Complicated patient that I have several questions about

3. RE: Complicated patient that I have several questions about

Recommend

Posted 09-01-2025 14:35

There are a lot of factors and a lot of questions in this case could be NAION with the risk factors , could be AION with negative biopsy or 'occult ' GCA , but could be TB related optic neuritis , it has to go both ways till one is confirmed , but TB treatment has a priority and the use of steroids must be coordinated with pulmonologist , but second TBA after steroids with the first one negative so soon may not add to the diagnosis

Sherif

Sent from Yahoo Mail for iPhone

Original Message

Original Message:
Sent: 9/1/2025 2:19:00 PM
From: Larry Frohman
Subject: RE: Complicated patient that I have several questions about

I think the cow is out of the barn, but I would get ID to see him soon, and pulmonary. If CXR finding is new, or changing, you likely need tissue by either induced sputum x 3 or lung biopsy. On the short term, I would use 250 q6h and cover for TB until you get your anwer about that. I would get second TA biospy- get him to use his device for OSA. I would be hesitant to staarty Actembra until I had my answer for TB

Original Message:
Sent: 9/1/2025 1:56:00 PM
From: Robert Bellinoff
Subject: Complicated patient that I have several questions about

Dear All,

Your advice will be much appreciated. One of my colleagues presented this patient to me.

1. 72 year old male

2. History of sleep apnea, type 2 diabetes, (recent A1c 7.4), hypertension,hyperlipidemia on a statin, coronary artery disease.

3. Had NAION 2010 OS, records not available. Not sure if OD was a disc at risk back then

4. Hasn't used CPAP for years

5. Started ozempic 5/2024 with some weight loss

6. Presented 7/9/25 with one week vision loss OD,chronic bilateral temporal pain, positive jaw claudication,scalp tenderness.

VA OD was 20/70, OS was 20/40(this is previous NAION eye),color plates 3/14 OD and 14/14 OS, 2+APD OD,very constricted vf OD with central island on Humphrey. VF in the past was normal OD. OS had inferior nasal reduction in confrontationVF, but on Humphrey it is a larger central island vs OD.Grade 5 disc edema OD and .2 pale nerve OS. OD also had a few disc heme.

OCT NFL OD was 270 on 7/9/25 and 170 on 7/21/25, OS was 50 each time

7. Started on oral pred 60mg/daily. Initial labs were esr 19, CRP was 8(normal is 2-8), and platelets 243

8. Had a TAB 7/14/25 described as arteriosclerosis changes with focal minute breaks in internal elastic lamina. He had a CTA head/neck earlier in the month without stenosis or occlusion. Tapered off the prednisone because of the "negative biopsy" for 30mg/day for a week, then 20, then 10 then stopped.

9. 5 days later presented with increasing headaches and decreasing vision. VA on 8/20/25 is now 20/80 OD and 20/60 OS color plates 1/14 OD and 14/14 OS. VF now show worse constriction OU. The right nerve is now pale, no edema and OCT is now done to 70 RNFL. ESR and CRP are now both elevated.

10. Due to concern for false negative TAB, restarted on pred at 30mg but he stopped it after one day due to sugars out of control. MOG and aquaporin negative. Other labs ordered and what came back was POSITIVE quantiferon. His daughter said he has had a severe dry cough for two weeks. CXR done a month ago showed 1cm modular density right lower lung base.

11. MRI brain and orbits pending.

12. He is now in the hospital so they can get sputum cultures for TB, and hopefully MRI.

Questions:

1. Is this GCA, do we do another TAB?

2. Many risk factors for NAION including untreated sleep apnea, diabetes, htn hyperlipidemia.

3. Is the quantiferon test unrelated to his disc edema? Do we try and restart steroids knowing he may have active TB?

4. Start actemra regardless?

Sorry for such a long description but wanted to give as much ino as possible. Thank you very much.

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.

4. RE: Complicated patient that I have several questions about

Recommend

Barbara Yates

Posted 09-01-2025 15:08

Interesting case.... Given the ESR, CRP (needs to be 10 or above per criteria) and platelets were low, plus negative biopsy, GCA falls lower on the list in this patient with multiple comorbidities. But if still unsure, check off all the criteria points to see if additional testing is revealing. You would need to do the temporal arterial testing or ultrasound testing within 3 days of re-initiating steroids.

I would also be interested in carotid artery ultrasound of neck to see his stroke risk in the future, consider FA to look for patchy ischemia in the choroidal vasculature if still suspect GCA. Consider imaging of the axillary arteries to see if other larger arteries have signs of vasculitis vs. reassurance it is negative.

