The importance of visual field testing in idiopathic intracranial hypertension

Transverse Sinus Stenting Reverses Medically Refractory Idiopathic Intracranial Hypertension

Aim

To characterise the ophthalmic indications for, and ophthalmic efficacy of, transverse sinus stenting in adults with medically refractory idiopathic intracranial hypertension.

Methods

A retrospective cohort study was undertaken on a single-author database of 226 successive patients with confirmed idiopathic intracranial hypertension (IIH). A total of 32 patients were identified who received a transverse sinus stent for medically refractory disease. This which was defined as visual threat and/or intolerance of maximal medical therapy. Patients with medically refractory disease proceeded to stenting, if found to have a significant transverse sinus stenosis gradient at catheter venography. Visual threat was quantified via the degree of papilledema on optical coherence tomography of the retinal nerve fibre layer, and via the visual field mean deviation. CSF opening pressure at lumbar puncture and cerebral venous sinus pressure measurements from catheter venography were correlated with the ophthalmic data, noting also intolerance of maximal medical therapy. Complications of stenting were fully assessed.

Results

Medically refractory IIH was found in 18% of the total cohort of IIH patients. 90% of those with medically refractory disease had a significant transverse sinus stenosis pressure gradient, and 80% proceeded to stenting. The intervention eliminated papilledema in 96% of stented patients, and allowed 81% to cease acetazolamide. The need for a further procedure was low at 6%, and the safety profile was favourable.

Conclusions

Medically refractory disease in IIH is common (18%), and nearly always associated with a significant transverse sinus stenosis pressure gradient (90%). Endovascular stenting of the stenosis deserves wider uptake as a highly effective, safe, and usually definitive treatment. It safeguards vision by eliminating papilledema (96%), and allows most patients to cease acetazolamide (81%). By analogy with glaucoma, if acetazolamide is the prostaglandin of IIH and CSF diversion the emergency glaucoma filter, stenting is the minimally invasive glaucoma surgery.

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.

Visual evoked potentials follow-up in idiopathic intracranial hypertension

OBJECTIVE

To demonstrate the importance of visual evoked potential (VEP) in determining the severity and prognosis of the disease and in monitoring the clinical course in patients with idiopathic intracranial hypertension (IIH).

METHODS

This is a prospective cross-sectional study conducted covering the period between March 2014 and January 2015. The study included 32 patients recently diagnosed with IIH and 30 healthy volunteers. The initial VEP values of the IIH patients were compared to the VEP values of the healthy control group. Furthermore, the initial VEP values of the IIH patients were compared with their VEP values after one month of treatme RESULTS: The mean age of the IIH patients was 37.8+/-12.02 years. Of the IIH patients, 27 (84%) were females and 5 (16%) were males. There was a statistically significant association of the initial VEP values with the visual field findings (p=0.011) and visual acuity (p=0.040). Moreover, a statistically significant difference was found between the control group and IIH patients in terms of right (p less than 0.001) and left P100 values (p less than 0.001). While 18 (56%) of the initial VEPs of IIH patients were pathological, 14 (44%) of the second VEPs were pathological, and this difference was not statistically significant (p=0.125).

CONCLUSION

A relationship between the VEP P100 values and the severity of the disease was detected, while the importance of monitoring VEP values in the follow-up of IIH patients was not demonstrated.

Update on the Diagnosis and Treatment of Idiopathic Intracranial Hypertension

Advances in ophthalmic diagnostics and results of interventional clinical trials are shifting diagnosis and management of idiopathic intracranial hypertension (IIH) to be more technology- and evidence-based. In this article, the evidence supporting current diagnostic criteria, evaluation, and medical and surgical management of IIH are reviewed.