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Wolters Kluwer — Technical Presentation (February 2021)
24 slides from Wolters Kluwer's technical presentation, February 2021
Slide 1: An older patient with difficulty reading
An older patient with difficulty reading Victoria S. Pelak, MD February 2021 Professor of Neurology and Ophthalmology University of Colorado School of Medicine
Slide 2: History of Present Illness
History of Present Illness • 54-year-old man with 3-4 years of difficulty reading • Trouble seeing up close – hard for him to describe • Vision not blurry • Difficulty with spreadsheets that impacted his work as military data analyst and he had to stop working • Increased font size on computer, use
Slide 3: Overview of course
Overview of course • Two years ago, after 2nd pair of new glasses and continued reading difficulty referred to cataract surgeon and had successful cataract extraction with intraocular lens placement, both eyes: no help • Three months prior to neuro-ophthalmology presented, he stopped driving becau
Slide 4: Past History
Past History • Ocular • Former smoker (2 pack years) • Wears progressive lenses • Family • PCIOL OU: 2 years prior • Colon cancer: father and two male siblings • Medical • Congenital color blindness: • Obstructive sleep apnea, father obesity, hypertension • Meds • Social • Lisinopril 10 mg / day • C
Slide 5: Exam - Basic
Exam - Basic Right Left Best corrected acuity 20/25 20/25+1 difficulty managing use of pinholes J2 J2 Color vision Ishihara 14 Control +4 Control +4 Pupils 5 light /3 dark; brisk; 5 light /3 dark; brisk no APD no APD Intraocular Pressure 14 14 Extraocular Movement Full ductions Full ductions +saccad
Slide 6: Exam – Slit Lamp
*posterior chamber intraocular lens Exam – Slit Lamp Right Left Lids/Lashes Normal Normal Conjunctiva/Sclera White/Quiet White/Quiet Cornea Clear Clear Anterior Chamber Deep/Quiet Deep/Quiet Iris Normal Normal Lens *PCIOL; no posterior capsule opacity *PCIOL; no posterior capsule opacity Vitreous Sy
Slide 7: Neurologic Examination
Neurologic Examination Mental Status completed during first clinic visit: • Alert and oriented to person, place and time with normal attention, recent and remote memory. • Language: occasional word finding difficulty but normal grammar and able to write. • Mood and affect normal, although somewhat d
Slide 8: Further Evaluation
Further Evaluation • Retinal Optical Coherence Tomography: Normal • Macula and Retinal Nerve Fiber Layer thickness • Farnsworth-Munsell Dichotomous D-15 Test (test of color hue): Normal
Slide 9: Differential Diagnosis: guides next step
Differential Diagnosis: guides next step • Summary: 54-year-old with difficulty reading causing an inability to work with a normal eye examination and 20/25 vision. He had normal ocular alignment and no evidence of convergence insufficiency. • Potential causes (with notations) • Brain-related alexia
Slide 10: What is the next best step?
What is the next best step? Fluorescein angiogram Humphrey Visual Field Repeat MRI Brain scan Psychiatry Consultation
Slide 11: Answer B: We chose Humphrey 24-2 Visual Field
Answer B: We chose Humphrey 24-2 Visual Field Interpretation: Left homonymous hemianopia Left Eye Right Eye Assessment for central visual field loss (i.e., central 24 degrees or 10 degrees) is important for patients reporting reading difficulties with normal visual acuity
Slide 12: What to do next?
What to do next? Visual Evoked Response Electroretinogram (ERG) Refer patient to Psychiatry Review the MRI brain scan
Slide 13: Answer D: We chose to review the MRI
Answer D: We chose to review the MRI For age 54, he has more significant occipital, temporal, and parietal atrophy than expected
Slide 14: Localization and differential diagnostic reasoning
Localization and differential diagnostic reasoning • Why is this likely to be a true central nervous system problem? • Posterior cortical visual regions include occipital, posterior temporal, and the posterior parietal regions. With degeneration of these posterior regions, dysfunction occurs and res
Slide 15: Next step: Formal neuropsychological testing
Next step: Formal neuropsychological testing Options for referral for neuropsychological (i.e., cognitive) testing: 1) Refer to a neurologist: call in advance to let them know your concerns and they can see patient and order testing. 2) Refer to a neuropsychologist for cognitive testing and then to
Slide 16: Neuropsychological test results and diagnosis
Neuropsychological test results and diagnosis • Neuropsychological testing: revealed findings of relative sparing of memory, executive, and language functions compared to impairment in higher order visual processing. • Additional lab evaluation: all normal or negative - TSH, comprehensive metabolic
Slide 17: Posterior Cortical Atrophy (PCA) Syndrome
Posterior Cortical Atrophy (PCA) Syndrome PCA syndrome is a progressive, neurodegenerative condition most commonly due to Alzheimer’s disease (AD) with specific criteria1. • Visual dysfunction, particularly reading impairment, is the most common initial presentation of PCA syndrome to the neuro-opht
Slide 18: Summary of the Clinical Criteria for PCA Syndrome
Summary of the Clinical Criteria for PCA Syndrome1 • Gradual progression with prominent early disturbances in visual or other posterior cognitive functions • Three of the following core features should be present early in the course: space perception deficit, object perception deficit, constructiona
Slide 19: AD and the PCA syndrome continued
AD and the PCA syndrome continued AD is the most common form of age-related dementia and affects over 6 million people in the US alone. Early onset AD (age <65 years) occurs in 5% of patients. Prominent visual symptoms with relative sparing of memory loss can be the initial presentation of AD at any
Slide 20: Homonymous visual field loss and a report of a normal brain imaging
Homonymous visual field loss and a report of a normal brain imaging • If homonymous visual field patterns occur in the setting of a reportedly normal brain scan, or a brain scan described as having cortical atrophy only, neurodegenerative disease should be suspected and further evaluation for such s
Slide 21: FDG-PET in a patient with PCA Syndrome
Fluorodeoxyglucose-positron emission tomography (FDG-PET) in a patient with PCA Syndrome Arrows pointing to the right occipital and right parietal areas of hypometabolism noted by the “less orange” color. Images left to right move from rostral to caudal as labeled. These regions corresponded to this
Slide 22: Dissociation between visual complaints and examination findings in an older patient
Dissociation between visual complaints and examination findings in an older patient • …should raise the suspicion for a neurodegenerative disorder. • Impairment of activities of daily living (reading, working, driving) without explanation is a common presenting feature of PCA. • Subtle problems on e
Slide 23: After 3 years, the posterior atrophy became severe
After 3 years, the posterior atrophy became severe And after 5 years, the patient could no longer live at home with his wife and is currently in a memory care facility with dementia with behavioral issues.
Slide 24: References
References 1. Crutch SJ, Schott JM, Rabinovici GD, et al. Consensus classification of posterior cortical atrophy. Alzheimer's & Dementia 2017; 1-15. 2. Olds JJ, Hills WL, Warner J, Falardeau J, Alasantro LH, Moster ML, Egan RA, Cornblath WT, Lee AG, Frishberg BM, Turbin RE, Katz DM, Charley JA, Pela
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