Spontaneous regression of optic gliomas: thirteen cases documented by serial neuroimaging

OBJECTIVE

To demonstrate spontaneous regression of large, clinically symptomatic optic pathway gliomas in patients with and without neurofibromatosis type 1 (NF-1).

METHODS

Patient cases were collected through surveys at 2 consecutive annual meetings of the North American Neuro-Ophthalmology Society (NANOS) and through requests on the NANOSNET Internet listserv. Serial documentation of tumor signal and size, using magnetic resonance imaging in 11 patients and computed tomography in 2 patients, was used to evaluate clinically symptomatic optic pathway gliomas. All tumors met radiologic criteria for the diagnosis of glioma and 4 patients had biopsy confirmation of their tumors. In 3 patients, some attempt at therapy had been made many years before regression occurred. In one of these, radiation treatment had been given 19 years before tumor regression, while in another, chemotherapy had been administered 5 years before signal changes in the tumor. In the third patient, minimal surgical debulking was performed 1 year before the tumor began to shrink.

RESULTS

Spontaneous tumor shrinkage was noted in 12 patients. Eight patients did not have NF-1. In an additional patient without NF-1, a signal change within the tumor without associated shrinkage was detected. Tumor regression was associated with improvement in visual function in 10 of 13 patients, stability of function in 1, and deterioration in 2.

CONCLUSIONS

Large, clinically symptomatic optic gliomas may undergo spontaneous regression. Regression was seen in patients with and without NF-1. Regression may manifest either as an overall shrinkage in tumor size, or as a signal change on magnetic resonance imaging. A variable degree of improvement in visual function may accompany regression. The possibility of spontaneous regression of an optic glioma should be considered in the planning of treatment of patients with these tumors.

Reading-evoked visual dimming

PURPOSE

To carry out a neuroradiologic investigation in a monocular 49-year-old patient who during the past five years described symptoms of dimming of central vision in his left eye, which was provoked only by reading.

METHODS

Computed tomography and magnetic resonance imaging were performed.

RESULTS

An orbital apex intraconal tumor situated laterally to and above the optic nerve was found.

CONCLUSIONS

Reading-evoked visual dimming can be a variant of gaze-evoked amaurosis. The optic nerve displaced laterally and superiorly, and stretched by the act of reading, may be compressed between the tumor above and the contracted inferior rectus muscle inferiorly.

Papilloedema and hydrocephalus in spinal cord ependymoma

Images

Orbital porencephalic cyst following penetrating orbitocranial trauma

In a 10-year-old boy an orbitocranial penetrating wound produced by an umbrella tip caused an orbital roof bone fragment to penetrate up to the anterior part of the third ventricle behind the left foramen of Monro. Hemorrhages and encephalomalacia developed along the trajectory of the fragment and subsequently a porencephalic cyst was formed at this site. Six months after the trauma, increased pressure developed in the left ventricular system due to obstructive hydrocephalus and consequently the porencephalic cyst herniated into the orbit through the orbital roof fracture, producing intermittent diplopia, left exophthalmos, and palpebral swelling. A ventriculo-peritoneal shunt led to shrinkage of the orbital cyst content and resolution of the symptoms.

Relationship between visual acuity and nasal field thresholds in patients with temporal hemianopia

The area of nasal field found with Goldmann static perimetry and the sum of decibels by Humphrey threshold 30/2 was calculated in normal subjects and in subjects with chiasmatic lesions, temporal field loss, and normal or abnormal visual acuity. There was a significant reduction of the mean of the area of the nasal field by static Goldmann perimetry and of the mean of decibels in the nasal field on Humphrey perimetry in patients with temporal field loss and chiasmatic lesions, as compared with normal controls. There were significant correlations of nasal field depression (Goldmann) and visual acuity and for sums of nasal field decibels (Humphrey) and visual acuity. Thus, a generally depressed nasal field was found in patients with chiasmatic lesions and temporal field loss when accompanied by lowering of visual acuity. This would appear to be the earliest stage of nasal field involvement.

Pineal germinoma with unilateral blindness. Seeding of germinoma cells in optic nerve sheath

A 13-year-old boy presented with blindness and loss of the papillomacular bundle in the left eye, bilateral papilledema sparing the area of axonal loss, and Parinaud's syndrome. Computerized tomography (CT) revealed an enlarged kinked left optic nerve and enlarged optic canal as well as a tumor in the pineal area producing hydrocephalus. Magnetic resonance (MR) scans showed multiple spinal metastases. The histological diagnosis was germinoma. On completion of four courses of chemotherapy with cis-platin, vinblastine, and bleomycin, repeated CT of orbita and MR imaging of the spine demonstrated the disappearance of the tumor surrounding the left optic nerve and of the spinal metastases. This is believed to be the first case report of seeding of germinoma into the perioptic arachnoid space.

