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Patient Counseling Patient Counseling (Section G) tests you on appropriately counseling patients and family, and resources available to overcome challenges of obesity, low vision, and genetic diseases. 1 / 3 A 65 year old man is found on routine optometric examination to have reduced visual acuity in the right eye and a temporal hemianopic defect in the left eye on formal visual field examination. There is a right afferent pupil defect and the right optic disc is pale. Otherwise the optometric examination is normal. A heavy smoker, he is being treated for systemic hypertension. Imaging shows this aneurysm. If untreated, what chance is there that the aneurysm will rupture? 1% per year 2% per year 4% per year 8% per year https://collections.lib.utah.edu/details?id=2461360 Correct Answer: 8% per year The pattern of vision loss described here—reduced visual acuity and afferent pupil defect in one eye and a temporal hemianopic visual field defect in the other eye—localizes to the optic nerve-optic chiasm junction. Mass lesions are usually responsible. The most common ones are pituitary adenomas, meningiomas, craniopharyngiomas, and pilocytic astrocytomas, but aneurysms are not far behind. This patient has a giant (> 25 mm diameter) aneurysm of the supraclinoid internal carotid artery. Studies have established an 8% per year rupture rate, with a 50% mortality rate. Fortunately, aneurysms can be prevented from rupturing by clipping them at their necks, placing coils within them that promote clotting, and by diverting arterial blood flow with stents. Admittedly, such interventions carry risks of stroke and intra-procedural aneurysm rupture. But some type of aneurysm repair should take place unless the patient is too sick to be a candidate. Of all the possible causes of this pattern of vision loss, aneurysm is the most feared because of the threat of rupture and instant death. For that reason, patients with these presenting visual features must undergo relatively prompt retrobulbar imaging, including sequences that adequately visualize blood vessels. Correct Answer: 8% per year The pattern of vision loss described here—reduced visual acuity and afferent pupil defect in one eye and a temporal hemianopic visual field defect in the other eye—localizes to the optic nerve-optic chiasm junction. Mass lesions are usually responsible. The most common ones are pituitary adenomas, meningiomas, craniopharyngiomas, and pilocytic astrocytomas, but aneurysms are not far behind. This patient has a giant (> 25 mm diameter) aneurysm of the supraclinoid internal carotid artery. Studies have established an 8% per year rupture rate, with a 50% mortality rate. Fortunately, aneurysms can be prevented from rupturing by clipping them at their necks, placing coils within them that promote clotting, and by diverting arterial blood flow with stents. Admittedly, such interventions carry risks of stroke and intra-procedural aneurysm rupture. But some type of aneurysm repair should take place unless the patient is too sick to be a candidate. Of all the possible causes of this pattern of vision loss, aneurysm is the most feared because of the threat of rupture and instant death. For that reason, patients with these presenting visual features must undergo relatively prompt retrobulbar imaging, including sequences that adequately visualize blood vessels. 2 / 3 Courtesy: Jonathan D. Trobe A 35 year old woman is found to have a best-corrected visual acuity of 20/50 (6/15, 0.40) in her left eye and 20/20 (6/6, 1.0) in her right eye on a routine optometric examination. Formal visual fields show a nerve fiber bundle defect in the affected left eye and a normal visual field in the right eye. There is an afferent pupil defect in the left eye, but otherwise the examination of both eyes is normal, including the appearance of both optic discs on ophthalmoscopy. Brain/orbit MRI shows this isolated abnormality. You would tell the patient that… This is an intracranial sphenoid ridge meningioma and that surgery has a better than 50% chance of improving vision in the affected eye and less than a 10% chance of harming vision in the unaffected eye This is a meningioma and that x-irradiation is favored over surgery because it has a better than 50% chance of improving vision and lower risks than surgery This is likely a meningioma, but biopsy is needed to exclude other lesions Delaying any intervention is best because both surgery and radiation have risks and vision is unlikely to worsen over time https://collections.lib.utah.edu/details?id=2461356 INCORRECT Correct Answer: This is an intracranial sphenoid ridge meningioma and that surgery has a better