I just did a talk for WIO reviewing the utility of ultrasound this diagnose GCA.... If the ultrasonographer is comfortable obtaining the temporal artery and axillary arteries as well at the carotid arteries, you may get your answers the quickest with a great ultrasongrapher.

Best,

Barbara

Original Message

Original Message:
Sent: 9/1/2025 2:19:00 PM
From: Larry Frohman
Subject: RE: Complicated patient that I have several questions about

I think the cow is out of the barn, but I would get ID to see him soon, and pulmonary. If CXR finding is new, or changing, you likely need tissue by either induced sputum x 3 or lung biopsy. On the short term, I would use 250 q6h and cover for TB until you get your anwer about that. I would get second TA biospy- get him to use his device for OSA. I would be hesitant to staarty Actembra until I had my answer for TB

Original Message:
Sent: 9/1/2025 1:56:00 PM
From: Robert Bellinoff
Subject: Complicated patient that I have several questions about

Dear All,

Your advice will be much appreciated. One of my colleagues presented this patient to me.

1. 72 year old male

2. History of sleep apnea, type 2 diabetes, (recent A1c 7.4), hypertension,hyperlipidemia on a statin, coronary artery disease.

3. Had NAION 2010 OS, records not available. Not sure if OD was a disc at risk back then

4. Hasn't used CPAP for years

5. Started ozempic 5/2024 with some weight loss

6. Presented 7/9/25 with one week vision loss OD,chronic bilateral temporal pain, positive jaw claudication,scalp tenderness.

VA OD was 20/70, OS was 20/40(this is previous NAION eye),color plates 3/14 OD and 14/14 OS, 2+APD OD,very constricted vf OD with central island on Humphrey. VF in the past was normal OD. OS had inferior nasal reduction in confrontationVF, but on Humphrey it is a larger central island vs OD.Grade 5 disc edema OD and .2 pale nerve OS. OD also had a few disc heme.

OCT NFL OD was 270 on 7/9/25 and 170 on 7/21/25, OS was 50 each time

7. Started on oral pred 60mg/daily. Initial labs were esr 19, CRP was 8(normal is 2-8), and platelets 243

8. Had a TAB 7/14/25 described as arteriosclerosis changes with focal minute breaks in internal elastic lamina. He had a CTA head/neck earlier in the month without stenosis or occlusion. Tapered off the prednisone because of the "negative biopsy" for 30mg/day for a week, then 20, then 10 then stopped.

9. 5 days later presented with increasing headaches and decreasing vision. VA on 8/20/25 is now 20/80 OD and 20/60 OS color plates 1/14 OD and 14/14 OS. VF now show worse constriction OU. The right nerve is now pale, no edema and OCT is now done to 70 RNFL. ESR and CRP are now both elevated.

10. Due to concern for false negative TAB, restarted on pred at 30mg but he stopped it after one day due to sugars out of control. MOG and aquaporin negative. Other labs ordered and what came back was POSITIVE quantiferon. His daughter said he has had a severe dry cough for two weeks. CXR done a month ago showed 1cm modular density right lower lung base.

11. MRI brain and orbits pending.

12. He is now in the hospital so they can get sputum cultures for TB, and hopefully MRI.

Questions:

1. Is this GCA, do we do another TAB?

2. Many risk factors for NAION including untreated sleep apnea, diabetes, htn hyperlipidemia.

3. Is the quantiferon test unrelated to his disc edema? Do we try and restart steroids knowing he may have active TB?

4. Start actemra regardless?

Sorry for such a long description but wanted to give as much ino as possible. Thank you very much.

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.

5. RE: Complicated patient that I have several questions about

Recommend

Jade Schiffman

Posted 09-01-2025 17:34

The fact disc OD is now pale and not edematous and this was happening quickly and likely would have been thin in 2 weeks speaks for a GC ischemic insult likely, but so much swelling is unusual.

True jaw claudication speaks for GCA especially since MRA was oK and external carotid was not mentioned to be affected by stenosis (you may want to check)

This speaks more for GCA

But would do LP and blood cultures also since in house and we would want to see both clean.

ID should determine what coverage for TB while on higher dose steroids like Larry suggested.

JSS

Jade S. Schiffman MD, FAAO, FAAN

Co-Director of Neuro-Eye Clinical Trials, Inc.

