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Abstract
BACKGROUND Monitoring patients with idiopathic intracranial hypertension (IIH) and optic atrophy may be difficult as papilledema may not be appreciable on ophthalmoscopy. This retrospective chart review evaluated whether papilledema recurrence can be detected in this population using optical coherence tomography (OCT). METHODS Serial clinical assessments, ophthalmoscopy, and peripapillary OCT were reviewed in a cohort of patients with IIH and optic atrophy. Atrophy was defined as moderate if average peripapillary retinal nerve fiber layer (pRNFL) thickness was ≤80 μm and severe if average pRNFL thickness was ≤60 μm on at least 2 consecutive high-quality OCT scans. Based on the upper tolerance limit of test-retest variability, mean pRNFL elevation of ≥6 μm with subsequent decrease to baseline thickness was considered papilledema. RESULTS In a cohort of 165 patients with IIH, 32 eyes of 20 patients and 22 eyes of 12 patients demonstrated moderate and severe optic atrophy, respectively. Over a median follow-up of 198.5 weeks (range, 14.0-428.9), 63.3% (19 of 30) of patients had at least 1 episode of relapse, and 50.0% (15 of 30) had at least 1 episode of papilledema. There was a total of 36 relapse episodes, of which 7 occurred in patients with clinical signs and symptoms but no OCT evidence of relapse, 12 occurred in patients with OCT changes but no clinical signs and symptoms of relapse, and 17 occurred in patients with both clinical and OCT evidence to support relapse. The median percent pRNFL increase in the latter 2 groups was 13.7% (range, 7.5-111.8), and 7 eyes (13.0%) of 5 patients (16.7%) showed thickening greater than 20.0% from baseline. The rate, magnitude, and concordance of pRNFL swelling were similar between moderately vs severely atrophic eyes. CONCLUSIONS Papilledema recurrence can be detected in atrophic optic discs using OCT. All patients with atrophic IIH should be longitudinally monitored with pRNFL measurement. Concurrence of other relapse-suggestive features should prompt further evaluation.
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Affiliation(s)
- Jim Shenchu Xie
- Michael G. DeGroote School of Medicine (JSX), McMaster University, Hamilton, Canada; Division of Ophthalmology (LD), Department of Surgery, McMaster University, Hamilton, Canada; Department of Ophthalmology and Vision Sciences (EAM), University of Toronto, Toronto, Canada; and Division of Neurology (EAM), Department of Medicine, University of Toronto, Toronto, Canada
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Pandya BU, Margolin EA, Micieli JA. Nuclear DNA Mutation in KIF5A Causing Autosomal Dominant Phenotypic Leber Hereditary Optic Neuropathy. J Neuroophthalmol 2024; 44:e17-e19. [PMID: 35921593 DOI: 10.1097/wno.0000000000001699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Bhadra U Pandya
- Temerty Faculty of Medicine (BUP), University of Toronto, Toronto, Canada; Department of Ophthalmology and Vision Sciences (EAM, JAM), Faculty of Medicine, University of Toronto, Toronto, Canada; and Kensington Vision and Research Centre (JAM), Toronto, Canada
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Tao BK, Handzic A, Hua NJ, Vosoughi AR, Margolin EA, Micieli JA. Utility of ChatGPT for Automated Creation of Patient Education Handouts: An Application in Neuro-Ophthalmology. J Neuroophthalmol 2024; 44:119-124. [PMID: 38175720 DOI: 10.1097/wno.0000000000002074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Patient education in ophthalmology poses a challenge for physicians because of time and resource limitations. ChatGPT (OpenAI, San Francisco) may assist with automating production of patient handouts on common neuro-ophthalmic diseases. METHODS We queried ChatGPT-3.5 to generate 51 patient education handouts across 17 conditions. We devised the "Quality of Generated Language Outputs for Patients" (QGLOP) tool to assess handouts on the domains of accuracy/comprehensiveness, bias, currency, and tone, each scored out of 4 for a total of 16. A fellowship-trained neuro-ophthalmologist scored each passage. Handout readability was assessed using the Simple Measure of Gobbledygook (SMOG), which estimates years of education required to understand a text. RESULTS The QGLOP scores for accuracy, bias, currency, and tone were found to be 2.43, 3, 3.43, and 3.02 respectively. The mean QGLOP score was 11.9 [95% CI 8.98, 14.8] out of 16 points, indicating a performance of 74.4% [95% CI 56.1%, 92.5%]. The mean SMOG across responses as 10.9 [95% CI 9.36, 12.4] years of education. CONCLUSIONS The mean QGLOP score suggests that a fellowship-trained ophthalmologist may have at-least a moderate level of satisfaction with the write-up quality conferred by ChatGPT. This still requires a final review and editing before dissemination. Comparatively, the rarer 5% of responses collectively on either extreme would require very mild or extensive revision. Also, the mean SMOG score exceeded the accepted upper limits of grade 8 reading level for health-related patient handouts. In its current iteration, ChatGPT should be used as an efficiency tool to generate an initial draft for the neuro-ophthalmologist, who may then refine the accuracy and readability for a lay readership.
