Idiopathic intracranial hypertension in children and adolescents

PURPOSE

To investigate sex distribution, frequency of obesity, and other associated conditions among children and adolescents with idiopathic intracranial hypertension.

METHODS

We conducted a retrospective chart review of patients aged 18 years or younger diagnosed with idiopathic intracranial hypertension between 1988 and 1995 at two medical centers. Meta-analyses were performed using our data pooled with published information.

RESULTS

Of 374 patients, 175 (46.8%) were male and 199 (53.2%) were female. Obesity was noted in 50 (29.6%) of the 169 patients for whom relevant data are available, and other associated conditions were noted in 185 (53.2%) of the 348 patients.

CONCLUSIONS

Idiopathic intracranial hypertension among children and adolescents affects boys and girls equally; concurrent obesity occurs less frequently than in adults; and other associated conditions or secondary causes are common.

Neuro-ophthalmologic findings in the Asperger disorder

Asperger disorder is a complex behavioral disorder that may be related to autism. We examined a 49-year-old man with Asperger disorder who had multiple neuro-ophthalmologic abnormalities, including colobomatous defects involving the optic discs and peripapillary retina, and abnormal ocular motility with an oculocephalic dyskinesia. Asperger disorder may be associated with a variety of neuro-ophthalmologic disturbances.

Automated suprathreshold static perimetry screening for detecting neuro-ophthalmologic disease

PURPOSE

To devise and evaluate a rapid, accurate, and cost-effective method of detecting neuro-ophthalmologic visual field defects.

METHODS

One hundred fifty-nine consecutive patients were evaluated with 76-point, central 30 degree automated static threshold perimetry on the Humphrey Visual Field Analyzer, as well as by a 76-point, central 30 degree suprathreshold examination with the central reference levels set at 2 or 4 dB lower than the estimated normal median central reference level adjusted for age. Six masked readers reviewed the fields. Their readings were compared with those of the other observers, as well as with the final diagnoses as determined from all available clinical information.

RESULTS

In detecting abnormality, the full-threshold 30 degree test had a sensitivity (percent of eyes with true field defects identified by the field test) of 93 percent or 99 percent (depending on whether borderline results were counted as a positive or negative test) and a specificity (percent of cases without true field defects appropriately identified by the field test) of 71 percent or 91 percent. In comparison, the 4-dB offset suprathreshold test had a sensitivity (averaged over all reviewers) of 79 percent or 87 percent and a specificity of 81 percent or 89 percent, whereas the 2-dB test had a sensitivity of 87 percent or 94 percent and a specificity of 73 percent or 85 percent. The mean duration of the suprathreshold tests was 3.5 +/- 1.0 minute, compared with 14.8 +/- 2.8 minutes for the full-threshold technique.

CONCLUSION

The central 30 degree, 76-point, 2-dB offset suprathreshold automated perimetry is more rapid and nearly as effective as the full-threshold test in detecting visual field abnormalities due to neuro-ophthalmologic disease. More quantitative, full-threshold perimetric strategies should be used in all equivocal cases and to follow progression of established disease.

Effect of light on the prevalence of simple anisocoria

PURPOSE

Because simple anisocoria is believed to decrease in bright light, the authors determined the prevalence of simple anisocoria under different lighting conditions.

METHODS

The authors measured the pupil size of 104 healthy subjects with infrared videography at four clinically accessible light levels: darkness; darkness with a hand-held light shining from below; room light; and room light with the hand light shining from below.

RESULTS

Of the 104 subjects, 40 (38%) were men and 64 (62%) were women. The ages ranged from 12 to 71 years (mean, 36.3 +/- 12.5 years). The mean decrease in pupillary diameter from darkness to the brightest condition was 1.89 mm. Based on the traditional definition of a pupillary diameter difference of 0.4 mm or greater, the prevalence of simple anisocoria decreased from 18% in darkness to 8% in room light with the hand-held light shining from below. The prevalence of anisocoria varied considerably when other definitions were used. Repeated measures analysis of variance showed that pupillary area difference decreased with brighter conditions (P = 0.026). However, the ratio of the pupillary areas did not change with brighter conditions (P = 0.666).

CONCLUSIONS

The prevalence of simple anisocoria decreases with brighter conditions based on pupillary diameter difference. However, this decrease is not apparent when anisocoria is expressed as pupillary area ratio. Those clinicians who measure pupils will find that simple anisocoria decreases in bright light. However, with gross observation where perception of an anisocoria may be related more to the ratio of the pupillary areas, simple anisocoria may not seem to change much with brighter conditions.

