Acute visual loss and other disorders of the eyes

Requirement for Head Magnetic Resonance Imaging in Children Who Present to the Emergency Department With Acute Nontraumatic Visual Disturbance

OBJECTIVES

This study aimed to investigate the clinical features and head magnetic resonance imaging (MRI) findings in children who presented to the emergency department with acute nontraumatic visual disturbance and to study related clinical factors for discovering positive lesions on head MRI.

METHODS

We performed a retrospective study of 1-month to 15-year-old children who underwent head MRI as an evaluation for acute nontraumatic visual disturbance as a chief complaint in our pediatric emergency department between March 2010 and March 2015. The symptoms of visual disturbance were blurred vision, diplopia, loss of vision, and visual hallucination. Head MRI findings were considered positive when lesions could explain the symptoms.

RESULTS

We identified 39 patients (25 with blurred vision, 9 with diplopia, 3 with loss of vision, and 2 with visual hallucination) with a mean age of 8.35 ± 4.06 years. Positive head MRI findings were identified in 13 patients (33.3%). Brain tumors were most common (53.8%), followed by optic nerve inflammations (23.1%), congenital brain lesions (15.4%), and hypertensive encephalopathy (7.7%). Compared with the negative head MRI group, the positive head MRI group showed significantly less transient visual disturbance (duration <1 hour to complete recovery) (P = 0.001), more limited eye movement (P = 0.003), and more pupillary abnormalities (P = 0.030).

CONCLUSIONS

We suggest performing urgent head MRI in children with acute nontraumatic visual disturbance if the symptoms last longer than 1 hour without complete recovery and are accompanied by limited eye movement or pupillary abnormality.

Intracranial aneurysms presenting with mass effect over the anterior optic pathways: neurosurgical management and outcomes

Object

Intracranial aneurysms may grow closer to anterior optic pathways, causing mass effect over these anatomical structures, including visual deficit. The authors retrospectively reviewed a series of aneurysms in patients presenting with visual field deficit caused by mass effect, to analyze the aneurysm's characteristics, the neurosurgical management of these aneurysms, as well as their clinical, visual, and radiological outcomes.

Methods

The authors reviewed the medical charts, neuroimaging examination results, and surgical videos of 15 patients presenting with visual symptoms caused by an aneurysm's mass effect over the anterior optic pathways. These patients were treated at the Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, Brazil. Statistical analysis was performed to identify the variables related to partial or total recovery of the visual symptoms.

Results

All patients underwent microsurgical clip placement and emptying of their aneurysms. After a mean follow-up of 38.5 months, the mean postoperative Glasgow Outcome Scale score was 4.33, and the visual outcomes were as follows: 1 patient (6.6%) unchanged, 7 (46.6%) improved, and 7 (46.6%) experienced complete recovery from visual deficits. The variables that influenced the visual outcomes were the size of the aneurysm (p = 0.039), duration of the visual symptoms (p = 0.002), aneurysm wall calcification (p = 0.010), and intraluminal thrombosis (p = 0.007). Postoperative examination using digital subtraction angiography showed complete aneurysm occlusion in 14 (93.3%) of the 15 patients.

Conclusions

Intracranial aneurysms causing mass effect over the anterior optic pathways usually present with complex features. The best treatment option must include not only the aneurysm occlusion but also relief of the mass effect. Microsurgical clip placement with reduction of aneurysmal mass effect achieved improvement in visual ability or recovery from visual impairment, as well as total aneurysm occlusion, in 93.3% of the study group. Therefore, this option is well supported as the first choice of treatment for intracranial aneurysms presenting with mass effect over the anterior visual pathways.

Stage IV hepatic encephalopathy associated with acute blindness after liver transplantation

A 5-yr-old boy who diagnosed acute liver failure and Stage IV hepatic encephalopathy underwent living related liver transplantation and awakened with persistent hand motions visual loss. Serum Tacrolimus, electrolytes, magnesium levels were normal as well as blood pressure. His neurologic and opthamologic examinations were otherwise normal. Visual evoked potential (VEP) was prolonged and brain magnetic resonance immaging (MRI) revealed bilateral parietooccipital white matter signal abnormalities with gliosis. During follow up his visual loss resolved spontoneously as well as the VEP and MRI abnormalities. In this case we aimed to point out hepatic encephalopathy might be a cause of postoperative visual loss and serial VEP analysis is an important diagnostic tool for monitoring visual function of liver graft recipients in the post-operative period.

Current neuro-ophthalmic therapies

The clinical characteristics, differential diagnosis, and treatment options are presented for five different categories of neuro-ophthalmic disease. Nystagmus, optic neuritis, diplopia, pseudotumor cerebri, and temporal arteritis, are frequently encountered in neuro-ophthalmic practice. This article focuses on current therapies for these neuro-ophthalmic disorders. Potential differences in approach to pediatric versus adult patients are emphasized.

Neuroophthalmologic manifestations of systemic disease

Significant contributions on the neuroophthalmologic manifestations of systemic disease have been published in the past year. The first part of this paper is devoted to practical guidelines that may help in the diagnosis and the management of oculomotor disorders, especially in connection with systemic diseases; the second part is focused on specific entities. Including idiopathic intracranial hypertension and ophthalmoplegic migraine in this review might be debatable; however, although the cause of these conditions is still unclear, relevant findings suggest that they may be the consequence of other adjacent processes rather than the cause itself. We believe that the diagnosis of idiopathic intracranial hypertension as well as that of ophthalmoplegic migraine remains a challenging issue for the ophthalmologist and may easily be overlooked.