Diagnostic accuracy of confrontation visual field tests

FunctionaL Assessment Scale of Hemianopia (FLASH): A New Multidisciplinary Tool to Assess Hemianopia in Patients with Severe Acquired Brain Injury

BACKGROUND

Severe acquired brain injury (sABI) encompasses a range of neurological impairments. Visual dysfunction, particularly homonymous visual field defects (HVFDs) and homonymous hemianopia (HH), commonly afflicts sABI survivors, affecting their cognitive and motor rehabilitation. This study presents the FunctionaL Assessment Scale of Hemianopia (FLASH), developed to analyze the most common postural behaviors exhibited by sABI patients with hemianopia during activities of daily living. A comparison to traditional static automated perimetry for diagnosing visual field deficits (VFDs) to determine the sensitivity and specificity of the FLASH was used. Additionally, this study also aimed to assess its reliability.

METHODS

Fifty-six patients (25 F, 31 M, mean age 60.59 ± 14.53) with strokes in the sub-acute phase (<6 months from the onset) were assessed with both FLASH and a Humphrey Field Analyzer.

RESULTS

After removing two items found to be less reliable than others, FLASH showed high sensitivity (81%) and specificity (77%) when compared to static automated perimetry. Inter-rater reliability was also high, with an intra-class correlation coefficient of 0.954, as well as the internal consistency computed by Cronbach's alpha, equal to 0.874.

CONCLUSION

FLASH could offer a valuable and cost-effective screening tool for VFD in sABI patients during neurorehabilitation, with potential implications for healthcare cost reduction.

Direct-cortical visual evoked potential monitoring during brain tumor resection

BACKGROUND

Visual evoked potential (VEP) recording is traditionally regarded as an unreliable evoked potential monitoring technique, precluding widespread use in intracranial neurosurgery. However, VEPs can serve as a useful intraoperative adjunct for real-time detection of mechanical damage to optic apparatuses. The low obtainability and prognostic utility of VEPs are associated with transcranial recording, which typically provides non-focal information and poor signal-to-noise ratio. Direct cortical VEP (DC-VEP) recordings may offer a solution.

METHODS

We evaluated the obtainability of DC-VEPs as well as their prognostic utility in predicting postoperative visual function deterioration in a series of brain tumor patients undergoing craniotomies for tumor resection. Patient records were retrospectively reviewed for all consecutive patients undergoing brain tumor resections with DC-VEP monitoring. Pre- and postoperative visual fields were characterized from patient charts and associated with the presence of intraoperative monitoring alerts to determine the sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of DC-VEPs in detecting postoperative visual field deficits.

RESULTS

Twenty-two patients (9 male, 13 female) were included, with a median age of 60 years. DC-VEPs were reliably detected in 19 of 23 included surgeries (82.6%). The reported sensitivity, specificity, PPV, and NPV in detecting postoperative visual field deficits was 60%, 92.9%, 75%, and 86.7%, respectively. There was a statistically significant association between monitoring alerts and the presence of visual field deterioration by Fischer's exact test (p = 0.0374).

CONCLUSIONS

DC-VEPs can be reliably obtained and are useful for detecting mechanical injury to optic areas and tracts during tumor resection.

Sensitivity and Specificity of the Brentano Illusion Test in the Detection of Visual Hemi-Field Deficits in Patients with Unilateral Spatial Neglect

Stroke survivors with right-brain damage (RBD) often present with attentional deficits such as left unilateral spatial neglect. Some patients also present with contralesional visual hemi-field deficits. A late detection of visual hemi-field deficits (VHFD) contributes to hampering neurorehabilitation and functional outcome of patients with neglect. The Brentano Illusion Test (BRIT) may be used for an early detection of VHFD during the neuropsychological assessment. In the present study, we determined the sensitivity and specificity of the BRIT for screening VHFD in patients with neglect. Sixty-four consecutive RBD patients were examined. Forty-five presented with neglect. Of these, 23 presented with VHFD (hemianopia or quadrantanopia) as detected by the Humphrey automated static visual field testing (reference standard). Consecutive patients also included 19 participants without neglect, who did not have any VHFD. The sensitivity and specificity of the BRIT for neglect patients were 78.3% (95% CI: 61.4-95.1) and 90.9 (95% CI: 78.9-100.0), respectively. Positive predictive value (PPV) was 89.6% (95% CI: 76.4-100.0); negative predictive value (NPV) 80.7% (95% CI: 65.2-96.2). No false positives in the group without neglect were identified. We conclude that the BRIT is an effective tool for clinical neuropsychologists to screen for possible VHFD in neglect patients during the neuropsychological assessment, allowing the refinement of the clinical picture in the neuropsychological report. An early detection of VHFD also allows referring the patient to standard diagnostics for a formal visual field examination, right from the first neuropsychological assessment.

The presenting visual symptoms of optic chiasmal disease

Recognising optic chiasmal disease early is important in order to avoid irreversible visual loss and the potential risk of mortality for patients. Yet, there is frequently a delay in the initial diagnosis. Whilst the signs of optic chiasmal disease, particularly the perimetric findings, are well documented in the recent literature, the symptoms have been less well reported. Whilst some patients with optic chiasmal disease will be asymptomatic, many will complain of visual symptoms including symptomatic field defects, problems with central vision, difficulty with near tasks, binocular visual disturbances, colour vision disturbances, photophobia, phosphenes, glare, and rarely, oscillopsia and visual hallucinations. Others may have headache or the severe and sudden visual symptoms associated with pituitary apoplexy. The visual symptoms may be vague or non-specific, even when there are significant bitemporal visual field defects. We aim in this review to describe the presenting visual symptoms of optic chiasmal disease, and to illustrate these with selected qualitative descriptions from the literature. Our hope is that this will aid clinicians in eliciting a careful history of the sometimes subtle symptoms that may be present.