Prevalence of palpebral fissure asymmetry in white persons

PURPOSE

Because palpebral fissure asymmetry in horizontal gaze is reportedly common in otherwise normal persons, we determined the prevalence of physiologic palpebral fissure asymmetry for primary and horizontal gazes.

METHODS

We measured the palpebral fissure height of both eyes of 88 healthy white subjects. Measurements were obtained with high-resolution videography, with the eyes in primary position, in 45-degree right gaze, and in 45-degree left gaze.

RESULTS

Of the 88 subjects, 36 (41%) were male and 52 (59%) were female. The ages ranged from 12 to 50 years, with a mean of 32.5 +/- 9.0 years. When a criterion of equal to or greater than 1 mm was used, the prevalence of physiologic palpebral fissure asymmetry was 5.7% (five of 88) in primary gaze, 18.2% (16 of 88) in right gaze, and 14.8% (13 of 88) in left gaze. The largest observed palpebral fissure asymmetry was 2.1 mm. After correcting for any existing fissure asymmetry in primary gaze, two-tailed trivariate analysis of variance showed that the fissure of the adducting eye tended to be wider. The mean increase in the palpebral fissure of the adducting eye was 0.12 mm for right gaze (P = .052) and 0.13 mm for left gaze (P = .034). Additionally, a chi 2 test indicated that the occurrence of wider adducting eye in both right and left gazes was highly significant (P = .0023).

CONCLUSIONS

In this sample of white subjects, palpebral fissure height asymmetry increased in horizontal gaze to the right and to the left, which is in part because of a tendency of the adducting eye to widen slightly. In contrast to previous reports, the prevalence of palpebral fissure asymmetry was low, and the abducting eye did not widen significantly.

Prevalence of foveal lesions in type 1 and type 2 Usher's syndrome

PURPOSE

To evaluate possible differences in the prevalence of clinically detectable foveal lesions between patients with type 1 and type 2 Usher's syndrome.

METHODS

Records of 48 patients with type 1 and 98 patients with type 2 Usher's syndrome were retrospectively evaluated for the presence of a foveal lesion. The age, gender, and racial distribution of patients were similar in the two subtypes. Two investigators reviewed fundus photographs from all patients and, when available, fluorescein angiograms.

RESULTS

In the 48 patients with type 1 Usher's syndrome, 30 (62%) showed a clinically apparent atrophic- or cystic-appearing foveal lesion, whereas in the 98 patients with type 2 Usher's syndrome, 33 (34%) had either an atrophic- or a cystic-appearing foveal lesion. Logistic regression analysis showed that the probability of exhibiting a foveal lesion in both type 1 and type 2 Usher's syndrome increases with age and that patients with type 1 Usher's syndrome are more likely to have a foveal lesion than are patients with type 2 Usher's syndrome.

CONCLUSIONS

Patients with type 1 Usher's syndrome show a greater probability of having either an atrophic- or cystic-appearing foveal lesion than do patients with type 2 Usher's syndrome. This higher prevalence of foveal lesions is consistent with a previous observation that the severity of visual acuity impairment with age is greater for patients with type 1 than type 2 Usher's syndrome. These data are useful in counseling such patients as to their prognosis for central visual function.

Atypical retinochoroidal coloboma in patients with dysplastic optic discs and transsphenoidal encephalocele

OBJECTIVE

To evaluate the clinical significance of V- or tongue-shaped infrapapillary retinochoroidal depigmentation in association with dysplastic optic discs.

METHODS

Clinical data from all patients with V- or tongue-shaped infrapapillary retinochoroidal depigmentation and dysplastic optic discs were evaluated retrospectively.

RESULTS

Five patients with this atypical colobomatous anomaly had transsphenoidal encephalocele. A sixth patient had an ectopic midline pharyngeal mass with no skull-base defect.

CONCLUSION

In patients with optic disc dysplasias, the finding of this V- or tongue-shaped retinochoroidal pigmentary anomaly should prompt neuroimaging to look for transsphenoidal encephalocele.

Pain in anterior ischemic optic neuropathy

PURPOSE

The diagnoses of both anterior ischemic optic neuropathy (AION) and optic neuritis are clinical ones with significant overlap of symptoms and signs. This study investigates the presence and character of pain at the onset of AION, in order to evaluate this symptom as a differentiating diagnostic feature between optic neuritis and AION.

METHODS

Forty-one consecutive patients over 45 years of age with a clinical syndrome consistent with AION were questioned about the presence and character of associated pain.

RESULTS

Pain was reported by 12% (5 of 41) of the patients with AION. This is contrasted with data compiled on 448 patients in the optic neuritis treatment trial, of whom 92.2% complained of pain.

CONCLUSION

While there is overlap in the incidence and character of pain in AION and optic neuritis, its presence/absence remains a useful differentiating feature.