Entoptic [corrected] phenomena in pregeniculate and postgeniculate hemianopsia with splitting of macula by perimetry

With splitting of macula by perimetry, the entopic phenomena (the perception of one's own foveal xanthophilic pigment and macular vessel leukocytes) were utilized to study the character of macular sparing or splitting in patients with pregeniculate or postgeniculate hemianopsia. In the pregeniculate group, 11 of 14 eyes perceived the Haidinger brushes figure as a half circle corresponding to the perimetric macular splitting, whereas flying corpuscles were not perceived at all or were less numerous on the hemianoptic side than on the normal field side. In contrast, six of seven patients with postgeniculate lesions perceived the Haidinger brushes figure as a complete circle, four of six perceived fewer flying corpuscles on the hemianoptic side than on the normal field side, and two patients reported perceiving an equal number in all quadrants. This study indicated that in pregeniculate hemianopsia there is usually a true splitting of the macula, whereas in postgeniculate hemianopsia, there is some macular sparing even when perimetry shows macular splitting.

Loss of accommodation produced by peristriate lesion in man?

We observed a bilateral accommodative paresis associated with a spontaneous parieto-occipital hematoma in a 37-year old patient. There was no clinical or computerized tomography (CT) evidence of transtentorial herniation or upper brainstem pathology. With resolution of the hematoma, accommodation returned to normal.

Amaurosis fugax at downward gaze

A 54-year-old man with a past history of hypertension, diabetes mellitus, hypercholesterolemia and two myocardial infarctions presented with repeated attacks of amaurosis fugax in the right eye. The fact that the amaurosis occurred only on downward gaze is sufficient evidence to exclude carotid atheromatous disease and to imply an orbital etiology.

Papilledema in traumatic lesion of optic nerve with amaurosis

A patient with subdural hematoma and right amaurosis resulting from traumatic injury to the optic nerve developed papilledema in both eyes a few days after the trauma. This was interpreted as supplementary proof of the existence of axonal flow in the first weeks after occurrence of the optic axon lesion. In the amaurotic eye, the papilledema was less pronounced and disappeared more rapidly (after 3 weeks, as opposed to 6 weeks for the other eye). The nerve fiber layer disappeared between 4 and 6 weeks after the trauma.

Ocular changes in invasive osteogenic sarcoma of the skull

Serial narrow-band green-light fundus photographs documented the evolution of descending optic atrophy in a case of rapid bilateral blindness produced by a highly invasive osteogenic sarcoma of the base of the skull. Disappearance of the nerve fiber layer (NFL) was observed to take place between the sixth and 12th week after onset of blindness; thus, it is similar to the evolution of descending atrophy found to occur in clinical cases of blindness caused by traumatic involvement of the optic nerve. Parallel to the disappearance of the NFL there was an increase in optic nerve head excavation and a change in the appearance of the vessels on the disk surfaces.

Diencephalic syndrome due to a suprasellar epidermoid cyst. Case report

A 5-year-old child with the unusual association of late-onset diencephalic cachexia and pituitary insufficiency is described. At operation a suprasellar epidermoid cyst was found and excised. This curable tumor should be added in the differential diagnosis of diencephalic syndrome.

Pupil cycle time in space occupying lesions of anterior optic pathways

Twenty-nine patients with presumed compressive optic neuropathy were studied, and pupil cycle times were measured. We found (1) normalcy of the test in cases of space-occupying lesion without suprasellar extension or after successful operation; (2) prolongation of pupil cycle time in cases of subclinical disorder conformed by visual evoked responses as well; (3) a good correlation between the values of prolonged pupil cycle time and degree of involvement of the visual field in pathological cases.

Pupil cycle time in noncompressive optic neuropathy

Pupil cycle time was found to correlate with the clinical findings in 24 patients with noncompressive optic nerve pathology, including 11 cases of multiple sclerosis. Furthermore, subclinical multiple sclerosis was detected by the prolongation of pupil cycle time and was confirmed by visual evoked potential analysis. There was a correspondence between dynamics in the clinical findings and the pupil cycle time in two cases of multiple sclerosis that were followed up.

Narrow-band (540NM) green-light stereoscopic photography of the surface details of the peripapillary retina

We used narrow-band (540-nm) green-light stereoscopic fundus photography to study the surface details of the peripapillary retina in 14 patients. Each photograph was divided into four areas; the papillomacular bundle, the upper arcuate bundle, the lower arcuate bundle, and the nasal sectorial fibers. We scored each area on a scale of 0 (normal) to 3 (total loss of nerve fiber layer), and compared these scores to those obtained by testing the corresponding visual fields. The scores were the same in 88 of 111 comparisons; the retinal scores were higher in 17 comparisons and the visual field scores were higher in six comparisons. This photographic technique makes the nerve fiber layer easier to see and evaluate and the detection of defects becomes less difficult.

