Unexplained Visual Loss

1
Unexplained Visual Loss

• Laura S. Gilmore, MD
• Grand Rounds
• September 9, 2005
• Texas Tech University HSC
• Lubbock, TX
• Discussant Kenn Freedman, MD

2
History

• Chief Complaint Vision loss, ODgtOS
• HPI 22yo WF with progressively deteriorating
  vision over 2-3 months, worse OD, with no
  associated neurologic symptoms.
• PMH Dxd with Crohns Disease 4 years ago, on
  remicaide and prednisone. Currently suspect for
  MS.
• Ocular History 20/20, no glasses. One episode 1
  year ago of OD blurring, with associated slurring
  of speech, difficulty walking, and involuntary
  eye movements. Spontaneously resolved.
• FH migraines, blindness secondary to glaucoma
• SH tobacco
• Meds Remicaide, prednisone

3
Physical Exam

• VS BP 100/70, pulse 64, RRR
• VA OD 20/400, BC 20/160 OS 20/40, BC NI
• Color 5/9 OD, 8/9 OS
• Amsler Central blur OD, nl OS
• VF constricted OD, hemifield defect OS
• Pupils Round, reactive, No APD
• Motility Full OU
• IOP 16 OU
• Ant segment Clear, D/Q, no synechiae
• DFE normal OU, no disc pallor/elevation/heme

4
Visual Field
5
Workup

• MRI brain/orbits with/without contrast
• DM, thyroid w/u per PCP, reportedly negative
• ESR, CRP, CBC, FTAbs, ACE, B12, folate, BUN/CR,
  ANA

6
Results

• Strongly ANA positive-nucleolar
• High prevalence in Progressive Systemic
  Sclerosis, a diffuse progressive form of
  scleroderma, and in some rheumatic diseases
• Lower prevalence in SLE
• MRI negative except small, 5mm pituitary
  microadenoma on left side. No plaques or other
  tumors. No optic nerve involvement.
• Prior MRI at similar episode 1 year ago
  reportedly with small brainstem lesion, not
  apparent on this study. Films not available.
  Several MRIs in 3 prior MS w/us-normal

7
Differential Diagnosis

• Optic neuropathy
• Retrobulbar neuritis
• Brain/visual pathway lesion
• MS
• PSS
• SLE
• Rheumatic disease
• Granulomatous processes (syphilis, sarcoid)
• Medication side effect

8
Next Steps

• Increase PO prednisone, referral to Rheumatology
  RE ANA, Neurology 2nd opinion, D/W GI RE
  medications for Crohns
• Why?
• Remicaide has been reportedly associated with
  vision loss, visual field defects, onset and/or
  exacerbation of demyelinating disease

9
Remicaide

• Anti-TNF antibody first introduced in Autumn 1999
• Used in tx of RA, Crohns, spondyloarthropathy,
  juvenile idiopathic arthritis, Behcets,
  Wegeners, HLA-B27 uveitis, chronic severe
  refractory uveitis, psoriasis
• Reported side effects infections, development of
  ANA and anti-dsDNA antibodies, lupus-like
  syndrome, lymphoma, exacerbation of or
  development of demyelinating disease, CHF,
  injection-site reactions
• Side effects seem to be cumulative, often
  occurring after third dose usually dosed q 4 or
  8 weeks

10
Case Reports

• 3 cases of toxic anterior optic neuropathy after
  remicaide, with cecocentral VF defects that did
  not improve with steroid tx and with ONH pallor
  first evident at 2 months (10)
• Rare cases of clinical sx and/or MRI changes
  suggestive of MS or optic neuritis (10)
• Increases MRI activity in MS pts (11)
• Report of onset of a demyelinating process after
  the institution of remicaide tx for Crohn's
  disease. (8,9)
• Report of a 35-year-old woman with colitis who
  developed MS symptoms after treatment with
  remicaide (2)

11
Course

• VA OD subjectively slightly improved at 6 week
  f/u, 6 weeks post cessation of remicaide, but obj
  essentially stable (BCVA 20/200) OS stable
• No change in VA after 6 weeks
• HVF slightly improved 3 months after first exam,
  but still with dense cecocentral scotoma OD
• 3 months post first exam, first sign of early
  temporal pallor OU. Possible early optic
  atrophy?
• Neuro has dxd as MS, d/cd remicaide and
  continued prednisone
• Pt lost to f/u with us after 3 month appt

12
Photos, 3 months out
13
Visual Field, 3 months out
14
Summary

• Anti-TNF alpha antibody preparations are becoming
  TOC for several diseases
• Emerging side effects of these medications
  include visual changes, as well as MS-like
  processes
• Long-term care studies still evolving
• Therefore must keep meds in mind is it truly MS?
  Or MS induced by tx? Or prior, undiagnosed MS
  exacerbated by tx? Or unknown mechanism and
  effects that just looks like MS?

15
Bibliography

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