Ophthalmic system
Pankaj Desai in Pre-eclampsia, 2020
Established ophthalmic entities associated with (pre)-eclampsia is cortical blindness, serous retinal detachment, Purtscher-like retinopathy, central retinal vein occlusions and retinal or vitreous haemorrhages. Ensuing visual symptoms include blurry vision, diplopia, amaurosis fugax, photopsia and scotomata, including homonymous hemianopia. There are multiple explanations for the ophthalmic features in pre-eclampsia. One of these is peripheral, meaning that the cause is in the retina. The exudative retinal detachment is a rare cause of visual loss in pre-eclampsia and eclampsia, produced by the involvement of the choroidal vascularization. While on ophthalmic changes in severe pre-eclampsia and eclampsia, it is worthwhile to revisit the funduscopic changes in this condition. Metaphorically, it has been stated that retinal vessels reflect the changes in renal and intracranial vessels. Another feature of these visual disturbances in women with imminent eclampsia is a recurrence. It is not uncommon to find such women reporting with first signs of visual alterations to the emergency obstetric care units seeking help.
Answers
Sukhpreet Singh Dubb, Kumaran Shanmugarajah, Darren Patten, Michael Schachter, Cristina Koppel in 500 Single Best Answers in Medicine, 2011
Retinal artery (B) and vein (A) occlusion are also painless and of sudden onset, but they typically occur in older patients and result in prolonged visual loss. Amaurosis fugax may herald retinal artery occlusion which is confirmed on ophthalmoscopy showing oedema and a cherry red macula. It is also a complication of giant cell (temporal) arteritis. Retinal haemorrhages and cotton wool spots are typically seen in retinal vein occlusion. Optic neuritis (D) is associated with MS and patients complain of painful, blurred vision. Acute angle glaucoma (E), again seen in older patients, presents with painful, blurred vision. Patients describe ‘seeing haloes around things’.
Demyelinating disorders
Matthew Tate, Johnathan Cooper-Knock, Zoe Hunter, Elizabeth Wood in Neurology and Clinical Neuroanatomy on the Move, 2015
Question 49 A 35-year-old man has a 6-year history of relapsing and remitting neurological symptoms. During the last 2 years, he has had a 1-month episode of recurrent intense electric-shock-like pain affecting the left side of his face, which eventually stopped with carbamazepine. He recently had an episode of progressive weakness and heaviness in his left leg, and he was unable to walk on it for 2 weeks. The patient is referred to a neurologist for advice on his future management. Which of the following is the most appropriate management? Please choose the single best answer from the following answers: 1) Information and reassurance 2) Interferon 1-beta 3) Long-term oral antibiotics 4) Oral course of high-dose methylprednisolone for 5 days 5) Regular baclofen Question 50 A 23-year-old woman develops worsening visual loss in her left eye over several days, associated with pain on moving the eye, particularly on looking up. On examination, she has reduced visual acuity in the left eye, and she has lost the perception of colour in the centre of her vision, but the fundi are normal. A swinging torch test shows a left afferent pupillary defect. Over the next 4 weeks, her vision returns to normal. Which of the following is the most likely diagnosis? Please choose the single best answer from the following answers: 1) Amaurosis fugax 2) Giant cell arteritis 3) Occipital lobe lesion 4) Optic neuritis 5) Orbital tumour Question 51 A 30-year-old woman presents with vertigo, double vision, slurred speech and imbalance on walking. On examination, she has a right-sided dysmetria, brisk tendon reflexes, extensor plantar responses and an ataxic gait. She has a horizontal jerking nystagmus, worse on looking right, and a right internuclear ophthalmoplegia. Two years previously, she had a 4-week period of blurred vision in her left eye. Which investigation is most likely to confirm the diagnosis? Please choose the single best answer from the following answers: 1) Computed tomographic (CT) scan of the head 2) Full blood count 3) Midstream urine sample 4) Magnetic resonance imaging (MRI) scan of the head 5) Visually evoked responses Question 52 A 48-year-old man presents with a 5-to 7-year history of gradual functional deterioration in his legs. For the last few years, he has noticed that his legs become stiff and heavy if he walks more than a couple of miles, and he has recently fallen over a few times. Over the last few months, he has been having problems with urinary frequency and nocturia. On examination, he has spastic paraparesis with brisk tendon reflexes and extensor plantar responses. Joint position sense is absent in the toes, and touch is reduced up to both knees. There are no eye movement, fundal or cranial nerve abnormalities. Please choose the single best answer from the following answers: 1) Cervical myelopathy 2) Guillain-Barré syndrome 3) Primary progressive MS 4) Relapsing-remitting MS 5) Transverse myelitis Answers Investigations: SBAs Answer 48 2) Multiple sclerosis: The history of neurological symptoms affecting the eye 1 year previously followed by upper motor symptoms in one leg is typical of MS. Answer 49 2) Interferon 1-beta: This history suggests two severe episodes of relapsing MS over the last 2 years. Sharp facial pains suggest trigeminal neuralgia, which is a common presentation of MS. Patients with at least two relapses in 2 years often benefit from disease-modifying treatment such as Interferon 1-beta, which has been shown to reduce relapses by 30% in active relapsing-remitting MS.