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Affiliation(s)
- Brendan K Tao
- Faculty of Medicine (BKT), The University of British Columbia, Vancouver, Canada ; Department of Ophthalmology & Vision Science (AH, EAM, JAM), University of Toronto, Toronto, Canada; Temerty Faculty of Medicine (NJH), University of Toronto, Toronto, Canada; Department of Ophthalmology (ARV), Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Mount Sinai Hospital (EAM), Toronto, Canada; Division of Neurology (EAM, JAM), Department of Medicine, University of Toronto, Toronto, Canada; Toronto Western Hospital (EAM, JAM), Toronto, Canada; University Health Network (EAM, JAM), Toronto, Canada; Kensington Vision and Research Center (JAM), Toronto, Canada; and St. Michael's Hospital (JAM), Toronto, Canada
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Handzic A, Tao BK, O'Cearbhaill RM, Nicholson PJ, Margolin EA, Micieli JA. Assessment of Reversibility of Transverse Venous Sinus Stenosis in Patients With Papilledema. J Neuroophthalmol 2024:00041327-990000000-00577. [PMID: 38373047 DOI: 10.1097/wno.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Bilateral transverse venous sinus stenosis (TVSS) or stenosis of a dominant venous sinus has been found to be very sensitive radiological findings in patients with intracranial hypertension (IH), yet there is still an ongoing debate whether they constitute reversible or permanent phenomena. Thus, the purpose of this study was to investigate the reversibility of TVSS in patients with IH, including conservatively treated patients with signs of IH as defined by the presence of papilledema. METHODS This was a retrospective chart review of all patients diagnosed with IH between 2016 and 2022, assessed from 2 tertiary university-affiliated neuro-ophthalmology practices. Inclusion criteria were the presence of papilledema, as quantified by optical coherence tomography, and bilateral TVSS, which is considered typical of IH on neuroimaging. During follow-up, included patients must have had confirmation of papilledema resolution as well as subsequent neuroimaging after conservative treatment or cerebrospinal fluid flow diversion. Patients with dural sinus vein thrombosis or intrinsic stenosis from sinus trabeculations or significant arachnoid granulations were excluded from the study. Either CT venography or MRI/MR venography was reviewed by a fellowship-trained neuroradiologist, and the degree of stenosis was scored through the combined conduit score (CCS), as described by Farb et al. The primary outcome was to assess TVSS changes after resolution or improvement of papilledema. RESULTS From 435 patients, we identified a subset of 10 who satisfied all inclusion criteria. Our cohort comprised entirely women with a median age of 29.5 years and a median BMI of 32.5 kg/m2. Treatment consisted of acetazolamide in 7 patients, of which 1 had additional topiramate and 2 underwent cerebrospinal fluid flow diversion. Furthermore, 6 patients demonstrated significant weight loss during follow-up. For the primary outcome, 5 of 10 patients exhibited no appreciable TVSS change, and 5 patients demonstrated significant improvement in TVSS, of which 4 received conservative treatment only. Papilledema resolution or improvement was statistically significantly associated with increasing average CCS, TVSS diameter, and grade. CONCLUSIONS We were able to demonstrate that TVSS can be both irreversible and reversible in patients with resolved papilledema. The finding of TVSS reversibility from conservative treatment alone is novel and has important implications to optimize patient care. Future studies should work to identify factors associated with irreversible TVSS for subsequent targeted intervention and prevention.
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Affiliation(s)
- Armin Handzic
- Department of Ophthalmology and Vision Sciences (AH, EAM, JAM), Faculty of Medicine, University of Toronto, Toronto, Canada; Faculty of Medicine (BKT), University of British Columbia, Vancouver, Canada; Division of Neuroradiology (RMOC, PJN), Department of Radiology, Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Neurology (EAM, JAM), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada; and Kensington Vision and Research Center (JAM), Toronto, Canada
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Mason RH, Handzic A, Nichani PAH, Margolin EA. Amiodarone Producing Insidious Optic Neuropathy. Can J Neurol Sci 2024:1-2. [PMID: 38174412 DOI: 10.1017/cjn.2023.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Ryan H Mason
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Armin Handzic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Prem A H Nichani
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Edward A Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, ON, Canada
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Kisilevsky E, Donaldson L, Margolin EA. Leber Hereditary Optic Neuropathy With Childhood Onset Producing Severe Unilateral Optic Neuropathy With No Relative Afferent Pupillary Defect. J Neuroophthalmol 2023; 43:e337-e339. [PMID: 36166811 DOI: 10.1097/wno.0000000000001634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Eli Kisilevsky
- Department of Ophthalmology and Vision Sciences (EK, LD, EAM), University of Toronto, Toronto, Canada; and Department of Medicine (EAM), Division of Neurology, University of Toronto, Toronto, Canada
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Handzic A, Margolin EA. Posterior Cerebral Artery Stenosis Presenting With Amaurosis Fugax. J Neuroophthalmol 2023; 43:e276-e277. [PMID: 35439227 DOI: 10.1097/wno.0000000000001566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Armin Handzic
- Department of Ophthalmology (AH), Hospital of the Canton of Lucerne, Lucerne, Switzerland; Department of Ophthalmology and Vision Sciences (EM), University of Toronto, Toronto, Canada; and Department of Medicine (EM), Division of Neurology, University of Toronto, Toronto, Canada
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Tao BK, Vosoughi AR, Pandya BU, Ishaq J, Margolin EA, Micieli JA. Inappropriate Indexing of Case Reports to the "Papilledema" Subject Heading: A Systematic Review. J Neuroophthalmol 2023; 43:525-530. [PMID: 37307081 DOI: 10.1097/wno.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Papilledema must be managed distinctly from other causes of optic disc edema (ODE) due to its basis in raised intracranial pressure (ICP). However, evidence indicates that the term "papilledema" is widely misused across specialties to describe ODE without raised ICP. Sources of this misconception remain undiscerned. Because all physicians consult medical databases, our objective was to evaluate whether nonspecific "papilledema" subject heading definitions misleadingly associate articles on other conditions with papilledema proper. METHODS Systematic review of case reports, prospectively registered on PROSPERO (CRD42022363651). MEDLINE and Embase were searched to July 2022 for any full-length case report indexed to the "papilledema" subject heading. Studies were graded for incorrect indexing, defined as cases lacking evidence for raised ICP. Nonpapilledema diagnoses were assigned to a predefined set of diseases and pathophysiological mechanisms for subsequent comparison. RESULTS Incorrect indexing occurred in 40.67% of 949 included reports. Embase-derived studies were misindexed significantly less than MEDLINE-derived studies ( P < 0.01). There was also significant heterogeneity in incorrect indexing among specific diseases ( P = 0.0015) and mechanisms ( P = 0.0003). The most commonly misindexed diseases were uveitis (21.24% of errors), optic neuritis (13.47%), and instances with no mention of ODE (13.99%). The most commonly misindexed mechanisms were inflammation (34.97%), other mechanism (e.g., genetic; 25.91%), and ischemia (20.47%). CONCLUSIONS Database subject headings, especially from MEDLINE, do not adequately distinguish between true papilledema and other causes of ODE. Inflammatory diseases were most often incorrectly indexed among other diseases and mechanisms. Current "papilledema" subject headings should be revised to reduce the probability of misinformation.
