A 25-year-old obese woman comes to the office due to sudden onset of blurry vision and pain in her left eye with a headache that began 2 days ago. She was watching television when she noticed a throbbing headache behind her left eye and eye pain that is exacerbated with movement. She has also noticed that colors in her visual field, especially red, have become less bright. She has had no diplopia, vertigo, dysphasia, pulsatile tinnitus, dysarthria, or weakness.
Medical history is unremarkable. Family history is significant for stroke and diabetes mellitus. The patient takes no medications except for birth control pills. She is a stay-at-home mom and does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 130/80 mm Hg and pulse is 88/min and regular. The patient is awake, alert, and oriented. Cranial nerve testing reveals a visual acuity of 20/30 in the right eye and 20/200 in the left eye. Funduscopic examination of both eyes is unremarkable. The pupils are round and symmetrical; however, there is a relative afferent pupillary defect on the left with the swinging flashlight test. Muscle power is 5/5 and deep tendon reflexes are 2+ in all 4 extremities. The remainder of the neurological examination is unremarkable.
Which of the following is the best next step in management of this patient?

Question

A 25-year-old obese woman comes to the office due to sudden onset of blurry vision and pain in her left eye with a headache that began 2 days ago.  She was watching television when she noticed a throbbing headache behind her left eye and eye pain that is exacerbated with movement.  She has also noticed that colors in her visual field, especially red, have become less bright.  She has had no diplopia, vertigo, dysphasia, pulsatile tinnitus, dysarthria, or weakness.
Medical history is unremarkable.  Family history is significant for stroke and diabetes mellitus.  The patient takes no medications except for birth control pills.  She is a stay-at-home mom and does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 130/80 mm Hg and pulse is 88/min and regular.  The patient is awake, alert, and oriented.  Cranial nerve testing reveals a visual acuity of 20/30 in the right eye and 20/200 in the left eye.  Funduscopic examination of both eyes is unremarkable.  The pupils are round and symmetrical; however, there is a relative afferent pupillary defect on the left with the swinging flashlight test.  Muscle power is 5/5 and deep tendon reflexes are 2+ in all 4 extremities.  The remainder of the neurological examination is unremarkable.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9876_4d80_853d_891c18e9e349_MD0002_00 This patient's presentation is consistent with optic neuritis, an inflammatory condition due to demyelination of the optic nerve. Optic neuritis frequently presents as acute vision loss, decreased color perception, afferent pupillary defect, headache, and pain with eye movement. Funduscopic examination may reveal swelling and hyperemia of the disk; however, two-thirds of patients have a normal funduscopic examination. Optic neuritis can be a manifestation of clinically isolated syndrome (CIS), defined as the first episode of central nervous system dysfunction due to demyelination. A majority of these patients progress to multiple sclerosis (MS); however, CIS can also occur as an isolated event. All patients with CIS should undergo a brain MRI to evaluate for demyelinating plaques and assess the risk of developing MS. Patients who are considered at high risk for progression (eg, presence of multiple demyelinating plaques) may be started on early disease-modifying therapy such as interferon or glatiramer acetate for relapse prevention (Choice B). Patients with a normal brain MRI have a 20% risk of conversion to MS and are usually treated conservatively with repeat MRIs at 6 months and 1 year; if imaging remains negative, no further screening is necessary. (Choice A) Cerebrovascular disease (eg, aneurysm, dissection, stroke) leading to visual changes may be associated with headaches but would be unlikely to cause pain with eye movement. In addition, cerebrovascular disease would be unusual in a young, otherwise healthy patient. (Choice C) Lumbar puncture to check for opening pressure is indicated to evaluate for idiopathic intracranial hypertension, which can present with headache and visual loss in an obese female. However, symptoms are typically positional, diplopia is common, and papilledema is noted in funduscopic examination. In patients with CIS who have a normal brain MRI, lumbar puncture can also help with further risk stratification (eg, oligoclonal bands increase MS risk). (Choice E) A visual evoked potential is used to electrophysiologically evaluate the white matter visual pathways and assesses for subclinical demyelination of the optic nerve. However, it is not diagnostic for optic neuritis. Educational objective: Clinically isolated syndrome is defined as the first episode of central nervous system dysfunction caused by demyelination; it may progress to multiple sclerosis (MS). All such patients should undergo a brain MRI to evaluate for demyelinating plaques and assess MS risk stratification. Patients with abnormal MRI findings may receive disease-modifying therapy. __________ References: Isolated demyelinating syndromes: comparison of different MR imaging criteria to predict conversion to clinically definite multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/10782781) Clinically isolated syndromes suggestive of multiple sclerosis, part I: natural history, pathogenesis, diagnosis, and prognosis. (http://www.ncbi.nlm.nih.gov/pubmed/15847841)

A 25-Year-Old Obese Woman Comes to the Office Due to Sudden