Acute Vision Loss

Blinding lights: Acute persistent vision loss in pregnancy

Acute persistent vision loss in pregnancy is an emergent presentation with a broad differential and should prompt rapid assessment and treatment of the underlying etiology. In pregnancy, causes can include preeclampsia, severe gestational hypertension, and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. Nonobstetrically related etiologies that can exacerbate in pregnancy include optic neuritis, giant cell arteritis, central retinal artery occlusion, or retinal detachment. In this case report, we describe a case of acute vision loss due to Purtscher's-like retinopathy, a rare but serious complication of pancreatitis in pregnancy. To our knowledge, this is the first published case of Purtscher's-like retinopathy in pregnancy unrelated to preeclampsia. Given the impact of permanent visual loss associated with Purtscher's-like retinopathy, more research is needed to determine treatments to substantively improve outcomes.

Sudden bilateral vision loss: a case report of frosted branch angiitis following pentavalent vaccination in a 2-year-old boy

BACKGROUND

Frosted branch angiitis (FBA) is a rare form of retinal vasculitis that can lead to significant vision loss. This case report presents a unique case of idiopathic FBA in a 2-year-old boy following pentavalent vaccination.

CASE PRESENTATION

A previously healthy 2-year-old Emirati boy presented with sudden painless bilateral vision loss for one day. His mother noted difficulty walking and a lack of interest in visual stimuli. A few days prior, the child had received a pentavalent vaccination and experienced upper respiratory tract symptoms. Ophthalmic examination revealed bilateral dilated pupils, anterior chamber inflammation, and extensive retinal vascular sheathing. Investigations were unremarkable. The patient was treated with oral Prednisolone and Acyclovir. Within two weeks, the vision improved significantly, with complete resolution of retinal vasculitis observed within one month. Over the course of one year, the patient showed no recurrence of symptoms, and only small, stable retinal scars were noted.

CONCLUSION

This case highlights the potential association between pentavalent vaccination and the onset of idiopathic FBA. The pathophysiology behind this association remains speculative, with potential mechanisms including immune dysregulation and molecular mimicry. Prompt recognition and treatment with systemic steroids can lead to favorable outcomes, emphasizing the importance of monitoring visual symptoms in pediatric patients following vaccination.

Optic Perineuritis Presenting with Transient Monocular Vision Loss (TMVL): Case Report

Optic perineuritis is an inflammatory condition that presents with reduced visual acuity and painful eye movement. The presentation of optic perineuritis is similar of optic neuritis which results in delayed diagnosis and management. Up to this date, we found a single case of optic neuritis that presented with transient monocular vision loss (TMVL). No cases of optic perineuritis were associated with TMVL. Here, we report a case of a 30-year-old woman who presented with recurrent attacks of painless vision loss in her left eye, reaching up to 30 attacks per day. Ophthalmological examination was otherwise unremarkable. Lab investigations were normal. Magnetic resonance imaging was done, which showed left optic nerve sheath enhancement suggestive of left-sided focal optic perineuritis. Patient was managed with 1 mg IV methylprednisolone for 3 days. We report this case to shed light on the importance of accurate and early diagnosis of optic perineuritis presenting with TMVL. Prompt management of optic perineuritis is crucial in reducing morbidity and risk of relapse.

Ocular involvement in primary antiphospholipid syndrome: results of an extensive ophthalmological evaluation performed in the APS-Rio cohort

OBJECTIVE

To study ophthalmological manifestations in a well-characterized primary antiphospholipid syndrome (PAPS) cohort (APS-Rio) and compare them with a healthy control group.

METHODS

We examined PAPS patients and controls with an extensive ophthalmological evaluation, which included anamnesis, visual acuity, slit-lamp biomicroscopy, binocular indirect ophthalmoscopy, and retinography of the anterior and posterior segments of the eye. PAPS group also underwent angiography exam and optical coherence tomography using spectral domain technology (SD-OCT).