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Affiliation(s)
- Brendan K Tao
- Faculty of Medicine (BKT), The University of British Columbia, Vancouver, Canada; Max Rady College of Medicine (ARV), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Temerty Faculty of Medicine (BUP), University of Toronto, Toronto, Canada; Michael G. DeGroote School of Medicine (JI, EAM, JAM), Faculty of Health Sciences, McMaster University, Hamilton, Canada; Department of Ophthalmology and Vision Sciences (EAM, JAM), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada; Division of Neurology (EAM, JAM), Department of Medicine, University of Toronto, Toronto, Canada; Kensington Vision and Research Center (EAM, JAM), Toronto, Canada; St. Michael's Hospital (EAM, JAM), Toronto, Canada; Toronto Western Hospital (EAM, JAM), Toronto, Canada; and University Health Network (EAM, JAM), Toronto, Canada
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Affiliation(s)
- Laura C Donaldson
- Department of Ophthalmology and Vision Sciences (LD, EM), University of Toronto, Toronto, Canada; and Division of Neurology, Department of Medicine (EM), University of Toronto, Toronto, Canada
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Pandya BU, Jhaveri A, Shamshad F, Margolin EA, Micieli JA. The Causes of Optic Disc Edema in Patients Presenting With Significantly Compromised Vision. J Neuroophthalmol 2023:00041327-990000000-00499. [PMID: 37938075 DOI: 10.1097/wno.0000000000002030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND To evaluate the most common causes of optic disc edema (ODE) in patients with significantly compromised vision (initial best-corrected visual acuity [BCVA] of 20/400 or worse) at presentation. METHODS Retrospective chart review over a 5-year period of consecutive patients presenting to tertiary neuro-ophthalmology clinics at the University of Toronto. RESULTS A total of 656 patients with ODE were included, and 49 patients (7.47%) had an initial BCVA of 20/400 or worse. There were 54 eyes included at baseline and 49 eyes at final follow-up. There were 29 female and 20 male patients. The mean age at first visit across patients was 55.9 years. Female patients (n = 29) were significantly older than male patients (n = 20) (P < 0.05). The causes of ODE were optic neuritis (ON) (n = 22; 40.7%), nonarteritic anterior ischemic optic neuropathy (NAION) (n = 22; 40.7%), arteritic anterior ischemic optic neuropathy (AAION) (n = 5; 9.26%), uveitis-related (n = 3; 5.56%), papilledema from idiopathic intracranial hypertension (IIH) (n = 1; 1.85%), and Vogt-Koyanagi-Harada disease (n = 1; 1.85%). Initial BCVA was not significantly different between ON and NAION groups (P = 0.52); however, final BCVA was significantly better in the ON group (P < 0.0001). The mean initial BCVA was worst in the AAION group (2.62 ± 0.54 logarithm of the minimum angle of resolution). The most common cause of ODE in patients <40 years old was ON (83.3%), whereas the 2 most common causes in patients >80 were NAION (60%) and AAION (40%). In patients between the ages of 60-80, NAION (100%) was the only cause. CONCLUSIONS Patients with ODE and poor vision at presentation represent a minority of cases seen in neuro-ophthalmology clinics (<10%). Optic neuritis and NAION are the 2 most common causes of ODE with poor vision at presentation. These findings are limited by a small sample size and potential sampling bias.
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Affiliation(s)
- Bhadra U Pandya
- Temerty Faculty of Medicine (BUP, AJ), University of Toronto, Toronto, Canada; Faculty of Medicine (FS), University of Alberta, Edmonton, Canada; Department of Ophthalmology and Vision Sciences (EAM, JAM), Faculty of Medicine, University of Toronto, Toronto, Canada; and Kensington Vision and Research Centre (JAM), Toronto, Canada
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Handzic A, Xie JS, Margolin EA. Diagnostic Yield of Investigations in Symmetric Optic Neuropathy. J Neuroophthalmol 2023:00041327-990000000-00448. [PMID: 37616072 DOI: 10.1097/wno.0000000000001947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Symmetric optic neuropathy (SON) is commonly seen in neuro-ophthalmic practice and is often discovered incidentally. Although multiple investigations might be performed to discover the underlying cause, they are not always indicated. The aim of this study was to report a clinically reasonable and cost-effective approach to investigating patients with SON. METHODS SON was defined as bilateral optic neuropathy with normal and/or symmetrically decreased central visual acuity, absence of relative afferent pupillary defect, presence of symmetric optic disc pallor, symmetric thinning of peripapillary retinal nerve fiber layer on optical coherence tomography, and absence of other identifiable causes of optic neuropathy. Records of all patients diagnosed with SON seen at a tertiary university-affiliated neuro-ophthalmology practice from 2016 to 2022 were reviewed to identify the yield of various investigations. Clinical data from the initial and last follow-up visit were obtained. Subgroup analysis was performed to ascertain whether diagnostic yield is higher in patients with severe visual loss (central acuity worse than 20/40) compared with those with mild visual loss (acuity 20/40 or better). RESULTS One hundred thirty-six patients met inclusion criteria. Testing for OPA1 and OPA2 mutations had the highest diagnostic yield (16.0%), followed by mitochondrial genome sequencing (13.6%), serum vitamin B12 (6.1%), and serum folate (1.6%). MRI brain was performed in 54.4% of patients and had a diagnostic yield of only 5%. Both patients who had abnormal MRI had symptoms of demyelination at presentation. Patients were followed for a mean of 15.0 (SD 21.3) months. The most frequently identified etiologies of SON were Leber hereditary optic neuropathy (8.1%), alcohol/tobacco amblyopia (7.4%), vitamin B12 deficiency (5.9%), and dominant optic atrophy (2.9%). Patients with severe visual impairment were more likely to have a final diagnosis compared with those with milder visual impairment (63.9% vs 12.0%, P < 0.001). CONCLUSIONS The diagnostic yield of investigating SON in patients with preserved visual function, normal diet, and absence of other neurological symptoms is very low. It is reasonable to observe patients with SON with mild visual impairment, reserving costly investigations for those with the visual acuity worse than 20/40 or progressive course.
