Longitudinal optical coherence tomography indices in idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) may result in optic nerve fiber loss and even atrophy. The timing of the optical coherence tomography (OCT) indices reaching the lowest point (nadir) and the factors that predict the patient's anatomical outcome are not known. We aimed to determine the timing and the factors that affect nadir retinal nerve fiber layer (RNFL) thickness. The medical records of 99 IIH patients who were treated from December 2009 to January 2020 were retrospectively reviewed. The mean RNFL thickness at presentation was 263.5 ± 106.4 µm. The mean time to nadir was 7.9 ± 6.3 months. The average RNFL and ganglion cell complex (GCC) thickness at the nadir were 92.6 ± 14.5 µm (47% showed thinning) and 77.9 ± 27.8 µm (70% showed thinning), respectively. The Frisén disc edema stage and average RNFL thickness at baseline correlated with a longer time to nadir, (r = 0.28 P = 0.003 and r = 0.24, P = 0.012, respectively). The nadir average RNFL thickness and the nadir average GCC thickness (r = 0.32, P = 0.001, r = 0.29, P = 0.002, respectively) correlated with the baseline visual field mean deviation. The final anatomical outcome of IIH episodes in this study resulted in RNFL and GCC thinning. The time to RNFL nadir and its values correlated with IIH severity at presentation.

Study in Patients With Unilateral Horner Syndrome Supports the Role of Müller's Muscle in the Eyelid-Dark Reflex

Purpose

A previous study demonstrated upper eyelid retraction synchronized with pupil dilation following a transition from photopic to scotopic conditions. The current study aimed to evaluate the role of Müller's muscle as the efferent arm of this suggested reflex arc.

Methods

A video scan of both eyes of patients with unilateral Horner syndrome was performed using optical coherence tomography infra-red mode to document the transition between photopic and scotopic conditions. The affected side with sympathetic denervation was the study group, whereas the contralateral unaffected side of the same patients served as the control group. The pupil diameter, upper eyelid margin-to-reflex distance 1, lower eyelid margin-to-reflex distance 2, and vertical palpebral fissure height were measured. The control group was compared to the healthy subjects of a previous study to verify any compensatory changes to the side contralateral to denervation.

Results

Ten patients with unilateral Horner Syndrome were included in the study. Transitioning from photopic to scotopic conditions, the mean change in margin-to-reflex distance 1 in the study and control groups was 315 ± 276 µm (P < 0.05) and 723 ± 432 µm (P = 0.005), respectively. Margin-to-reflex distance 1 and palpebral fissure height were significantly higher in the control group both in photopic (P = 0.005 and P = 0.017, respectively) and scotopic conditions (P = 0.005 and P = 0.007, respectively). The change in margin-to-reflex distance 1 and palpebral fissure height following the transition from light to dark was significantly greater in the control group (P = 0.022).

Conclusions

Reflexive eyelid retraction following a transition from photopic to scotopic conditions was significantly diminished in eyelids with sympathetic denervation compared with the unaffected contralateral side of the same patients. This study provides further evidence that the sympathetically innervated Müller's muscle serves as the efferent arm of this reflex.

Diplopia in the Younger Adult (≤65 Years Old) Compared With Older Adult (>65 Years Old) Population-Presentation, Progression, and Outcome

BACKGROUND

Despite the impact of new-onset diplopia on the quality of life, there are few studies concerning new-onset diplopia in seniors. This study aimed to describe the epidemiology, etiology, prognosis, and outcome of different treatments in the older adults compared with younger adult patients presenting with new-onset binocular diplopia.

METHODS

A retrospective chart review of patients ≥18 YO with new-onset binocular diplopia presenting between 2010 and 2021. Data collected included age at presentation, gender, duration of time since diplopia onset, imaging results, known trigger, etiology, treatment, and follow-up.

RESULTS

Two hundred ten patients were included. Of them, 75 patients were ≤65 YO (35.7%, the "younger adult group") and 135 > 65 YO (64.3%, the "older adults group"). The common etiology in both groups was neurogenic (54.7% ≤ 65 vs 62.2% >65, P = 0.29). Cranial nerve palsies were more commonly microvascular in the older adults (96.0% vs 74.1%, P = 0.005), whereas tumor-related cranial nerve palsies were more frequent in younger adults (14.81% vs 2.04%, P = 0.03). A restrictive etiology was observed in 20% of younger adult compared with 11.1% of older adults group (P = 0.08). Sagging eye syndrome (SES) was the second most common etiology in the older adults group at 11.9%, compared with 1.3% in the younger adult group (P = 0.01). Decompensated phoria/tropia appeared in 16% of younger adult group compared with 11.9% of older adults (P = 0.4), with an obvious trigger (mostly cataract surgery) in the latter (80% older adults vs 20% younger adults, P = 0.019). Positive imaging findings were found in 46.7% of patients ≤65 compared with 25.3% of >65 (P = 0.01) and complete spontaneous resolution of diplopia was noted in 32.1% of the older adults compared with 11.8% of younger adults (P = 0.003).

CONCLUSIONS

Neurogenic diplopia was the most common etiology for both groups, but is more prominent in the older adults. Noticeable findings in the older adults were SES diagnosis, identification of triggers for impaired fusion/diplopia, and a paucity of positive findings in imaging results. It is important to know these differences not only for managing seniors better, but also to minimize symptoms of binocular diplopia after lens-related procedures.

Prognostic Value of Optical Coherence Tomography Characteristics in Anterior Visual Pathway Meningiomas

BACKGROUND

Anterior visual pathway meningiomas (AVPM) represent 2.5%-18% of all meningiomas. They may affect visual function, including visual acuity (VA) and visual field (VF). The principal modes of treatment are surgery and radiotherapy. The prognostic value of macular ganglion cell complex count (GCC) thickness has not been assessed in the literature thus far. The purpose of this study was to evaluate the prognostic value of pre-treatment optical coherence tomography (OCT) parameters (retinal nerve fiber layer and GCC) for visual outcomes in patients with AVPM.

METHODS

We retrospectively reviewed the medical records of all patients with AVPM who were treated in the Sheba Medical Center between 2011 and 2020. Included were patients with valid data containing preintervention OCT findings on the CIRRUS device and a minimum follow-up of 6 months. Preintervention and postintervention data on comprehensive ophthalmic examinations and OCT parameters of the affected eyes were retrieved. The correlation between preintervention OCT parameters and the visual outcome was assessed. The patients were also divided into 2 groups according to preintervention GCC (thin vs normal), and the visual outcome was compared between groups.

RESULTS

In total, 186 patients' medical records were analyzed, and 38 patients who met the inclusion criteria were included in the study (mean age at diagnosis 52.8 ± 12.2 years, 28 women). Twenty-nine patients had 1 affected eye, and 9 had bilateral insult. A higher preinterventional average GCC was associated with better VA at 6 months, 1 year, and 2 years after intervention (r = -0.5, P ≤ 0.004, 0.005, and 0.03, respectively). There was a significant correlation between preinterventional GCC and VF mean deviation 2 years after intervention (r = 0.7, P ≤ 0.001). The thinner the GCC, the more prominent was the change in VA from before intervention to 2 years after intervention ( P ≤ 0.008). Correction for multiple comparisons with the Benjamini-Hochberg procedure did not change the significance of our findings.

CONCLUSIONS

OCT parameters (GCC) have a predictive value in AVPM. There is strong correlation between preinterventional GCC and VA shortly after the intervention. Although a thin GCC is generally considered a negative prognostic factor, improvement in clinical parameters was also evident in patients with thin GCC. The potential of improvement despite preinterventional GCC thinning can add to the clinical discussion of the prognosis, and therefore, we recommend the patients with AVPM to undergo OCT and to be advised that GCC thinning alone should not be used as a major criterion in deciding whether treatment should be pursued.