than 50% chance of improving vision in the affected eye and less than a 10% chance of harming vision in the unaffected eye The imaging features here are so characteristic of meningioma that biopsy is not needed for confirmation. Experienced skull-base neurosurgeons are achieving improvement in vision in over 50% of operated cases and causing no harm to the unaffected eye so long as they do not attempt to remove every bit of tumor! Primary x-irradiation may stop tumor growth and even shrink tumor size, but it rarely improves vision. It is an option if surgery is too dangerous or fails to remove enough tumor, or if tumor growth occurs after surgery. Avoiding any intervention is always an option if the patient is afraid of surgery or x-irradiation, but the chances of further tumor growth and vision loss are high, especially in such a young patient. YOUR CORRECTNESS IS UNMATCHED! This is an intracranial sphenoid ridge meningioma and that surgery has a better than 50% chance of improving vision in the affected eye and less than a 10% chance of harming vision in the unaffected eye The imaging features here are so characteristic of meningioma that biopsy is not needed for confirmation. Experienced skull-base neurosurgeons are achieving improvement in vision in over 50% of operated cases and causing no harm to the unaffected eye so long as they do not attempt to remove every bit of tumor! Primary x-irradiation may stop tumor growth and even shrink tumor size, but it rarely improves vision. It is an option if surgery is too dangerous or fails to remove enough tumor, or if tumor growth occurs after surgery. Avoiding any intervention is always an option if the patient is afraid of surgery or x-irradiation, but the chances of further tumor growth and vision loss are high, especially in such a young patient. 3 / 3 A 32 year old woman reports blurred vision in her left eye for several days, together with left periocular pain worsened by eye movement. Visual acuity is normal in the right eye, but subnormal in the left eye, which has an afferent pupil defect. The ocular examination, including the optic fundus, is normal. There is no personal or family history of multiple sclerosis (MS) and the patient has no symptoms or signs of MS. The brain MRI scan is normal. This is her orbit MRI. Within 15 years, what is the chance that she will develop clinically-definite MS? 10% 15% 20% 25% https://collections.lib.utah.edu/details?id=2461345 Correct Answer: 25% The clinical manifestations are highly suggestive of typical optic neuritis. MRI is the strongest predictor of the chance of developing clinically-definite MS. With no white matter signal abnormalities, the untreated 15-year risk is 25%. When there is at least one signal abnormality typical of demyelination, the risk rises to 75%. The chance of recovering normal or near-normal visual function in the affected eye after a first bout of typical optic neuritis is 85% to 90%. The chance of a recurrence of optic neuritis in either eye over the next 15 years is 30%, evenly split between the previously affected and unaffected eyes. The chance of having long term neurologic disability—including visual disability—is only 10%. Whether treatment of any kind reduces the risks of developing MS in patients with isolated optic neuritis is unsettled; treatment is not currently recommended. Once MS is diagnosed, treatment with immune-modulating drugs probably reduces the pace of the illness. Correct Answer: 25% The clinical manifestations are highly suggestive of typical optic neuritis. MRI is the strongest predictor of the chance of developing clinically-definite MS. With no white matter signal abnormalities, the untreated 15-year risk is 25%. When there is at least one signal abnormality typical of demyelination, the risk rises to 75%. The chance of recovering normal or near-normal visual function in the affected eye after a first bout of typical optic neuritis is 85% to 90%. The chance of a recurrence of optic neuritis in either eye over the next 15 years is 30%, evenly split between the previously affected and unaffected eyes. The chance of having long term neurologic disability—including visual disability—is only 10%. Whether treatment of any kind reduces the risks of developing MS in patients with isolated optic neuritis is unsettled; treatment is not currently recommended. Once MS is diagnosed, treatment with immune-modulating drugs probably reduces the pace of the illness. Your score isThe average score is 40% 0% Restart quiz
Patient Counseling
Patient Counseling (Section G) tests you on appropriately counseling patients and family, and resources available to overcome challenges of obesity, low vision, and genetic diseases.