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Affiliation(s)
- Armin Handzic
- Department of Ophthalmology and Vision Sciences (AH, EAM), Faculty of Medicine, University of Toronto, Toronto, Canada; Michael G. DeGroote School of Medicine (JSX), McMaster University, Hamilton, Canada; and Division of Neurology (EAM), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
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Vosoughi AR, Donaldson L, Micieli JA, Margolin EA. Maculopathies Referred to Neuro-Ophthalmology Clinic as Optic Neuropathies: A Case Series. J Neuroophthalmol 2023:00041327-990000000-00421. [PMID: 37477986 DOI: 10.1097/wno.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND The clinical features of maculopathies and optic neuropathies often overlap: Both present with decreased visual acuity and variable loss of color vision; thus, maculopathy can be misdiagnosed as optic neuropathy, leading to patient harm. We aimed to determine what findings and/or tests were most helpful in differentiating between optic neuropathy and maculopathy. METHODS A retrospective chart review of consecutive patients over 4.5 years who were referred to neuro-ophthalmology clinics with the diagnosis of optic neuropathy but whose final diagnosis was maculopathy. Patient demographics, mode of presentation, clinical profile, complete ophthalmological examination, results of all ancillary testing, and final diagnosis were recorded. RESULTS A total of 47 patients (27 women) were included. The median age was 55 years (range, 18-85). Most referrals were by ophthalmologists (72.3%) and optometrists (12.8%). The diagnosis of maculopathy was made in 51.1% of patients at the time of first neuro-ophthalmic consultation. Only 6.4% patients (3) had relative afferent pupillary defect. Benign disc anomalies (tilted, myopic, small, or anomalous discs) were present in 34.0%, and 21.3% had pathologic disc changes unrelated or secondary to maculopathy. Macular ocular coherence tomography (OCT) was abnormal in 84.4% (with outer retinal pathology in 42.2% and inner retina pathology in 17.8%). Retinal nerve fiber layer (RNFL) thickness was normal in 82.6% of patients. CONCLUSIONS Macular OCT is a high-yield test in differentiating between optic neuropathy and maculopathy and should be obtained in patients with suspected optic neuropathies who have normal RNFL thickness. Macular dystrophies, particularly cone dystrophies, unspecified retinal disorders, and macular degeneration were the most common mimics of optic neuropathy. The diagnosis was often present on OCT of the macula. The presence of coexistent benign and pathological disc anomalies may lead to maculopathy being misdiagnosed as optic neuropathy.
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Affiliation(s)
- Amir R Vosoughi
- Max Rady College of Medicine (ARV), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Division of Ophthalmology (LD), Department of Surgery, McMaster University, Hamilton, Canada; Department of Ophthalmology and Vision Sciences (JAM, EAM), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada; and Division of Neurology (JAM, EAM), Department of Medicine, University of Toronto, Toronto, Canada
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Sverdlichenko I, Tayeb S, Zaslavsky K, Micieli JA, Margolin EA. Antivirals vs Antivirals and Steroids for Treatment of Herpes Zoster-Related Ophthalmoplegia: A Case Series and Systematic Review. J Neuroophthalmol 2023:00041327-990000000-00374. [PMID: 37307095 DOI: 10.1097/wno.0000000000001901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Up to 1/3 of patients with herpes zoster ophthalmicus (HZO) may develop ophthalmoplegia. Although zoster-related ophthalmoplegia (ZO) is typically treated with antiviral agents, there is controversy regarding the therapeutic role of systemic steroids. METHODS This was a retrospective case series and case report-based systematic review. For the case series, participants were recruited from tertiary neuro-ophthalmology clinics. Eligible participants were those who developed cranial nerve palsies (CNP) within 1 month of HZO diagnosis. In the systematic review, all adults with ZO in the literature who were treated with antivirals or steroids only, or combination therapy were included. Main outcomes were initial presentation, investigations, neuroimaging, treatment regimen, and final outcomes of ophthalmoplegia. RESULTS Eleven immunocompetent patients with ZO were included. The most common CNP was CN III (5/11), followed by CN VI (2/11) and CN IV (2/11). One patient had multiple CNPs. All patients were treated with antivirals, and 4 also treated with a short course of oral steroids. At 6-month follow-up, 75% of patients treated with combination therapy and 85.7% treated with antivirals alone had complete recovery of ZO. The systematic review identified 63 studies consisting of 76 cases of ZO. When comparing patients treated with antivirals with those treated with antivirals and steroids, patients on combination therapy had more severe ocular findings, including complete ophthalmoplegia (P < 0.001). Age was the only significant predictor of complete recovery of ophthalmoplegia on multivariable logistic regression (P = 0.037). CONCLUSIONS The rate of complete recovery in immunocompetent patients with ZO was similar in patients treated with antivirals alone vs those treated with antivirals and oral steroids. The systematic literature review affirmed these findings. However, age may influence recovery of ophthalmoplegia.
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Affiliation(s)
- Irina Sverdlichenko
- Faculty of Medicine (IS), and Department of Ophthalmology and Vision Sciences (ST, KZ, JAM, EAM), Faculty of Medicine, and Division of Neurology (JAM, EAM), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
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Eshtiaghi A, Margolin EA, Micieli JA. Idiopathic Intracranial Hypertension and Socioeconomic Status in the Greater Toronto Area, Canada. J Neuroophthalmol 2023; 43:197-201. [PMID: 35921276 DOI: 10.1097/wno.0000000000001680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have identified an association between obesity and socioeconomic variables such as poverty, minority status, and a low level of education. Because obesity is a major risk factor for the development of idiopathic intracranial hypertension (IIH), this study aims to identify and assess relationships between socioeconomic and geographic variables in patients with IIH in Canada. METHODS A retrospective chart review was performed to identify female patients with IIH presenting to 2 neuro-ophthalmology clinics in Toronto between 2014 and 2022. Consecutive female patients younger than 50 years who did not have IIH were identified as controls. Patient age, body mass index (BMI), and postal code were obtained from electronic medical records. Patient postal codes were then converted to geographic dissemination areas based on the 2016 Canadian census, and data on socioeconomic outcomes were collected from Statistics Canada. RESULTS Three hundred twenty-two female patients with IIH (mean age: 32.3 ± 10) and 400 female controls (mean age: 33.9 ± 9) were included. The mean BMI was 35.0 ± 8 for patients with IIH and 26.7 ± 7 for control patients ( P < 0.00001). There was a significant difference between dissemination areas resided by patients with IIH and control patients for median income ($34640 vs $36685 CAD, P = 0.02) and rate of postsecondary degree attainment (57.7% vs 60.5%, P = 0.01). There were no significant differences in the percentage of visible minorities, percentage of immigrants, knowledge of official languages, percentage of married individuals, average household size, or unemployment rate. There was a weak but significant inverse relationship between the rate of postsecondary degree attainment in dissemination areas resided by patients with IIH and their BMI ( P = 0.01, R 2 = 0.02). CONCLUSION Patients with IIH reside in geographic areas with lower average levels of income and education than control patients. Patients with lower levels of education may be at higher risk of elevated BMI and therefore disease incidence and progression.