A Consensus Statement on the Terminology for Automated Visual Field Abnormalities

BACKGROUND

A multitude of terms have been used to describe automated visual field abnormalities. To date, there is no universally accepted system of definitions or guidelines. Variability among clinicians creates the risk of miscommunication and the compromise of patient care. The purposes of this study were to 1) assess the degree of consistency among a group of neuro-ophthalmologists in the description of visual field abnormalities and 2) to create a consensus statement with standardized terminology and definitions.

METHODS

In phase one of the study, all neuro-ophthalmologists in Israel were asked to complete a survey in which they described the abnormalities in 10 selected automated visual field tests. In phase 2 of the study, the authors created a national consensus statement on the terminology and definitions for visual field abnormalities using a modified Delphi method. In phase 3, the neuro-ophthalmologists were asked to repeat the initial survey of the 10 visual fields using the consensus statement to formulate their answers.

RESULTS

Twenty-six neuro-ophthalmologists participated in the initial survey. On average, there were 7.5 unique descriptions for each of the visual fields (SD 3.17), a description of only the location in 24.6% (SD 0.19), and an undecided response in 6.15% (SD 4.13). Twenty-two neuro-ophthalmologists participated in the creation of a consensus statement which included 24 types of abnormalities with specific definitions. Twenty-three neuro-ophthalmologists repeated the survey using the consensus statement. On average, in the repeated survey, there were 5.9 unique descriptions for each of the visual fields (SD 1.79), a description of only the location in 0.004% (SD 0.01), and an undecided response in 3.07% (SD 2.11%). Relative to the first survey, there was a significant improvement in the use of specific and decisive terminology.

CONCLUSIONS

The study confirmed a great degree of variability in the use of terminology to describe automated visual field abnormalities. The creation of a consensus statement was associated with improved use of specific terminology. Future efforts may be warranted to further standardize terminology and definitions.

A Multidisciplinary Thyroid Eye Clinic: A One-stop Shop

BACKGROUND

Little is known about the success of multidisciplinary thyroid eye disease (TED) clinic.

OBJECTIVES

To present the characteristics, treatments, and outcomes of patients treated in a multidisciplinary TED clinic.

METHODS

A medical record review of all patients who attended a TED clinic was performed. Data included demographics, medical history, laboratory tests, visual function tests, ocular examinations, clinical activity score (CAS), and assessment of quality-of-life (QOL).

RESULTS

Clinic visits included 132 patients seen during 385 appointments at a TED clinic (mean 12 appointments per patient). Management of TED included medical treatments for 48 patients (36.3%) and surgical treatment for 56 (42.4%). There was a positive significant correlation between the CAS and thyroid-stimulating immunoglobulin (TSI) activity at the first visit and at the last follow-up visit (P < 0.01 and P < 0.02, respectively). However, no correlation was found between the CAS and the thyroid-stimulating hormone levels or between the free triiodothyronine (fT3) and fT4 levels at the first or last visit. There was a significant negative correlation between the CAS and color vision (-0.347, P < 0.01, Pearson correlation) at the first visit, but not between the CAS and visual acuity and visual field at either the first or last visit. Changes in the QOL and the CAS scores were significantly negatively correlated (-0.240, P < 0.01).

CONCLUSIONS

Treatment and management decisions for TED should be based on multiple parameters including clinical examinations by ophthalmologists and endocrinologists, laboratory tests, and CAS and QOL scores.

Clinical profile of 80-year-old and older thyroid eye disease patients

PURPOSE

Thyroid eye disease (TED), an autoimmune orbital disorder, follows a time-of-onset bimodal peak: 40-44 and 60-64 years for women, 45-49 and 65-69 years for men. TED, however, can also commence in old age. The study's purpose was to evaluate TED in octo- and nonagenarians.

METHODS

Medical records of 19 ≥ 80 years geriatric patients at time of diagnosis were compared to 122 TED patients, aged 20-79. A second analysis was performed after subdividing the control group into two age groups, ≤ 40 ("young group," 16 patients) and 41-79 years ("middle-aged group," 106 patients).

RESULTS

The geriatric group's mean age was 84 years (80-94), 11 males and 8 females. Mean follow-up time was 16 months. Compared to the controls, the geriatric patients smoked less (p = 0.012), were more often hypothyroid (p = 0.019), and had concurrent myasthenia gravis (p = 0.02) at time of diagnosis. Diplopia was the most common presenting symptom among the elderly (p = 0.005) and proptosis among the controls, specifically the young group (p = 0.027). Bilateral signs were more common among seniors (p = 0.049). Optic neuropathy was diagnosed in 10% of the geriatric group (2/19) and 11% of middle-aged group (12/106), all being resolved after steroids or orbital decompression. Active disease (clinical activity score (CAS) score =  > 3) was more common among the middle-aged group (p = 0.024) while the geriatric patients tended towards higher TED severity grades. Orbital decompression and eyelid repositioning surgeries were more common among the middle-aged group. Strabismus surgeries were more common among seniors.

CONCLUSIONS

TED among octo- and nonagenarians has unique patterns, with different demographic features, more exposed to diplopia, hypothyroidism, association with myasthenia gravis, and bilateral involvement. Special attention should be given when medically managing this subgroup.

Cognitive Performance of Patients With Multiple Sclerosis and Optic Neuritis at Presentation

BACKGROUND

Cognitive dysfunction is common among patients with multiple sclerosis (MS), but the effect of coexisting optic neuritis (ON) at the first presentation of multiple sclerosis on the course of cognitive decline is unknown. The purpose of this study was to assess whether ON at presentation has any effect on the progression of cognitive decline in MS.

METHODS

Historical cohort study. We retrospectively compared the cognitive performance of patients with relapsing-remitting MS with and without ON at the time of MS diagnosis. Subjects were included if cognitive test results were available both at baseline and after at least 36 months from presentation and grouped based on the presence (MS-ON) or absence (MS-non-ON) of optic neuritis at presentation.

RESULTS

One hundred seventy consecutive subjects with MS were found suitable, with a 1:2 male:female ratio and a mean age at diagnosis of 33.0 ± 10.9 years. Forty-six patients (27.1%) presented with ON. No significant differences were found in cognitive performance at onset between the 2 groups. Both groups had a similar follow-up duration. The prevalence of cognitive decline in the general score was significantly higher in the MS-ON group compared with the MS-non-ON group (6.5% vs 0%, respectively; P < 0.001), as well as in the attention (8.7% vs 1.6%; P = 0.046) and the executive function (17.4% vs 2.4%; P = 0.001) domains.

CONCLUSIONS

Optic neuritis at presentation of MS is associated with a higher prevalence of cognitive decline over time. Potential benefit of early intervention to prevent cognitive decline may be warranted.

Neuro-Ophthalmic Phenotype of OPA3

BACKGROUND

Type III 3-methylglutaconic aciduria (OPA 3) is a neuro-ophthalmologic syndrome consisting of early-onset bilateral optic atrophy. Since Costeff described the phenotype of 19 patients in 1989, several reports described approximately 50 patients, but most of them lack details about neuro-ophthalmic phenotype. Our aim was to characterize the clinical neuro-ophthalmic phenotype of this syndrome.

METHODS

Nine patients underwent meticulous visual function history and medical documents' review. Results of best-corrected visual acuity (VA), color vision, visual field (VF), ocular motility, pupillary reaction, slit-lamp, and dilated fundus examinations were recorded. Optical coherence tomography (OCT) was performed whenever possible.