Nasal visual field loss with intracranial lesions of the optic nerve pathways

Five patients developed nasal visual field defects as a result of involvement of the intracranial portion of the optic nerves. The cause in each patient, respectively, was as follows: (1) dolichoectatic carotid arteries, (2) optochiasmatic arachnoiditis, (3) meningioma of the olfactory groove, (4) pituitary apoplexy, and (5) pituitary chromophobe adenoma. The common factor in these cases was probably impaired circulation in the prechiasmal arterial anastomotic network. The nasal visual field loss present in these cases was characterized by a pattern similar to that seen in glaucoma but with impairment of visual acuity. The superior nasal visual field was usually normal and the lower temporal visual field often defective.

Cell mediated immunity to human myelin basic protein in Vogt-Koyahagi-Harada syndrome

An immunological basis for neurological involvement in Vogt-Koyanagi-Harada syndrome was sought by means of the migration-inhibition factor technique with human myelin basic protein. The test was carried out in four patients who had recent manifestations of the syndrome, two of whom were evaluated both before and after initiation of steroid treatment; in one patient 4 years after recovery from the syndrome; in three patients having uveitis of other causes, and in 12 healthy controls. The results were positive in all four patients who had recent manifestations, whereas they were negative in all the others. This finding may constitute evidence of a cell-mediated immunity toward components of the nervous system in this disease entity.

Inhibition of macrophage migration by choroidal malignant melanoma-associated antigens in patients with unveal melanoma

The specific cell-mediated immunity of the lymphocytes of eight patients with choriodal malignant melanoma (MM) to four extracts of choroidal MM-associated antigens was tested with the aid of the MIF technique. Seven of the patients with choroidal MM responded to at least one of the four extracts used, whereas patients with choroidal nevus or carcinoma as well as healthy controls did not respond to any of the MM choroidal extracts. There was no response to iris extracts obtained from the enucleated eyes with MM in any of the subjects tested.

Visual fields in metastatic choroidal carcinoma

A large choroidal metastasis was diagnosed in the right eye of a 44-year-old man referred for admission to hospital because of 'retinal detachment.' At the same time in the second, symptomless, eye a very small metastasis was observed. Close follow-up during the next month showed an extremely rapid deterioration of visual acuity and visual field in this eye. This is thought to be characteristic of such metastatic tumours in contrast to the slower progress of choroidal malignant melanoma. The application of local radiotherapy to the same eye led to an impressive improvement in the visual acuity and visual field. The source of these bilateral choroidal metastases, which was found only after the patient's death, proved to a bronchial carcinoma.

Malignant optic glioma in a 70-year-old patient

In a 70-year-old man with glioma of the optic nerves and tracts, the initial symptom was a unilateral loss of vision that progressed rapidly and was followed by amaurosis of both eyes. All diagnostic radiological procedures were negative. Four months after the onset of the disease, the patient developed hemiplegia, became comatose, and died. Post-mortem examination revealed a glioblastoma multiforme of both optic nerves, chiasma, and optic tracts that extended posteriorly into the left thalamus and medial geniculate body. The tumoral thickening of the optic nerves was absent in the intracanalicular part, a finding that concurred with the normal radiological appearance of the optic foramen. Glioblastoma multiforme of the optic pathways should be included in the differential diagnosis of acute visual failure in elderly people, even though the final diagnosis may be possible only at postmortem examination.

Retinal red-free light photographs in two congenital conditions: a case of optic hypoplasia and a case of congenital hemianopia

Two patients with congenital anomalies involving the optic pathways are described. The first case presented a unilateral hypoplastic optic nerve as well as an ipsilateral inferior conus and an elevated disc. The second case showed the features of homonymous hemianopia with sparing of the macula and decreased visual acuity on the side of the affected cerebral hemisphere. Red-free photographs were obtained in both cases. The importance of this old-new investigative tool in completing a neuro-ophthalmological study is stressed.

Spontaneous hyphema and vessel anomaly

We describe a case of spontaneous hyphema, in which results of fluorescein angiography revealed that the condition was caused by anomalous iris vessels. A cavernous hemangloma of the ipsilateral orbit was discovered. We stress the importance of performing fluorescein angiography in all cases of spontaneous hyphema.

Prepapillary metastatic abscess in a case of subacute bacterial endocarditis

The case of a 49-year-old woman is described in which the presenting symptom of subacute bacterial endocarditis was the rare condition of a prepapillary abscess. There was a rapid decrease in visual acuity in the patient's left eye 10 days after the onset of an influenza-like episode, and ophthalmological examination revealed a pus-containing formation covering the optic disc, star-figure exudates in the macula, and some retinal hemorrhages with white centers. These findings in a patient known to have old valvular stenosis indicated a diagnosis of subacute bacterial endocarditis which was confirmed by further investigation. Both forms of endogenous primary retinitis were present in the same eye, i.e. (1) acute suppurative metastatic retinitis in the form of a prepapillary abscess and (2) subacute focal retinitis with the characteristic Roth's spots. Intensive antibiotic treatment was instituted, and within one month the prepapillary abscess was resorbed, with a parallel improvement in the general condition of the patient.