1 / 3
A 65 year old man is found on routine optometric examination to have reduced visual acuity in the right eye and a temporal hemianopic defect in the left eye on formal visual field examination. There is a right afferent pupil defect and the right optic disc is pale. Otherwise the optometric examination is normal. A heavy smoker, he is being treated for systemic hypertension. Imaging shows this aneurysm. If untreated, what chance is there that the aneurysm will rupture?
https://collections.lib.utah.edu/details?id=2461360
Correct Answer: 8% per year
The pattern of vision loss described here—reduced visual acuity and afferent pupil defect in one eye and a temporal hemianopic visual field defect in the other eye—localizes to the optic nerve-optic chiasm junction. Mass lesions are usually responsible. The most common ones are pituitary adenomas, meningiomas, craniopharyngiomas, and pilocytic astrocytomas, but aneurysms are not far behind. This patient has a giant (> 25 mm diameter) aneurysm of the supraclinoid internal carotid artery. Studies have established an 8% per year rupture rate, with a 50% mortality rate. Fortunately, aneurysms can be prevented from rupturing by clipping them at their necks, placing coils within them that promote clotting, and by diverting arterial blood flow with stents. Admittedly, such interventions carry risks of stroke and intra-procedural aneurysm rupture. But some type of aneurysm repair should take place unless the patient is too sick to be a candidate. Of all the possible causes of this pattern of vision loss, aneurysm is the most feared because of the threat of rupture and instant death. For that reason, patients with these presenting visual features must undergo relatively prompt retrobulbar imaging, including sequences that adequately visualize blood vessels.
2 / 3
Courtesy: Jonathan D. Trobe
A 35 year old woman is found to have a best-corrected visual acuity of 20/50 (6/15, 0.40) in her left eye and 20/20 (6/6, 1.0) in her right eye on a routine optometric examination. Formal visual fields show a nerve fiber bundle defect in the affected left eye and a normal visual field in the right eye. There is an afferent pupil defect in the left eye, but otherwise the examination of both eyes is normal, including the appearance of both optic discs on ophthalmoscopy. Brain/orbit MRI shows this isolated abnormality. You would tell the patient that…
https://collections.lib.utah.edu/details?id=2461356
INCORRECT
Correct Answer: This is an intracranial sphenoid ridge meningioma and that surgery has a better than 50% chance of improving vision in the affected eye and less than a 10% chance of harming vision in the unaffected eye
The imaging features here are so characteristic of meningioma that biopsy is not needed for confirmation. Experienced skull-base neurosurgeons are achieving improvement in vision in over 50% of operated cases and causing no harm to the unaffected eye so long as they do not attempt to remove every bit of tumor! Primary x-irradiation may stop tumor growth and even shrink tumor size, but it rarely improves vision. It is an option if surgery is too dangerous or fails to remove enough tumor, or if tumor growth occurs after surgery. Avoiding any intervention is always an option if the patient is afraid of surgery or x-irradiation, but the chances of further tumor growth and vision loss are high, especially in such a young patient.
This is an intracranial sphenoid ridge meningioma and that surgery has a better than 50% chance of improving vision in the affected eye and less than a 10% chance of harming vision in the unaffected eye
3 / 3
A 32 year old woman reports blurred vision in her left eye for several days, together with left periocular pain worsened by eye movement. Visual acuity is normal in the right eye, but subnormal in the left eye, which has an afferent pupil defect. The ocular examination, including the optic fundus, is normal. There is no personal or family history of multiple sclerosis (MS) and the patient has no symptoms or signs of MS. The brain MRI scan is normal. This is her orbit MRI. Within 15 years, what is the chance that she will develop clinically-definite MS?
https://collections.lib.utah.edu/details?id=2461345
Correct Answer: 25%
The clinical manifestations are highly suggestive of typical optic neuritis. MRI is the strongest predictor of the chance of developing clinically-definite MS. With no white matter signal abnormalities, the untreated 15-year risk is 25%. When there is at least one signal abnormality typical of demyelination, the risk rises to 75%. The chance of recovering normal or near-normal visual function in the affected eye after a first bout of typical optic neuritis is 85% to 90%. The chance of a recurrence of optic neuritis in either eye over the next 15 years is 30%, evenly split between the previously affected and unaffected eyes. The chance of having long term neurologic disability—including visual disability—is only 10%. Whether treatment of any kind reduces the risks of developing MS in patients with isolated optic neuritis is unsettled; treatment is not currently recommended. Once MS is diagnosed, treatment with immune-modulating drugs probably reduces the pace of the illness.
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The average score is 40%
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