RESULTS

The average VA was 1.4 ± 0.8 logarithm of the minimum angle of resolution. Poor vision was the presenting symptom in 5 patients. Six patients had decreased VA and variable degrees of optic atrophy. Humphrey VF testing of 7 patients revealed generalized depression in 5 and a cecocentral defect in 2. All patients demonstrated dysmetric saccades. Four patients had strabismus, 3 with exotropia, and one with esotropia. Seven patients had nystagmus. Ocular motility abnormality is possibly the result of cerebellar atrophy that was found in MRI studies of our patients. OCT of the retina was possible in 6 patients and revealed retinal nerve fiber layer (RNFL) thinning as well as average retinal thinning. Three patients, in whom ganglion cell layer-inner plexiform layer (IPL) measurement was possible, also showed diffused thinning.

CONCLUSIONS

This study compiled data regarding neuro-ophthalmic manifestation of OPA 3 Type III patients. Contrary to established literature, poor vision was the presenting symptom in only 50% of our patients. This is the first report of OCT findings in 3MGA patients. The results demonstrated diffused thinning of the RNFL and ganglion cell complex-IPL with correlation to VA, which is in contrast to OPA1 patients in whom the most severe thinning is at the level of the papillomacular bundle. Average retinal thinning was identified at second and third decades of life, possibly resulting from early ganglion cell loss. These results may contribute to visual prognosis, and OCT may help monitor experimental therapies.

OCULAR SURFACE TEMPERATURE DIFFERENCES IN RETINAL VASCULAR DISEASES

PURPOSE

To define the effect of age-related macular degeneration (AMD) and diabetic retinopathy (DR) on the ocular thermographic profile.

METHODS

This retrospective cross-sectional study included subjects diagnosed with DR or AMD between January and April 2019. Individuals without ocular disease served as controls. A thermal imaging camera was used for ocular surface temperature (OST) acquisition. The mean temperatures of the medial cantus, lateral cantus, and cornea were calculated.

RESULTS

Thermographic images were obtained from 133 subjects (260 eyes, 97 DR and 163 AMD) and 48 controls (55 eyes). Ocular surface temperature was higher among patients with AMD and lowest among patients with DR (P < 0.001). A subgroup analysis revealed that eyes with diabetic macular edema had significantly higher OSTs than DR eyes without diabetic macular edema. Moreover, the OST in eyes with diabetic macular edema was similar to the measurements of the AMD group. There were no differences in OSTs between neovascular and nonneovascular AMD eyes.

CONCLUSION

Although AMD and DR are considered posterior segment conditions, their effect on OST implies that the entire globe is involved. Although both conditions result from similar multifactorial pathophysiologic changes, the differences in OST between DR and AMD might be due to dissimilarity in the balance of pathologic processes involved in each condition. Further research is required to better understand the pathophysiology of these diseases and their effect on OST as well as to determine the effect of vasculature, circulation, and tissue metabolism on ocular temperature.

Broadening the phenotype of LRRK1 mutations - Features of malignant osteopetrosis and optic nerve atrophy with intrafamilial variable expressivity

Osteosclerotic metaphyseal dysplasia is a rare disorder which features osteosclerosis involving long bones, vertebrae, ribs, clavicles and the iliac crests. Additional features which have variably been reported include developmental delay, short stature, hypotonia and seizures. The disease is caused by pathogenic variants in the LRRK1 gene, and inherited in an autosomal recessive manner. We report three siblings (ages 14 years, 11.5 years and 0.9 years), born to consanguineous parents of Arab-Muslim descent, harboring a homozygous pathogenic variant in the LRRK1 gene (Chr15:101068759 AGGGGCT>A, c.5965_5970del TGGGGC, p.Trp1989Gly1990del). The patients displayed variable degrees of skeletal dysplasia, with the oldest sibling most severely affected, and the youngest infant with minor skeletal involvement. Two of the siblings exhibited normal neurological development, while the youngest sibling exhibited global developmental delay. None of the siblings had seizures; however, two of them exhibited nystagmus. Optic nerve involvement has not previously been reported to be part of the clinical spectrum of this disease. The degree of optic nerve involvement did not correlate with the degree of skeletal involvement. This indicates both intra-familial variable expressivity along with a broadening of the spectrum of LRRK1-associated disease. These findings warrant reconsideration of therapeutic strategies, including the possibility of hematopoietic stem cell transplantation (HSCT) as is performed in cases of malignant and intermediate forms of osteopetrosis.

Neuro-ophthalmologic outcomes of standard versus hypo-fractionated stereotactic radiotherapy of AVPM

BACKGROUND

Most anterior visual pathway meningiomas (AVPM) are benign and slow-growing, but these tumors may affect visual functions, including visual acuity (VA) and visual field (VF). Due to location, most are treated non-surgically by fractionated stereotactic radiotherapy (FSRT), aiming to prevent tumor progression and visual functions deterioration. Unfortunately, FSRT in itself may affect visual functions. The current preferred treatment regimen (in terms of safety and effectiveness) is undetermined. While most cases are treated with conventional fractionation (cFSRT)-50.4-54 Gy in 28-30 fractions of 1.8-2 Gy, advances in technology have allowed shortening of total treatment length to hypofractionation (hSRT)-25-27 Gy in 3-5 fractions of 5-9 Gy. Our aim was to evaluate the association of radiotherapy regimen for treating AVPM (cFSRT vs. hSRT) with visual function outcomes (VA, VF) at the last neuro-ophthalmologic evaluation.

METHODS

We conducted a retrospective cohort study of AVPM cases treated at Sheba Medical Center during 2004-2015. We compared cFSRT and hSRT regimens regarding visual function (VA, VF) outcomes at the last neuro-ophthalmologic evaluation. VA was determined by the logarithm of the minimum angle of resolution (LogMAR). VF was determined by the mean deviation (MD). A clinically relevant change in VA was defined as 0.2 LogMAR.

RESULTS

48 patients (13 receiving hSRT, 35 receiving cFSRT) were included, with a median follow-up of 55 months. No significant difference was evident regarding LogMAR or MD of involved eyes at the last evaluation. Six (17%) patients in the cFSRT group experienced clinically relevant VA deterioration in the involved eye, compared with six (46%) in hSRT (p = 0.06).

CONCLUSION

Our findings, using comprehensive and meticulous investigation of visual outcomes, suggest that hSRT may be associated with higher risk for VA and VF deterioration in AVPM especially in ONSM. We recommend the use of cFSRT for ONSM.

Ocular surface temperature differences in glaucoma

PURPOSE

Accumulating evidence suggests that neuroinflammation and immune response are part of the sequence of pathological events leading to optic nerve damage in glaucoma. Changes in tissue temperature due to inflammation can be measured by thermographic imaging. We investigated the ocular surface temperature (OST) profile of glaucomatous eyes to better understand the pathophysiology of these conditions.

METHODS

Subjects diagnosed with glaucoma (primary open angle glaucoma [POAG] or pseudo exfoliation glaucoma [PXFG]) treated at the Sam Rothberg Glaucoma Center (11/2019-11/2020.) were recruited. Healthy subjects with no ocular disease served as controls. The Therm-App thermal imaging camera was used for OST acquisition. Room and body temperatures were recorded, and the mean temperatures of the medial cantus, lateral cantus, and cornea were calculated with image processing software.

RESULTS

Thermographic images were obtained from 52 subjects (52 eyes: 25 POAG and 27 PXFG) and 66 controls (66 eyes). Eyes with glaucoma had a significantly higher OST compared to controls (mean 0.9 ± 0.3°C, p < 0.005). The difference between the two groups remained significant after adjustment for age, sex, intraocular pressure (IOP) and room and body temperatures. Lens status and topical IOP-lowering medication did not significantly affect OST. A subgroup analysis revealed that the OST was higher among eyes with POAG compared to eyes with PXFG, but not significantly.