Eye Signs in Stroke

A large part of the central nervous system is involved in the normal functioning of the vision, and hence vision can be affected in a stroke patient. Transient visual symptoms can likewise be a harbinger of stroke and prompt rapid evaluation for the prevention of recurrent stroke. A carotid artery disease can manifest as transient monocular visual loss (TMVL), central retinal artery occlusion (CRAO), anterior ischemic optic neuropathy or ocular ischemic syndrome (OIS). Stroke posterior to the optic chiasm can cause sectoranopias, quadrantanopias, or hemianopias, which can be either congruous or incongruous. Any stroke involving the dorsal stream (occipito-parietal lobe), or ventral stream (occipito-temporal lobe) can manifest with visuospatial perception deficits. Similarly, different ocular motility abnormalities can result from a stroke affecting the cerebrum, cerebellum, or brainstem. Among these deficits, vision and perception disorders are more difficult to overcome. Clinical, experimental, and neuroimaging studies have helped us to understand the anatomical basis, physiological dysfunction, and the underlying mechanisms of these neuro-ophthalmic signs.

Improving the Telemedicine Evaluation of Patients With Acute Vision Loss: A Call to Eyes

Acute vision loss related to cerebral or retinal ischemia is a time-sensitive emergency with potential treatment options including intravenous or intraarterial thrombolysis and mechanical thrombectomy. However, patients either present in delayed fashion or present to an emergency department that lacks the subspecialty expertise to recognize and treat these conditions in a timely fashion. Moreover, healthcare systems in the United States are becoming increasingly reliant on telestroke and teleneurology services for acute neurologic care, making accurate diagnosis of acute vision loss even more challenging due to critical limitations to the remote video evaluation, including the inability to perform routine ophthalmoscopy. The COVID-19 pandemic has led to a greater reliance on telemedicine services and helped to accelerate the development of novel tools and care pathways to improve remote ophthalmologic evaluation, but these tools have yet to be adapted for use in the remote evaluation of acute vision loss. Permanent vision loss can be disabling for patients and efforts must be made to increase and improve early diagnosis and management. Herein, the authors outline the importance of improving acute ophthalmologic diagnosis, outline key limitations and barriers to the current video-based teleneurology assessments, highlight opportunities to leverage new tools to enhance the remote assessment of vision loss, and propose new avenues to improve access to emergent ophthalmology subspeciality.

Development of core outcome sets and core outcome measures for central visual impairment, visual field loss and ocular motility disorders due to stroke: a Delphi and consensus study

OBJECTIVES

Reporting of research for stroke-related visual impairment is inconsistent. The aim of this study was to define three core outcome sets (COS) and related core outcome measurements (COM) for central visual impairment, visual field loss and ocular motility disorders in stroke research.

DESIGN

The consensus process consisted of an online three-round Delphi survey followed by a consensus meeting of key stakeholders.

SETTING

UK-wide survey.

PARTICIPANTS

Stakeholders included orthoptists, occupational therapists, ophthalmologists, stroke survivors and COS users such as researchers, journal editors and guideline developers.

OUTCOME MEASURES

For COS development, a list of potentially relevant visual outcomes was created after review of the literature and further grouped into outcome domains. For COM development, a list of potential instruments was created after review of the literature and quality appraised for reliability and validity.

RESULTS

COS-119 potential outcomes extracted from published literature. Similar assessment outcomes were grouped into 24 outcome domains. Delphi process included 123 participants in round 1, 65 round 2, 51 round 3. Twelve participants attended the consensus meeting with recommended outcome domains for central visual impairment (visual acuity, functional vision, quality of life), visual field loss (visual fields, functional vision, quality of life) and ocular motility disorders (eye alignment, eye movements, functional vision, quality of life). COM-52 test options extracted from the COS outcomes and grouped into 16 domains. Thirteen participants attended the COM consensus meeting. Recommended instruments for measurement of these outcomes include; Logarithm of the Minimal Angle of Resolution visual acuity, cover test, cardinal position eye movement assessments, peripheral visual field perimetry, Visual Function Questionnaire-25.

CONCLUSIONS

COS and COM are defined for vision research for stroke survivors. Their use has potential to reduce heterogeneity in routine clinical practice and improve standardisation and accuracy of vision assessment. Future research is required to evaluate the use of these COS and COM.

Rehabilitation of visual perception in cortical blindness

Blindness is a common sequela after stroke affecting the primary visual cortex, presenting as a contralesional, homonymous, visual field cut. This can occur unilaterally or, less commonly, bilaterally. While it has been widely assumed that after a brief period of spontaneous improvement, vision loss becomes stable and permanent, accumulating data show that visual training can recover some of the vision loss, even long after the stroke. Here, we review the different approaches to rehabilitation employed in adult-onset cortical blindness (CB), focusing on visual restoration methods. Most of this work was conducted in chronic stroke patients, partially restoring visual discrimination and luminance detection. However, to achieve this, patients had to train for extended periods (usually many months), and the vision restored was not entirely normal. Several adjuvants to training such as noninvasive, transcranial brain stimulation, and pharmacology are starting to be investigated for their potential to increase the efficacy of training in CB patients. However, these approaches are still exploratory and require considerably more research before being adopted. Nonetheless, having established that the adult visual system retains the capacity for restorative plasticity, attention recently turned toward the subacute poststroke period. Drawing inspiration from sensorimotor stroke rehabilitation, visual training was recently attempted for the first time in subacute poststroke patients. It improved vision faster, over larger portions of the blind field, and for a larger number of visual discrimination abilities than identical training initiated more than 6 months poststroke (i.e., in the chronic period). In conclusion, evidence now suggests that visual neuroplasticity after occipital stroke can be reliably recruited by a range of visual training approaches. In addition, it appears that poststroke visual plasticity is dynamic, with a critical window of opportunity in the early postdamage period to attain more rapid, more extensive recovery of a larger set of visual perceptual abilities.