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Affiliation(s)
- Arshia Eshtiaghi
- Faculty of Medicine (AE), Department of Ophthalmology and Vision Sciences (EM, JAM), Division of Neurology (EM, JAM), Department of Medicine, University of Toronto, Toronto, Canada; and Kensington Vision and Research Centre (JAM), Toronto, Canada
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Abstract
BACKGROUND We aim to compare the clinical characteristics, disease course and visual outcomes between Canadian patients with idiopathic intracranial hypertension (IIH) who were incidentally discovered and those who sought care due to symptoms of IIH. METHODS Retrospective chart review of consecutive IIH patients conducted at tertiary neuro-ophthalmology clinics. Patients were divided into Group 1 (incidentally discovered disease) and Group 2 (patients seeking medical care due to symptoms of intracranial hypertension). RESULTS One hundred eighty-six patients were included in the study; of which, 75 (40.3%; Group-1) were incidentally discovered and 111 presented due to symptoms of IIH (Group-2). There were no differences in proportion of females (P = 0.101), age (P = 0.450), body mass index (P = 0.386), MRI findings of empty or partially empty sella (P = 0.41), and sella grade (P = 0.704). Group-1 patients were less likely to have experienced headache (P = 0.001), transient visual obscurations (P < 0.001), and diplopia (P = 0.026) at presentation. Group-1 patients were less likely to receive medical (P < 0.001) and surgical (P = 0.004) treatment. There was no difference in proportion of patients who lost weight between the groups (P = 0.848). At baseline, Group-1 patients exhibited better visual acuity (P = 0.001), Humphrey mean deviation (P < 0.001) and retinal nerve fiber layer thickness (P < 0.001). Group-1 patients continued to have better visual acuity (P = 0.002) and Humphrey mean deviation (P < 0.001) at final follow-up. CONCLUSIONS A significant portion of IIH patients were incidentally discovered. This group exhibited a favorable prognosis and only a minority of these patients required treatment. The way in which patients enter the medical system may be a valuable way to risk stratify IIH patients.
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Affiliation(s)
- Amir R Vosoughi
- Max Rady College of Medicine (ARV), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada ; Department of Ophthalmology and Vision Sciences (EAM JAM), University of Toronto, Toronto, Canada ; Division of Neurology (EAM Department of Medicine, University of Toronto, Canada ; and Kensington Vision and Research Centre (JAM), Toronto, Canada
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Kwok JM, Jeeva-Patel T, Margolin EA. Binasal Visual Field Defects Due to Sickle Cell Maculopathy. J Neuroophthalmol 2022; 42:e434-e436. [PMID: 34238888 DOI: 10.1097/wno.0000000000001299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 26-year-old African American man with sickle cell disease noticed blurry vision in both eyes after a recent complicated hospital admission for sickle cell crisis. Anterior and posterior segment examination of each eye was normal, but visual field testing revealed binasal scotomas. Optical coherence tomography of the macula demonstrated severe thinning of the temporal inner retina, suggesting previous bilateral occlusions of terminal retinal arterioles involving the temporal macula, an uncommon complication of sickle cell disease. This case is a reminder that retinal pathology should always be considered as a potential cause of unexplained visual field defects and highlights the role of macular OCT in evaluation of these patients.
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Affiliation(s)
- Jason M Kwok
- Department of Ophthalmology and Vision Sciences (JMK, TJ-P, EAM), University of Toronto, Toronto, Canada; and Division of Neurology (EAM), Department of Medicine, University of Toronto, Toronto, Canada
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Donaldson LC, Eshtiaghi A, Sacco S, Micieli JA, Margolin EA. Junctional Scotoma and Patterns of Visual Field Defects Produced by Lesions Involving the Optic Chiasm. J Neuroophthalmol 2022; 42:e203-e208. [PMID: 34417771 DOI: 10.1097/wno.0000000000001394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lesions of the optic chiasm (OC) typically produce bitemporal hemianopia (BTH) on visual field (VF) testing, whereas lesions located at the nasal optic nerve-chiasmal (ON-OC) junction have been proposed to produce junctional scotoma (JXS), a central defect in the ipsilateral eye with temporal field loss in the contralateral eye. In this study, we investigated whether the pattern of VF loss in patients with chiasmal compression predicted the appearance of the causative lesion on neuroimaging and described the clinical presentation of these patients with different types of VF defect. METHODS Retrospective chart review of patients seen in tertiary neuro-ophthalmology practice over 6 consecutive years with lesions abutting or displacing the OC was performed. Lesion size and location relative to the OC on neuroimaging was determined and correlated with VF defects as well as optical coherence tomography (OCT) of the peripapillary retinal nerve fiber layer and macular ganglion cell complex (GCC). RESULTS Fifty-three patients were enrolled. VFs demonstrated JXS (n = 18), BTH (n = 14), monocular VF defect (n = 4), and no VF defect (n = 17); 64.7% of cases with normal VFs had radiologic OC compression. Lesion volume was highest in the JXS group, and these patients also had the poorest presenting visual acuity. All patients with JXS showed involvement of the ON-OC junction; however, not all cases showed compression of the OC from the nasal direction (15 of 18), and 17 of 18 also showed compression of one or both prechiasmatic ONs. Compression of the ON-OC junction was also seen in 79% of BTH, 100% of monocular VF defect, and 59% of no VF defect cases. Fifty percent of patients with normal VFs already had thinning of the GCC on OCT. GCC thinning was most pronounced nasally in the BTH group, but diffuse bilateral thinning was found in 38% of cases compared with 60% of JXS. VFs improved in 6 of 6 patients with BTH but only in 5 of 8 JXS cases after treatment. CONCLUSIONS JXS is more often seen with larger lesions and when there is compression of both the prechiasmatic ON and ON-OC junction. These patients have worse presenting visual acuity and poorer outcomes. Not all patients with radiologic compression had VF defects, although 50% of patients with normal VFs had evidence of compression on the macular GCC analysis, emphasizing the importance of macular OCT in the evaluation of patients with lesions involving the OC.
