Nonarteritic anterior ischaemic optic neuropathy

Predictors of visual functional outcome following treatment for cavernous sinus meningioma

OBJECTIVE

Cavernous sinus meningioma (CSM) can affect visual function and require expeditious treatment to prevent permanent visual loss. Authors of this retrospective study sought to determine the factors associated with visual functional outcomes in CSM patients treated with surgery, stereotactic radiosurgery (SRS), or stereotactic radiation therapy (SRT), alone or in combination.

METHODS

Consecutive patients with CSM who had presented at an academic tertiary care hospital from 2000 to 2018 were identified through retrospective chart review. Visual function-visual eye deficit (VED), optic disc (OD) appearance, intraocular pressure (IOP), and extraocular movement (EOM)-was assessed before and after treatment for CSM. VED with visual acuity (VA) ≤ 20/200 and visual field defect ≥ -11 dB, pale OD appearance in the ipsilateral or contralateral eye, increased ipsilateral IOP, and/or EOM restriction were defined as a poor visual functional outcome. Multivariable logistic regression was used to evaluate the associations between pretreatment visual functional assessment and posttreatment visual outcomes.

RESULTS

The study cohort included 44 patients (73% female; median age 55 years), with a median clinical follow-up of 14 months. Ipsilateral VED improved, remained stable, or worsened, respectively, in 0%, 33.4%, and 66.6% of the patients after subtotal resection (STR) alone; in 52.6%, 31.6%, and 15.8% after STR plus radiation treatment; in 28.5%, 43.0%, and 28.5% after gross-total resection (GTR) alone; and in 56.3%, 43.7%, and 0% after radiation treatment (SRS or SRT) alone. Contralateral VED remained intact in all the patients after STR alone and those with radiation treatment (SRS or SRT) alone; however, it improved, remained stable, or worsened in 10.5%, 84.2%, and 5.3% after STR plus radiation treatment and in 43.0%, 28.5%, and 28.5% after GTR alone. EOM remained intact, fully recovered, remained stable, and worsened, respectively, in 0%, 50%, 50%, and 0% of the patients after STR alone; in 36.8%, 47.4%, 15.8%, and 0% of the patients after STR with radiation treatment; in 57.1%, 0%, 28.6%, and 14.3% of the patients after GTR alone; and in 56.2%, 37.5%, 6.3%, and 0% of the patients after radiation treatment (SRS or SRT) alone. In multivariable analyses adjusted for age, tumor volume, and treatment modality, initial ipsilateral poor VED (OR 10.1, 95% CI 1.05-97.2, p = 0.04) and initial ipsilateral pale OD appearance (OR 21.1, 95% CI 1.6-270.5, p = 0.02) were associated with poor ipsilateral VED posttreatment. Similarly, an initial pale OD appearance (OR 15.7, 95% CI 1.3-199.0, p = 0.03), initial poor VED (OR 21.7, 95% CI 1.2-398.6, p = 0.03), and a higher IOP in the ipsilateral eye (OR 55.3, 95% CI 1.7-173.9, p = 0.02) were associated with an ipsilateral pale OD appearance posttreatment. Furthermore, a higher initial ipsilateral IOP (OR 35.9, 95% CI 3.3-400.5, p = 0.004) was indicative of a higher IOP in the ipsilateral eye posttreatment. Finally, initial restricted EOM was indicative of restricted EOM posttreatment (OR 20.6, 95% CI 18.7-77.0, p = 0.02).

CONCLUSIONS

Pretreatment visual functional assessment predicts visual outcomes in patients with CSM and can be used to identify patients at greater risk for vision loss.

Assessment of peripapillary vessel density in acute non-arteritic anterior ischemic optic neuropathy

PURPOSE

To assess the peripapillary perfusion in eyes with acute non-arteritic anterior ischemic optic neuropathy (NAION) using optical coherence tomography angiography (OCTA).

METHODS

Twenty-five patients with unilateral acute NAION were included in this observational cross-sectional study. They were divided into two groups: group I (25 eyes) included eyes with acute NAION, and group II (25 eyes) included fellow normal eyes. Diagnosis of NAION was based on clinical examination and fluorescein angiography. OCTA (AngioVue, Optovue) was used to evaluate the optic nerve head perfusion and measure the peripapillary vessel density in all eyes included in the study.