CONCLUSIONS

Differences in the OST between glaucomatous and normal eyes strengthens current thinking that inflammation affects the pathophysiology of glaucoma. Longitudinal studies are warranted to establish the prognostic value of thermographic evaluations in these patients.

Er:YAG laser-assisted filtration surgery: initial results in rabbits

Background

Glaucoma is a leading cause of global blindness, especially preventable blindness. The increased prevalence of glaucoma has led to a growing demand for newer, safer, more rapid, and simpler treatments for the reduction of intraocular pressure (IOP). In this study, we evaluated the safety and feasibility of performing filtration glaucoma surgery with an Ab-Interno Er:YAG laser in rabbits.

Methods

Nine New Zealand White rabbits age 16weeks were studied. After subconjunctival injection of mitomycin C (MMC), a novel Ab-Interno Er:YAG laser probe was inserted into the anterior chamber (AC) through a clear corneal 1mm paracentesis and directed at the trabecular meshwork adjacent to the MMC injection area. A pulsed laser beam was applied to create a patent sclerostomy connecting the AC to the subconjuctival space, resulting in a filtering bleb. The laser system used was the Er:YAG laser system - LAS25-FCU, (Pantec Biosolutions AG, Liechtenstein). Parameters used: Wave lengh: 2940nm, Pulse length: 100400sec,frequency: 250Hz. Average laser power in accordance to the fiber tip diameter: 0.85W(range 0.80.92W). Complete ocular exams, including IOP measurements, were performed on 1, 7, 14, and 23days postoperatively. Three rabbits were sacrificed on days 1, 14, and 23, and histological examinations were performed on all nine eyes.

Results

All procedures resulted in a functional medium-large superior bleb without significant complications. The bleb was sustained in all rabbits by day 14 and in one of the three rabbits that reached the last follow-up at 23days. No cases of postoperative hypotony were observed. There was a transient significant reduction in mean IOP on postoperative days 5 and 7 (P=0.028). Histopathological analysis revealed a patent full-thickness scleral tunnel with only a minor degree of surrounding coagulation necrosis.

Conclusions

The Ab-Interno laser sclerostomy procedure is potentially safe and effective based on initial experience in an in-vivo rabbit animal model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01986-4.

Young Adults With Anterior Ischemic Optic Neuropathy: A Multicenter Optic Disc Drusen Study

PURPOSE

Optic disc drusen (ODD), present in 2% of the general population, have occasionally been reported in patients with nonarteritic anterior ischemic optic neuropathy (NA-AION). The purpose of this study was to examine the prevalence of ODD in young patients with NA-AION.

DESIGN

Retrospective, cross-sectional multicenter study.

METHODS

All patients with NA-AION 50 years old or younger, seen in neuro-ophthalmology clinics of the international ODDS (Optic Disc Drusen Studies) Consortium between April 1, 2017, and March 31, 2019, were identified. Patients were included if ODD were diagnosed by any method, or if ODD were excluded by enhanced-depth imaging optical coherence tomography (EDI-OCT) using ODDS Consortium guidelines. NA-AION eyes with ODD were termed "ODD-AION"; those without were termed "NODD-AION".

RESULTS

A total of 65 patients (127 eyes) with NA-AION were included (mean 41 years old). Of the 74 eyes with NA-AION, 51% had ODD-AION, whereas 43% of fellow eyes without NA-AION had ODD (P = .36). No significant differences were found between ODD-AION and NODD-AION eyes in terms of Snellen best-corrected VA or perimetric mean deviation. According to EDI-OCT results, 28% of eyes with NODD-AION had peripapillary hyperreflective ovoid mass-like structures (PHOMS); 7% had hyperreflective lines, whereas 54% with ODD-AION had PHOMS; and 66% had hyperreflective lines (P = .006 and P < .001, respectively).

CONCLUSIONS

Most of these young NA-AION patients had ODD. This indicates that ODD may be an independent risk factor for the development of NA-AION, at least in younger patients. This study suggests ODD-AION be recognized as a novel diagnosis.

Prognostic value of JAK2V617F mutation in pseudotumor cerebri associated with cerebral venous sinus thrombosis

OBJECTIVES

To examine the clinical characteristics and prognosis of cerebral venous sinus thrombosis (CVST) that presented as pseudotumor cerebri (PTC) patients with JAK2V617F mutation.

METHODS

Medical records of all consecutive patients that presented with PTC and a JAK2V617F mutation who were treated were retrospectively reviewed. Data regarding demographics and ocular presenting symptoms and signs, neurological signs, hematological factors treatment, and prognosis were collected.

RESULTS

The most common presenting symptoms were headache (5 patients, 83.3%) and visual obscurations (5 patients, 83.3%). CVST of the sagittal sinus and sigmoid sinus were the most common site of thrombus. Platelet count and hemoglobin count were higher than normal during follow-up. There was significant change in the disk edema degree as well as decline in retinal nerve fiber layer (RNFL) thickness (P < 0.001, P < 0.001, Matched pairs). There was no significant change in visual acuity (VA) or mean deviation (MD) during follow-up (P = 0.95, 0.64, respectively, Matched pairs).

CONCLUSIONS

Pseudotumor cerebri resulting from CSVT in our patients with JAK2V617F mutation was frequent in young patients and needed medical and surgical treatment, without improvement in visual functions and in third caused poor visual outcome. Therefore, we believe that a screening test for JAK2V617F mutation should be considered for patients with CVST without known risk factor presenting with PTC, especially when sagittal sinus or sigmoid sinus involvement or thrombocytosis or high hemoglobin are found upon presentation. This might lead to more aggressive management which may improve the visual prognosis of those young patients.

In whom does horizontal canal BPPV recur?

PURPOSE

The objective of this study is to examine the rate of horizontal canal BPPV recurrence of the same type and search for predisposing factors.

Parinaud syndrome: Any clinicoradiological correlation?

INTRODUCTION

The significance of MRI findings of patients with Parinaud syndrome (PS) with respect to clinical characteristics is poorly defined. Over the past decades, all patients with PS undergo magnetic resonance imaging which allows a better identification of the lesion localization. We compared the neuro-ophthalmological findings of patients with PS caused by intrinsic (intra-axial) vs extrinsic (pineal gland tumor) brainstem lesions.

METHODS

Medical records of patients with PS evaluated between 2000 and 2016 were retrospectively reviewed.

RESULTS

Twenty-six patients with PS were included. Eight patients had pineal gland tumors and hydrocephalus. Two patients had hydrocephalus due to aqueduct stenosis and fourth ventricle tumor. Sixteen patients suffered from an intrinsic brainstem lesion and seven associated with hydrocephalus. The neuro-ophthalmological findings did not differ between patients with extrinsic and intrinsic brainstem lesions. No correlation was found between the grade of hydrocephalus and number of clinical findings except for more findings in low-grade hydrocephalus in intrinsic (40%) vs extrinsic (0%) lesions (P=.003). Patients with moderate brainstem lesions and hydrocephalus had more clinical findings (65%) than patients with the same grade of brainstem involvement without hydrocephalus (29%) (P=.03). The resolution rate of ophthalmological findings was comparable in all groups of patients.

CONCLUSIONS

Our results did not show differences in neuro-ophthalmological findings between intra- and extra-axial lesions causing PS. However, the presence of hydrocephalus was an important factor influencing clinical findings. The prognosis of PS was less favorable than generally reported.

Association of orbital decompression and the characteristics of subsequent strabismus surgery in thyroid eye disease

OBJECTIVE

To examine the association of orbital decompression and the characteristics and outcome of subsequent strabismus surgery in patients with thyroid eye disease (TED).