Co-Director Neuro-ophthalmology of Texas, P.L.L.C.

Adjunct Professor, Department of Clinical Sciences, UH College of Medicine

Former Professor of Ophthalmology and Neurology, University of Texas MD Anderson Cancer Center

Original Message

Original Message:
Sent: 9/1/2025 2:19:00 PM
From: Larry Frohman
Subject: RE: Complicated patient that I have several questions about

I think the cow is out of the barn, but I would get ID to see him soon, and pulmonary. If CXR finding is new, or changing, you likely need tissue by either induced sputum x 3 or lung biopsy. On the short term, I would use 250 q6h and cover for TB until you get your anwer about that. I would get second TA biospy- get him to use his device for OSA. I would be hesitant to staarty Actembra until I had my answer for TB

Original Message:
Sent: 9/1/2025 1:56:00 PM
From: Robert Bellinoff
Subject: Complicated patient that I have several questions about

Dear All,

Your advice will be much appreciated. One of my colleagues presented this patient to me.

1. 72 year old male

2. History of sleep apnea, type 2 diabetes, (recent A1c 7.4), hypertension,hyperlipidemia on a statin, coronary artery disease.

3. Had NAION 2010 OS, records not available. Not sure if OD was a disc at risk back then

4. Hasn't used CPAP for years

5. Started ozempic 5/2024 with some weight loss

6. Presented 7/9/25 with one week vision loss OD,chronic bilateral temporal pain, positive jaw claudication,scalp tenderness.

VA OD was 20/70, OS was 20/40(this is previous NAION eye),color plates 3/14 OD and 14/14 OS, 2+APD OD,very constricted vf OD with central island on Humphrey. VF in the past was normal OD. OS had inferior nasal reduction in confrontationVF, but on Humphrey it is a larger central island vs OD.Grade 5 disc edema OD and .2 pale nerve OS. OD also had a few disc heme.

OCT NFL OD was 270 on 7/9/25 and 170 on 7/21/25, OS was 50 each time

7. Started on oral pred 60mg/daily. Initial labs were esr 19, CRP was 8(normal is 2-8), and platelets 243

8. Had a TAB 7/14/25 described as arteriosclerosis changes with focal minute breaks in internal elastic lamina. He had a CTA head/neck earlier in the month without stenosis or occlusion. Tapered off the prednisone because of the "negative biopsy" for 30mg/day for a week, then 20, then 10 then stopped.

9. 5 days later presented with increasing headaches and decreasing vision. VA on 8/20/25 is now 20/80 OD and 20/60 OS color plates 1/14 OD and 14/14 OS. VF now show worse constriction OU. The right nerve is now pale, no edema and OCT is now done to 70 RNFL. ESR and CRP are now both elevated.

10. Due to concern for false negative TAB, restarted on pred at 30mg but he stopped it after one day due to sugars out of control. MOG and aquaporin negative. Other labs ordered and what came back was POSITIVE quantiferon. His daughter said he has had a severe dry cough for two weeks. CXR done a month ago showed 1cm modular density right lower lung base.

11. MRI brain and orbits pending.

12. He is now in the hospital so they can get sputum cultures for TB, and hopefully MRI.

Questions:

1. Is this GCA, do we do another TAB?

2. Many risk factors for NAION including untreated sleep apnea, diabetes, htn hyperlipidemia.

3. Is the quantiferon test unrelated to his disc edema? Do we try and restart steroids knowing he may have active TB?

4. Start actemra regardless?

Sorry for such a long description but wanted to give as much ino as possible. Thank you very much.

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.

7. RE: Complicated patient that I have several questions about

Recommend

Robert Bellinoff

Posted 09-01-2025 18:34

Thank you for all who responded. Working on these suggestions now. I agree with Dr. Forman. When I talk to pathologists previously they seem to say these focalbreaks are more consistent with arteriosclerotic changes so maybe going forward, if the other symptoms and signs point to GCA and this is the biopsy reading, would assume more likely GCA. By the way his new erp was 45 and CRP jumped to 56 from the original 8.

Bob

Original Message

Original Message:
Sent: 9/1/2025 6:29:00 PM
From: Scott Forman
Subject: RE: Complicated patient that I have several questions about

Why are "focal breaks in the IELamina NOT GCA? Giant cells are not necessary for the dx.