RESULTS

98 PAPS patients and 102 controls were included. The most common symptom in PAPS was amaurosis fugax (34.7% vs. 6.9%; p = .001). In the multivariate analyses, Raynaud's phenomenon was associated with amaurosis fugax (OR 3.71, CI:1.33-10.32; p = .012), and livedo correlated with hemianopia (OR 6.96, CI:1.11-43.72, p = .038) and diplopia (OR 3.49, CI:1.02-11.53, p = .047). After ophthalmological evaluation, 84 PAPS patients had ocular involvement (1.0% glaucoma, 94.0% posterior findings, 62.7% anterior findings, and 56.6% both posterior and anterior findings). Vascular tortuosity was more frequent in the PAPS group (63.2% vs. 42.2%; p = .002), as well as peripheral tortuosity (29.6% vs. 7.8%; p < .001). After excluding patients with atherosclerotic risk factors, peripheral vascular tortuosity was still statistically associated with PAPS (35.0 vs. 7.8%, p < .001). Triple positivity was more frequent in PAPS patients with peripheral vascular tortuosity than in those without this ocular finding (34.5% vs. 15.9%, p = .041).

CONCLUSION

Vasomotor phenomena are importantly related to ocular symptoms in PAPS. Vascular tortuosity was a frequent finding in PAPS patients. Peripheral vascular tortuosity was associated with triple positivity and might be a biomarker of ischemic microvascular retinopathy due to PAPS.

Child Neurology: Bartonella henselae Neuroretinitis in 2 Patients

Neuroretinitis due to Bartonella henselae infection is a rare cause of vision loss in children. Two pediatric cases of acute unilateral vision loss accompanied by edema of the optic nerve on fundoscopic examination are presented. Severe causes of vision loss were excluded. During the course of the disease, macular stellate exudates emerged on control fundoscopic examinations, and diagnosis of neuroretinitis was made. A causative agent was confirmed by serologic examination, as high titers of IgM and IgG antibodies to Bartonella henselae were detected. Both patients significantly recovered after oral antibiotic treatment.

Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners

Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.

Neurological symptoms and blood neurofilament light levels

Neurofilament light chain (NfL) is an incredibly specific marker of neuronal injury that is not specific for cause or location of the neuronal damage. NfL is increasingly considered as possible biomarker of disease activity in neurological conditions. Several works reviewed the utility of NfL in the different diseases. Nonetheless, NfL is a universal marker of neuronal damage, which interpretation spaces beyond the single disease. Because of this, the interpretation of NfL may benefit by also considering how neurological symptoms relate to its blood concentration. Here, we review how different neurological symptoms can be associated with blood NfL levels with a practical interpretation of it.

The unusual course of a migraine attack during COVID-19 infection - Case studies of three patients

The effect of the coronavirus disease 2019 (COVID-19) on the nervous system remains undefined. Some studies have shown that headache is one of the most common symptoms and often the first neurological symptom in patients with confirmed infection. There are only a few reports concerning the effects of COVID-19 on the course of migraine.

This article investigates three female patients with prolonged history of migraine, in which atypical phenomenology and course of migraine attacks were observed during COVID-19 infection.

Inpatient Ophthalmology Consultations

Comprehensive patient care requires an integrated approach that often includes different specialties. Of these specialties, Ophthalmology stands out with its variable pathologic conditions, unique tools, and special examination techniques, which are not part of the standard training of internal medicine or other specialties. The authors review prior studies focused on inpatient ophthalmology consultations, common reasons for inpatient ophthalmology consultation, and the recommended approach to the most common ocular complaints that could present to the inpatient provider. They also shed light on the basic ocular history and eye examination that should be obtained before requesting an ophthalmic evaluation.

Imaging of the Primary Visual Pathway based on Visual Deficits

Vision loss can occur due to a variety of etiologies along the primary visual pathway. Understanding the anatomic organization of the visual pathway, which spans the globe to the occipital cortex, can help tailor neuroimaging to identify the cause of visual dysfunction. In this review, relevant anatomy and optimization of computed tomography and magnetic resonance imaging techniques will be described. This will be followed by a discussion of imaging findings related to pathologies at each functional anatomic level.

