Andrew G. Lee, MD Chair Ophthalmology, Houston Methodist Hospital, - PowerPoint PPT Presentation

12/4/2015 Five things every eye MD needs to I have no financial interest know about pseudotumor cerebri in the contents of this talk � Andrew G. Lee, MD � Chair Ophthalmology, Houston Methodist Hospital, Professor of Ophthalmology, Neurology, & Neurosurgery, Weill Cornell Medical College; Clinical Professor, UTMB Galveston; UT MD Anderson Cancer Center; Adjunct Professor, Baylor COM, U. Iowa and U. Buffalo, SUNY It’s called pseudotumor but Five things to know about it is a real disease that blinds pseudotumor cerebri people � Size does not matter in NeuroOp � Obesity epidemic is here � Fulminant IIH is an emergency � Diamox and weight loss work � Sheath fenestration vs. CSF shunt 1

12/4/2015 1978: I wanted to be a doctor… Size doesn’t matter 2 nd choice Jedi knight Little edema can be Big problem Little edema 2

12/4/2015 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1985 BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% No Data <10% 10%–14% Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1987 BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) person) No Data <10% 10%–14% No Data <10% 10%–14% 3

12/4/2015 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1989 BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% No Data <10% 10%–14% Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1991 BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% No Data <10% 10%–14% 15%–19% 4

12/4/2015 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1993 BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% No Data <10% 10%–14% 15%–19% Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1995 BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% No Data <10% 10%–14% 15%–19% 5

12/4/2015 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1997 BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20% No Data <10% 10%–14% 15%–19% ≥20% Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 1999 BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20% No Data <10% 10%–14% 15%–19% ≥20% 6

12/4/2015 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 2002 BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% No Data <10% 10%–14% 15%–19% 20%–24% ≥25% Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 2003 BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% No Data <10% 10%–14% 15%–19% 20%–24% ≥25% 7

12/4/2015 Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 2005 BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. Adults Obesity Trends* Among U.S. Adults BRFSS, 2007 BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% 8

12/4/2015 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 Only in America (*BMI ≥ 30, or about 30 lbs. overweight for 5’4” person) 1999 1990 2008 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Grades translated to real Grades of evidence world 1. Must do (standard of care, highly recommended practice) 2. Should do (show just cause why not following recommendation) 3. Could do (practice option) 4. Voo doo (“so new it might not be true”) 5. Doo doo (unsupported, might be false, evidence to suggest potentially 9

12/4/2015 Acetazolamide (+ diet) better than Placebo (+diet) Frisen grades of papilledema 10

12/4/2015 Stenting of TSS in IIH Placebo Acetazolamide Pressure gradient Chicken and the Egg across stenosis 11

12/4/2015 Collapsible sinus Rigid sinus (stented) Stent for IIH with IIH with severe acute visual stenosis loss: lumbar drain + surgery Weight loss + Diamox Get ready for cold steel 12

12/4/2015 More shunts for IIH ONSF in US hospitals Curry et al. Neurosurgery 2005;57:97-108 (1998-2002) Curry et al. Neurosurgery 2005;57:97-108 1988 to 2002 Rising annual aggregate caseload of new CSF shunts for IIH increased 350% during this 14-year interval, or 9.4% annually ( P < 0.001). Patient outcome: Cost & Rise in bariatric surgery 0.5% mortality! Curry et al. Neurosurgery 2005;57:97-108 Curry et al. Neurosurgery 2005;57:97-108 13

12/4/2015 What behavior changes do I want for you to Five things to know about make…. not just for your patients but for pseudotumor cerebri your kids, grandkids, yourself?? � Size does not matter � Obesity epidemic � Fulminant IIH � Diamox and weight loss work � Sheath fenestration vs. CSF shunt Drag yourself & your kid away from the computer! 14

12/4/2015 1978: I wanted to be a Thanks for your time & attention doctor…2 nd choice Jedi knight � Andrew G. Lee, MD � Chair Ophthalmology, Houston Methodist Hospital, Professor of Ophthalmology, Neurology, & Neurosurgery, Weill Cornell Medical College; Adjunct Professor: Baylor College of Medicine, U. Iowa & Clinical Professor, UTMB Galveston, UT MD Anderson Cancer Center, U. Buffalo, SUNY It turns out I got to be both 15