Neuro-Ophthalmic Disorders in Optometry SIG

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1 Neuro-Ophthalmic Disorders in Optometry SIG AMERICAN ACADEMY OF OPTOMETRY Chair s Message: SIG LEADERSHIP Joseph Sowka, OD, FAAO, Diplomate, Glaucoma Chair Dr. Sowka is a Professor of Optometry and serves as the Director of the Glaucoma Service and Chief of the Advanced Care Service. He is a Diplomate in Glaucoma. Patricia Modica, OD, FAAO Vice Chair Dr. Modica is an assistant clinical professor at the University Eye Center at the SUNY College of Optometry. She teaches the neuro-ophthalmic disease curriculum as well as runs the Neuro-Eye Service at the College. Kelly Malloy, OD, FAAO, Diplomate Several years ago, the America Academy of Optometry had only one encompassing Disease Sec9on. Under this umbrella, there were the subsec9ons of Glaucoma, Re9na, Neuro-ophthalmic Disease, and Anterior Segment Disease. At that 9me, I was Chair and Diplomate Chair of the Disease Sec9on and worked with each subsec9on. I was especially pleased to work amongst the individuals in the neuro-ophthalmic disease sec9on, including Drs. Len Messner, Kelly Malloy, Mark Sawamura, and PaJy Modica. They were a great group of dedicated individuals who were a pleasure to learn from and to be around. When the AAO decided to discon9nue the Disease Sec9on in favor of individual disease-related specialty subsec9ons and special interest groups (SIGS), it was a natural decision to get together this talented group and form our current SIG, with Len Messner as our ﬁrst Chair. It is with great humility that I take over the leadership of the Neuro-ophthalmic Disorders in Optometry Special Interest Group from Dr. Len Messner. Over the previous years, Len provided great guidance and wisdom as we developed our mission, programs, and SIG. We are especially honored to be able to present the annual Larry Gray Memorial Symposium to keep alive Larry s ideals, teachings, and interest in neuro-ophthalmic disease. Larry was a pioneer who truly showed how optometry could work collabora9vely with neurology and neuro-ophthalmology to assist pa9ents in geqng the best care possible. We in the Neuro-ophthalmic Disorders in Optometry SIG look forward to con9nuing our mission of providing educa9on and resources to our colleagues in this discipline. We hope to see you all at the Larry Gray Memorial Symposium Thursday, Oct 12 at 10 am. Joe Sowka, OD, FAAO, Diplomate Chair, 2017 & 2018 Education Chair D r. M a l l o y i s a n A s s o c i a t e Professor and Director of the Neuro-Ophthalmology Service at The Eye Institute of Salus University. She is a Diplomate in Neuro-Ophthalmic Disorders. 1

