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Neuro-Ophthalmology​

Case 19

Contributor: Arshia Eshtiaghi (CC3)

Patient Presentation: A 24-year-old woman was referred to a tertiary ophthalmology clinic after reporting 3 days of painless, blurred vision in the superior field of her left eye. Her past medical history was significant for congenital nephrotic syndrome; she was receiving hemodialysis every other day for the last 2 years. On examination, her best-corrected distance visual acuity is 20/20 OU. There was a left RAPD. Fundus examination was performed and shown below:

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Question: What is the abnormality in the fundus photography above?

A Humphrey visual field (24-2) was subsequently performed and showed a superior altitudinal defect in the left eye.

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Further review of the patient’s electronic medical record demonstrated 7 episodes of hypotension during dialysis treatments over the last 3 months, the most recent event being one week ago where her blood pressure fell to 70/40 for 5 minutes. 

Question: What is the most likely diagnosis for this patient?

OCTs of the retinal nerve fiber layer and ganglion cell analysis were acquired and shown below.

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Question: How would you describe these OCTs in the left eye?

A second series of OCTs of the retinal nerve fiber layer and ganglion cell analysis were acquired and shown below. 

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Question: Based on the above OCTs, when were these OCTs performed in relation to the patient’s clinical presentation?

Question: What can we expect on repeat RNFL and GCA analysis in a year from now?

Question: What treatment recommendation should be made to prevent subsequent NAION in the fellow eye?

References:

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  1. Cestari DM, Gaier ED, Bouzika P, et al. Demographic, Systemic, and Ocular Factors Associated with Nonarteritic Anterior Ischemic Optic Neuropathy. Ophthalmology. 2016. doi:10.1016/j.ophtha.2016.08.017

  2. Kerr NM, Chew SSSL, Danesh-Meyer H V. Non-arteritic anterior ischaemic optic neuropathy: A review and update. J Clin Neurosci. 2009. doi:10.1016/j.jocn.2009.04.002

  3. Fard MA, Ghahvehchian H, Subramanian PS. Optical coherence tomography in ischemic optic neuropathy. Ann Eye Sci. 2020. doi:10.21037/aes.2019.12.05

Learning Objectives:

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  1. To identify the classic clinical, fundus and OCT signs of NAION.

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