METHODS

Data on patients with TED who underwent orbital decompression at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between January 1990 to December 2011 were extracted. The characteristics of decompression and strabismus surgeries were recorded. The outcomes and association of both surgical procedures were analyzed. Statistical analysis included distribution, Pearson correlation, and matched paired tests.

RESULTS

145 eyes underwent orbital decompression, of which 45 eyes (31.0%) underwent strabismus surgery. Esotropia developed in 70% of the patients. Men and smokers underwent strabismus surgeries after decompression procedures more frequently than women and nonsmokers (χ² test, p = 0.07, 0.002). Moreover, patients who complained of diplopia before the decompression surgery underwent strabismus surgery more frequently (χ² test, p = 0.005). Seventy-seven percent of the patients who underwent medial wall decompression developed esotropia (χ² test, p = 0.004).

CONCLUSIONS

To the best of our knowledge, this is the largest series in the literature examining the association between decompression and strabismus surgeries. The patients' characteristics and the orbital walls involved in the decompression procedures are associated with the characteristics of subsequent strabismus that develops thereafter. These findings may have significant implications in planning TED management.

Susac syndrome: clinical characteristics, clinical classification, and long-term prognosis

Susac syndrome is a rare condition characterized by the clinical triad of central nervous system (CNS) dysfunction, sensorineural hearing impairment, and branch retinal artery occlusion (BRAO). The purpose of this study is to examine the demographics, clinical characteristics, treatment, and long-term prognosis of Susac syndrome. The data recorded for all Susac syndrome patients treated at the Sheba Medical Center between 1998 and 2014 included demographics, clinical signs at presentation and during the disease course, imaging findings, treatment, and prognosis.Susac syndrome was diagnosed in 10 patients (age range 30-45 years). Only 2 patients presented with the full triad and 7 patients developed the full triad during mean follow-up period of 35 months. The average time to full triad was 7 months. Based on our observations at presentation, we divided the disease course into suspected, incomplete, and complete Susac syndrome. All 10 patients were treated at diagnosis with a pulse of high-dose intravenous methylprednisolone. There was improvement in visual acuity and visual field at the end of follow-up compared to baseline, but it was not statistically significant (P = 0.479 and P = 0.053, respectively). Five patients remained with neurological damage, and 5 patients had no improvement of their hearing loss at study closure. In conclusion, Susac syndrome is a rare condition that can mimic other disorders. The diagnosis is challenging because most patients do not initially present with the definitive triad. We suggest a clinical classification for the syndrome that may assist in early diagnosis.

Acute Optic Neuropathy and Development of Posttraumatic Stress Disorder

This study aimed to determine the prevalence and risk factors of posttraumatic stress disorder (PTSD) in 171 acute optic neuropathy (AON) patients, and to compare the findings to those previously reported on 366 rhegmatogenous retinal detachment (RRD) patients. PTSD positively screened AON patients underwent a structured psychiatric interview and a Visual Function Questionnaire (VFQ). Clinical measures were retrieved from medical records and compared between cohorts. None of the AON patients was diagnosed with PTSD, as opposed to 2.5% of RRD patients (P = 0.063). Of the AON cohort, 34% of patients were administered steroids, compared to none of the RRD patients, whereas all of the RRD patients underwent surgery, compared to none of the AON patients (P < 0.001). Clinical measures and VFQ scores were not found as risk factors for PTSD prediction. Results imply the potential role of surgery and of steroid treatment in developing PTSD in cases of ocular insults.

[Clinical characteristics of dysthyroid optic neuropathy]

PURPOSE

To describe the clinical presentation, management and outcome of dysthyroid optic neuropathy (DON) patients in order to find markers for this diagnosis among Graves orbitopathy (GO) patients.

METHODS

We conducted a retrospective review of the medical records of 15 patients presenting with clinical and radiologic evidence of DON, from a series of 131 patients with Graves orbitopathy, treated at our health care center between the years 1999 and 2008. The worse eye of each of the 15 DON patients was determined according to visual acuity and visual field defects, and was paired with an eye of a matched patient from the GO group. Paired comparisons were performed in order to appreciate the differences in the rates of various signs and symptoms between both groups.

RESULTS

A total of 15 patients (11%), mean age 55 years (range 37-76 years) were diagnosed with DON, (53%) of them were smokers. The most common manifestations among DON patients were proptosis (78%), visual field defects (76%) and restriction of abduction (73%). In a paired comparison between the worse eye of DON patients and their counterparts in the GO group, statistically significant differences were noted in the rate of proptosis (p = 0.02), extent of visual field damage (p = 0.001), visual field mean deviation (p = 0.02) and abduction limitation (p = 0.02). A trend with no statistical significance was demonstrated for the difference in adduction limitation (p = 0.06).

CONCLUSIONS

The clinical presentation and management of dysthyroid optic neuropathy patients is described in a cohort of 15 patients. As visual field defects and restriction of abduction were the most common signs with the diagnosis of optic neuropathy, we recommend follow-up to include routine visual field screening in Graves' orbitopathy patients. Treatment with intravenous corticosteroids and decompressive surgery was shown to be effective in our cohort.

The role of B cells in the early onset of the first demyelinating event of acute optic neuritis

PURPOSE

We evaluated the molecular pathways that operate in the early phase of acute optic neuritis (ON) by studying gene expression profiles of peripheral blood mononuclear cells (PBMCs) subpopulations, including CD19(+) B cells, CD14(+) macrophages, and CD4(+) and CD8(+) T cells.

METHODS

Samples of PBMC subpopulations were obtained from 18 MS patients within 96 hours of the acute onset of the first demyelinating event of ON, and from 14 age- and sex-matched healthy subjects. High throughput gene expression analysis was performed on samples from six ON patients and nine healthy subjects using Affymetrix technology. Data were analyzed using Partek software, and most informative genes (MIGs) were defined as genes with P < 0.01 and fold change > 2.0. Molecular pathways were analyzed by Ingenuity software. Verification of key MIGs was done on samples from five independent ON patients and five healthy subjects by quantitative (Q) RT-PCR and Western blot. Functional assay to test antigen presentation ability of sorted B cells was performed on blood samples from seven additional ON patients.

RESULTS

Significantly differentiating gene expression signatures consisting of 467, 55, and 55 MIGs respective of CD19(+), CD14(+), and CD4(+) cells, were identified between ON and healthy subjects. No MIGs were detected for CD8(+) cells. The major involvement of CD19(+) B cells in the early stage of ON was characterized by enrichment of genes involved in activation of immune mechanisms (P = 3.2 × 10(-25) to 2.5 × 10(-3)), including cellular immune response (P = 7.1 × 10(-12)), B-cell cellular growth and proliferation (P = 1.0 × 10(-7)), activation of immune cells trafficking pathways (P = 5.4 × 10(-15) to 2.0 × 10(-3)), and stimulation of antigen presentation (P = 8.9 × 10(-11)). This massive B-cell-restricted initiation of the immune response in the early disease process of ON was followed by low CD14(+) and CD4(+) cells activity and CD8(+) cells anergy.

CONCLUSIONS

Our findings demonstrate that CD19(+) B cells have a significant role in the pathogenesis of the first demyelinating event of acute ON and suggest their role as a possible target for immunomodulation.