2 Academy 2017 Chicago, IL October 11-14, 2017 EVENTS Lawrence G. Gray Symposium on NeuroOphthalmic Disorders Thursday, October AM - Noon The 2017 Gray Symposium: Neuro-Ophthalmic Top 10 Lists This symposium will help the clinician learn how to avoid common errors when evalua9ng neuro-ophthalmic cases such as diplopia, visual ﬁeld loss and unexplained loss of vision. Speakers: Joseph Sowka, OD, FAAO Jonathan Trobe, MD Cherie Fartash, OD, FAAO Valerie Purvin, MD What Happened at ACADEMY 2016 Anaheim? The 2016 Lawrence G. Gray Symposium NEURO-OPHTHALMIC AND BINOCULAR VISION DISORDERS FROM KIDS TO ADULTS: ConsideraPon of the ExaminaPon of the Neuro Peds PaPent: Patricia Modica, OD, and Chris9ne LLerena Law, OD, PhD. SUNY College of Optometry, NOVA SE. Drs. Modica and Law discussed strategies when conduct tes9ng on pediatric pa9ents with neuro-ocular dysfunc9on. In some instances, seda9on is necessary but this procedure is not completely risk free. There is a greater risk of respiratory and cardiac complica9ons so coordina9on with a pediatrician is recommended. Neuro-Ophthalmology: Pediatrics vs Adults. Stacy Pineles, MD, MS. Jules Stein Eye Ins9tute, David Geﬀen School of Medicine at UCLA. Dr. Pineles contrasted several condi9ons that aﬄict children and adults. The ﬁrst was Idiopathic Intracranial Hypertension. In pre-pubertal cases, gender and weight are nonfactors but there is a shi_ as these pa9ents age to females with higher BMI. Revised criteria for opening CSF pressure in pediatric IIH is 280 mm H2O. The second topic was ocular myasthenia. There is bimodal distribu9on in age of onset: under 5 and years of age. Eight to 30% will go on to develop generalized disease. Seventy-six percent have a Cogan s lid twitch but pediatric OMG can mimic any condi9on. Acetylcholine receptor an9body tes9ng is not as sensi9ve in children. The third condi9on presented with pediatric op9c neuri9s. This is a rare condi9on in children but when it presents, it is bilateral in 55% of cases with disc swelling in 61%. IndicaPons for Surgical and Non-Surgical Treatments of Acquired Binocular Diplopia. Joseph Demer, MD, PhD. Jules Stein Eye Ins9tute, David Geﬀen School of Medicine at UCLA. Dr. Demer discussed various surgical strategies to manage cases of acquired diplopia including tenotomy, recession-resec9on, plica9on of a folded tendon, transposi9on, myopexy, and pulley surgery. He then discussed his work on superior oblique palsies, orbital imaging and sagging eye syndrome. In his 2011 IOVS study, he found that only 35/50 pa9ents with a SO palsy had all three steps posi9ve on a Parks Three Step test (Sensi9vity of 70% and speciﬁcity of 50%). Sagging Eye Syndrome (SES) is a cause of acute onset diplopia in older adults. Orbital imaging shows degenera9on of the superior orbit pulley system due to the elonga9on of the LR-SR band. This degenera9ve change occurs in everyone but can aﬄict some pa9ents to a higher degree than others. The eye drops in the orbit and has poor ability to look in upgaze. Pa9ents with aponeuro9c ptosis are more likely to manifest this due to similar type of 9ssue change. SES pa9ents have 40% elonga9on of the SR muscle. Drs. Sowka, Law, Modica, Pineles, Demer, Malloy, and Messner (L to R 2

3 NEURO-OPHTHALMIC DISORDERS SIG and FELLOWS DOING RESEARCH SIG PROJECT At last year s academy, the Neuro-Ophthalmic Disorders in Optometry SIG and the Fellows Doing Research SIG partnered to conduct a research project on the ﬂoor of the Exhibit Hall during the mee9ng. It was themed: What Pupils Remember. The focus of the project was to analyze how pupil func9on may be inﬂuenced by prior trauma9c brain injury. The inves9ga9on u9lized the RAPDx instrument by Konan as an objec9ve and quan9ﬁable measurement device for dynamic pupillary func9on. The study recruited 300 subjects over the course of the 4 days of the mee9ng. Subjects were queried about a history of trauma9c brain injury as well as ocular and medical history. Approximately 30% of the subjects had a history of mild TBI. Sta9s9cal analysis was applied to the ﬁndings to iden9fy whether age, history of mild TBI, res9ng pupil diameter predicted pupil dynamics. This data will be presented at the 2017 AAO mee9ng. The study team was headed by Patricia Cisarik, OD, PhD, FAAO of the Southern College of Optometry. Members of the Neuro-ophthalmic Disorders SIG and Fellows Doing Research SIG were instrumental in the support roles of subject recruitment, research assistant recruitment and training, data collec9on and logis9cs. 3

4 THANK YOU FOR YOUR LEADERSHIP The oﬃcers of the Neuro-Ophthalmic Disorders SIG and the American Academy of Optometry thanked Dr. Leonard Messner for his dis9nguished service as the Chair of the SIG for the past 4 years. Prior to this appointment, Dr. Messner was the Chair of the Subsec9on on the NeuroOphthalmic Disorders within the Disease Sec9on. Under his visionary leadership, the SIG and the North American Neuro-Ophthalmology Society have partnered to provide high quality educa9on at the Lawrence G. Gray Memorial Symposium each year. A posi9on paper was authored that outlined the importance of optometry in the care of neuroophthalmic disorders pa9ents. His research in trauma9c brain injury has brought to the forefront, the important role of optometrists in the diagnosis of concussion, on the sideline or in the oﬃce. Addi9onally, collabora9ve research projects with the Fellows Doing Research SIG have produced signiﬁcant clinical ﬁndings. Thank you for your devoted leadership and collegiality. Dr. Leonard Messner (Past Chair) and Dr. Joe Sowka (Chair) 4

