Semester 2 tutor handbook Module 2 2010-11 PBL Scenano : Keele Med Miss Anita Baghram was a 22 year old medical student and had worn myopic contact lenses for a long time. During the summer vacation she went to her optometrist, Mr Williams, for an eye check because of three worrying episodes of double vision over the past year, each of which had lasted for several weeks and had interfered with her studies, especially her ability to interpret microscope slides These symptoms were accompanied by a dull ache behind one or other eye which were made worse by eye movement. The optometrist performed a full examination and found a visual acuity of 6/12 in the right eye and 6/6 in the left. These visual acuities could not be improved with spectacles or a pin hole. One year earlier, the same optometrist had recorded her vision as 6/6 in each eye. He also found that there was a reduction of movement of the left eye, specifically reduced abduction Mr Williams told Anita to consult her GP, who in turn referred her to the ophthalmic casualty department of her local hospital, PAUSE for discussion She was seen in the ophthalmic casualty department by the on-call doctor, Dr Khan, who Anita thought looked calm and efficient, and who confirmed the optometrist's findings. Dr Khan also noted that there was a relative afferent pupillary defect (RAPD) although she felt that examination of the ocular fundus did not show any abnormality. In particular the optic discs appeared normal. It was noted that there see was reduced colour perception in the right eye, There were no other causes of iqto reduced vision in the right eye; no uveitis, cataract, retinal detachment, or glaucoma. |seehort Anita was informed by Dr Khan that this examination aimed at establishing a differential diagnosis, ruling out serious and common causes of visual loss and selecting further investigations. Anita was reassured by the full information she was given and it confirmed the positive impression she had formed of Dr Khan. PAUSE for discussion Anita went on to have a visual field assessment which showed a non-specific reduction of the visual field in the right eye, She also had an urgent MRI scan which showed several enhancing lesions with the T1 weighted sequence and several other lesions with a T2 weighted sequence. These findings suggested active and old demyelinating episodes. She was referred to the neurology team and underwent a 113Semester 2 tutor handbook Module 2 2010-11 Facilitator / Tutor Notes This case describes the presentation and clinical course of a young woman presenting with multiple sclerosis (MS). The symptoms of reduced visual acuity and PBL Case 2-Tutor Notes altered colour perception are fairly typical. The course of MS is highly variable. Presentation with a single episode of optic neuritis would not lead to the diagnosis. However, some individuals may only experience a small number of episodes of Overvies demyelination over time, and experience minimal or only a very slow neurological Probtem deterioration. At the other end of the spectrum, frequent episodes may occur with Scenqnio rapid neurological deterioration and the development of significant disability. Students should consider the neurobiology of normal visual perception and how individuals cope with visual impairment. Specific ILOs Ciatended Learning Outcomes) _ Scientific Basis of Understand the gross anatomy of the eye Medicine * Understand the neural circuitry of the retina oye * Understand the mechanism of phototransduction Focilitators | + Know the neural pathways involved in the have & Cop PY st transmission of visual data and the effects of the IlOs so transection at various levels in these pathways * Broad understanding of cranial nerve testing Know what eae the ¢ tudents s + Know some of the major tests to assess vision be learni 40M |. Review of cells and function of the immune * Know some of the major disorders of vision +the problem system including cytokines scenano i * Review understanding of immune mediated disorders, Type 1 — Type 4 hypersensitivity and ques , the mechanisms of autoimmune disease Clinical, communication |» Obtain an accurate neurological history and IT skills + Communicate with people with sensory impairments Individual, Community and |» Distinguish factors that can influence information | Population Health processing and decision making, with reference to visual perception * Consider the impact of visual impairment on the individual * Assess the consequences for the individual and ‘their social network students donstgeta copy 115 of the tuber nolSemester 2 tutor handbook Module 2 2010-11 Detailed Facilitator/ Tutor Notes Comments/prompts for tutors (1): The major focus of discussion in this section should be on gaining an overall understanding of the gross anatomy of the eye and retinal structure and the muscles controlling eye movements (along with their nerve supply). Students should also briefly discuss the optical basis for refractive errors but limit a detailed discussion as they have covered this in Year 1 Tre ideo iste of NTS Paragraph 1: wot stor ange gor erences “22 year old medical student..., worn myopic contact lenses...” aise ing ¥ en" Other possible causes of reduced vision in a young contact lens weaver include (KON corneal ulcer, retinal detachment, vascular event (retinal artery or vein occlusion) Peon and optic neuritis from demyelination, but this discussion should be limited (students ledge will have a broad based lecture called Common and Important Diseases of the Eye this week). Refractive errors are the most common cause, of course, and will be discussed in practical. This section also cues students to consider how disability and, more specifically, visual impairment could impact on one’s ability to study medicine and the adjustments and any adaptations to the physical environment which would need to be made. This links with the EL session on Communicating with People with Sensory Disabilities (Week 1). Facilitators mas) ‘atop ess this info as the students wor through the “episodes of double vision" scenario aS and when the needis ,. ied Double vision (binocular diplopia) is caused when there is weakness or paralysis of vdentigi one or more extra-ocular muscles so that the eyes are no longer correctly aligned. Internuclear opthalmoplegia is characteristic symptom experienced by MS patients and occurs when demyelination affects the neurons of the medial longitudinal fasciculus, a centre in the brain stem that coordinates movements between the two. eyes. This results in the rectus muscles not contracting effectively so the eyes do not move in tune with each other producing double vision. This can also occur in stroke and myasthenia gravis “interfered with her studie: ability to interpret microscope slides” Interference with her studies is a trigger to consultation but note that she had delayed until summer. Students should be able fo apply what they already know about triggers and barriers to consultation, This section also cues a distinction 117Tatended Learning Outcomes - decided by students 9, ILOs Anatomy a. Cranial nerves — Il, II, TV, VI b. Eye + optic nerve Histology of the eye . Neurobiology of vision a. Visual pathway i. Phototransduction of rods and cones ii, Pathway of visual stimulus, optic tract What is the function of myelin in relation to .. How is MRI effective in diagnosing MS? Overview of (how vision is affected): Myopia Glaucoma Cataract Uveitis Retinal detachment MS g. Etcete. What are the mechanisms of treatments a. Prednisolone b. Beinterferon How are symptoms explained: a. Double vision b. Dull ache behind eyes (worsened by eye mov.) c. Reduced abduction Review ROCKs lecture mepoese 10, Social support for people with visual impairment