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Affiliation(s)
- Laura C Donaldson
- Department of Ophthalmology and Vision Sciences (LD, JM, EM), University of Toronto, Toronto, Canada; Faculty of Medicine (AE), University of Toronto, Toronto, Canada; Department of Medical Imaging (SS), University of Toronto, Toronto, Canada; and Department of Medicine (JM, EM), Division of Neurology, University of Toronto, Toronto, Canada
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18
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Mason R, Jeeva-Patel T, Mandell D, Shannon P, Margolin EA. Case of Clinical Mimicry: Atherosclerosis Masquerading as Giant Cell Arteritis. J Neuroophthalmol 2022; 42:e359-e361. [PMID: 33630783 DOI: 10.1097/wno.0000000000001197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ryan Mason
- Departments of Ophthalmology and Vision Sciences (RM, TJ-P, EAM), Medical Imaging (DM), and Laboratory Medicine (PS), University of Toronto, Toronto, Canada; and Division of Neurology (EAM), Department of Medicine, University of Toronto, Toronto, Canada
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Abstract
BACKGROUND Syphilis is an uncommon cause of optic nerve head edema; however, differentiating syphilis from other etiologies of optic nerve head swelling may be challenging. We describe 4 cases of ocular syphilis presenting with swollen optic nerve head(s) without overt signs of intraocular inflammation to better define the phenotypic presentation of this condition to allow its early recognition and treatment and discuss potential pathophysiological mechanisms of syphilitic optic neuropathy. METHODS Retrospective case series of patients presenting to a tertiary neuro-ophthalmology practice with a swollen optic nerve head(s) but no overt signs of intraocular inflammation, which was eventually determined to be secondary to syphilis. RESULTS Four patients were included in the study. The mean age was 43 years, 2 were women and 2 had bilateral involvement. Two patients had a recent history of skin rash, and one patient was investigated for abdominal pain and elevated liver enzymes. Two patients presented with photopsias and preserved visual function, whereas 2 presented with vision loss. Although chorioretinitis was present in all cases, it was very subtle in all and was only appreciated on fundus autofluorescence (FA) in 3 of 4 cases. Three patients demonstrated evidence of optic perineuritis on neuro-imaging. All patients were treated with a course of intravenous penicillin with a variable degree of visual recovery. CONCLUSIONS Systemic symptoms are common in patients with syphilic optic neuropathy. Optic disc edema as a manifestation of syphilis is usually accompanied by subtle chorioretinitis, which is best appreciated on FA. Optic perineuritis is common in patients with syphilitic optic neuropathy, with its pathophysiology likely similar to meningitis seen in neurosyphilis.
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Affiliation(s)
- Anna Kabanovski
- Faculty of Medicine, University of Toronto (AK); Department of Ophthalmology and Vision Sciences, Faculty of Medicine (LD, TJ-P, EM); Division of Neurology, Department of Medicine, Faculty of Medicine (EM), University of Toronto, Toronto, Canada
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20
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Abstract
BACKGROUND To determine whether significant compression of the optic nerve by the internal carotid artery (ICA) can produce an optic neuropathy with optic disc cupping that resembles glaucoma in patients without elevated intraocular pressure (IOP). METHODS This was a retrospective case series of patients referred to neuro-ophthalmology for a possible nonglaucomatous optic neuropathy. Patients were included in the study if they had preserved visual acuity, optic disc-related visual field defects, optic nerve cupping, IOP less than 21 mm Hg, open angles, and unequivocal radiological compression of the ipsilateral optic nerve by an intracranial blood vessel. RESULTS Three patients were included with a mean age of 56.3 (range 29-82) years. Patient 1 was a 58-year-old man incidentally noted to have left optic nerve cupping on a routine examination. He had an inferior arcuate defect and the left prechiasmatic optic nerve was elevated and compressed by a tortuous left ICA. Patient 2 was a 29-year-old man with a normal-tension glaucoma (NTG) diagnosis for 7 years in the right eye treated with latanoprost. He had a superior greater than inferior arcuate defect and there was vascular compression of the optic nerve between the supraclinoid ICA and A1 segment of the anterior cerebral artery. Patient 3 was an 82-year-old woman with an NTG diagnosis for 10 years who had progression of her visual field defects despite low IOPs. MRI showed mass effect on the right optic nerve by a dolichoectatic right supraclinoid ICA. CONCLUSIONS Significant compression of the optic nerve by a normal, tortuous, or dolichoectatic ICA may result in an optic neuropathy with optic disc cupping that resembles glaucoma.
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Affiliation(s)
- Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences (JAM, EAM), University of Toronto, Toronto, Canada ; Division of Neurology, Department of Medicine (JAM, EAM), University of Toronto, Toronto, Canada; and Kensington Vision and Research Centre (JAM), Toronto, Canada
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21
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Moss HE, Margolin EA, Lee AG, Van Stavern GP. Should Lumbar Puncture Be Required to Diagnose Every Patient With Idiopathic Intracranial Hypertension? J Neuroophthalmol 2021; 41:379-384. [PMID: 34415272 PMCID: PMC9159906 DOI: 10.1097/wno.0000000000001373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Heather E Moss
- Departments of Ophthalmology and Neurology & Neurological Sciences (HEM), Stanford University, Stanford, California; Department of Ophthalmology and Visual Sciences (EM), University of Toronto, Toronto, Ontario; Blanton Eye Institute (AGL), Houston Methodist Hospital, Houston, Texas; and Department of Ophthalmology and Visual Sciences (GPVS), Washington University in St. Louis School of Medicine, St. Louis, Missouri
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22
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Zaslavsky K, Margolin EA. Leber's Hereditary Optic Neuropathy in Older Individuals Because of Increased Alcohol Consumption During the COVID-19 Pandemic. J Neuroophthalmol 2021; 41:316-320. [PMID: 34415266 DOI: 10.1097/wno.0000000000001333] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Leber's hereditary optic neuropathy (LHON) is a disorder affecting oxidative phosphorylation in mitochondria. A majority of affected patients are men of 15 to 35 years of age. Phenotypic penetrance of this condition is only 50% in man and 10% in women and increases if the cellular energy demands go up, with the most common risk factors being smoking and alcohol use. METHODS Review of clinical features of 3 patients who were diagnosed with LHON in their sixth decade of life after doubling their alcohol intake during the recent COVID-19 pandemic. RESULTS All 3 patients were older than the age of 50 when they developed severe sequential visual loss. All have at least doubled their alcohol intake for at least 4 weeks preceding visual loss, and 2 who were smokers increased the number of cigarettes consumed daily because of the stress and boredom during the lockdowns triggered by the pandemic. CONCLUSIONS Significant increase in substance abuse in the general population during the recent lockdowns to combat the COVID-19 pandemic is well documented. We report 3 patients older than the age of 50, one of them a woman, who developed severe bilateral visual loss due to LHON after doubling their alcohol consumption and increasing number of cigarettes smoked daily during the pandemic. Clinicians are reminded to consider LHON in the differential diagnosis when encountering older patients with bilateral sequential visual loss and to specifically inquire about alcohol use and cigarette smoking in these patients.
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Affiliation(s)
- Kirill Zaslavsky
- Departments of Ophthalmology and Vision Sciences (KZ, EM), University of Toronto, Toronto, Canada ; and Department of Medicine (EM), Division of Neurology, University of Toronto, Toronto, Canada
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Popovic M, Donaldson L, Margolin EA. Sudden, severe bilateral vision loss after coronary artery bypass grafting. BMJ Case Rep 2021; 14:14/8/e243754. [PMID: 34344653 PMCID: PMC8336136 DOI: 10.1136/bcr-2021-243754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a rare complication of coronary artery bypass grafting (CABG) in a young man who presented with sudden, severe, bilateral visual loss after surgery. His ophthalmological examination was non-revealing; however, MRI of the brain revealed bilateral occipital lobe infarction. His infarction was presumed to be secondary to emboli arising from surgical manipulation within the atherosclerotic ascending aorta or from a cardiogenic thrombus formed due to perioperative arrhythmia.
