Title: Vision loss in an adult with uncontrolled hypertension, increased intracranial pressure, and myelin-oligodendrocyte glycoprotein antibody disease
Hi my name is dr andrew stein and i’m an internal medicine resident at the university of florida i’ll be presenting a case report vision loss in an adult with uncontrolled hypertension increased intracranial pressure and myelin oligodendrocyte glycoprotein antibody disease myelin oligodendrocyte glycoprotein antibody disease or mogad incidence is 0.16 per 100
000 per year idiopathic intracranial hypertension referred to as iih another rare cause of acute vision loss has an incidence of 0.9 to 1 per 100 000 in the general population hypertensive retinopathy is a more prevalent loss of vision etiology we present the case of a patient who displayed components of all of the aforementioned pathologies at presentation a 36
Year old african-american female with history of hypertension and morbid obesity presented to our facility for acute bilateral vision loss eye redness and pain with eye movements on initial opth examination her visual acuity was light perception in the right eye and no light in the left her intraocular pressures or iop were mildly elevated at 24 and 27 millimeters
Mercury in the right and left eye respectively both peoples were dilated and non-reactive on pupillary exam and dilated fungus examination showed bilateral grade three optic dyskidema and tortuous vasculature she also had elevated systolic blood pressure of 220 millimeters mercury a non-contrast ct scan of the head suggested underlying intracranial hypertension
With a mildly expanded partially empty cella and signs of bilateral optic high drops with optic disc edema as seen in figure 1. bromonidine and timolol were initiated for elevated iop and her hypertension was eventually controlled with hydrochlorothiazide labatolol and amylodipine further evaluation with mri revealed bilateral optic neuritis and left thalamus and
Midbrain focal lesions figure 2 demonstrates the left thalamic lesion while figures 3 to 6 show different mri windows of her optic neuritis iv methylprednisolone was started and subsequent lumbar puncture demonstrated an elevated opening pressure a 39 millimeters mercury with unremarkable cell count acetazolamide was initiated and the opening pressures three days
Later was 21 millimeters mercury for complete workup mr venography ruled out central venous sinus thrombosis and head and neck ct angiogram ruled out dural fistula she was discharged with a diagnosis of iih and hypertensive retinopathy and continued on acetazolamide the aquaporin-4 antibody lab was negative and other labs pending and visual acuity had improved
To 20 over 400 in the right eye and count fingers in her left eye weeks later the mog antibody returned positive confirming a diagnosis of mogad rituximab was initiated leading to complete resolution of optic dyskidema and almost full recovery of visual acuity there has since been no recurrence at one year follow-up this is the first reported case of mogad with
Iih and an adult mogad has recently recognized inflammatory demyelinating cns disease similar to dermalitis optic spectrum disorder and multiple sclerosis mogad’s defining feature is a positive serum mog antibody with other characteristics including optic disc edema and more extensive cns involvement bilateral optic neuritis is the most common presenting feature
And the disease course is either monophasic or relapsing with the strongest predictor of disability being transverse myelitis mri frequently shows enhancement of the anterior optic nerve in sheath and adjacent orbital fat and csf findings can include pleiocytosis and raise protein iih is classically found in overweight females in their fourth decade of life it
Is characterized by increased icp of at least 25 millimeters mercury with unknown cause in the absence of space occupying lesion beams thrombosis or meningeal disease a recent study of 34 patients with iih found no evidence of mogad or aquaporin4 antibodies hypertensive retinopathy acute or chronic is perhaps the most common contributor to vision loss with an
Incidence of 66 in the general population and 83 in those with hypertension hypertensive emergency presents in two percent of the hypertensive population with risk factors of female gender obesity and medication non-compliance if blood pressure is decreased too rapidly or there’s an increased intracranial hypertension optic nerve ischemia can occur our patient’s
Acute vision loss was most likely multifactorial fitting diagnostic criteria for all the above pathologies with good response to their associated treatments including steroids seizolamide and antihypertensives this case presents a unique presentation of acute vision loss influenced by multiple underlying pathologies mogad is a rare disease and has not yet been
Reported in conjunction with iih and hypertensive retinopathy we demonstrate the importance of a broad workup in acute vision loss and treating all suspected contributing etiologies thank you for listening
Transcribed from video
FL ACP 2021 – Clinical Vignette – Vision loss in an adult… By Drew Stein