Retinitis pigmentosa associated with a dominant mutation in codon 46 of the peripherin/RDS gene (arginine-46-stop)

PURPOSE

We identified genetic mutations and characterized their associated phenotypes in patients with retinitis pigmentosa.

METHODS

Patients with retinitis pigmentosa were prospectively examined and screened for genetic mutations.

RESULTS

A 46-year-old man with retinitis pigmentosa was found to have a heterozygous mutation in the peripherin/RDS gene (arginine-46-stop). He had late onset of symptoms and demarcated peripheral retinal atrophy. All five first-degree relatives including his parents had no detectable mutations or retinitis pigmentosa. Genotypic data were consistent with reported family structure.

CONCLUSIONS

This study shows that new dominant mutations are a rare cause of isolated, or simplex, cases of retinitis pigmentosa. Identification of these mutations is helpful for genetic counseling.

Racial differences in the prevalence of atrophic-appearing macular lesions between black and white patients with retinitis pigmentosa

We compared the prevalence of atrophic-appearing macular lesions between black and white patients with isolated or various genetic types of retinitis pigmentosa to determine if an appreciable difference existed between these two groups. The study included 720 patients of whom 138 (19.2%) were black patients from 115 families and 582 (80.8%) were white patients from 478 families. A logistic regression analysis combining isolated and all genetic types but randomly selecting one patient per family showed a statistically significant difference in the prevalence of atrophic-appearing macular lesions between black and white patients for the right eye (P = .0012) and left eye (P = .002). When considering either all patients or one patient per family, the estimated odds ratios were approximately 2.0 for blacks relative to whites. Our findings indicate that black patients with retinitis pigmentosa are approximately twice as likely as white patients to develop an atrophic-appearing macular lesion. This observation has implications for the prognosis of central visual function in such patients.

Visual loss from idiopathic intracranial pachymeningitis

We report three patients with chronic headaches and optic neuropathy due to widespread meningeal thickening shown on enhanced MRI; all had biopsy-proven intracranial pachymeningitis (fibrosclerosis of the meninges). Two patients had bilateral optic neuropathy, elevated CSF protein, and polyclonal serum hypergammaglobulinemia. They developed temporal lobe cortical necrosis or sagittal sinus thrombosis, presumably due to compromised dural venous drainage from extensive meningeal fibrosis. The other patient had multiple cranial nerve palsies and unilateral optic neuropathy with normal CSF. Corticosteroid therapy improved visual function in all three patients, although all had persisting visual deficits. Gadolinium-enhanced MRI was essential in identifying meningeal inflammation and locating suitable biopsy sites.

Chiasmal compression from fat packing after transsphenoidal resection of intrasellar tumor in two patients

After transsphenoidal resection of a pituitary (or other) tumor, the remaining intrasellar cavity, and sphenoid sinus are usually packed with exogenous fat or muscle to prevent cerebrospinal leak and prolapse of the optic chiasm into an empty sella. We treated two patients in whom chiasmal compression occurred postoperatively because of packing of fat. In one patient, the expected visual improvement in the postoperative period was suboptimal. The subsequent removal of fat resulted in total visual recovery. In the other patient, chiasmal compression persisted from intrasellar fat and residual tumor. Iatrogenic compression of the optic nerves or chiasm should be considered in all patients in whom visual recovery is incomplete.

Iris crystals in chronic iridocyclitis

Iris crystals in three patients with idiopathic iridocyclitis, Fuchs' heterochromic iridocyclitis, and iridocyclitis associated with systemic pseudolymphoma are described. Two patients had iris crystals in one eye, and the other patient had bilateral involvement. The number of iris crystals in each eye ranged from one to multiple crystals. Iris crystals were minute and refractile and glistened with light; they have previously been reported to be Russell bodies and to be associated with hypergammaglobulinaemia. However, two of the patients, who underwent serum protein electrophoresis, did not demonstrate hypergammaglobulinaemia.

Elevated serum sialic acid in idiopathic acute iridocyclitis

We measured the serum levels of sialic acid in 12 patients with idiopathic acute iridocyclitis and 18 normal controls. Sialic acid levels were significantly elevated in the patients with idiopathic acute iridocyclitis. Since animal studies have shown that intraocular inflammation alone cannot elevate serum level of sialic acid, the result of our study suggest that idiopathic acute iridocyclitis may be a multiorgan disease with systemic effects.

High incidence of sympathetic ophthalmia after contact and noncontact neodymium:YAG cyclotherapy

BACKGROUND

Two cases of sympathetic ophthalmia occurring after noncontact neodymium:YAG (Nd:YAG) cyclotherapy have previously been reported. In each case, the patient had undergone filtering surgery in the exciting eye. Although in each case Nd:YAG cyclotherapy was the last surgery performed, the inciting event of sympathetic ophthalmia was unclear.