What to Do with Incidentally Discovered Pituitary Abnormalities?

Pituitary incidentalomas are discovered in approximately 10% to 40% of brain images. A complete patient history, physical examination, and dedicated pituitary function testing are needed, and subsequent results should lead to appropriate patient management. However, most lesions are asymptomatic pituitary adenomas or Rathke cleft cysts with a benign course. Many lesions can be clinically significant, including prolactinomas or other pituitary adenomas that warrant specific pituitary disease treatment. In other cases, mass effect causing visual compromise or refractory headache indicates a need for surgery. Here, various facets of a complex evaluation and treatment algorithm for pituitary incidentalomas are reviewed.

Sensitivity and Specificity of New Visual Field Screening Software for Diagnosing Hemianopia

Purpose

To assess the diagnostic accuracy of visual field results generated by the newly developed software (CU-VF) and the standard automated perimetry (SAP) for detecting hemianopia.

Patients and Methods

Forty-three subjects with hemianopia and 33 controls were tested with the CU-VF software on a personal computer and SAP. Hemianopia was defined as the presence of a hemianopic field respecting the vertical meridian on SAP with the corresponding neuroimaging pathology as evaluated by 2 neuro-ophthalmologists. Results of CU-VF were independently evaluated by 2 neuro-ophthalmologists, 1 general ophthalmologist, and 1 general practitioner in terms of the presence of hemianopia. Sensitivity, specificity, and kappa coefficient for inter-observer reliability were calculated. Satisfaction and ease of use were evaluated with a visual analog-scale questionnaire and analyzed using paired t-test.

Results

The sensitivity (95% CI) and specificity (95% CI) of the CU-VF to detect hemianopia was 74.42% (58.53–85.96) and 93.94% (78.38–99.94). Kappa coefficient between neuro-ophthalmologists versus general ophthalmologist and general practitioner were 0.71 and 0.84, respectively. The mean (SD) test duration was 2.25 (0.002) minutes for the CU-VF and 5.38 (1.34) minutes for SAP (p < 0.001). Subjects reported significantly higher satisfaction and comfort using the CU-VF software compared to SAP.

Conclusion

The CU-VF screening software showed good validity and reliability to detect hemianopia, with shorter test duration and higher subject satisfaction compared to SAP.

Artifactual Visual Field Defects Identified on Technically "Reliable" Visual Field Studies in a Neuro-Ophthalmology Practice

Purpose

To assess the reliability of automated visual field studies with neurological abnormalities and normal reliability indices that were inconsistent with the remainder of the neuro-ophthalmic assessment.

Methods

Retrospective observational study from the clinical practice of a neuro-ophthalmologist at a tertiary referral center.

Results

From 2230 patient charts, ten cases were identified that met the inclusion criteria. In eight of the cases repeat visual field testing had no reproducible abnormality. Four of these cases were concerning for a bitemporal or homonymous hemianopia. None of the patients, including the two cases with a reproducible defect, developed any convincing manifestations of an organic disease related to the visual field defect.

Conclusion

Our findings suggest that even marked neurological abnormalities on reliable automated visual field tests can be false. When the remainder of the neuro-ophthalmic evaluation is inconsistent with the test result, we recommend that clinicians attempt to immediately repeat the visual field study.

Neuro-Ophthalmic Emergencies

Neuro-ophthalmic emergencies include optic nerve, central visual pathway, and ocular motility disorders that, if not identified and treated promptly, may lead to permanent vision loss, other significant morbidity, or mortality. This article provides a framework for approaching patients with neuro-ophthalmic symptoms and reviews the presentation, evaluation, and treatment of select emergent conditions that can cause them. Emergent causes of blurry vision, transient vision loss, papilledema, and diplopia, including giant cell arteritis, cardioembolic disease, and aggressive infection, are discussed.

Visual field outcomes in children treated for neurofibromatosis type 1-associated optic pathway gliomas: a multicenter retrospective study

BACKGROUND

Optic pathway gliomas associated with neurofibromatosis type 1 (NF1-OPGs) may adversely affect visual acuity, but data regarding visual field (VF) outcomes after treatment in children are limited. The purpose of this study was to investigate the effects of NF1-OPGs on VF function in a large cohort of children after treatment with chemotherapy.

METHODS

We performed a retrospective, international, multicenter study of VF outcomes in patients treated with chemotherapy for NF1-OPGs.

RESULTS

A total of 25 participants underwent VF testing using formal perimetric techniques. At the end of treatment, 19 participants (76%) had persistent VF deficits. Formal VF testing was available for 16 participants (64%) at initiation and completion of treatment. Of the 16 children who underwent VF testing at initiation and completion of treatment, 7 (44%) showed stability of VF changes, 3 (19%) showed improvement of VF function, and 6 (38%) had worsening of VFs. Improvement or worsening of VF outcome did not always correlate with visual acuity outcome. Posterior tumor location involving the optic tracts and radiations was associated with more frequent and more profound VF defects.

CONCLUSIONS

In our study cohort, children undergoing initial chemotherapy for NF1-OPGs had a high prevalence of VF loss, which could be independent of visual acuity loss. A larger, prospective study is necessary to fully determine the prevalence of VF loss and the effects of chemotherapy on VF outcomes in children with NF1-OPGs.