+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=

Scott Forman, MD

Senior Fellow North American Neuro-ophthalmology Society

Adult and Pediatric Neuro-ophthalmology

Comprehensive Ophthalmology

Functional Medicine

Original Message:
Sent: 9/1/2025 1:56:00 PM
From: Robert Bellinoff
Subject: Complicated patient that I have several questions about

Dear All,

Your advice will be much appreciated. One of my colleagues presented this patient to me.

1. 72 year old male

2. History of sleep apnea, type 2 diabetes, (recent A1c 7.4), hypertension,hyperlipidemia on a statin, coronary artery disease.

3. Had NAION 2010 OS, records not available. Not sure if OD was a disc at risk back then

4. Hasn't used CPAP for years

5. Started ozempic 5/2024 with some weight loss

6. Presented 7/9/25 with one week vision loss OD,chronic bilateral temporal pain, positive jaw claudication,scalp tenderness.

VA OD was 20/70, OS was 20/40(this is previous NAION eye),color plates 3/14 OD and 14/14 OS, 2+APD OD,very constricted vf OD with central island on Humphrey. VF in the past was normal OD. OS had inferior nasal reduction in confrontationVF, but on Humphrey it is a larger central island vs OD.Grade 5 disc edema OD and .2 pale nerve OS. OD also had a few disc heme.

OCT NFL OD was 270 on 7/9/25 and 170 on 7/21/25, OS was 50 each time

7. Started on oral pred 60mg/daily. Initial labs were esr 19, CRP was 8(normal is 2-8), and platelets 243

8. Had a TAB 7/14/25 described as arteriosclerosis changes with focal minute breaks in internal elastic lamina. He had a CTA head/neck earlier in the month without stenosis or occlusion. Tapered off the prednisone because of the "negative biopsy" for 30mg/day for a week, then 20, then 10 then stopped.

9. 5 days later presented with increasing headaches and decreasing vision. VA on 8/20/25 is now 20/80 OD and 20/60 OS color plates 1/14 OD and 14/14 OS. VF now show worse constriction OU. The right nerve is now pale, no edema and OCT is now done to 70 RNFL. ESR and CRP are now both elevated.

10. Due to concern for false negative TAB, restarted on pred at 30mg but he stopped it after one day due to sugars out of control. MOG and aquaporin negative. Other labs ordered and what came back was POSITIVE quantiferon. His daughter said he has had a severe dry cough for two weeks. CXR done a month ago showed 1cm modular density right lower lung base.

11. MRI brain and orbits pending.

12. He is now in the hospital so they can get sputum cultures for TB, and hopefully MRI.

Questions:

1. Is this GCA, do we do another TAB?

2. Many risk factors for NAION including untreated sleep apnea, diabetes, htn hyperlipidemia.

3. Is the quantiferon test unrelated to his disc edema? Do we try and restart steroids knowing he may have active TB?

4. Start actemra regardless?

Sorry for such a long description but wanted to give as much ino as possible. Thank you very much.

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.

8. RE: Complicated patient that I have several questions about

Recommend

Michael Altman

Posted 09-01-2025 18:35

Breaks in the Elastic lamina

Unfortunately are not as specific as we'd like

They can occur with aging, HTN/arteriosclerosis , Atherosclerosis, Genetic conditions

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Original Message

Original Message:
Sent: 9/1/2025 6:29:00 PM
From: Scott Forman
Subject: RE: Complicated patient that I have several questions about

Why are "focal breaks in the IELamina NOT GCA? Giant cells are not necessary for the dx.

+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=

Scott Forman, MD

Senior Fellow North American Neuro-ophthalmology Society

Adult and Pediatric Neuro-ophthalmology

Comprehensive Ophthalmology

Functional Medicine

Original Message:
Sent: 9/1/2025 1:56:00 PM
From: Robert Bellinoff
Subject: Complicated patient that I have several questions about

Dear All,

Your advice will be much appreciated. One of my colleagues presented this patient to me.

1. 72 year old male

2. History of sleep apnea, type 2 diabetes, (recent A1c 7.4), hypertension,hyperlipidemia on a statin, coronary artery disease.

3. Had NAION 2010 OS, records not available. Not sure if OD was a disc at risk back then

4. Hasn't used CPAP for years

5. Started ozempic 5/2024 with some weight loss

6. Presented 7/9/25 with one week vision loss OD,chronic bilateral temporal pain, positive jaw claudication,scalp tenderness.

