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Fall 2017 Newsletter
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Ophthalmic Technician Education Program

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EDUCATION

Case Study: Out of Left Field

Danesh Kim
Presenter: Jennifer Danesh, MD Discussant: Kimberly Gokoffski, MD, PhD
 

History

  • 63-year-old female presents as referral for bitemporal visual field defect OU
  • Past medical history significant for type 2 diabetes, hypertension, gout
  • Past ocular history significant for glaucoma suspect, ptosis, and dry eye syndrome
  • Review of systems negative for headaches, nausea, vomiting, fevers, or weight loss

Exam Findings

  • BCVA 20/20 OU, IOP WNL, P RR no RAPD. EOMI OU
  • Color plates full OU
  • Slit lamp exam: Absent tear lake bilaterally, otherwise WNL
  • DFE: CDR 0.7, sharp and pink OU, otherwise WNL
Figure 1: HVF 24-2 over the course of 1-2 years displayed above. Findings significant for a new, sudden onset dense bitemporal field defect.
Figure 1: HVF 24-2 over the course of 1-2 years displayed above. Findings significant for a new, sudden onset dense bitemporal field defect.

Differential Diagnosis

  • Most common
    • Pituitary adenoma
      • Macroadenoma
      • Secretory vs non-secretory
    • Sphenoid or parasellar meningioma
    • Craniopharyngioma*
    • ICA Aneurysm (parasellar)
  • Other possibilities
    • Chiasmal optic neuritis
      • Infectious or demyelinating
    • Chiasmal glioma, Pinealoma*
      • Kids
    • Abscess
    • Metastatic lesion

Additional Investigations

  • OCT MAC/RNFL/GCC all WNL
  • Prior to ordering an MRI, repeat visual fields were obtained
Figure 2: The bitemporal field was no longer noted.
Figure 2: The bitemporal field was no longer noted.

Diagnosis

  • Dry Eye Syndrome

Pathophysiology

  • Given the rapid, sudden nature of the field loss and normal repeat fields, the suspicion for a true central lesion is very low
  • Dry eye syndrome can manifest in a variety of ways on visual field testing, and can mimic defects resembling glaucoma, central lesions, and many others.
  • There are many extrinsic factors and ocular findings that may cause perimetry defects that are not secondary to true pathology. These include:
    • Anatomical features
      • Blepharoptosis
      • Artificial eyelashes
      • Tilted disc syndrome
      • Cataract (PSC>NSC)
      • Corneal opacities (scar, SPK/dry eye)
      • Non-organic/Functional causes
    • Extrinsic factors
      • Pupil size
      • Refractive error
      • Rim artifact
      • Multifocal IOL
      • Patient learning or fatigue
      • Proper technician involvement
  • Examples:
Figure 3A: HVF 24-2 illustrating an inferior arcuate and inferior nasal step which were actually due to lens rim artifact, as these defects resolved with lens adjustment and repeat testing.
Figure 3A: HVF 24-2 illustrating an inferior arcuate and inferior nasal step which were actually due to lens rim artifact, as these defects resolved with lens adjustment and repeat testing.
Figure 3B: Dermatochalasis causing bitemporal field defects concerning for a central lesion, namely a sellar mass. These patients had MRI's to rule out such pathology.
Figure 3B: Dermatochalasis causing bitemporal field defects concerning for a central lesion, namely a sellar mass. These patients had MRI’s to rule out such pathology.
Figure 3C: Tilted disc syndrome is a congenital, non-hereditary syndrome associated with high myopia, and is comprised of bilateral optic disc tilting, situs inversus of the major retinal vessels, and visual field defects- most commonly superior and/or temporal. Visual field defects associated with tilted disc syndrome may show great improvement with refractive correction during testing.
Figure 3C: Tilted disc syndrome is a congenital, non-hereditary syndrome associated with high myopia, and is comprised of bilateral optic disc tilting, situs inversus of the major retinal vessels, and visual field defects- most commonly superior and/or temporal. Visual field defects associated with tilted disc syndrome may show great improvement with refractive correction during testing.
Figure 3D: Toxic optic neuropathy due to a variety of medications (above, ethambutol. Osaquona et al 2014) can also mimic bitemporal field loss, though toxometabolic insults typically result in cecocentral scotomas.
Figure 3D: Toxic optic neuropathy due to a variety of medications (above, ethambutol. Osaquona et al 2014) can also mimic bitemporal field loss, though toxometabolic insults typically result in cecocentral scotomas.

Summary Points

  • Surgical excision

References

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Produced by: Monica Chavez, John Daniel, Dr. Vivek Patel and Mellissa Linton
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