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Affiliation(s)
- Marko Popovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Laura Donaldson
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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Kabanovski A, Jeeva-Patel T, Kaplan A, Bui E, Margolin EA. Older woman with abdominal pain and bilateral sequential vision loss due to syphilis. BMJ Case Rep 2021; 14:14/6/e243847. [PMID: 34193456 DOI: 10.1136/bcr-2021-243847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 62-year-old woman presented with non-specific abdominal pain, elevated alkaline phosphatase levels and bilateral sequential visual loss. Visual acuity was counting fingers in right eye (RE) and 20/400 in left eye (LE). She was noted to have optic nerve pallor in RE and mildly elevated optic disc with signs of ocular inflammation in LE. After 2 weeks, vision deteriorated to light perception bilaterally with now extensive vitreal inflammation present in both eyes. Positive rapid plasma reagen and Treponema pallidum's antibody tites confirmed syphilis infection. Unfortunately, as the diagnosis was delayed by many months, her visual acuity remained poor (hand motions in RE and 20/50 in LE) despite treatment with intravenous penicillin. This case reminds us of the re-emergence of this 'great masquerader' and highlights the importance of maintaining high suspicion for syphilis in patients with unexplained visual loss and systemic symptoms, even in older adults without identifiable risk factors.
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Affiliation(s)
- Anna Kabanovski
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Trishal Jeeva-Patel
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Kaplan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Esther Bui
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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25
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Kisilevsky E, Margolin EA. Leber's Hereditary Optic Neuropathy with visual recovery caused by two rare mutations. Ophthalmic Genet 2021; 42:500-502. [PMID: 33960259 DOI: 10.1080/13816810.2021.1923037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Eli Kisilevsky
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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26
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Jeeva-Patel T, Freund P, Margolin EA. Lipomatosis and optic neuropathy clinches the diagnosis of myoclonic epilepsy with ragged red fibres (MERRF) syndrome. BMJ Case Rep 2021; 14:14/3/e240463. [PMID: 33766967 PMCID: PMC8006766 DOI: 10.1136/bcr-2020-240463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a rare case of myoclonic epilepsy with ragged red fibres with high level of heteroplasmy presenting with optic neuropathy and a rare phenotype of lipomatosis. Cutaneous lipomas are typically thought of as a benign/isolated entity and this case emphasises importance of considering mitochondrial disease in all patients with lipomatosis especially in the presence of other systemic abnormalities.
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Affiliation(s)
- Trishal Jeeva-Patel
- Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Paul Freund
- Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Departent of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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27
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Kisilevsky E, Pesin N, Mandell D, Margolin EA. Rothia dentocariosa causing intracranial mycotic aneurysm and ischaemic stroke. BMJ Case Rep 2021; 14:14/3/e240349. [PMID: 33664036 PMCID: PMC7934739 DOI: 10.1136/bcr-2020-240349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We describe a case of subacute bacterial endocarditis and mycotic brain aneurysm caused by Rothia dentocariosa due to untreated dental caries. R. dentocariosa is a rare cause of endocarditis that has a high incidence of aneurysmal and haemorrhagic complications. All patients with intracranial aneurysms who have signs of systemic infection should be considered to have mycotic aneurysms until proven otherwise. Dental habits should be included in regular medical assessment and dental care should be considered for patients presenting with infectious symptoms.
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Affiliation(s)
- Eli Kisilevsky
- Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Nataly Pesin
- Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Daniel Mandell
- Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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Margolin EA, Mason RH. Female-to-male transgender patient with idiopathic intracranial hypertention. J Neurol Sci 2020; 415:116970. [PMID: 32521344 DOI: 10.1016/j.jns.2020.116970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/07/2020] [Accepted: 05/29/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Edward A Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada.
| | - Ryan H Mason
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
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29
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Jeeva-Patel T, Margolin EA, Mandell D. Sixth cranial nerve palsy secondary to compression by dolichoectatic vertebrobasilar artery. BMJ Case Rep 2020; 13:13/7/e234949. [PMID: 32636226 DOI: 10.1136/bcr-2020-234949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dolichoectasia refers to distinct elongation, dilatation and tortuosity of an artery. We present a rare well-illustrated case of dolichoectatic vertebrobasilar artery compressing the cisternal portion of the sixth cranial nerve resulting in chronic sixth nerve palsy. High spatial resolution, three-dimensional, heavily T2-weighted MRI sequences are uniquely positioned to assess the cranial nerves especially in their cisternal and canalicular portions and need to be performed for all patients with non-resolving cranial nerve palsies. Dolichoectatic vessels can be the cause of neurovascular conflict and cause non-resolving oculomotor palsies.
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Affiliation(s)
- Trishal Jeeva-Patel
- Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Mandell
- Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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30
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Margolin EA, Rai A, Goldfarb J, Zaslavsky K, Kohly R, Nicholson P. Dramatic recovery of vision in patient with acute central retinal artery occlusion treated with local intra-arterial tissue plasminogen activator. BMJ Case Rep 2020; 13:13/4/e234505. [DOI: 10.1136/bcr-2020-234505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Central retinal artery occlusion (CRAO) is a devastating disease resulting in severe visual loss in most cases. It has no proven treatment, and a variety of management options used clinically all have dismal rate of success. We report outcome of treatment with local intra-arterial thrombolysis administered 2.75 hours after devastating visual loss from incomplete CRAO.
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Abstract
When encountering patients with markedly dilated and tortuous retinal vessels, Wyburn-Mason syndrome (WMS) or racemous angiomatosis (phacomatosis) is commonly thought of as the archetypal entity that can produce these findings. We describe a patient with Cantu syndrome with phenotypical findings identical to those seen in patients with WMS and want to highlight this as another entity that can present with tortuous and dilated retinal vessels.