A Deep Learning Model for Screening Multiple Abnormal Findings in Ophthalmic Ultrasonography (With Video)

PURPOSE

The purpose of this study was to construct a deep learning system for rapidly and accurately screening retinal detachment (RD), vitreous detachment (VD), and vitreous hemorrhage (VH) in ophthalmic ultrasound in real time.

METHODS

We used a deep convolutional neural network to develop a deep learning system to screen multiple abnormal findings in ophthalmic ultrasonography with 3580 images for classification and 941 images for segmentation. Sixty-two videos were used as the test dataset in real time. External data containing 598 images were also used for validation. Another 155 images were collected to compare the performance of the model to experts. In addition, a study was conducted to assess the effect of the model in improving lesions recognition of the trainees.

RESULTS

The model achieved 0.94, 0.90, 0.92, 0.94, and 0.91 accuracy in recognizing normal, VD, VH, RD, and other lesions. Compared with the ophthalmologists, the modal achieved a 0.73 accuracy in classifying RD, VD, and VH, which has a better performance than most experts (P < 0.05). In the videos, the model had a 0.81 accuracy. With the model assistant, the accuracy of the trainees improved from 0.84 to 0.94.

CONCLUSIONS

The model could serve as a screening tool to rapidly identify patients with RD, VD, and VH. In addition, it also has potential to be a good tool to assist training.

TRANSLATIONAL RELEVANCE

We developed a deep learning model to make the ultrasound work more accurately and efficiently.

An interesting case report of delayed presentation of visual loss from an Ethmoid Mucocoele. Should we offer emergency decompression?

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Consider rhinological causes for unilateral vision disturbances or loss.

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Consider emergency flexible nasendoscopy and imaging to identify sinonasal disease.

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Consider emergency endoscopic intervention in compressive Optic neuropathy.

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Communicate frankly with patients about the chances of success and complications.

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Pre-operative bedside assessment of vision is recommended at the minimum.

Paranasal sinus mucocoeles commonly involve the frontoethmoidal sinuses and can rarely present with vision changes due to expansion and invasion through the orbit. A 50-year-old female presented out of hours with an acute, 16-h history of complete left sided visual loss, on a background of 3 days of visual changes. A left ethmoid mucocoele extending into the left orbital apex causing compression of the optic nerve was diagnosed on imaging. Emergency endoscopic sinus surgery with decompression and marsupialization of the ethmoid mucocoele was performed, which resulted in improvement of vision. This case is unusual due to improvement in vision despite the length of visual loss prior to surgical intervention. This case demonstrates the importance of considering rhinological causes for vision loss, and how critical early identification and surgical intervention can be to prevent serious complications such as permanent vision loss.

Ophthalmologic manifestations in primary antiphospholipid syndrome patients: A cross-sectional analysis of a primary antiphospholipid syndrome cohort (APS-Rio) and systematic review of the literature

OBJECTIVE

There is a broad spectrum of eye involvement in antiphospholipid syndrome (APS). The majority of descriptions are presented as case reports that include mostly APS patients secondary to systemic lupus erythematosus (SLE), with no compelling evidence in primary APS (PAPS). This study aimed to describe ocular manifestations in our well-defined PAPS cohort (APS-Rio) and then perform a systematic literature review (SLR) of ocular manifestations in patients with APS or positivity to aPL without SLE.

METHODS

We retrospectively analyzed PAPS patients followed at our outpatient clinics. All patients fulfilled Sydney APS classification criteria (2006). We evaluated them for ocular symptoms and previous ocular diagnoses. Antiphospholipid antibodies and clinical APS manifestations were compared between patients with and without ocular manifestations. For the SLR, electronic databases were searched up to November 2019.

RESULTS

We studied 105 PAPS patients; 90.5% were female and 56.2% were Caucasian. We found ocular manifestations in 37.1% of our cohort. Thrombosis was the main criteria manifestation (95.2%) and lupus anticoagulant was the most prevalent antibody. Ophthalmologic diagnoses were present in 7 patients, with 5 having retinal vessels thromboses. Amaurosis fugax was the leading complaint, present in 30 patients. In the univariate analysis, amaurosis fugax was related to livedo (p = 0.005), Raynaud's phenomenon (p = 0.048) and the presence of anticardiolipin antibody (≥40 GPL/MPL) (p = 0.041). Hemianopia was associated with arterial hypertension (p = 0.049). In the multivariate analysis, the only association found was between livedo and amaurosis fugax (OR 4.09, 95%CI 1.5-11.11, p = 0.006). Our SLR incorporated 96 articles of ocular manifestations in patients with PAPS or positivity to aPL without SLE. Ocular findings varied from 5 to 88%, including anterior and posterior segments, orbital and neuro-ophthalmologic changes.

