||Andrew G. Lee, MD, Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, TX, Professor of Ophthalmology, Weill Cornell Medicine; Hannah Wang, Baylor College of Medicine, Class of 2023
||Summary: • Differential diagnosis in neuro-ophthalmology can be approached from patient age and prevalence of disease • Mnemonic for differential diagnosis: o V-vascular o I-inflammatory/ischemic o T-trauma o A-anaplastic o M-metabolic o I-iatrogenic/idiopathic o N-neoplastic/nutritional • Prevalence is most common predictor of disease when looking at pretest likelihood of a disease o Most common predictor based on prevalence is age -Young patient: consider hereditary and congenital -Between ages of 20 and 40: consider demyelinating disease, inflammatory disorders, and neoplasm -Older patient: consider degenerative • Ischemic example: think arteritic versus non-arteritic o 75-year-old white male presents with acute unilateral loss of vision and RAPD in a swollen optic nerve. They have hypertension, diabetes, high cholesterol, and smoking. -Non-arteritic anterior ischemic optic neuropathy o Ischemic events in the eye -Consider inflammatory ischemic disease, giant cell arteritis • Young patient example: o 20 year old white female with acute unilateral loss of vision, RAPD in normal nerve, inflammatory, optic neuritis -Most common systemic neurological association with optic neuritis is multiple sclerosis (demyelinating disease) -MS mimics: lupus and other collagen vascular disorders -MS-like conditions: neuromyelitis optica [Transcript of video] "So today we're going to be talking about how I approach creating a differential diagnosis in neuro-ophthalmology from just the age alone and prevalence of disease. So in medical school you probably learned some sort of mnemonic that was very similar to this. I'll just use VITAMIN here. So, "vascular", and "I" might be "inflammatory", or you might put "ischemic" here. "Trauma". You can put "anaplastic" or "neoplastic". "Metabolic". You kind of get the idea of how we're going to use this. "Iatrogenic" or even "idiopathic". And, we already have "neoplastic" there, but maybe "neoplastic" or "nutritional". You kind of get the idea. So most people have some sort of thing, and you could make" VIN DIG MD" here as well. That's another popular mnemonic device, and basically the reason I think it's good to have this as a beginning structure is prevalence is the most common predictor of disease if you're looking at a pretest likelihood of a disease standpoint. And the most common predictor based on prevalence alone is age. So if you're a kid, really I'm going to be thinking about hereditary and congenital things. If you're an older person we're going to be thinking about degenerative. So some people would have "degenerative", and "dystrophic", "hereditary", and "congenital" as additional pieces of their mnemonic device. And so, if you had to pick from the list, if you're young-congenital and hereditary. If you're old-degenerative. If you're old and it's acute, pick ischemic. Between the ages of 20 and 40, demyelinating disease and inflammatory disorders as well as neoplasm are going to be higher in the list. And especially in young males, traumatic is going to be higher on the list. So just using age alone as a predictor, you can pick and modulate your VIN DIG MD or your VITAMIN MD or whatever you're choosing as your mnemonic device to drive the prevalence of disease and pretest likelihood. So we can construct the stem that already sounds ischemic. For example, a 75-year-old white male presents with acute unilateral loss of vision and RAPD in a swollen optic nerve. They have hypertension, diabetes, high cholesterol, and smoking. So that is a very classic stem for non-arteritic anterior ischemic optic neuropathy. And now if we have patients with ischemic events in the eye, we have to think about the inflammatory ischemic disease, giant cell arteritis. So in all of those patients, it's going to be arteritic versus non-arteritic. So arteritic versus non-arteritic anterior ischemic optic neuropathy, arteritic versus non-arteritic diplopia, arteritic versus non-arteritic central retinal artery occlusion, whatever it happens to be. And likewise, in a young person, 20-year-old white female with acute unilateral loss of vision, RAPD and normal nerve, inflammatory again, but this time optic neuritis. And the most common systemic neurological association with optic neuritis is multiple sclerosis. And so the demyelinating disease is at the top of the list. And then the young person who is a potentially inflammatory optic neuritis does not have to be demyelinating. You have to think about MS but also the MS mimics, things like lupus and other collagen vascular disorders that can mimic inflammatory optic neuropathy. And the MS-like conditions, neuromyelitis optica. So if you just use age as your predictor of disease, I think you'll find that you'll be able to modulate your differential diagnosis better and determine the pretest likelihood of disease, and if you use whatever mnemonic device that you're using, age plus this mnemonic device is a real powerful way to get started from a focused stem."