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Affiliation(s)
- Eli Kisilevsky
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
| | - Radha P Kohly
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Edward A Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
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Leung VC, Micieli JA, Margolin EA. Profound Vision Loss After a Traumatic Work Injury. JAMA Ophthalmol 2017; 135:1440-1441. [PMID: 28859187 DOI: 10.1001/jamaophthalmol.2017.2326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Victoria C Leung
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward A Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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Najem K, Derzko-Dzulynsky L, Margolin EA. IgG4-related disease presenting as panuveitis without scleral involvement. J Ophthalmic Inflamm Infect 2017; 7:7. [PMID: 28243891 PMCID: PMC5328900 DOI: 10.1186/s12348-017-0125-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/16/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The following case emphasizes the importance of including IgG4-related disease (RD) in the differential diagnosis of intraocular inflammation and multiple cranial nerve palsies. RESULTS A 33-year-old man, with a history of idiopathic bilateral panuveitis, presented with a new right pupillary-sparing partial third nerve palsy, which spontaneously resolved in 2 weeks, but was followed 1 month later, by a right sixth nerve palsy, which also resolved within a few weeks. Motility disturbance was accompanied by a decrease in the central acuity in the right eye. Magnetic resonance imaging/angiography (MRI/MRA) demonstrated a densely enhancing osteodestructive skull base process extending through the cavernous sinus and into the right superior orbital fissure. Biopsy of the lesion was consistent with IgG4-related disease (RD). CONCLUSIONS This is the first reported case of IgG4-RD associated panuveitis without scleral involvement, expanding the list of clinical manifestations of the IgG4-RD.
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Affiliation(s)
- Kinda Najem
- Department of Ophthalmology, Université de Montréal, 5415 de l’Assomption Boulevard, Montreal, Quebec H1T 2M4 Canada
| | - Larissa Derzko-Dzulynsky
- Department of Ophthalmology, University of Toronto, 340 College Street Suite 501, Toronto, Ontario M5T 3A9 Canada
| | - Edward A. Margolin
- Department of Ophthalmology, University of Toronto, 340 College Street Suite 501, Toronto, Ontario M5T 3A9 Canada
- 801 Eglinton Avenue West, Suite 301, Toronto, Ontario M5N 1E3 Canada
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34
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Micieli JA, Lam C, Najem K, Margolin EA. Aqueous Humor Cytokines in Patients With Acute Nonarteritic Anterior Ischemic Optic Neuropathy. Am J Ophthalmol 2017; 177:175-181. [PMID: 28302535 DOI: 10.1016/j.ajo.2017.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To measure and compare the cytokine concentrations in the aqueous humor of patients with acute nonarteritic anterior ischemic optic neuropathy (NAION) and normal age-related cataract controls. DESIGN Prospective, comparative observational study. METHODS Aqueous humor samples were obtained in 10 patients with acute NAION (within 14 days of symptom onset) and 15 control patients with age-related cataract. The levels of 6 cytokines-vascular endothelial growth factor (VEGF), tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-2, IL-6, and IL-8-were determined using a multiplex bead immunoassay. The clinical characteristics of patients were also collected for correlation analysis. RESULTS The mean concentration of VEGF (94.1 ± 40.4 pg/mL) was significantly higher in the NAION group compared to the cataract controls (52.2 ± 20.8 pg/mL; P = .010) and the mean concentration of IL-2 (5.56 ± 1.27 pg/mL) was significantly lower in the NAION group than in the cataract controls (16.6 ± 14.0 pg/mL; P = .002). There were no differences in the concentration of TNF-α, IL-1β, IL-6, and IL-8. There was a strong negative correlation between the VEGF concentration and the peripapillary retinal nerve fiber layer (RNFL) thickness at presentation (r = -0.657, P = .055). There was no significant correlation between the RNFL thickness and any other cytokines, the mean deviation on 24-2 Humphrey visual fields, or the duration of vision loss. CONCLUSIONS Acute NAION is associated with higher VEGF and lower IL-2 concentrations without a change in other inflammatory cytokines. This has implications for future therapeutic interventions and diagnostic testing in patients with this acute optic neuropathy.
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Affiliation(s)
- Kinda Najem
- Department of Ophthalmology, University of Toronto, Toronto, Ontario, Canada
| | - Edward A. Margolin
- Department of Ophthalmology, University of Toronto, Toronto, Ontario, Canada
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Najem K, Margolin EA. A Special Case of Horner Syndrome. JAMA Ophthalmol 2016; 134:1193-1194. [DOI: 10.1001/jamaophthalmol.2016.1654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kinda Najem
- Department of Ophthalmology, University of Toronto, Toronto, Ontario, Canada
| | - Edward A. Margolin
- Department of Ophthalmology, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Jonathan A. Micieli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Kay Lam
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward A. Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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Abstract
BACKGROUND Temporal artery biopsy is the gold standard for the diagnosis of giant cell arteritis, but the numbers and types of surgical specialists performing temporal artery biopsies are unknown. The goal of this study was to determine which surgical specialists performed temporal artery biopsies and how geographic location influenced this trend over a period of 10 years. METHODS This retrospective cohort study included all physicians practising in Ontario from 2002 to 2013. Using comprehensive physician services data from the IntelliHEALTH Medical Services database, physicians performing temporal artery biopsies were identified by the Ontario Health Insurance Plan billing code submitted for remuneration. Physicians were categorized by specialty and geographic Local Health Integration Unit. RESULTS A total of 9958 patients underwent a temporal artery biopsy during the study period: the biopsies were performed by 11 different subspecialties. The number of patients undergoing a temporal artery biopsy declined over the 10-year study period. Most procedures were performed by general surgeons (38.1%), followed by ophthalmologists (31.0%) and plastic surgeons (23.6%). Ophthalmologists performed more temporal artery biopsies per person compared with general surgeons, but significantly more general surgeons performed at least 1 biopsy. There was significant variation based on geographic location: plastic surgeons performed the most biopsies in regions with a population of more than 1 million people, and general surgeons performed most of the biopsies in rural areas. INTERPRETATION Geographic location heavily influenced which specialty was most likely to perform temporal artery biopsies. General surgery, ophthalmology and plastic surgery emerged as leaders in this area, and their residency programs should include formal training in this procedure in their curricula.
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Affiliation(s)
- Jonathan A Micieli
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, Ont
| | | | - Edward A Margolin
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, Ont
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Kisilevsky E, Margolin EA. Case of rapid bilateral cataract development in teenager using selective serotonin reuptake inhibitors. Can J Ophthalmol 2014; 49:e114-5. [DOI: 10.1016/j.jcjo.2014.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/03/2014] [Accepted: 06/16/2014] [Indexed: 10/24/2022]
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Herschorn AB, Yoganathan P, Margolin EA, Berger AR. Inadvertent subretinal triamcinolone injection in a case of recurrent scleritis. Can J Ophthalmol 2009; 44:e33-4. [DOI: 10.3129/i09-076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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