5 CASE PRESENTATION Subclavian Steal Syndrome: An Additional Risk Factor for Optic Neuropathy. Kelsey L. Moody, OD, Kelly Malloy, OD, FAAO, Diplomate, Erin Draper, OD, FAAO, Salus University Presented at the 2016 American Academy of Optometry Meeting in Anaheim, CA A 62-year old woman presented for evalua9on of glaucoma and possible op9c neuropathy. Her systemic history was remarkable for significant vascular disease including a heart ajack requiring a triple bypass and an arterial blockage in her le_ leg, requiring a stent. In addi9on, she had diabetes, hypertension, hypercholesterolemia and was a current smoker. She also had a history of alcohol abuse with head trauma. She had been previously treated for anatomically narrow angles with bilateral laser iridotomy. She complained of increasing glare/blur OS>OD and stars/spots in vision for the last 4 months. She also complained of le_ arm pain. Best corrected visual acuity was 20/20- OD and 20/30 OS. There was a rela9ve afferent pupil defect OD. Extensive op9c nerve cupping was seen and a superior and inferior arcuate defect was obtained with threshold perimetry. There was trace temporal pallor in the le_ eye. Blood pressure measurement was asymmetric at 118/68 RAS and 82/60 LAS, as was pulse rate. Blood pressure: 118/68 RAS / 82/60 LAS Pulse: 66 bpm RAS / 58 (thready) LAS 24-2 Humphrey visual field OS: generalized depression OD: generalized depression with sup > inf arcuate Optic Disc Cube OCT OD: thin NRR with thin sup> inf RNFL OS: normal NRR and RNFL At this point, she was diagnosed with bilateral op9c neuropathy with the right more severe than le_. There were mul9ple causes to consider based on history and examina9on: vascular, trauma, toxic/ nutri9onal, and glaucoma. To ascertain a cause, blood work was ordered including: CBC, ESR, CRP, platelets, serum folate, serum vitamin B12, Lyme 9ter, RPR, FTA-ABS, ACE, ANA, methymalonic acid, homocysteine, and SPEP. Neuroimaging in the form of brain and orbital MRI with and without contrast was obtained. Due to the asymmetric pulse and blood pressure, caro9d ultrasound was also obtained. 5

