Attendees were eager to learn from ace clinicians Kelly Malloy, OD, FAAO, and Erin Draper, OD, as they presented 12 neuro cases with interesting exam findings and asked those gathered how they would proceed with the situation. Their course, “To Refer or Not to Refer?... That is the Question,” helped highlight the tools that optometrists have at their disposal, such as important in-office tests, and the best times to recognize when to use them.

Drs. Malloy and Draper, both of the Pennsylvania College of Optometry at Salus University, understand it could be difficult to know when to refer a patient on to a specialist, outpatient work-up or even to the emergency department. “We hope we can help you decipher these cases and decide what you think you would do,” Dr. Malloy said in the lecture’s introduction.

Timing is Key

In the lecture’s first two cases, Dr. Malloy discussed patients whose transient vision loss was associated with transient ischemia. “Any transient ischemic attack (TIA) or vision loss or retinal ischemia or emboli has to be considered the same as stroke,” she noted. “It’s found that one-quarter of patients with an acute retinal ischemia or transient vision obscuration had an acute brain infarction on brain DWI-MRI.” Dr. Malloy also noted that 10% to 15% of those patients will have a disabling stroke within three months of a TIA, with half of those occurring within 48 hours.

“If a patient tells you that they had this episode of sudden vision loss for 15 to 30 minutes, that’s a medical emergency,” Dr. Malloy noted. “We have to send those patients to the emergency room STAT to get a work-up to see if they had a stroke and to prevent a future stroke.”

She emphasized that time is of the essence when it comes to sudden vision loss and potential stroke because time is brain.

In a case that Dr. Draper presented where optometrists may consider other causes of optic neuropathy, she noted that additional testing might be needed to rule out the non-glaucomatous etiologies. However, noticing a disc hemorrhage on the optic nerve head is typical in patients with normal-tension glaucoma. When deciding whether to go onto further work-up, Dr. Draper noted that eyes with disc hemorrhages tend to have visual field loss two times as fast as eyes without. “These patients need close monitoring and very aggressive treatment to keep IOPs nice and low,” she says.

Dr. Draper highlighted that looking carefully at the optic disc head helped with the diagnosis as well as determine whether to proceed with additional work-up. “If you take a fundus photo, it will be easy to pick up some of those smaller hemorrhages,” she said.

Other cases that Drs. Malloy and Draper presented helped highlight ways to save patients from unnecessary work-up, especially surgery.

As Many Diseases as They Please

Sometimes comanaging might not always determine all the factors in play. After a case presented by Dr. Draper on an intracranial meningioma, Dr. Malloy presented a case where she determined an intraorbital meningioma of the optic nerve sheath and told attendees they co-managed with neurosurgery. After the patient noticed diplopia, the neurosurgeon believed the meningioma was worsening and suggested preparing for radiation.

The team agreed that the optometrist needed to see the patent first. “Remember anybody can have as many diseases as they please, right?” Dr. Malloy joked. Cover testing and different positions of gaze revealed an abduction deficit in the fellow eye, which did not indicate radiation treatment. Neuroimaging found a cavernous sinus arachnoid cyst in the fellow eye. Dr. Draper commented on her love for having to really look into what was going on for that case . “Unfortunately, you can have more than one thing,” she noted. “Fortunately, the woman is doing really well.”

Sometimes you have to look further even when using the tools that the optometrist uses already confirm one thing. Dr. Draper provided some guidance and a warning when an optometrist uses B-scan ultrasound and fundus autofluorescence to determine if it is optic disc drusen or papilledema. “Keep in mind that a patient can have optic nerve head drusen and papilledema, and it’s going to be difficult to differentiate one from the other,” she said. “Just because you can confirm drusen does not mean there is not papilledema.”

If you are unsure if the drusen is causing elevation, Dr. Draper suggested that is it’s better to refer if unsure and it not be necessary than to not refer and it was necessary.

Tips for Better Confrontation Fields

  • Be sure that you are holding hands out far enough to pick up the defect
  • Use red targets to assess the field for more subtle defects
  • If there is a potential concern, even if the CF appears normal, get a formal VF

When Dr. Malloy presented a case of a boy who had amblyopia and headaches in whom she noticed an afferent pupillary defect and carried out visual fields and OCT. She highlighted performing the swinging-flashlight test yourself to time pupillary escape. “Even if you have an explanation for possible reduced visual acuity, careful pupil testing is essential to rule out an overlying pathology,” Dr. Malloy stated. “The pupils don’t lie.”

An MRI revealed an optic pathway glioma, and Dr. Malloy recommended referral to pediatric neuro-ophthalmology to rule out neurofibromatosis type 1. She noted these usually low-grade tumors present early in patients’ lives. “Look closely for APDs in children with amblyopia,” she repeated.

TIA or Retinal Ischemia/Emboli Cases: Facts and Follow Through

Morbidity risk is high

  • 25% of patients with acute retinal ischemia (even if transient) had an acute brain infarction on brain DWI-MRI in one study
  • 10-15% of patients will have a disabling stroke within three months after a TIA, with half occurring within 48 hours after resolution of TIA

What needs to be done?

  • DWI-MRI within 24-48 hours of vision loss
  • Imaging (CTA) of cervical and intracranial vessels
  • EKG and echocardiogram
  • Laboratory testing: CBC with platelets, coagulation studies, fasting lipid profile

How does this get done?

  • Do NOT send these patients to their PCP, cardiologist, neurologist, neuro-ophthalmologist or retina specialist
  • Do NOT try to obtain the work-up yourself
  • Send to an ED with an Acute Stroke Care Center!

Misleading Mimickers

Drs. Malloy and Draper helped attendees determine how to best manage certain cases and relieve their anxiety of missing a significant, and possibly life-threatening, finding. “It can be sometimes difficult, when a patient presents, to determine if it’s a true neuro disease process or a mimicker,” Dr. Malloy said. “If it’s a mimicker, is it still one that’s concerning and needs work-up or one more benign where you can assure the patient to not worry?”

If there’s still concern, she suggested to err on the side of caution. If you cannot rule out a neuro-ophthalmic disease process, refer the patient for a second opinion to neuro-ophthalmologist or another specialist you deem appropriate. Dr. Draper agrees. “Better to over-refer than not to refer,” she said.