Referral and optometric management in a patient with unilateral optic neuritis a case with multifocal RGP contact lenses Patrícia Lopes 1, Pedro Serra 2, Ricardo Luís 1, Paulo Almeida 1 1 2
Optometrist, Óptica Havaneza, Évora, Portugal PhD Student, Vision Sciences Research Group, University of Bradford, Bradford, United Kingdom
Introduction: ON refers to an inflammatory or demyelinating process affecting the optic nerve, with loss of myelin sheath. Women aged between 20 and 40 are more commonly affected. Ocular signs such as decrease in VA, afferent pupil defect (APD), change in colour vision, pallor of optic disc and diffuse depression in visual fields are frequent findings in these patients. A great number of patients with neurologic ocular pathologies seek for visual evaluation in optometry practices, complaining of reduction in vision, among other symptoms. The fundamental role of optometry in these cases should be the correct identification of symptoms and signs and posterior referral for neurophthalmologic evaluation. We report a case were the procedure followed the described steps, after pathological diagnose multifocal RGP CL were fitted aiming to improve VA. Case Report: A 41 year-old, white woman presented as main complain decrease in distance and near vision, in her LE. The on-set had nearly 2 months. The patient was a monofocal RGP CL wearer. Distance High-Contrast (HC) VA was (+2.0D) 0.8 and (+1.50D) 0.5 in the RE and LE respectively, near HC VA was 20/30 and 20/40 respectively for both eyes. Spectacle HC BCVA was (+3.25D) 1.2 and (+2.50D) 0.7, near vision was improved with +1.00D addition achieving near HC BCVA of 20/20 RE and 20/30 LE. No systemic diseases were mentioned, confirmed posteriorly by analytical blood exams. Anterior pole evaluation showed normal structures, with patient’s CL centred and clear surfaces. Ophthalmoscopy exhibited an asymmetry in both optic discs, with total pallor of the LE disc. Furthermore the patient presented an APD and decreased red saturation on the LE. Referral to neurophthalmologist was done based on the findings described above. Neurophthalmologic exploration revealed in the LE, inferior and superior scotomas (visual fields), decreased RNFL thickness (OCT and retinal polarimetry), cup/disk enlargement and decreased macular thickness (OCT) and dyscromatopsy (Farnsworth-15). Based on these findings and MRI results the diagnose advanced by the ophthalmologist was acute ON of inflammatory ethiology. Three months after referral patient complain related to loss of VA remained. Optometric management at this stage consisted in improving distance and near VA up to the limit allowed by the new neurologic condition. Evaluation of anterior segment was repeated and topography performed. Centration with the new RGP CL was achieved. A multifocal design (Menicon Z Progressive) was chosen to account for distance and near vision. BCVA was evaluated 1 week with new CL, distance HC BCVA 1.2 and 0.8 RE and LE respectively and near HC BCVA 20/20 RE and 20/30 LE.