RESULTS

Fourteen male and 11 female patients with a mean age of 60.2 ± 3.5 years were included in this study. The mean duration of presentation was 4.3 ± 0.6 days. Mean BCVA was 0.13 ± 0.06 and 0.69 ± 0.18 in eyes with NAION and normal eyes, respectively (p < 0.001). The peripapillary vessel was significantly decreased in all eyes with NAION compared with normal ones (p < 0.001). Two morphological changes were noted in eyes with NAION: vascular dropout related to area of disc edema in 25 eyes (100% of eyes) and vascular dilatation with tortuosity in 17 eyes (68%).

CONCLUSION

Eyes with NAION have decreased peripapillary vessel density with peripapillary vascular dilatation and tortuosity as assessed by OCTA.

Macular evaluation of the retinal and choroidal vasculature changes in anterior ischemic optic neuropathy-a case control study

BACKGROUND

This study aimes to characterize the fundus structural changes in patients with nonarteritic anterior ischemic optic neuropathy (NAION) and the correlation between macular vessel density, retinal nerve fibre layer (RNFL) parameters and visual field sensitivity (VFS) in NAION patients.

METHODS

A retrospective case control study was performed using 37 eyes with NAION, 30 uninvolved contralateral eyes, and 27 eyes of healthy age-matched subjects. Data on the retinas and choroidal vessel densities and VFS were compared among the three groups.

RESULTS

The NAION group exhibited significantly lower RNFL thicknesses, lower ganglion cell complexes (GCC), larger global loss volume (GLV) values and focal loss volume (FLV) values when compared with both uninvolved eyes and healthy eyes (p < 0.01 for all comparisons). The superficial vessel density (SVD) valus (whole, parafovea, superior-hemi and inferior-hemi) were significantly lower in NAION eyes, followed by uninvolved eyes and healthy eyes (p < 0.01; LSD, p < 0.05 for all comparisons). The deep vessel density (DVD) values (parafovea, superior-hemi and inferior-hemi) were the lowest by a significant value in NAION eyes, followed by uninvolved eyes and healthy eyes (p < 0.01; LSD, p < 0.05 for all comparisons). However, DVD value measurements (whole and fovea) of healthy and uninvolved eyes were not significantly different. The average threshold deviation (TD) was - 11.02 ± 3.75 dB for the overall field region, - 6.01 ± 2.21 dB for the affected superior field region and - 9.98 ± 3.34 dB for the affected inferior field region in NAION eyes. A statistically significant correlation was found between the RNFL thickness and visual field(VF) loss (r = - 0.788, p < 0.001).

CONCLUSION

In addition to peripapillary vascular changes occurring in NAION eyes, macular vessel density is also involved. Furthermore, NAION-uninvolved eyes exhibited abnormalities compared with healthy eyes. This indicates that vascular changes may occur before changes in retinal thickness at the early stages of NAION.

Could Topical Minoxidil Cause Non-Arteritic Anterior Ischemic Optic Neuropathy?

Minoxidil hair formulation is commonly used for the treatment of male or female androgenic alopecia. Minoxidil is a Health Canada and US FDA-approved medication for hair loss in men and women. The drug is marketed as 2% and 5% topical solutions. This over-the-counter product is considered safe, but should be used with caution. Furthermore, minoxidil is an orally active vasodilator for treatment of severe hypertension. Typical side effects of minoxidil are faster heart rate, augmented heart function and stroke volume (which can be associated with reduced vascular resistance upon baroflex stimulus), retained sodium and water and abnormal hair growth. The most common adverse reactions of the topical formulation are limited to irritant and allergic contact dermatitis on the scalp. Herein, we report a non-arteritic anterior ischemic optic neuropathy caused by topical 5% minoxidil treatment that was resolved after discontinuation of minoxidil.

Change of Retinal Nerve Layer Thickness in Non-Arteritic Anterior Ischemic Optic Neuropathy Revealed by Fourier Domain Optical Coherence Tomography

PURPOSE

To examine the changes of non-arteritic anterior ischemic optic neuropathy (NAION) by serial morphometry using Fourier domain optical coherence tomography (FD-OCT).

MATERIALS AND METHODS

Retrospective study in patients with newly diagnosed NAION (n=33, all unilateral) and controls (n=75 unilateral NAION patients with full contralateral eye vision) who underwent FD-OCT of the optic disk, optic nerve head (ONH), and macula within 1 week of onset and again 1, 3, 6, and 12 months later. The patients showed no improvement in vision during follow-up.