Costeff syndrome: clinical features and natural history

Costeff syndrome (CS) is a rare autosomal-recessive neurological disorder, which is known almost exclusively in patients of Iraqi Jewish descent, manifesting in childhood with optic atrophy, ataxia, chorea and spastic paraparesis. Our aim was to study the clinical spectrum of CS and natural history using a cross-sectional study design. Consecutive patients with CS were recruited to the study. Patients were diagnosed based on clinical features, along with elevated urinary levels of methylglutaconic and methylglutaric acid, and by identification of the disease-causing mutation in the OPA3 gene in most. All patients were examined by a neurologist and signs and symptoms were rated. 28 patients with CS (16 males, 21 families, age at last observation 28.6 ± 16.1 years, range 0.5-68 years) were included. First signs of neurological deficit appeared in infancy or early childhood, with delayed motor milestones, choreiform movements, ataxia and visual disturbances. Ataxia and chorea were the dominant motor features in childhood, but varied in severity among patients and did not seem to worsen with age. Pyramidal dysfunction appeared later and progressed with age (r = 0.71, p < 0.001) leading to spastic paraparesis and marked gait impairment. The course of neurological deterioration was slow and the majority of patients could still walk beyond the fifth decade. While visual acuity seemed to deteriorate, it did not correlate with age. CS is a rare neurogenetic disorder that causes serious disability and worsens with age. Spasticity significantly increases over the years and is the most crucial determinant of neurological dysfunction.

Visual outcome of mega-dose intravenous corticosteroid treatment in non-arteritic anterior ischemic optic neuropathy - retrospective analysis

BACKGROUND

To date, non arteritic anterior ischemic optic neuropathy (NAION) is still incurable. We wish to evaluate the effect of intravenous (IV) corticosteroids on the visual outcome of NAION patients.

METHODS

Visual parameters were retrospectively compared between NAION patients treated with IV corticosteroids and untreated NAION patients (control). Visual acuity (VA) and Humphrey automated static perimetry visual field (VF) defects of the affected eye were compared between groups at baseline, 1, 3, 6 months, and end of follow-up visits. The VF analysis consisted of number of quadrant involvements and mean deviation (MD).

RESULTS

Each group comprised 23 patients (24 eyes). Mean initial VA was similar in the control and treatment groups (p = 0.8). VA at end of follow-up did not improve in either groups (p = 0.8 treated group, p = 0.1 control group). No improvement and no difference in VF defects were found by either quadrant analysis (p = 0.1 treated group, p = 0.5 control group) or MD analysis (p = 0.2, treated group, p = 0.9 control group). VA and VF parameters tended to be worse in the treated group, although without statistical significance.

CONCLUSIONS

Our results suggest that IV corticosteroids may not improve the visual outcome of NAION patients. Since intravenous corticosteroids could potentially cause serious adverse effects, this treatment for NAION is questionable.

Visual outcome of mega-dose intravenous corticosteroid treatment in non-arteritic anterior ischemic optic neuropathy - retrospective analysis

BACKGROUND

To date, non arteritic anterior ischemic optic neuropathy (NAION) is still incurable. We wish to evaluate the effect of intravenous (IV) corticosteroids on the visual outcome of NAION patients.

METHODS

Visual parameters were retrospectively compared between NAION patients treated with IV corticosteroids and untreated NAION patients (control). Visual acuity (VA) and Humphrey automated static perimetry visual field (VF) defects of the affected eye were compared between groups at baseline, 1, 3, 6 months, and end of follow-up visits. The VF analysis consisted of number of quadrant involvements and mean deviation (MD).

RESULTS

Each group comprised 23 patients (24 eyes). Mean initial VA was similar in the control and treatment groups (p = 0.8). VA at end of follow-up did not improve in either groups (p = 0.8 treated group, p = 0.1 control group). No improvement and no difference in VF defects were found by either quadrant analysis (p = 0.1 treated group, p = 0.5 control group) or MD analysis (p = 0.2, treated group, p = 0.9 control group). VA and VF parameters tended to be worse in the treated group, although without statistical significance.

CONCLUSIONS

Our results suggest that IV corticosteroids may not improve the visual outcome of NAION patients. Since intravenous corticosteroids could potentially cause serious adverse effects, this treatment for NAION is questionable.

Reevaluation of presentation and course of idiopathic intracranial hypertension--a large cohort comprehensive study

OBJECTIVES

We analyzed the clinical and ophthalmological findings in a large group of patients with idiopathic intracranial hypertension (IIH) trying to find factors that might influence the course of the disease.

MATERIALS AND METHODS

Medical records of patients with IIH were retrospectively reviewed. The patients included were women after menarche and men older than 18 years of age who were followed up for at least 1 year.

RESULTS

Eighty-two patients (89% women) with a mean age of 30.2 ± 12.0 years were included. The prevailing complaint was headache and transient visual obscurations followed by tinnitus and double vision. Eighty-two percent of patients were overweight at the time of diagnosis. Overweight patients had higher opening cerebrospinal fluid (CSF) pressure than patients with normal weight did. The grade of papilledema correlated with the CSF opening pressure. Inverse correlation was found between the depression of the visual field sensitivity and the grade of papilledema. The mean follow-up time was 61.3 ± 62.3 months. Eighty-four percent of the patients have improved while in 22% CSF diversion procedures or optic nerve decompression was required. The mean body mass index (BMI) at the end of follow-up decreased significantly. Sixty-seven percent of the patients suffered a recurrence of IIH. The number of recurrences inversely correlated with weight loss. Visual field defects on presentation were encountered more frequently in patients with recurrence. Women with recurrence had a history of more pregnancies.

CONCLUSIONS

Our results confirm the strong association between overweight and IIH. The recurrence rate seemed to be influenced by the obstetrical history and the severity of visual field defects at presentation. In contrast to some previous studies, we have found an interrelation between the CSF opening pressure, grade of papilledema and depression of the visual field sensitivity.

[Neuro-ophthalmology and interventional neuro-radiology--co-treatment for carotid cavernous sinus fistula]

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous communications in the cavernous sinus. In many cases of CCF's the primary signs are ocular manifestations, which include: pulsatile proptosis, orbital bruit, chemosis and conjunctival injection, elevated intraocular pressure, venous stasis retinopathy, and cranial nerve pareses. Patients in whom the fistula causes arterial drainage into the cerebral veins and sinuses are at risk for intracranial hemorrhage. The most common treatment for CCF's is endovascular occlusion of the lesion. The goal of this procedure is to occlude the fistula but preserve the patency of the internal carotid artery. The CCF itself, as well as its treatment, can be sight- and even life-threatening. We describe 3 case reports of patients with CCF, in order to demonstrate the cooperation between the neuro-opthalmologist and the invasive neuro-radiologist, in the follow-up of the patient and in the treatment timing decision.

Functional visual loss in an Israeli pediatric population

BACKGROUND

Pediatric functional visual loss (FVL) is the loss of vision in a child that cannot be explained by an organic pathology. In the last decade, only a few studies on pediatric FVL have reported long-term patient follow-up.

OBJECTIVES

To report the characteristics of pediatric FVL with long-term follow-up in Israeli children.

METHODS

We conducted a retrospective chart review of the medical records of patients with FVL from 2000 to 2010. Only children with adequate follow-up (at least 2 months) were included.

RESULTS

Of the 12 patients identified, 9 were females. Mean patient age was 10.5 +/- 4.4 years (range 3.5-17 years). Most children (75%) had bilateral visual loss. One patient had a history of psychiatric illness and in three patients a preceding psychosocial event/trauma was identified. Brain imaging and electrophysiology testing (if done) were normal in all cases. No medications were prescribed to any of the patients,and all were reassured that there was a high chance of spontaneous resolution. The follow-up time was 2-108 months (mean 23.8 months, median 6). During the follow-up period 9 ofthe 12 had complete resolution and 2 had relief of symptoms. Three patients reported a recurrence of symptoms. No organic disease was ever diagnosed in this group.