An Open-source Static Threshold Perimetry Test Using Remote Eye-tracking (Eyecatcher): Description, Validation, and Preliminary Normative Data

Purpose

To describe, validate, and provide preliminary normative data for an open-source eye-movement perimeter (Eyecatcher).

Methods

Visual field testing was performed monocularly in 64 normally sighted young adults, using (i) a Humphrey Field Analyzer (HFA) and (ii) the novel Eyecatcher procedure. Eyecatcher used a remote eye-tracker to position stimuli relative to the current point of fixation, and observers responded by looking towards the stimulus. In both tests, Goldman III stimuli were sampled from a 24-2 grid, and were presented against a 10 cd/m² background. Participants completed each test twice to assess test–retest repeatability.

Results

Mean Sensitivity (MS) did not differ between Eyecatcher and the HFA (P = 0.086), and both tests exhibited similar test–retest repeatability (CoR_Eyecatcher = ±1.86 dB; CoR_HFA = ±1.95 dB). Eyecatcher was also able to detect changes in sensitivity across the normal visual field (the “Hill of Vision”), and could differentiate the physiological blind spot from adjacent retinal locations. Mean sensitivities and 95% limits of agreement are described for each pointwise location.

Conclusions

Eyecatcher can use eye movements to assess visual fields in young, normally sighted adults. In such observers, it provides results similar to the current gold standard clinical device (HFA).

Translational Relevance

Given further development, eye movement perimeters such as Eyecatcher could be particularly useful for individuals unable to perform traditional perimetric assessments, such as young children or stroke patients. Full technical details and information on how to freely acquire the source code are included.

How I do it: The Neuro-Ophthalmological Assessment in Parkinson's Disease

Visual disorders like double vision, dry eyes, and visual field deficits are common but frequently missed in Parkinson’s disease. Here, we aim to increase awareness for these visual disorders in Parkinson patients by discussing several common problems that can be easily diagnosed using comprehensive history taking and a basic neuro-ophthalmological examination. We offer practical guidance for the patient interview and physical exam that can facilitate a timelier recognition of visual disorders. Such recognition has immediate therapeutic relevance, because Parkinson patients are strongly dependent on an adequate vision, for example to optimally benefit from visual cueing strategies.

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.

Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review

Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevention and failure to treat the underlying vascular pathology. Understanding important anatomic variants, the clinical presentations, relevant physical examination findings, and the limitations of acute brain imaging may help reduce misdiagnosis. We present a symptom-based review of posterior circulation ischemia focusing on the subtler presentations with a brief discussion of basilar stroke, both of which can be missed by the emergency physician. Strategies to avoid misdiagnosis include establishing an abrupt onset of symptoms, awareness of the nonspecific presentations, consideration of basilar stroke in altered patients and using a modern approach to diagnosis of the acutely dizzy patient.

Chiasmal and Postchiasmal Disease

PURPOSE OF REVIEW

This article reviews the anatomy, symptoms, examination findings, and causes of diseases affecting the optic chiasm, optic tracts, optic radiations, and occipital lobes.

RECENT FINDINGS

Modern ophthalmic imaging can be used to monitor the effects of diseases of the optic chiasm and tract on the retinal ganglion cells. It can also be used to visualize transsynaptic degeneration of the anterior visual pathway in the setting of acquired retrogeniculate lesions. Visual prostheses that directly stimulate the occipital lobe are a potential strategy for rehabilitation that is in active clinical trials.

SUMMARY

Detecting and characterizing visual deficits due to optic chiasm and retrochiasmal disease are important for the diagnosis, localization, and monitoring of neurologic disease; identifying patient disability; and guiding rehabilitation.

Homonymous Horizontal Sectoranopia Caused by an Occipital Lobe Infarct

Homonymous horizontal sectoranopia is a rare visual field defect that characteristically occurs after damage to the lateral geniculate nucleus (LGN). While there are many reports of homonymous horizontal sectoranopia resulting from LGN damage, there are very few reports of homonymous horizontal sectoranopia resulting from damage to other areas of the brain. We present a unique case of a patient with a homonymous horizontal sectoranopia with an occipital lobe infarct. Visual field and radiologic findings are presented. To our knowledge, this is one of the few reported cases of homonymous horizontal sectoranopia resulting from an infarct to the occipital lobe.

Inpatient and Emergency Room Ophthalmology Consultations at a Tertiary Care Center

Background

An ophthalmology consultation service is of significant benefit to patients in the hospital and is an instructive component of a residency education program. Ophthalmology consultations in a hospital present unique challenges to those seen in an outpatient clinic, for which the consulting ophthalmologist should be prepared. The purpose of this study was to profile the emergency room and inpatient ophthalmology consultations seen at an academic institution.

Methods

A prospective study of 581 patients was conducted on inpatient and emergency room ophthalmology consultations at the University of Illinois at Chicago over twelve months. Characteristics such as the consulting service, type of and reason for consultation, subspecialty staffing service, diagnosis, and suitability for in-hospital evaluation were recorded.

Results

Consultations were received from either inpatient wards (59.4%) or the Emergency Department (40.6%). The most common inpatient consulting services were internal medicine (22%), followed by neurosurgery (16%) and neurology (7%). All the consultations were categorized as acute (72.3%), chronic (6.0%), or screening (21.7%). Consultations categorized as screening included papilledema (31.0%), fungemia (20.6%), syndromic evaluation (19.8%), visual field evaluation (17.5%), and miscellaneous evaluation (11.1%). We classified the ophthalmic diagnoses into 63 unique diagnoses. Amongst the ophthalmic subspecialties, neuro-ophthalmologic diagnoses were the most common (32.0%), followed by retina (20.1%) and cornea (19.4%). Neuro-ophthalmology had the highest proportion of screening consultations (36.6%), while glaucoma had the least overall number of consultations (10.1%), and the least proportion of screening consultations (3.6%). A significant proportion of nonacute consultations (19.0%) was deemed to be more suitable for outpatient evaluation.