RESULTS

Within 1 week of onset, all NAION eyes exhibited severe ONH fiber crowding and peripapillary retinal nerve fiber layer (RNFL) edema. Four had subretinal fluid accumulation and 12 had posterior vitreous detachment (PVD) at the optic disc surface. Ganglion cell complex (GCC) and RNFL thicknesses were reduced at 1 and 3 months (p < 0.05), with no deterioration thereafter. Initial RNFL/GCC contraction magnitude in the superior hemisphere correlated with the severity of inferior visual field deficits.

CONCLUSIONS

NAION progression is characterized by an initial phase of accelerated RNFL and GCC deterioration. These results reveal that the kinetic change of neural retina in NAION and may have implication on the time window for treatment of NAION. FD-OCT is useful in the evaluation of NAION.

The impact of suction drainage on orbital compartment syndrome after craniofacial surgery

PURPOSE

Postoperative orbital compartment syndrome is a potentially blinding complication of surgery in the orbital region. We describe the technique of orbital drain placement as a method of preventing vision loss resulting from orbital compartment syndrome.

METHODS

We present a retrospective case series of 29 patients who underwent orbital fracture, facial fracture, and orbital implant removal from 7/4/2008 to 5/3/2013 by the same craniofacial surgeon. An orbital drain was placed in each patient. The drainage was recorded daily until drain removal. Criteria for removal included less than or equal to 5 mL of drainage in 24 hours.

RESULTS

Of the 29 patients included in this study, 21 were men and 8 were women. Ages ranged from 17 to 67 years. The postoperative drainage ranged from less than 1 mL to 71 mL of serosanguinous fluid. All drains were removed between the first and sixth postoperative days. No postoperative visual loss, infections, or additional antibiotics were recorded with follow-up reaching as far as 40 months.

CONCLUSIONS

Postoperative orbital compartment syndrome is a dangerous complication of surgery in the orbital region. Its rapid onset necessitates immediate intervention to prevent permanent vision loss. Morphologic changes to the optic nerve as well as reductions in electroretinogram a- and b-wave amplitudes have been demonstrated with as little as 7 mL of fluid accumulation. Intraoperative orbital drain placement should be considered in all patients undergoing surgery in the orbital region as a preventative measure.

Long-term retinal nerve fiber layer changes following nonarteritic anterior ischemic optic neuropathy

Background

In cases of nonarteritic anterior ischemic optic neuropathy (NAION), retinal nerve fiber layer (RNFL) thickness changes have been described during the first 12 months following the acute event. The purpose of this study was to report on the long-term RNFL changes in these eyes beyond the first year following onset of NAION.

Methods

Fourteen eyes of 13 patients with NAION were analyzed in this retrospective observational case series study. Uninvolved eyes served as controls. All patients underwent a complete neuro-ophthalmological examination and repeat measurements of peripapillary RNFL thickness using Stratus optical coherence tomography.

Results

On optical coherence tomography scan performed on average 6 months following onset of NAION, the mean global RNFL thickness (59.8 ± 11.8 μm) was significantly thinner (P < 0.001) compared with uninvolved eyes (95.1 ± 13.9 μm). In a second optical coherence tomography scan performed on average 13 (range 12–23) months later, the mean global RNFL thickness (58.9 ± 6.5 μm) was not significantly different (P = 0.702) from the first scan.

Conclusion

There appears to be no further RNFL loss beyond the first 6 months following an acute event of NAION.

Ischemic optic neuropathy and implications for plastic surgeons: report of a new case and review of the literature

BACKGROUND

Postoperative visual loss is a rare and devastating complication after nonocular as well as ocular surgery. A case of such a complication arising as a consequence of nonocular surgery prompted a review of the literature, and an appraisal of current theories on etiology, risk factors, and potential treatment options, as well as implications for informed consent. It is clear from our review that all patients undergoing both reconstructive and cosmetic surgery are at risk.

METHODS

A literature review was performed to identify all cases of ischemic optic neuropathy (both anterior and posterior subtypes) subsequent to any type of plastic, reconstructive, and aesthetic surgery procedures. An analysis of current knowledge regarding risk factors, etiology, prevention, and treatment options was undertaken.

RESULTS

A total of 38 patients aged between 16 and 76 years affected by ischemic optic neuropathy were identified, many as a consequence of routine and sometimes minor operative procedures.

CONCLUSIONS

Ischemic optic neuropathy can be a devastating complication of surgery. Plastic surgeons need to be aware of the risks, as well as the signs and symptoms, and counsel at-risk patients accordingly because of the potentially devastating nature of this complication. There are significant implications in relation to informed consent, underscored by the legal case of Rogers v Whitaker, 67 ALJR 47 (Aust 1992), which highlights the importance within the consent process of complications threatening sight, no matter how small.