Optic Neuritis

Casebank History
1

Where are you:
FY2 in GP Surgery

Who the patient is:
Eileen Giles, a 28 year lady made an appointment to see you.

Other information you have about the patient:
None
What you must do:
Talk to the patient, take a history and discuss management.

Patient Information:

  • Your name is Eileen Giles. You are a 28 year-old lady.

  • You are having pain in right eye since yesterday and it’s getting worse.

  • The pain gets worse by eye movement.It is dull pain behind eye.

  • Pain does not radiate anywhere else.

  • Colour perception is difficult/difficulty in differentiating colours .

  • Vision problems could be present.

  • You got similar symptoms 3 months ago which resolved after about 1 weeks.You didn’t see a doctor at that time.

  • Your mum has Multiple Sclerosis and similar eye problems.

  • You believe that your diet is healthy. Drinks occasionally.

  • You work as an IT project developer and you have presentation in an hour.

  • No other significant past medical history.

Data Gathering

Introduction & confirm the identity of the patient

HISTORY & DIFFERENTIALS

  • SOCRATIS for pain

  • are you in pain now ? Offer analgesics…

Differential Diagnosis

  • Infection

  • Trauma or foreign body

  • Conjunctivitis - any discharge?

  • Glaucoma - Headache or vomiting ?

  • Multiple Sclerosis - Any weakness or sensory loss in legs ?

  • GCS- Any pain when opening your mouth or while combing your hair ?

Causes or Risk factors :

  • Multiple sclerosis or any other autoimmune condition in person or close relative.

  • Family hx of MS or optic neuritis ?

  • Virus or Infection.

  • Autoimmune condition / more common in Asian or Black African origin.

Others

  • FLAWS

  • MMA questions

  • DESA

  • Diet and smoking

  • ICE & PSYCHOSOCIAL

  • Has this affected you in any way ?

EXAMINATION

  • Vitals + eye examination ( painful eye movements and reduced visual acuity in affected eye 6/18 )
  • light reflex (poor response /sluggish)
  • Fundoscopy ( optic disc not visible or partially visible)
  • Neurological examination of face ,upper and lower limbs)

DIAGNOSIS

  • From what you have told me and my examination findings, you most likely have a condition called optic neuritis.

It is inflammation of the optic nerve which is the nerve responsible for vision. Inflammation of the optic nerve can cause pain when you’re moving your eyes and you may also have difficulty differentiating colors.

There can be different causes of optic neuritis. It can be due to infection but I’m concerned we need to rule out Multiple Sclerosis because your mother had Multiple Sclerosis. As Multiple Sclerosis tends to run in the family, so unfortunately you’re at risk for Multiple Sclerosis

Management

  • Go to hospital immediately,you will be seen by neurologist.

  • They will examine you ,perform some investigations like routine ,inflammatory markers, RBS ,urine ,MRI of the brain ,Lumbar puncture,nerve conduction studies.

  • They may give you steroids to reduce symptoms and medications to suppress your immune system .
  • Pt: Doctor I can’t go to the hospital I have a presentation in 1 hour
  • You need to go to the hospital immediately; you may not be able to see things properly on your presentation as you have reduced vision. It is a very serious condition. Why don’t you talk to your manager and see if the presentation can be done on a different day?
  • I can also give you a note explaining you have been advised to go to the hospital – sick note
  • Pt: Do you think it is Multiple Sclerosis?
  • At the moment given the family history optic neuritis is part of multiple sclerosis but you don’t have any other symptoms of multiple sclerosis so we need some further investigation to rule this out.
  • Pt: Will I lose my vision?
  • You did come to us and we will try to help you out with this and give you some medications to prevent any further visual loss.vision may get better but the problem can come and go.
  • Pt: Will I be wheel chair bound?
  • Unfortunately that may happen as multiple sclerosis progresses. There are meds that can reduce disease progress but unfortunately there’s no cure so as disease progresses that may happen

  • inform DVLA.

  • SAFETY NETTING

  • LEAFLET