Discussion

Consultation databases can be useful in preparing trainees for in-hospital clinical care. A wide range of ocular pathologies may present to the ophthalmology consultant, from acute trauma to screening for systemic syndromes. Some consultations may be more suitable for outpatient evaluation which may help optimize patient care.

A Window to the Brain: Neuro-Ophthalmology for the Primary Care Practitioner

Visual symptoms, including acute monocular visual loss, papilledema, visual field deficits, anisocoria, limitations of eye movements, and nystagmus, can be the presenting feature of a wide range of important neurologic diseases. It is important for primary care clinicians to be to be able to direct appropriate initial diagnostic assessment, treatment, and referral for further evaluation of these conditions.

The Use of Flow Diverting Stents to Treat Para-Ophthalmic Aneurysms

Background and purpose

Few publications have dealt exclusively with the use of flow diverter stents for the treatment of para-ophthalmic aneurysms. We sought to determine the efficacy of flow diverting stents (FDSs) to treat aneurysms in this specific location.

Methods

We retrospectively reviewed our database of prospectively collected information for all patients treated with flow diversion for an unruptured saccular para-ophthalmic aneurysm between September 2009 and January 2016. The aneurysm fundus size, neck size, number and type of FDS, complications, and follow-up data were recorded.

Results

We identified 74 patients that matched our inclusion criteria. Of these patients, 18 patients were male (24.3%). The average fundus size was 4.8 mm, 11 aneurysms had previous coil occlusions and 63 were treated solely with flow diversion. At an initial angiographic follow-up (mean avg. 3.2 months), 71.8% of the aneurysms were occluded, and at the last follow-up (mean avg. 31.8 months), 88.9% of aneurysms were occluded. One patient suffered permanent morbidity (1.36%) secondary to interruption of the antiplatelet medication and another died (1.36%) secondary to in-stent thrombosis that was also due to an interruption in the antiplatelet medication.

Conclusion

Treatment of saccular para-ophthalmic aneurysms with FDS is feasible and carries a high degree of technical success with low complication rates and excellent rates of aneurysm exclusion.

[Management of paraophthalmic aneurysms : Review of endovascular treatment strategies]

BACKGROUND

Aneurysms of the cerebral vessels are relatively common and aneurysms of the ophthalmic segment of the internal carotid artery (ICA) represent approximately 10% of intradural aneurysms.

ANATOMICAL ASPECTS

The ophthalmic segment of the ICA extends from the origin of the ophthalmic artery to the origin of the posterior communicating artery. Aneurysms can originate from the ophthalmic artery itself or directly from the ICA at a distance from the ophthalmic artery. The various anatomic configurations can alter the risks of treatment.

SURGICAL TREATMENT

Surgical treatment of aneurysms of the ophthalmic segment poses unique challenges for the neurosurgeon, given the deep location and complex nearby structures and optic nerve. The necessity to remove the clinoid process can make the operation technically challenging.

ENDOVASCULAR TREATMENT

Endovascular treatment of paraophthalmic aneurysms includes coil occlusion, and also stent- or balloon-assisted coil occlusion. More recently, hemodynamically active flow diverter stents improved the treatment results.

CONCLUSION

The management of paraophthalmic aneurysms is associated with specific risks. Careful consideration of the available techniques is necessary before each invention. Coil-occlusion remains the first choice for ruptured paraophthalmic aneurysms. For unruptured paraophthalmic aneurysms flow diversion offers improved results. The overall complication rates of these procedures are low; however, cerebral ischemia, intracranial hemorrhage and visual complications must be considered in advance and the patient must be informed of the risks.

The Fate of Side Branches Covered by Flow Diverters-Results from 140 Patients

BACKGROUND

Flow diverter stents (FDS) are a recognized treatment option for intracranial aneurysms. There remain ongoing concerns regarding the safety of FDS, especially regarding the fate of covered side branches. We report the patency of side branches covered by FDS.

METHODS

We retrospectively reviewed our database of prospectively collected information for all patients treated with FDS for an unruptured saccular aneurysm of the clinoid, ophthalmic, and terminating segments of the internal carotid artery between September 2009 and July 2016. The aneurysm location, fundus size, and the state of covered branches at last angiography were recorded compared with preoperative angiography.

RESULTS

We identified 140 patients, with 147 aneurysms, who met our inclusion criteria. Five patients had bilateral aneurysms. There were 31 male patients in our cohort (21.9%) and the mean average age was 56.2 ± 13.7 years. Sixty-seven aneurysms arose from the communicating, 58 from the ophthalmic, and 22 from the clinoidal segments. At last follow-up (mean, 22.3 months) 116 aneurysms were completely occluded (78.3%). On the most recent angiogram, 7 ophthalmic (5.3%), 20 posterior communicating (42.6%), 0 anterior choroidal (0%), and 2 anterior cerebral arteries (14.3%) were completely occluded. Reduced vessel caliber was seen in 11 ophthalmic (8.3%), 3 posterior communicating (6.4%), 0 anterior choroidal, and 6 anterior cerebral arteries (42.9%). One patient died during follow-up.

CONCLUSIONS

The side branch occlusion rate was 20% and included ophthalmic, posterior communicating, and anterior cerebral arteries. Consistent with other studies, we did not see occlusion of the anterior choroidal artery.

