NANOSNET

 View Only

  • 1.  What is my next step

    Posted 4 days ago
    I have a question for the group. Thank you for the honor of being part of it. I have not seen this 20 year old female, but will be inheriting her soon. She saw one of my partners. I will have limited information but hopefully enough that you can help.


    1. She has no insurance, just self pay
    2. 20 years old with healthy BMI
    3. Unknown if recent weight gain, but apparently some type of eating disorder,anxiety, no other details available
    4. Was seen a month ago and then today
    5. Was on doxycycline 50mg daily for 1.5 years, stopped one month before initial visit,tretinoin cream for one year,and birth control pills for one year
    6. Initial visit was normal VA grade2-3 bilateral papilledema
    7. Normal VF
    8. Had whooshing sounds, headaches, and a couple TVO
    9. OCT nerves rnfl was 220,187 average
    10. CBC metabolic panel normal, no other labs
    11. MRI Brain and MRV done, MRV showed bilateral transverse stenosis. MRI partially empty sella,dilated optic nerve sheath complexes, and Chiari 1 formation
    12. LP attempted ,unsuccessful, not a good experience
    13. Stopped the doxy, tretinoin, and birth control pills
    14. Today was seen for follow up. whooshing sounds a little better, still with headaches, not sure about TVO. VF today normal blind spot OU, and edema of nerves looks a little better also
    15. OCT nerves today 187/163, so 15 % decrease OD and 10% OS

    Not sure if they will get the LP soon, we are waiting for them to schedule

    In the meantime
    Since she has improved on OCT and by exam, 
    1. Any other labs to order?
    2. Insist on LP prior to starting diamox?
    3. Start diamox, forego LP and see if swelling continues to decrease?
    4. Or since improvement, just observe monthly and no diamox and no LP?
    5. I know very little about Chiari 1 and what should be done about that


    Thank you all

    Bob
     
    --

    Robert Bellinoff, MD

    Division Head, Eye Department, Mercy Medical Group

    Site Medical Director of Midtown Medical and Surgical Specialties

     

    Mercy Medical Group

    3000 Q Street

    Sacramento, CA 95816

    (916) 733-3311 (O)

    (916) 733-3307 (F)

     

    Caution: This email is both proprietary and confidential, and not intended for transmission to (or receipt by) any unauthorized person(s). If you believe that you have received this email in error, do not read any attachments. Instead, kindly reply to the sender stating that you have received the message in error. Then destroy it and any attachments. Thank you.


  • 2.  RE: What is my next step

    Posted 4 days ago

    She didn't need to stop the birth control pills unless they caused weight gain, but you indicated that her BMI is fine.

    If her headaches are bothering her and her vision is normal, I would think about topiramate, starting with a low dose (25 mg daily) and go back on the oral conceptive.

    Not sure about the "Chiari I" – it may just be tonsillar descent from increased ICP. Would not do anything about it if she is otherwise neurologically normal.

    Deb

     




    Original Message


  • 3.  RE: What is my next step

    Posted 3 days ago
    Fine to start Diamox empirically pending LP And if optic nerve swelling continues to resolve, likely obviates the need for the LP. Most importantly, she should be counseled Never to resume doxycycline or vitamin A analogs ever again. You don't know which one of these agents resulted in her presumed papilledema and therefore neither of these agents or related drugs should be used in the future. You can simply repeat the MRI down the line to see if the chiari resolved with presumed normalization of intracranial pressure as would be inferred By resolution of the optic nerve swelling As well as assess for resolution of the other features of elevated ICP on the MRI.

    Matt

    Sent from my Galaxy




    Original Message


  • 4.  RE: What is my next step

    Posted 3 days ago
    I would start Loading dose of diamox immediately without LP as long as it is a sure diagnosis with the accused agents determined , of course must be all stopped at least for the time being probably to find alternative treatments , the follow up by Fundus examination and visual fields closely to monitor sure improvement on the determined dose according to the severity of papilledema , as long as there is tolerance to acetazolamide with potassium supplements for me I would go for any other agent , I would follow her up weekly for at least three visits till we are sure there is maintained improvement 



    Original Message


  • 5.  RE: What is my next step

    Posted 3 days ago

    Thank you all. I will update you in a month 

    Bob




    Original Message


  • 6.  RE: What is my next step

    Posted 3 days ago
    Hello
    I would start Diamox and if pt agreed book DSA
    Irene Vanek
    Sent from my iPhone



    Original Message


Related Content