mm/hr (8/6/14) – (both elevated) - PTT: 23.8 to 27.1 sec. (normal) - Fibrinogen: 521 mg/dL. (elevated) - INR: 1.0 (low) - ANA: negative •Ancillary Testing: - B-Scan and Optic Nerve Head OCT: bilateral buried disc drusen - CT scan: no evidence of acute pathology (6/7/14) III. Differential Diagnosis: •Bilateral non-arteritic anterior ischemic optic neuropathy (NAION) •Bilateral arteritic anterior ischemic optic neuropathy (AAION) •Diabetic papillopathy •Papilledema from intracranial hemorrhage •Malignant hypertension •Inflammatory optic neuritis •Compressive tumor IV. Diagnosis and Discussion: •NAION: Primary diagnosis is bilateral non-arteritic ischemic optic neuropathy (+) Crowded optic discs. Upon resolution of edema, optic nerve C/D was 0.10 round OU with significant pallor. (+) Buried disc drusen (+) Previous uncontrolled diabetes (+) Rapid improvement in retinopathy within one month likely secondary to non- perfusion due to extensive capillary dropout (+) Stable gross vision loss (-) Segmental disc edema typically seen in NAION (severe edema 360˚) •AION: (-) Abnormal age for Giant Cell Arteritis: 49 years old (-) No classic symptoms of GCA: scalp tenderness, jaw claudication, temporal artery tenderness, weight loss, fever or joint aches (+) Significant bilateral ONH pallor upon resolution of disc edema (+) Elevated ESR and CRP •Diabetic Papillopathy: (-) Newly controlled diabetes: •A1C (5/19/14): 11.0 •A1C (7/23/14): 6.4 (-) No improvement in vision loss or retinal ischemia as typically noted in diabetic papillopathy. •Papilledema: (-) No symptoms of increased intracranial pressure: intensifying headaches, postural change-triggered headaches, diplopia, tinnitus, nausea or vomiting (-) CT scan showed no evidence of acute pathology V. Treatment and Management: •Co-managed with retinal ophthalmologist. •Urgent referral for co-management with a primary care physician for the treatment and management of diabetes and for a work-up regarding a possible underlying systemic inflammatory condition due to elevated ESR and CRP. •Referral to low vision specialist if no improvement in vision. VI. Conclusion: •Clinical Pearls - Patient history - Onset of symptoms - Type of patient symptoms Symptoms of GCA Symptoms of Papilledema - Underlying systemic conditions - +/- Improvement of symptoms with time or treatment •Will be supplemented with fundus photos, OCT, B-scan, VF, and references. .
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