Quantification of visual function assessment using remote eye tracking in children: validity and applicability

PURPOSE

Measurements of visual and oculomotor functions are essential for providing tailored support to visually impaired children. In young or intellectually disabled children these measurements can be difficult or even impossible to perform. Recordings of orienting gaze in response to specific visual information, made with eye tracking, may offer a solution. The aim of this study was to observe and quantify eye tracking (ET)-based gaze responses to provide information about visual and oculomotor functioning, and to compare this information with standard visual function assessments (VFA).

METHODS

One hundred and twenty-six visually impaired children from 1-14 years underwent a VFA. Next they underwent a remote ET test. Four aspects of oculomotor control (nystagmus, fixation, saccades, pursuit) and three visual functions (visual field, contrast, colour) were selected to compare both methods. Performance was assessed (1) during VFA using standard behavioural observation and test scores and (2) after ET by observing and scoring the eye movement recordings. Validity, in terms of agreement between results, was measured by correlation analyses. From the orienting gaze responses, quantitative parameters (gain, fixation duration and directional saccades) were calculated to characterize visual performance.

RESULTS

Good agreement between the two test methods was found for observational assessment of oculomotor control and visual functions (correlations ranging from rs  = 0.39 to rs  = 0.69). The quantitative parameters of visual performance showed distinct results between children with and without specific functional impairments, both in children aged 1-6 and 7-14 years.

CONCLUSION

Eye tracking-based gaze recordings are a promising tool to assess oculomotor and visual performance in a communication-free manner. Calculating quantitative parameters from specific gaze responses could assist in the characterization of functional visual performance in children, independent of age. Gaze responses are a useful addition to standard VFA in clinical practice.

Rehabilitation of visuospatial neglect by prism adaptation: effects of a mild treatment regime. A randomised controlled trial

Closely examining the effects, optimal regime and time window of prism adaptation (PA) promotes guidelines for effective rehabilitation practice. The effects of short-term repetitive PA on spatial neglect manifestations were evaluated in patients with heterogeneous post-stroke delays, using a digital Visuospatial Neglect Test Battery. Subsequently, potential differences in PA effects between acute, subacute or chronic neglect were explored. A multicentre randomised controlled trial was conducted in 43 right-hemisphere neglect patients. They were treated with a mild PA regime: seven sessions of experimental or placebo prism training over 7-12 days. The outcome measures were diverse neglect variables related to peripersonal navigation, visual extinction, visuospatial memory, bisection, cancellation, drawing and visual search. The treatment effects were assessed after a short and a long time interval. Two to 24 hours after PA, conventional effects were found for drawing and centred bisection, and novel effects for peripersonal visuospatial navigation, visual extinction, and non-motor memory (with caution). No effects were found for visual search times and cancellation. The assessments after three months were still indicative of PA benefits for navigational, drawing and memory functions. PA did not prove to be more effective in acute, subacute or chronic patients. The extension of effects is theoretically framed within the debate about the levels of cognitive processing that are impacted by PA. Clinical suggestions are formulated regarding PA implementation in neglect treatment.

Preschool children's vision screening in New Zealand: a retrospective evaluation of referral accuracy

OBJECTIVES

To assess the accuracy of preschool vision screening in a large, ethnically diverse, urban population in South Auckland, New Zealand.

DESIGN

Retrospective longitudinal study.

METHODS

B4 School Check vision screening records (n=5572) were compared with hospital eye department data for children referred from screening due to impaired acuity in one or both eyes who attended a referral appointment (n=556). False positive screens were identified by comparing screening data from the eyes that failed screening with hospital data. Estimation of false negative screening rates relied on data from eyes that passed screening. Data were analysed using logistic regression modelling accounting for the high correlation between results for the two eyes of each child.

PRIMARY OUTCOME MEASURE

Positive predictive value of the preschool vision screening programme.

RESULTS

Screening produced high numbers of false positive referrals, resulting in poor positive predictive value (PPV=31%, 95% CI 26% to 38%). High estimated negative predictive value (NPV=92%, 95% CI 88% to 95%) suggested most children with a vision disorder were identified at screening. Relaxing the referral criteria for acuity from worse than 6/9 to worse than 6/12 improved PPV without adversely affecting NPV.

CONCLUSIONS

The B4 School Check generated numerous false positive referrals and consequently had a low PPV. There is scope for reducing costs by altering the visual acuity criterion for referral.

Vision related quality of life in spinocerebellar ataxia

OBJECTIVE

Spinocerebellar ataxia (SCA) leads to abnormal ocular motility and alignment. The objective of this study was to quantitatively assess vision, ocular motility and alignment and its impact on vision related quality of life (VRQOL) in SCA.

METHODS

Nineteen genetically diagnosed SCA subjects (11 SCA type 3, 3 SCA type 1 and 5 SCA type 6) participated at two university centers. All subjects completed the National Eye Institute Visual Function Questionnaire (NEI-VFQ), 10-Item Neuro-Ophthalmic Supplement (NOS), scale for assessment and rating of ataxia (SARA) and ophthalmic examination. Twelve subjects seen at one of the 2 sites underwent quantitative ocular motility and alignment assessment.

RESULTS

Composite scores for NEI-VFQ (mean 76.3±13) and NOS (mean 65.2±16.8) were significantly decreased in SCA subjects. NEI-VFQ subscale scores were decreased for general, near, distance and peripheral vision and driving. SCA patients had decreased low contrast sensitivity, stereoacuity and multiple ocular motility defects which included gaze limitation (9/12), nystagmus (5/12), distance esophoria (11/12), near exophoria (12/12) and receded near point of convergence. A significant negative correlation was noted between composite scores and distance convergence fusional amplitude.