VA OD was 20/70, OS was 20/40(this is previous NAION eye),color plates 3/14 OD and 14/14 OS, 2+APD OD,very constricted vf OD with central island on Humphrey. VF in the past was normal OD. OS had inferior nasal reduction in confrontationVF, but on Humphrey it is a larger central island vs OD.Grade 5 disc edema OD and .2 pale nerve OS. OD also had a few disc heme.

OCT NFL OD was 270 on 7/9/25 and 170 on 7/21/25, OS was 50 each time

7. Started on oral pred 60mg/daily. Initial labs were esr 19, CRP was 8(normal is 2-8), and platelets 243

8. Had a TAB 7/14/25 described as arteriosclerosis changes with focal minute breaks in internal elastic lamina. He had a CTA head/neck earlier in the month without stenosis or occlusion. Tapered off the prednisone because of the "negative biopsy" for 30mg/day for a week, then 20, then 10 then stopped.

9. 5 days later presented with increasing headaches and decreasing vision. VA on 8/20/25 is now 20/80 OD and 20/60 OS color plates 1/14 OD and 14/14 OS. VF now show worse constriction OU. The right nerve is now pale, no edema and OCT is now done to 70 RNFL. ESR and CRP are now both elevated.

10. Due to concern for false negative TAB, restarted on pred at 30mg but he stopped it after one day due to sugars out of control. MOG and aquaporin negative. Other labs ordered and what came back was POSITIVE quantiferon. His daughter said he has had a severe dry cough for two weeks. CXR done a month ago showed 1cm modular density right lower lung base.

11. MRI brain and orbits pending.

12. He is now in the hospital so they can get sputum cultures for TB, and hopefully MRI.

Questions:

1. Is this GCA, do we do another TAB?

2. Many risk factors for NAION including untreated sleep apnea, diabetes, htn hyperlipidemia.

3. Is the quantiferon test unrelated to his disc edema? Do we try and restart steroids knowing he may have active TB?

4. Start actemra regardless?

Sorry for such a long description but wanted to give as much ino as possible. Thank you very much.

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.

14. RE: Complicated patient that I have several questions about

Recommend

Floyd Warren

Posted 09-01-2025 20:54

You can see breaks with arherosclerosis. I had been taught reduplication of ILM spoke to "healed srteritis."

Sent from the all new AOL app for iOS

Original Message

Original Message:
Sent: 9/1/2025 6:29:00 PM
From: Scott Forman
Subject: RE: Complicated patient that I have several questions about

Why are "focal breaks in the IELamina NOT GCA? Giant cells are not necessary for the dx.

+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=

Scott Forman, MD

Senior Fellow North American Neuro-ophthalmology Society

Adult and Pediatric Neuro-ophthalmology

Comprehensive Ophthalmology

Functional Medicine

Original Message:
Sent: 9/1/2025 1:56:00 PM
From: Robert Bellinoff
Subject: Complicated patient that I have several questions about

Dear All,

Your advice will be much appreciated. One of my colleagues presented this patient to me.

1. 72 year old male

2. History of sleep apnea, type 2 diabetes, (recent A1c 7.4), hypertension,hyperlipidemia on a statin, coronary artery disease.

3. Had NAION 2010 OS, records not available. Not sure if OD was a disc at risk back then

4. Hasn't used CPAP for years

5. Started ozempic 5/2024 with some weight loss

6. Presented 7/9/25 with one week vision loss OD,chronic bilateral temporal pain, positive jaw claudication,scalp tenderness.

VA OD was 20/70, OS was 20/40(this is previous NAION eye),color plates 3/14 OD and 14/14 OS, 2+APD OD,very constricted vf OD with central island on Humphrey. VF in the past was normal OD. OS had inferior nasal reduction in confrontationVF, but on Humphrey it is a larger central island vs OD.Grade 5 disc edema OD and .2 pale nerve OS. OD also had a few disc heme.

OCT NFL OD was 270 on 7/9/25 and 170 on 7/21/25, OS was 50 each time

7. Started on oral pred 60mg/daily. Initial labs were esr 19, CRP was 8(normal is 2-8), and platelets 243

8. Had a TAB 7/14/25 described as arteriosclerosis changes with focal minute breaks in internal elastic lamina. He had a CTA head/neck earlier in the month without stenosis or occlusion. Tapered off the prednisone because of the "negative biopsy" for 30mg/day for a week, then 20, then 10 then stopped.

9. 5 days later presented with increasing headaches and decreasing vision. VA on 8/20/25 is now 20/80 OD and 20/60 OS color plates 1/14 OD and 14/14 OS. VF now show worse constriction OU. The right nerve is now pale, no edema and OCT is now done to 70 RNFL. ESR and CRP are now both elevated.