CONCLUSION

There is little evidence on ocular manifestations in PAPS. We described an association between livedo and amaurosis fugax. Prospective studies are needed to promote the best treatment and avoid blindness in PAPS patients.

Evaluation of acute anterior ischaemic optic neuropathy using diffusion tensor imaging

BACKGROUND

Adequate diagnosis of acute anterior ischaemic optic neuropathy (AION) is challenging to achieve with traditional medical imaging approaches. The aim of this study was to evaluate the detection capacity of diffusion tensor imaging for abnormalities of the optic nerve in acute AION patients.

METHODS

Diffusion tensor imaging data were collected from 31 patients with acute AION and 20 healthy subjects. The mean fractional anisotropy and apparent diffusion co-efficient subsequently were evaluated across all subjects.

RESULTS

In affected nerves, the mean fractional anisotropy was reduced and the mean apparent diffusion co-efficient was increased in acute AION patients compared with control nerves (p < 0.001), as well as clinically unaffected contralateral nerves (p < 0.001). The mean fractional anisotropy and apparent diffusion co-efficient demonstrated no difference between normal control nerves and clinically unaffected contralateral nerves (p = 0.73 and 0.92, respectively).

CONCLUSION

Diffusion tensor imaging of the optic nerves demonstrated diagnostic potential for acute AION and could serve as a novel tool for the detection and evaluation of therapies.

Neurological and Neuropsychiatric Adverse Effects of Dermatologic Medications

Severe, recalcitrant dermatologic conditions often require systemic treatment. Although efficacious, these medications have been associated with wide-ranging adverse reactions. Some are reversible, predictable, and either dose-dependent or treatment length-dependent, while others are unpredictable, irreversible, and potentially fatal. This review examines the neuropsychiatric adverse effects associated with US FDA-approved medications for treatment of the following dermatologic pathologies that typically require systemic therapy: autoimmune dermatoses, acne, psoriasis, and melanoma. A search of the literature was performed, with adverse effects ranging from mild headaches and neuropathy to severe encephalopathies. The medications associated with the most serious reactions were those used to treat psoriasis, especially the older non-biologic medications such as cyclosporine A and methotrexate. Given the importance of these systemic dermatologic therapies in treating severe, recalcitrant conditions, and the wide variety of potentially serious neuropsychiatric adverse effects of these medications, neurologists, psychiatrists, dermatologists, oncologists, and primary care providers must be aware of the potential for these neuropsychiatric adverse reactions to allow for appropriate counseling, management, and medication withdrawal.

Update on the evaluation of transient vision loss

Transient vision loss may indicate underlying vascular disease, including carotid occlusion and thromboembolism, or it may have a more benign etiology, such as migraine or vasospasm. This review focuses on the differential diagnosis and workup of patients presenting with transient vision loss, focusing on several key areas: the relationship to thromboembolic vascular disease, hypercoagulable testing, retinal migraine, and bilateral vision loss. The objective is to provide the ophthalmologist with information on how to best manage these patients. Thromboembolic etiologies for transient vision loss are sometimes managed with medications, but when carotid surgery is indicated, earlier intervention may prevent future stroke. This need for early treatment places the ophthalmologist in the important role of expediting the management process. Hospital admission is recommended in patients presenting with transient symptoms within 72 hours who meet certain high-risk criteria. When the cause is giant cell arteritis, ocular ischemic syndrome, or a cardioembolic source, early management of the underlying condition is equally important. For nonthromboembolic causes of transient vision loss such as retinal migraine or retinal vasospasm, the ophthalmologist can provide reassurance as well as potentially give medications to decrease the frequency of vision loss episodes.