CONCLUSION

VRQOL is significantly decreased in SCA compared to normal population. All SCA patients should be screened for visual disability and referred for neuro-ophthalmic assessment promptly.

Clinical and Psychometric Evaluations of the Cerebral Vision Screening Questionnaire in 461 Nonaphasic Individuals Poststroke

Background. Cerebral vision disorders (CVDs) are frequent after brain damage and impair the patient’s outcome. Yet clinically and psychometrically validated procedures for the anamnesis of CVD are lacking. Objective. To evaluate the clinical validity and psychometric qualities of the Cerebral Vision Screening Questionnaire (CVSQ) for the anamnesis of CVD in individuals poststroke. Methods. Analysis of the patients’ subjective visual complaints in the 10-item CVSQ in relation to objective visual perimetry, tests of reading, visual scanning, visual acuity, spatial contrast sensitivity, light/dark adaptation, and visual depth judgments. Psychometric analyses of concurrent validity, specificity, sensitivity, positive/negative predictive value, and interrater reliability were also done. Results. Four hundred sixty-one patients with unilateral (39.5% left, 47.5% right) or bilateral stroke (13.0%) were included. Most patients were assessed in the chronic stage, on average 36.7 (range = 1-620) weeks poststroke. The majority of all patients (96.4%) recognized their visual symptoms within 1 week poststroke when asked for specifically. Mean concurrent validity of the CVSQ with objective tests was 0.64 (0.54-0.79, P < .05). The mean positive predictive value was 80.1%, mean negative predictive value 82.9%, mean specificity 81.7%, and mean sensitivity 79.8%. The mean interrater reliability was 0.76 for a 1-week interval between both assessments (all P < .05). Conclusion. The CVSQ is suitable for the anamnesis of CVD poststroke because of its brevity (10 minute), clinical validity, and good psychometric qualities. It, thus, improves neurovisual diagnosis and guides the clinician in the selection of necessary assessments and appropriate neurovisual therapies for the patient.

Primary care management of the female patient presenting with nipple discharge

Nipple discharge is a common primary care finding in female patients. The nurse practitioner must possess the skills and knowledge to correctly and safely manage this clinical finding. The following is a review of the etiology of nipple discharge, the differential diagnoses, and treatment modalities.

Homonymous hemianopia: challenges and solutions

Stroke is the most common cause of homonymous hemianopia (HH) in adults, followed by trauma and tumors. Associated signs and symptoms, as well as visual field characteristics such as location and congruity, can help determine the location of the causative brain lesion. HH can have a significant effect on quality of life, including problems with driving, reading, or navigation. This can result in decreased independence, inability to enjoy leisure activities, and injuries. Understanding these restrictions, as well as the management options, can aid in making the best use of remaining vision. Treatment options include prismatic correction to expand the remaining visual field, compensatory training to improve visual search abilities, and vision restoration therapy to improve the vision itself. Spontaneous recovery can occur within the first months. However, because spontaneous recovery does not always occur, methods of reducing visual disability play an important role in the rehabilitation of patients with HH.

A participatory approach to develop the Power Mobility Screening Tool and the Power Mobility Clinical Driving Assessment tool

The electric powered wheelchair (EPW) is an indispensable assistive device that increases participation among individuals with disabilities. However, due to lack of standardized assessment tools, developing evidence based training protocols for EPW users to improve driving skills has been a challenge. In this study, we adopt the principles of participatory research and employ qualitative methods to develop the Power Mobility Screening Tool (PMST) and Power Mobility Clinical Driving Assessment (PMCDA). Qualitative data from professional experts and expert EPW users who participated in a focus group and a discussion forum were used to establish content validity of the PMCDA and the PMST. These tools collectively could assess a user's current level of bodily function and their current EPW driving capacity. Further multicenter studies are necessary to evaluate the psychometric properties of these tests and develop EPW driving training protocols based on these assessment tools.

Functional outcome measures for NF1-associated optic pathway glioma clinical trials

OBJECTIVE

The goal of the Response Evaluation in Neurofibromatosis and Schwannomatosis Visual Outcomes Committee is to define the best functional outcome measures for future neurofibromatosis type 1 (NF1)-associated optic pathway glioma (OPG) clinical trials.

METHODS

The committee considered the components of vision, other ophthalmologic parameters affected by OPG, potential biomarkers of visual function, and quality of life measures to arrive at consensus-based, evidence-driven recommendations for objective and measurable functional endpoints for OPG trials.

RESULTS

Visual acuity (VA) assessments using consistent quantitative testing methods are recommended as the main functional outcome measure for NF1-OPG clinical trials. Teller acuity cards are recommended for use as the primary VA endpoint, and HOTV as a secondary endpoint once subjects are old enough to complete it. The optic disc should be assessed for pallor, as this appears to be a contributory variable that may affect the interpretation of VA change over time. Given the importance of capturing patient-reported outcomes in clinical trials, evaluating visual quality of life using the Children's Visual Function Questionnaire as a secondary endpoint is also proposed.

CONCLUSIONS

The use of these key functional endpoints will be essential for evaluating the efficacy of future OPG clinical trials.

Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel?

BACKGROUND

The inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a 'task shifting' strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology.

METHODS

Specialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated.

RESULTS

Sensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2.

CONCLUSIONS

In this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.

