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A case of AAION PowerPoint Presentation

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Description : giant cell arterirtis caused AAION

Tags : optha cases,giant cell arteritis

Published on : Dec 08, 2019 | Views : 1983 | Downloads : 0

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Department of Ophthalmology CASE DISCUSSION JANGAM CHAKRAVARTHI BLOCK 4
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Case A 70-year old woman suffered sudden but painless loss of vision in one eye. She also has experienced headaches and shoulder pain during the past several months. The affected eye is shown in the photograph. Her other eye remains normal.
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Salient Features 70 year old female Sudden but painless unilateral loss of vision Headaches Shoulder pain Pale swollen optic disc
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Differential Diagnosis Amaurosis Fugax Non-arteritic ischemic optic neuropathy (NAION) Arteritic ischemic optic neuropathy (AION) Giant Cell Arteritis
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Amaurosis Fugax ( AF )
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Non-arteritic anterior ischemic optic neuropathy (NAION)
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Arteritic anterior ischemic optic neuropathy (AAION)
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Giant Cell Arteritis
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Arteritic anterior ischemic optic neuropathy (AAION) caused by Giant cell arteritis (GCA) Final Diagnosis
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Discussion
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ION is due to: poor blood flow to the optic nerve Acute occlusion of the feeding arteries Ischemic Optic Neuropathy ( ION ) Short posterior ciliary arteries Ophthalmic artery
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Ischemic Optic Neuropathy ( ION ) Nonarteritic ION (cardiovascular risk factors) Arteritic ION (vasculitis) Nonarteritic Anterior ION (NAION) with swollen optic disc Nonarteritic Posterior ION (NA-PION) with normal optic disc Arteritic Anterior ION (AAION) with swollen optic disc Arteritic Posterior ION (APION) with normal optic disc
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Anterior Ischemic Optic Neuropathy Most serious type of ION. Most common over 50 years Primary cause is due to a disease called GCA or Giant Cell Arteritis or temporal arteritis. Gender – more common in women 3:1 Painless monocular over hours to days
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Pathophysiology
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Age: Fifty years of age or older at onset. Gender : 3 times more common in women than in men Race: Common among Caucasians > other races Giant cell arteritis New onset of localized headache. Temporal artery pulse. Elevated ESR. Positive temporal artery biopsy. RISK FACTORS
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CLINICAL FEATURES (Ocular)
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PRESENTATION (Physical)
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Systemic symptoms GCA : Patients with NA-AION have no systemic symptoms of giant cell arteritis. Visual symptoms: Amaurosis fugax is highly suggestive of AAION and is extremely rare in NA-AION. Hematologic abnormalities:Elevated ESR and CRP, particularly CRP, is helpful in the diagnosis of GCA. Patients with NA-AION do not show any of these abnormalities. Early massive visual loss: Extremely suggestive of A-AION. Chalky white optic disc edema: This is almost diagnostic of A-AION and is seen in 69% of AAION eyes. In NAAION, chalky white optic disc edema occurs only very rarely with embolic occlusion of the posterior ciliary artery. AAION associated with cilioretinal artery occlusion . This is almost diagnostic of AAION. Fluorescein fundus angiography: Evidence of posterior ciliary artery occlusion in AAION. Temporal artery biopsy. DIFFERENTIATION : AAION FROM NAAION
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Peripapillary hemorrhages Nerve fiber layer edema Obscured borders 20 The involved swollen optic disc is acutely pale AAION NAION
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WORK UP : AAION The diagnostic work-up for GCA includes Erythrocyte sedimentation rate (ESR) >47mm C-reactive protein >2.45 MG/DL Fluorescein fundus angiographic (FFA): Critical diagnostic test for A-AION during the early stages shows thrombosis and occlusion of the posterior ciliary artery in GCA Jaw Claudication Neck pain
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GIANT CELL ARTERITIS (Temporal Arteritis) Generalized granulomatous inflammation of medium- to large-sized vessels that occurs in the elderly. The most common primary vasculitis in adults. Presents with vision loss. Associated symptoms: headache, jaw claudication, diplopia, myalgias, and constitutional symptoms.
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Diagnosis
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There are specific funduscopic findings Choroidal hypoperfusion indicates multifocal ischemia on Fluorescein angiography normal choroid Lack of choroidal perfusion 24
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The workup of suspected Arteritic ION GCA Symptoms / signs ? Do blood tests but ESR, CRP, Hb, PLT, Fibrinogen Urgent TAB* TAB* in 1 wk Iv Methylprednisolone  oral Prednisone + aspirin yes no IV Methylprednisolone  oral Prednisone + aspirin until biopsy results high normal NAION * TAB = Temporal Artery Biopsy 26
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Treatment AAION is an EMERGENCY. Early treatment is essential. Tocilizumab is a monoclonal antibody humanized for treatment of AAION Methotrexate is one of the most widely studied “steroid sparing” agents. Steroids Oral prednisone in the range of 60-100mg/day may be used initially and for follow up to intravenous pulse therapy IV methylprednisolone at 1g/day for the first three days has been recommended for severe cases.
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Thank you!
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PRESENTATION Sudden onset Painless Monocular Always discovered on awakening Nocturnal Hypotension VISUAL LOSS Non-arteritic anterior ischemic optic neuropathy (NAION)
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SIGNS PARAMETER Visual Acuity Visual Field Colour Vision Ophthalmic Exam Findings FA Finding Laboratory Evaluation FINDING Often better than 20/100. Typically Inferior Altitudinal defect. May be severely impaired when VA is good. Diffuse OR sectorial hyperaemic disc swelling associated with FEW peripapillary splinter- shaped haemorrhages. Small OR cupless disc in fellow eye. Swelling gradually resolves and pallor in 3-6 weeks after onset. Acute Stage: localized disc hyperfluorescence, intense, eventually involves entire disc. No associated laboratory abnormalities.
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Non-arteritic Anterior Ischemic Optic Neuropathy
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The pathogenesis of NAION differs from IHD or CVA decrease in blood flow Edema of optic disc Blockage of axonal flow Compression of axons and blood vessels Necrosis and demyelination of nerve fibers Cardiovascular risk factors Crowded optic disc 33