10. Due to concern for false negative TAB, restarted on pred at 30mg but he stopped it after one day due to sugars out of control. MOG and aquaporin negative. Other labs ordered and what came back was POSITIVE quantiferon. His daughter said he has had a severe dry cough for two weeks. CXR done a month ago showed 1cm modular density right lower lung base.

11. MRI brain and orbits pending.

12. He is now in the hospital so they can get sputum cultures for TB, and hopefully MRI.

Questions:

1. Is this GCA, do we do another TAB?

2. Many risk factors for NAION including untreated sleep apnea, diabetes, htn hyperlipidemia.

3. Is the quantiferon test unrelated to his disc edema? Do we try and restart steroids knowing he may have active TB?

4. Start actemra regardless?

Sorry for such a long description but wanted to give as much ino as possible. Thank you very much.

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.

17. RE: Complicated patient that I have several questions about

Recommend

Matthew Kay

Posted 09-02-2025 07:31

Because you can have focal disruption of the ILM as an atherosclerotic change if it's associated with Focal calcium deposits... That needs to be reviewed with the pathologist as they can certainly tell the difference.

Matt

Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone

Original Message

Original Message:
Sent: 9/1/2025 6:29:00 PM
From: Scott Forman
Subject: RE: Complicated patient that I have several questions about

Why are "focal breaks in the IELamina NOT GCA? Giant cells are not necessary for the dx.

+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=

Scott Forman, MD

Senior Fellow North American Neuro-ophthalmology Society

Adult and Pediatric Neuro-ophthalmology

Comprehensive Ophthalmology

Functional Medicine

Original Message:
Sent: 9/1/2025 1:56:00 PM
From: Robert Bellinoff
Subject: Complicated patient that I have several questions about

Dear All,

Your advice will be much appreciated. One of my colleagues presented this patient to me.

1. 72 year old male

2. History of sleep apnea, type 2 diabetes, (recent A1c 7.4), hypertension,hyperlipidemia on a statin, coronary artery disease.

3. Had NAION 2010 OS, records not available. Not sure if OD was a disc at risk back then

4. Hasn't used CPAP for years

5. Started ozempic 5/2024 with some weight loss

6. Presented 7/9/25 with one week vision loss OD,chronic bilateral temporal pain, positive jaw claudication,scalp tenderness.

VA OD was 20/70, OS was 20/40(this is previous NAION eye),color plates 3/14 OD and 14/14 OS, 2+APD OD,very constricted vf OD with central island on Humphrey. VF in the past was normal OD. OS had inferior nasal reduction in confrontationVF, but on Humphrey it is a larger central island vs OD.Grade 5 disc edema OD and .2 pale nerve OS. OD also had a few disc heme.

OCT NFL OD was 270 on 7/9/25 and 170 on 7/21/25, OS was 50 each time

7. Started on oral pred 60mg/daily. Initial labs were esr 19, CRP was 8(normal is 2-8), and platelets 243

8. Had a TAB 7/14/25 described as arteriosclerosis changes with focal minute breaks in internal elastic lamina. He had a CTA head/neck earlier in the month without stenosis or occlusion. Tapered off the prednisone because of the "negative biopsy" for 30mg/day for a week, then 20, then 10 then stopped.

9. 5 days later presented with increasing headaches and decreasing vision. VA on 8/20/25 is now 20/80 OD and 20/60 OS color plates 1/14 OD and 14/14 OS. VF now show worse constriction OU. The right nerve is now pale, no edema and OCT is now done to 70 RNFL. ESR and CRP are now both elevated.

10. Due to concern for false negative TAB, restarted on pred at 30mg but he stopped it after one day due to sugars out of control. MOG and aquaporin negative. Other labs ordered and what came back was POSITIVE quantiferon. His daughter said he has had a severe dry cough for two weeks. CXR done a month ago showed 1cm modular density right lower lung base.

11. MRI brain and orbits pending.

12. He is now in the hospital so they can get sputum cultures for TB, and hopefully MRI.

Questions:

1. Is this GCA, do we do another TAB?

2. Many risk factors for NAION including untreated sleep apnea, diabetes, htn hyperlipidemia.

3. Is the quantiferon test unrelated to his disc edema? Do we try and restart steroids knowing he may have active TB?

4. Start actemra regardless?

Sorry for such a long description but wanted to give as much ino as possible. Thank you very much.

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)

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