Determining the validity of the AMA guide: A historical cohort analysis of the assessment of driving related skills and crash rate among older drivers

BACKGROUND

Chronic health conditions associated with ageing can lead to changes in driving ability. The Canadian Driving Research Initiative for Vehicular Safety in the Elderly (Candrive II) is a 5-year prospective study funded by the Canadian Institutes of Health Research aiming to develop an in-office screening tool that will help clinicians identify potentially at-risk older drivers. Currently, no tools exist to directly predict the risk of motor vehicle collision (MVC) in this population. The American Medical Association (AMA), in collaboration with the National Highway Traffic Safety Association, has designed an opinion-based guide for assessing medical fitness to drive in older adults and recommends that physicians use the Assessment of Driving Related Skills (ADReS) as a test battery to measure vision, cognition and motor/somatosensory functions related to driving. The ADReS consists of the Snellen visual acuity test, visual fields by confrontation test, Trail Making Test part B, clock drawing test, Rapid Pace Walk, and manual tests of range of motion and motor strength. We used baseline data from the Candrive/Ozcandrive common cohort of older drivers to evaluate the validity of the ADReS subtests. We hypothesized that participants who crashed in the 2 years before the baseline assessment would have poorer scores on the ADReS subtests than participants who had not crashed.

METHODS

In the Candrive/Ozcandrive study, 1230 participants aged 70 years or older were recruited from 7 Canadian cities, 1 Australian city and 1 New Zealand city, all of whom completed a comprehensive clinical assessment at study entry. The assessment included all tests selected as part of the ADReS. For this historical cohort study, data on all crashes (at-fault and non-at-fault) that occurred within 2 years preceding the baseline assessment were obtained from the respective licensing jurisdictions. Those who crashed were compared to those who had not crashed on their ADReS subtest scores using Pearson's chi-squared test and Student's t-test.

RESULTS

Sixty-three of the 1230 participants (5.1%) were involved in an MVC within the 2 years preceding the baseline assessment. Contrary to our hypothesis, there were no statistically significant associations between abnormal performance on the tests constituting the ADReS and history of crash in the previous 2 years (p>0.01).

DISCUSSION

We found that a history of crash in the previous 2 years was not associated with abnormalities on the subtests comprising the ADReS. This suggests the need for prospective analyses of risk factors over time to establish sensitive, valid predictors of crash that can be incorporated in clinical practice guidelines.

Protocol for Candrive II/Ozcandrive, a multicentre prospective older driver cohort study

The Candrive II/Ozcandrive study, a multicentre prospective cohort study examining the predictive validity of tools for assessing fitness to drive, aims to develop an in-office screening tool that will help clinicians identify older drivers who may be unsafe to drive. This paper describes the study protocol. We are following a cohort of drivers aged ≥70 years for up to 4 years. Starting in 2009, 928 participants have been recruited in seven cities in four Canadian provinces, as well as 302 participants in two sites in Melbourne, Australia and Wellington, New Zealand. Participants underwent a comprehensive assessment at baseline and repeat the assessment yearly thereafter, as well as a brief follow-up assessment at 4 and 8 months each year. A recording device is installed in participants' vehicles to assess driving patterns, and driving records are obtained from licensing authorities to determine the outcomes: at-fault crashes per kilometre driven and violations. To date, the protocol has been generally well adhered to, with 1230 participants, and barriers and challenges are being addressed, as necessary. The Candrive II/Ozcandrive study is unique owing to its size, duration, partnerships with Canadian, Australian and New Zealand stakeholders, and international research collaboration.

Role of posterior parietal cortex in reaching movements in humans: clinical implication for 'optic ataxia'

OBJECTIVE

To clarify the spatio-temporal profile of cortical activity related to reaching movement in the posterior parietal cortex (PPC) in humans.

METHODS

Four patients with intractable partial epilepsy who underwent subdural electrode implantation were studied as a part of pre-surgical evaluation. We investigated the Bereitschaftspotential (BP) associated with reaching and correlated the findings with the effect of electrical stimulation of the same cortical area.

RESULTS

BPs specific for reaching, as compared with BPs for simple movements by the hand or arm contralateral to the implanted hemisphere, were recognized in all patients, mainly around the intraparietal sulcus (IPS), the superior parietal lobule (SPL) and the precuneus. BPs near the IPS had the earlier onset than BPs in the SPL. Electrical stimulation of a part of the PPC, where the reach-specific BPs were recorded, selectively impaired reaching.

CONCLUSIONS

Intracranial BP recording and cortical electrical stimulation delineated human reach-related areas in the PPC.

SIGNIFICANCE

The present study for the first time by direct cortical recording in humans demonstrates that parts of the cortices around the IPS and SPL play a crucial role in visually-guided reaching.

Are vision-specific quality of life questionnaires important in assessing rehabilitation for patients with hemianopia post stroke?

OBJECTIVE

To explore the relationship between disability and functional measures with vision-specific quality of life (QoL) measures for people with hemianopia and stroke.

METHOD

The Behavioral Inattention Test (BIT) and the Mayo-Portland Adaptability Inventory (MPAI) were compared with scores on 2 vision-specific QoL measures, the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and Veteran Low Vision Visual Function Questionnaire (VA LV VFQ-48).

SETTING

Rehabilitation hospitals in Adelaide, South Australia.

PARTICIPANTS

Stroke patients (n = 24) with homonymous hemianopia.

RESULTS

Most of the BIT and MPAI scores were significantly associated with the NEI VFQ-25 and VA LV VFQ-48 scores. Behavioral test scores of the BIT and the MPAI total score correlated with more aspects of the QoL measures than the other components of the BIT and the MPAI.

CONCLUSION

BIT and MPAI measure constructs associated with QoL for people with hemianopia following stroke. Vision-specific QoL questionnaires can complement the functional instruments by identifying the domains of difficulty, based on the instrument's subscale, that can guide rehabilitation therapists to address the person's deficit.