METHODS

The authors studied three additional patients who developed sympathetic ophthalmia after Nd:YAG cyclotherapy for glaucoma.

RESULTS

Two patients developed sympathetic ophthalmia 4 months after noncontact Nd:YAG cyclotherapy, and 1 patient developed sympathetic ophthalmia 18 months after contact Nd:YAG cyclotherapy. All patients had previous cataract extractions but no filtering surgery in the exciting eye. Clinical features included chronic iridocyclitis, choroidal folds, Dalen-Fuchs nodules, and optic disc edema. Combining these cases with the two previously reported cases, the incidence of sympathetic ophthalmia at our institution thus far is 5.8% (4 of 69) and 0.67% (1 of 150) after noncontact and contact Nd:YAG cyclotherapy, respectively.

CONCLUSIONS

The incidence of sympathetic ophthalmia after Nd:YAG cyclotherapy is high compared with other ocular procedures. The clinician should vigilantly monitor patients after Nd:YAG cyclotherapy and report additional cases that may have occurred at other institutions.

Optic neuropathy in Hodgkin's disease

Hodgkin's disease is a rare cause of infiltrative optic neuropathy, which typically evolves late in the disease course. We managed an unusual case of isolated optic neuropathy in a 21-year-old man occurring during clinical remission from Hodgkin's disease. Radiotherapy and treatment with high-dose systemic corticosteroids resulted in dramatic improvement in vision. Even without other evidence of recurrent disease, acute-onset optic neuropathy in a patient with a history of a lymphoproliferative disorder should raise the question of a reemergence of the malignancy.

Effect of mydriasis on visual field area in retinitis pigmentosa

PURPOSE

The effect of mydriasis on Goldmann visual field area in patients with retinitis pigmentosa has not been suitably defined. The aim of this study is to determine whether visual field area in these patients varies with pharmacologic mydriasis.

METHODS

Fifteen adult patients with retinitis pigmentosa were studied prospectively. Goldmann visual fields with II4e and V4e isopters were obtained in both eyes before and after full pharmacologic mydriasis of the right eye. The isopter areas were quantified and analyzed to determine the effect of mydriasis on visual field area.

RESULTS

The difference in the right eye isopter areas was compared with the difference in the left eye isopter areas using paired t tests, where the differences were computed from areas obtained before and after dilation of the right eye. Mydriasis had no significant effect on the visual field in terms of isopter area difference (II4e, P = 0.87; V4e, P = 0.45) and percent change in isopter area (II4e, P = 0.81; V4e, P = 0.24).

CONCLUSION

Pharmacologic mydriasis had no appreciable effect on the Goldmann visual field area in a selected group of patients with retinitis pigmentosa. These findings suggest that visual fields of such patients obtained in the dilated or undilated state can be meaningfully compared.

Pseudotumor cerebri from cranial venous obstruction

Dural sinus hypertension from cerebral venous outflow impairment is a cause of pseudotumor cerebri. The authors documented six such patients: two with unilateral neck dissection, one with surgical ligation of the dominant sigmoid sinus, two with thrombosed central intravenous catheterization, and one with dural sinus thrombosis. The site of cerebral venous outflow obstruction was variable and identified in three patients with computed tomography, conventional magnetic resonance imaging, magnetic resonance angiography, and/or angiography. Magnetic resonance angiography used in two patients characterized the venous flow pattern and identified the site of obstruction, confirming magnetic resonance angiography as an effective noninvasive blood flow technique in diagnosing and following these patients. Three patients were treated successfully with medical therapy and one patient with optic nerve fenestration. The two patients with thrombosed central venous catheters had serious systemic illnesses and suffered permanent visual loss.

Bilateral retinal hemorrhages from megaloblastic anemia: case report and review of literature

A 33-year-old woman who was a chronic alcohol abuser and had bilateral visual loss was found to have megaloblastic anemia with thrombocytopenia. Both fundi showed retinal venular dilatation and tortuosity, superficial and deep intraretinal hemorrhages, white-centered retinal hemorrhages, and optic disc edema. Her megaloblastic anemia was caused by vitamin B12 and folate deficiencies, resulting from an inadequate diet and alcohol abuse. The retinal changes were believed to be the result of the severe anemia and thrombocytopenia. Both the megaloblastic anemia and retinal changes resolved promptly after she received vitamin B12 and folate supplements. This case shows that megaloblastic anemia should be suspected as a cause of bilateral retinal hemorrhages.