CONCLUSIONS

FVL may occur in all age groups, including children. In cases of visual loss, it is usually bilateral and can involve both acuity and visual field loss. In the present report most of the patients experienced normalization or relief of their symptoms without medical treatment.

Sixth nerve palsy as the presenting symptom of metastatic colon carcinoma

Isolated cranial mononeuropathies in patients over 50 years of age most commonly result from microvascular ischemic demyelination. A 51-year-old female without vasculopathic risk factors presented with isolated sixth nerve palsy. Magnetic resonance imaging (MRI) of the brain and orbits revealed a cavernous sinus lesion that was diagnosed as a meningioma. Laboratory tests showed abnormal liver function, and an abdominal computerized tomogram demonstrated an obstructive colonic mass with liver metastasis. The pathology tests of specimens taken during a laparotomy diagnosed colon adenocarcinoma. The MRI interpretation was changed to cavernous sinus metastasis from a primary adenocarcinoma of the colon. This case had common cranial nerve symptoms but with a very rare etiology, emphasizing the importance of a high index of suspicion of remote origins in patients with isolated sixth nerve palsy and no atherosclerotic risk factors.

Intravenous immunoglobulin in recurrent-relapsing inflammatory optic neuropathy

OBJECTIVE

Recurrent-relapsing inflammatory optic neuropathy, including chronic relapsing inflammatory and autoimmune optic neuropathies, is rare, but can cause severe visual loss. Long-term steroids may preserve vision, yet side effects are frequent. We describe our experience with intravenous immunoglobulins (IVIg).

DESIGN

A semi-prospective case series from 4 medical centres.

PARTICIPANTS

Patients with steroid responsive recurrent-relapsing optic neuropathy.

METHODS

Semiprospective case series of IVIg treatment in steroid-responsive recurrent-relapsing optic neuropathy at 4 medical centres. Outcome measures included visual outcome; time to, and duration of, remission; duration of corticosteroid use; and adverse events.

RESULTS

Vision stabilized in all 6 patients treated with IVIg without steroids for extended periods of time. None improved and none worsened. One adverse event occurred during an IVIg infusion after 3 uneventful years of IVIg maintenance. Average steroid use prior to IVIg was 12 months. After IVIg treatment, 5/6 patients no longer required corticosteroids. Two patients experienced late relapses on IVIg, one of whom was treated with cyclosporine, the other with steroids.

CONCLUSIONS

IVIg can be considered an effective steroid-sparing agent in selected cases with steroid-dependent recurrent-relapsing autoimmune optic neuropathy.

Intraocular Pressure Is Low in Eyes With Giant Cell Arteritis

BACKGROUND

Although ocular ischemia occurs in giant cell arteritis (GCA), intraocular pressure (IOP) has not been systematically evaluated as a diagnostic sign.

METHODS

We conducted a retrospective, case-controlled, observational study of IOP in patients with ocular manifestations of GCA (GCA patients), age-matched patients diagnosed with nonarteritic ischemic optic neuropathy (NAION patients), and age-matched patients with cataract (control patients). Medical records were examined for all consecutive patients with the diagnosis of GCA from 1995 to 2004 (n = 16) and NAION from 2002 to 2004 (n = 16) and for patient candidates for cataract extraction (n = 16). The eye intended for cataract extraction was chosen as the "affected eye" in the control patients.

RESULTS

The mean IOP in the affected eye of 16 GCA patients was 11.9 mm Hg, significantly lower than the 15.1 mm Hg in affected eyes of age-matched NAION patients and 15.8 mm Hg in control patients (P = 0.002). At presentation, 5 GCA patients had IOP < 10 mm Hg (mean 6.8 mm Hg) without other signs of anterior segment ischemia. None of the NAION or control patients displayed such low IOPs.

CONCLUSIONS

IOP was significantly lower in the patients with GCA than in patients with NAION or cataract. Hypotony occurred in one third of GCA patients without other signs of anterior ocular ischemia. These findings suggest that low IOP may be a distinguishing factor between GCA and NAION in patients with ischemic optic neuropathy, but evaluation of a larger group of patients is needed for confirmation.

Prospective evaluation of clinical and laboratory effects of intrathecal chemotherapy on children with acute leukemia

The objective of this prospective 18-month study was to evaluate the clinical and laboratory effects of repeated intrathecal injections of chemotherapy in children with acute leukemia. All procedures were performed under general anesthesia, and complications were prospectively recorded. Laboratory measurements included lumbar puncture opening pressure, cerebrospinal fluid (CSF) chemistry, and cell count and morphology. Central venous pressure and ophthalmologic examinations were also performed. Forty-seven children underwent 247 intrathecal injections of chemotherapy. Adverse effects (13.7% of the procedures) included nausea and vomiting, back pain, and headache. One child each had transient cauda equina syndrome, transient communicating hydrocephalus, and persistent sacral plexus injury. The mean lumbar puncture opening pressure was significantly higher after intrathecal therapy than before (22 +/- 8 vs. 15 +/- 9 cm H2O, P = 0.02) and higher than reported in age-matched children without leukemia. All CSF chemistries, cell count, and morphology were normal. The overall incidence of complications was 13.7%. Most were mild and resolved quickly, but significant neurologic complications did occur. Lumbar puncture opening pressure was significantly higher in children with acute leukemia after intrathecal chemotherapy.

Nonarteritic anterior ischemic optic neuropathy is associated with a specific platelet polymorphism located on the glycoprotein Ibalpha gene

OBJECTIVE

To evaluate the association between platelet glycoprotein polymorphisms and the risks of single and second eye involvement with nonarteritic anterior ischemic optic neuropathy (NAION).

DESIGN

Case-control study.

PARTICIPANTS

Ninety-two consecutive patients with NAION, 26 of whom had second eye involvement, and 145 controls who attended the eye clinic for nonvascular entities.

METHODS

Polymerase chain reactions and restriction enzyme analyses were performed for genotyping 5 platelet glycoprotein polymorphisms on DNA extracted from whole blood.

MAIN OUTCOME MEASURES

Frequencies of the various platelet polymorphisms.

RESULTS

One of the 5 platelet glycoprotein polymorphisms analyzed, the B allele of the glycoprotein Ibalpha variable number of tandem repeats (VNTR), was a significant independent risk factor for NAION, with an odds ratio of 4.25 and a 95% confidence interval of 1.67 to 10.82 (P = 0.0026). All other platelet glycoprotein polymorphisms were similarly distributed in patients and controls. In addition, 9 of 16 patients who bore the VNTR B allele (56.3%) had second eye involvement, whereas among patients not harboring the VNTR B allele only 17 of 72 patients (23.6%) had second eye involvement (P = 0.009). Moreover, second eye involvement occurred earlier in patients who bore the specific polymorphism.

CONCLUSIONS

The presence of the VNTR B allele of glycoprotein Ibalpha confers a significant risk for NAION and predisposes affected patients to second eye involvement.

[Ptosis--etiology, diagnosis and management]

Ptosis is a common complaint in patients who refer to ophthalmologists especially oculoplastic surgeons. Occasionally, ptosis may be the presenting sign or symptom of a systemic disease. Therefore, it is of great importance to know the causes of ptosis, its clinical presentation, and the systemic evaluation that one must undergo before going into surgery. This review presents the common causes of ptosis according to age of appearance, systemic diseases that must be ruled out, and the surgical options that exist.

Idiopathic intracranial hypertension in pregnancy

OBJECTIVE

Since idiopathic intracranial hypertension (IIH) is most prevalent in obese women of childbearing age, concerns arise regarding the impact of pregnancy on the disorder and the potential teratogenicity of some therapeutic agents. We evaluated the course, management of pregnant IIH patients and the visual and pregnancy outcomes.

