Comprehensive ophthalmologists often encounter patients with neuro-ophthalmic problems and are tasked with making rapid referral decisions. How do you distinguish the routine from the urgent based on timing of symptoms and clinical findings? Sophia M. Chung, MD, offered guidance for when to treat and when to refer in cases of acute vision loss in elderly patients during a Saturday symposium, “A Practical Approach to Neuro-Ophthalmic Problems: When to Treat and When to Refer” (Sym09V).
When to observe. In the absence of constitutional symptoms, patients with hemorrhagic disc edema with a small cup-to-disc ratio are likely have nonarteritic anterior ischemic optic neuropathy (NAION). There are no effective treatments available, according to Dr. Chung, and these patients can be managed with conservative observation. Physicians can discuss controlling risk factors such as blood pressure, diabetes, and sleep apnea with the patient to lower the risk of contralateral involvement.
When to treat and refer. If the dilated examination reveals pallid disc edema, this should raise concerns for arteritic anterior ischemic optic neuropathy (AAION). Treat immediately with high-dose intravenous or oral corticosteroids, as these patients have a high risk of contralateral vision loss. Blood work should also be performed. Clinicians can then consider scheduling a temporal artery biopsy, or refer to a rheumatologist or neuro-ophthalmologist
When to refer. The combination of acute painless vision loss and relative afferent pupillary defect supports an ischemic etiology, said Dr. Chung. If there is transient monocular vision loss or evidence of a central or branch retinal artery occlusion, refer immediately to a stroke center or the emergency department, as these patients have a significantly increased risk of stroke. In addition, patients with pituitary apoplexy (vision loss accompanied by ophthalmoparesis and severe headache) or acute homonymous hemianopia should be sent to the emergency department for further evaluation.
During the dynamic panel discussion, session chair Valerie Biousse, MD, fielded questions from the audience relating to the urgent nature of acute vision loss. Timing, in this case, makes a difference. She noted that with any vascular problem involving the eye, acute is within one week. Patients seen outside this window should be referred for an emergency stroke workup. While wrapping up the session, Dr. Biousse offered this final thought: “Neuro-ophthalmology symptoms often reveal an underlying neurology emergency.” —Keng Jin Lee, PhD
Watch the symposium in full. If you are registered for AAO 2020 Virtual, you have access to the archived presentations on the virtual meeting platform until Feb. 15, 2021. Log in to the virtual meeting platform: Next, from the Lobby screen, select “Sessions” from the top navigation; click “Agenda” from the drop-down menu; click the “Saturday” tab; and select the “Saturday” tab; and either enter “Sym09V” into the filter or else scroll down to “Sym09V: A Practical Approach to Neuro-Ophthalmic Problems: When to Treat and When to Refer!.”
Financial disclosures. Dr. Biousse: GenSight: C; Neurophoenix: C. Dr. Chung: None.
Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.
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