6 The only serologic abnormality was low Vitamin B12, for which she was started on supplements. Neuroimaging was normal. However, results of the caro9d ultrasound revealed more than 70% stenosis on the right and 50-60% stenosis on the le_ with proximal stenosis of the le_ subclavian artery. This was consistent with a diagnosis of subclavian steal syndrome (SSS). Vascular consulta9on resulted in right caro9d endarterectomy and addi9on of aspirin therapy to her previously prescribed clopidogrel. This resulted in resolu9on of le_ arm pain and her op9c neuropathy has been stable. Dietary counseling and smoking cessa9on were urged. Subclavian Steal Syndrome: An AddiPonal Risk Factor for OpPc Neuropathy: Caro9d artery disease is a well-known vascular condi9on that is o_en looked into for cases of nonglaucomatous op9c neuropathy, asymmetric op9c neuropathy and asymmetric re9nopathy. However, subclavian steal syndrome is not typically considered a poten9al e9ology, even though it o_en is seen in combina9on with caro9d artery disease, as they both occur due to atherosclerosis. Subclavian Steal Syndrome is retrograde blood flow in the vertebral artery or the internal thoracic artery, due to a proximal stenosis and/or occlusion of the subclavian artery. Posterior circula9on symptoms are more common in Subclavian Steal Syndrome due to reversal of blood in the ipsilateral vertebral artery in order to supply blood to the arm. Therefore, the areas of the brain typically supplied by the vertebral artery, namely the occipital lobe, cerebellum and brainstem can experience ischemia. Ischemic symptoms for these regions may include transient visual field loss, nystagmus and double vision. When a pa9ent presents with any of these transient symptoms, SSS should be considered as a poten9al e9ology. flow When inves9ga9ng e9ologies for op9c neuropathy, a clinical work-up can be cumbersome and a financial burden to the pa9ent, o_en including blood work, neuro-imaging of the brain and orbit and a caro9d ultrasound. To help target a work-up, clinicians can take blood pressure and pulse on both arms/wrists to detect any asymmetry, which may raise Subclavian Steal Syndrome and possibly caro9d artery disease higher on the differen9al diagnosis list. The presence of a blood pressure measurement between the two arms greater than 20 mmhg has been proven to be a sensi9ve test for the detec9on of SSS. In most cases, the affected arm will also have a weak or absent pulse and arm pain with exer9on. Only a small percentage of pa9ents with SSS will require treatment, but some may for co-morbid condi9ons or symptoms. About the authors: Dr. Kelsey L. Moody received her Bachelor of Science degree in Biology from Florida State University in She received her Doctorate of Optometry degree from the Pennsylvania College of Optometry at Salus University in 2015 where she graduated summa cum laude and with clinical honors. During her optometric studies, she completed an Advanced Studies cer9ficate program in Anterior Segment Disease. Dr. Moody is currently in her 2nd year of the new Two Year Advanced Residency in Neuro- Ophthalmic Disease at The Eye Ins9tute of Salus University. 6

7 Dr. Kelly Malloy is an Associate Professor at the Pennsylvania College of Optometry at Salus University, where she specializes in neuro-ophthalmic disease. She is the Director of the Neuro-Ophthalmic Disease Specialty Clinical Service at The Eye Ins9tute, and has achieved Diplomate status in this specialty at the American Academy of Optometry (AAO). She recently started the first of its kind 2-year Neuro- Ophthalmic Disease Residency program at Salus, which is now a fully accredited program. Although she currently spends the majority of her 9me related to clinical pa9ent care ac9vi9es and as the cocoordinator of the neuro-ophthalmic residency program, she also teaches in the Neuro-Anatomy and Neuro-Ophthalmic Disease courses at Salus University. Dr. Erin Draper earned her Doctorate of Optometry from the Pennsylvania College of Optometry at Salus University. She completed a residency in Low Vision Rehabilita9on at the Feinbloom Center and a fellowship in Neuro-Ophthalmic Disease at The Eye Ins9tute. Dr. Draper is an Assistant Professor at Salus University. She spends the majority of her 9me in clinical care at The Eye Ins9tute in both the Neuroophthalmic Disease Service and in Low Vision Rehabilita9on. Dr. Draper is an instructor in the Neuroanatomy and Neuro-Ophthalmic Disease courses at Salus University. She also serves as the cocoordinator for the Neuro-ophthalmic Disease Residency Program. THE SIG ON NEURO-OPHTHALMIC DISORDERS Mission Statement: The mission of the Neuro-ophthalmic Disorders in Optometry Special Interest Group is to enhance the knowledge of its members in the area of neuro-ophthalmic disease and improve the care given to patients with neuro-ophthalmic diseases as guided by the teachings of Dr. Larry Gray. The purposes of the Neuro-ophthalmic Disorders in Optometry Special Interest Group will be to: Serve as a primary resource for the Academy for papers, posters, courses, information, and research regarding neuro-ophthalmic disorders, and to advise the Academy on policy in these areas. Encourage inquiry and research into neuro-ophthalmic disorders. Promote, advance and enhance the identity of optometry as a profession with expertise in neuroophthalmic disorders. For more information: Please contact Dr. Joe jsowka@nova.edu 7

Sequential non-arteritic anterior ischemic optic neuropathy (NAION) Jonathan A. Micieli, MD Valérie Biousse, MD

Sequential non-arteritic anterior ischemic optic neuropathy (NAION) Jonathan A. Micieli, MD Valérie Biousse, MD A 68 year old white woman had a new onset of floaters in her right eye and was found to have