Atypical erythrocytes and platelets in a patient with a pro-thrombin mutation
Published in Platelets, 2014
Etheresia Pretorius, Natasha Vermeulen, Janette Bester
Prothrombin mutation G20210A, anti-phospholipid syndrome as well as iron overload has previously been shown to cause thrombotic events. The main reason for this is the involvement of these anomalies in causing hypercoagulability of the coagulation system, which frequently leads to venous and arterial thrombotic events. We report the case of a 37-year-old white female with prothrombin mutation G20210A, anti-phospholipid syndrome, as well as an increased serum ferritin level, who experienced two transient ischemic attacks and suffers from regular amaurosis fugax. We present an ultrastructural depiction of erythrocytes, platelets, and the fibrin network, to explain the clinical manifestations of the thrombotic state seen in this patient.
Spontaneous internal carotid dissection in a 38-year-old woman: a case report
Published in Journal of Community Hospital Internal Medicine Perspectives, 2015
Kareem Abed, Amit Misra, Viren Vankawala
This case report describes a patient found to have amaurosis fugax as a result of non-traumatic internal carotid dissection. Monocular blindness can be due to multiple causes including keratitis, acute glaucoma, vitreous hemorrhage, uveitis, retinal vascular occlusion, retinal detachment, optic neuropathy, trauma, or vascular malformations. In the setting of headache, neck pain, and an otherwise normal ophthalmic examination, this case report highlights the importance of recognizing transient ischemic attack and carotid artery dissection in the differential diagnosis. To further clarify the diagnosis, carotid ultrasound may aid diagnosis as was seen in this case, where decreased internal carotid artery velocities were found and subsequent CT angiography of the neck confirmed a diagnosis of carotid dissection. If a dissection is present, progression of symptoms may indicate impending cerebral infarction and warrant immediate attention. Antiplatelet therapy is the first-line treatment with anticoagulation, thrombolysis, and surgery reserved for cases of recurrent, progressive symptomatic episodes. Surgical options include endovascular repair such as angioplasty, stent placement, embolization, surgical revascularization, and bypass.
New Information on the Value of Plaque Characterisation — Relation to Symptoms
Published in Acta Chirurgica Belgica, 2000
T. J. Tegos, E. Kalodiki, M. M. Sabetai, P. Stavropoulos, A. N. Nicolaides
This paper reviews the literature on the significance of carotid plaque echomorphology and degree of stenosis in relation to the different types of cerebrovascular symptomatology (amaurosis fugax, hemispheric transient ischaemic attacks, stroke) and the asymptomatic status. It provides evidence that amaurosis fugax is associated with hypoechoic and severely stenosed plaques, the hemispheric transient ischaemic attacks and stroke are associated with plaques of intermediate echodensity and stenosis while the asymptomatic status is associated with hyperechoic and moderately stenosed plaques. It lends support to the notion that plaque hypoechoicity is associated with embologenicity. It supports the view that the severe carotid stenosis facilitates the opening of the cerebral collateral circulation and that amaurosis fugax is associated with an “opened” cerebral collateral supply as contrasted to the cerebrovascular symptomatology. It proposes the inclusion of the cerebral collateral circulation as a stroke risk factor along with the plaque echomorphology and the degree of stenosis in the natural history studies of asymptomatic individuals with carotid bifurcation plaques.