METHODS

Case series of pregnant women diagnosed with IIH. IIH symptoms, neuro-ophthalmological findings, IIH management, visual and pregnancy outcomes were documented.

RESULTS

Among 240 women with IIH, 12 had 16 pregnancies. Ten had headaches, five had transient visual obscurations, and three had diplopia. Visual acuity was severely decreased in one and mildly reduced in three women. Six had marked and six had mild bilateral papilledema. Visual field loss occurred in four women. Visual symptoms and loss improved for the duration of the pregnancy after diagnostic lumbar puncture and salt restricted diet in three. Two additional women needed continuous spinal drainage for two days. One woman was treated with acetazolamide and medical abortion. The one woman with severe vision loss had fenestration of one optic nerve sheath and a lumboperitoneal shunt as well as corticosteroids and was the only case with permanent field loss. After intervention, visual acuity improved in all cases with reduced vision. There were 10 full-term normal deliveries, three missed abortions, one therapeutic abortion and two intrauterine fetal deaths.

CONCLUSIONS

IIH appears to present during the first two trimesters of pregnancy with typical symptoms and findings. Visual outcome is similar as for non-pregnant women. Treatment should be oriented towards dietary control, without ketosis. Repeated spinal fluid drainage, if needed, can be helpful.

Cavernous carotid aneurysms rarely cause subarachnoid hemorrhage or major neurologic morbidity

GOAL

To determine whether aneurysms of the cavernous internal carotid artery (CCA) cause major neurologic morbidity or death.

METHODS

Retrospective analysis of all patients with a spontaneous CCA evaluated by a referral multidisciplinary neurovascular service from 1981 to 2000. All patients had complete clinical neuro-ophthalmologic and neurologic examinations and magnetic resonance imaging (MRI) or computed tomography (CT) with angiographic diagnostic confirmation. Follow-up evaluations were performed by our service in the majority of patients, and the remaining patients' subsequent examinations were obtained from the referring physicians.

RESULTS

One hundred seventy-four patients (mean age 60.7 years, median age 63 years, 161 women, 13 men) had 193 CCA. All 19 patients with bilateral CCAs were female. Twenty-eight patients had 1 or more subarachnoid aneurysms. The presentation included 156 aneurysms with pain or cranial neuropathy or both, 13 with a carotid cavernous fistula (CCF), and 24 asymptomatic CCAs. Two patients, both with a coagulopathy, had a cerebral infarct ipsilateral to the CCA, 1 at presentation and the other 2 years after partial third nerve palsy. One patient had a subarachnoid hemorrhage (SAH) 2.3 years after presentation, and no patient had arterial epistaxis or a CCA-related death. Excluding the 15 patients (16 aneurysms) who had no follow-up or died from SAH due to a subarachnoid aneurysm, 177 aneurysms were followed up for a mean duration of 3.10 years (SD = 3.6). One hundred six never-treated aneurysms were followed for 4.5 years (SD = 3.80, range 0.1-17), and 71 ultimately treated aneurysms were followed for 1.56 years (SD = 2.69, range 0.1-15). The overall rate for SAH was 0.19% and for a CCA-associated cerebral infarct was 0.37% per patient year. There were no correlations with cerebral infarct, SAH, or CCF and diabetes mellitus, hypertension, gender, age, cranial neuropathy, or size of the aneurysm, except for the largest diameter of the aneurysm and CCF (r = 0.17, P = .018). However, all of the patients with cerebral infarct or SAH and 12 of the 13 CCF had an aneurysm diameter > or = 1 cm.

CONCLUSIONS

CCA is a disorder with strong female gender bias that uncommonly causes major neurologic complications. These data suggest that CCA should not be included in analyses that determine the risk of severe neurologic morbidity, hemorrhage, or death due to intracranial aneurysms.

Thrombophilia as a cause for central and branch retinal artery occlusion in patients without an apparent embolic source

PURPOSE

To assess the prevalence of vascular risk factors and thrombophilias in central and branch retinal artery occlusion in patients in whom an embolic source is not apparent.

METHODS

The study group consisted of 21 consecutive patients with retinal artery occlusion (RAO) in whom Doppler ultrasonography of the carotid arteries and transthoracic or transoesophageal echocardiography were normal. Laboratory methods included polymerase chain reaction for detection of factor V G1691A, factor II G20210A and methylentetrahydrofolate reductase C677T mutations, assays of plasma levels of protein C, free protein S, antithrombin, fibrinogen and homocysteine; and tests for the presence of lupus anticoagulant and anticardiolipin antibodies. Controls for the laboratory tests were 243 healthy subjects.

RESULTS

Nine of the 21 (43%) patients had at least one thrombophilic marker: 4 were homozygous for MTHFR C677T, 1 was heterozygous for factor V G1691A, 1 had a high titre of IgM anticardiolipin, 2 were heterozygous for factor V G1691A and homozygous for MTHFR C677T, and 1 had lupus anticoagulant, a high titre of IgM anticardiolipin, homozygosity for MTHFR C677T and hyperhomocysteinaemia. An interaction between vascular risk factors and thrombophilias seemed important since out of 14 patients with hypertension, diabetes and/or hypercholesterolaemia 7 (50%) had a thrombophilia. Homozygous MTHFR C677T was a significant risk factor with odds ratio of 3.18 (95% CI 1.20-8.47). The prevalence of factor V G1691A was also higher in the RAO patients versus controls with an odds ratio of 2.36 (95% CI 0.63-8.88), but this value did not reach significance, probably due to the small sample size.

CONCLUSION

A search for thrombophilia in RAO is advisable in patients without evident source of emboli even when vascular risk factors are identified.

Unilateral swollen disc due to increased intracranial pressure

Truly unilateral papilledema is rare and poses a diagnostic problem. The authors have prospectively looked for patients with truly unilateral papilledema and found 15 patients, 10 of whom had idiopathic intracranial hypertension. Neuroimaging did not indicate a reason for the lack of swelling in the other nerve. The visual deficits and outcomes were similar to those of patients with bilateral papilledema. Although monocular papilledema is uncommon, a lumbar puncture with opening pressure measurement should be considered.

The role of angiotensin converting enzyme and angiotensin II type 1 receptor gene polymorphisms in patients with nonarteritic anterior ischemic optic neuropathy

OBJECTIVE

To determine the role of angiotensin converting enzyme (ACE) and angiotensin II type 1 receptor (AT1R) polymorphisms in the pathogenesis of nonartertic anterior ischemic optic neuropathy (NAION).

DESIGN

Retrospective, case-control study.

PARTICIPANTS

Seventy-four patients with NAION diagnosed from 1984 through 1999. Seventy-one patients who visited the Eye Institute comprised the control group. TESTING INTERVENTION: DNA was extracted from whole blood obtained from all patients and control participants. Polymerase chain reaction (PCR) was used for analysis of ACE and AT1R polymorphisms.

RESULTS

The frequency of the polymorphism for ACE among the NAION patients (39.2% deletion allele [DD], 54.0% deletion/insertion [D/I] locus, 6.8% insertion allele [II]) was similar to that of the control group (50.7% DD, 39.4% D/I, 9.9% II), with P = 0.21. The frequency of the polymorphism of AT1R in the NAION patients was 5.4% CC, 44.6% CA, 50% AA, and in the control group it was 4.2% CC, 33.8% CA, 62.0% AA, with P = 0.35. Participants less than 55 years of age and those more than 55 had quite similar distributions.

CONCLUSIONS

Angiotensin converting enzyme and AT1R polymorphisms have no part in the mechanism of NAION. Thus drugs such as ACE inhibitors or AT1R antagonists are not specifically indicated for treatment of these patients.