Optic neuropathy in methylmalonic acidemia: the role of neuroprotection

We report the case of a patient with an optic neuropathy induced by neurotoxicity in the setting of methylmalonic acidemia. The patient responded with a significant and long-term improvement in visual acuity, perimetry, and chromatic function after a neuroprotective treatment with vitamin E and coenzyme Q10 was started. Coenzyme Q10 levels had been proven to be normal before starting treatment. This case report is particularly important because it describes a possible treatment for optic neuropathy in methylmalonic patients. Although the response might be, in part, specific to the individual, it suggests the existence of a cause-effect relationship between the treatment undergone by our patient and the improvement in her visual acuity. To date, no other treatments with beneficial effects have been reported for the few optic neuropathies caused by methylmalonic acidemia. Further studies should determine the applicability of coenzyme Q10 and vitamin E for the treatment of optic neuropathies in methylmalonic acidemia.

Syphilis and the monk

Primary orbital aspergillus infection may occur in immunocompetent individuals. It frequently represents a diagnostic challenge for clinicians due to nonspecific clinical presentations and neuroimaging signs. We present a 47-year-old otherwise healthy man with an isolated unilateral optic neuropathy secondary to primary orbital aspergillosis. He had a remote history of tuberculosis and positive syphilis serologies. After he worsened despite intravenous penicillin therapy, a biopsy showed chronic inflammation. Corticosteroids treatment was followed by further deterioration of his clinical condition. Finally, a repeat biopsy revealed the aspergillus infection. Despite antifungal therapy, the outcome was unfavorable. A high index of suspicion should result in aggressive diagnostic testing and prompt institution of antifungal therapy in patients with primary orbital aspergillosis.

[Assessment of a patient with optic neuropathy]

Optic neuropathy (ON) is defined as the reduction of vision due to inflammatory lesion of the optic nerve. The patient with ON has to be evaluated clinically but also with complex techniques (magnetic resonance imaging, visual evoked potentials, cerebrospinal fluid examination) because ON could be the presenting symptom in multiple sclerosis patients. Corticosteroids should be administrated intravenous and the patient should be followed by the neurologist in order to signal the appearance of new neurological signs.

[Management of Graves' ophthalmopathy]

Graves's ophthalmopathy, the commonest extrathyroidal manifestation of Graves' disease is an autoimmune disorder of the orbit. Restoration of thyroid dysfunction, lubricant eye drops and smoking cessation is important. Clinical activity and disease severity determine specific treatment. Referral to specialist centres is urgent in sight-threatning optic neuropathy. Intravenous methylprednisolone is first-line therapy for clinically active disease. Retrobulbar irradiation may help in persistant ocular muscle inflammation. Prompt orbital decompression is warranted for sight-threatning neuropathy not responding to high-dose methylprednisolone. Decompression is otherwise performed in the chronic phase, before possible eye-muscle and eyelid surgery. Rituximab is a promising immunomodulating drug for resistant clinically active cases.

[Glaucoma--neurodegenerative disease]

Glaucoma is a specific optical neuropathy, with local nerve damage and pathogenesis incompletely understood. The progressive death of retinal ganglion cells and optical neural loss suggests the following hypothesis: primary destructive event (ischemia, elevated intraocular pressure and genetic risk factors) and secondary degeneration (apoptosis and excitotoxicity). The concept of neuroprotection is a therapeutical paradigm for preventing and delaying neuronal cell death and maintaining the function of neurons. Other additional concept--neurorescue is used to prevent neuronal death by interrupting the biological cascade of secondary events. Most substances that can be found (glutamate, nitric oxide, a.o) in excess in extra cellular spaces induce damage of retinal ganglion cells, while others (memantine, gingko biloba, nicergoline, flavonoids, ascorbic acid) are used to restore these cells and their axons, i.e., neuroreparation and neuroregeneration in various degrees. This paper is an up-date of numerous studies which demonstrate that open-angle glaucoma is considered to be a neurodegenerative disease connected with alterations of the cardiovascular, central nervous, immune, endocrine, psychological systems and of sleep, requiring the introduction of glaucoma in general medical context.

Infectious optic neuropathy

A wide variety of infectious agents are known to cause optic neuropathy. This article will consider the bacteria, spirochetes, fungi, and viruses that most commonly affect the optic nerve. Clinical presentation is variable, but some pathogens often produce a characteristic funduscopic pattern. Diagnosis is usually made on the basis of clinical suspicion and serologic testing. Polymerase chain reaction is also increasingly utilized. Most infectious agents can be effectively treated but visual recovery is highly variable.

Optic neuropathy due to anaplastic large cell lymphoma

PURPOSE

To report a case of anaplastic large cell lymphoma (ALCL) of the central nervous system (CNS) producing an optic neuropathy.

METHODS

Observational case report.

RESULTS

A 29-year-old male presented with new onset headaches. Magnetic resonance imaging (MRI) of the brain revealed a large enhancing parietal lobe mass. Ocular exam at that time was normal. Initial diagnoses included possible bacterial cerebritis and fungal abscess. Serial lumbar punctures showed increased white blood cells but cytology was negative. A brain biopsy was non-diagnostic. The patient then presented with a left optic neuropathy. Repeat MRI of the brain and orbits revealed infiltration of the clivus and left orbital apex including the optic nerve. The patient had elevated liver function studies and an abdominal ultrasound disclosed two hypoechoic lesions. Liver biopsy confirmed the diagnosis of ALK-1 positive ALCL. The patient was treated with chemotherapy but expired seven months after the initial presentation.

CONCLUSION

ALCL should be considered to be a very rare but potential cause of optic neuropathy. To our knowledge, this is the first reported case of ALCL causing an optic neuropathy.

Repeated peribulbar injections of triamcinolone acetonide: a successful and safe treatment for moderate to severe Graves' ophthalmopathy

PURPOSE

In this study, we aimed to evaluate the efficacy of peribulbar triamcinolone injections to treat inflammatory signs of Graves' ophthalmopathy (GO) in patients with moderate to severe GO and associated optic neuropathy (ON).

METHODS

Twenty-one patients with active GO [clinical activity score (CAS) > or = 4] and systemic thyroid disease under control were enrolled in this prospective pilot study. Peribulbar triamcinolone acetonide was injected in each orbit (42 eyes), in four doses of 20 mg at 2-week intervals. Ophthalmological examination including CAS evaluation, visual field, computerized tomography (CT) scan and digital photography were performed before and after treatment.

RESULTS

Twenty-one patients (11 with moderate disease, 10 with ON) were enrolled in this study and followed for at least 14 months. Initial mean CAS was 6.38 +/- 1.49, which dropped to 1.8 +/- 1.12 after 6 months of treatment (P = 0.01; mean difference of 4.57 +/- 1.56; range 1-8 score points). ON was diagnosed in 10 patients. Of these, 66% improved with peribulbar triamcinolone exclusively. A transitory increase in intraocular pressure in two patients was controlled with topic medication.

CONCLUSION

Peribulbar triamcinolone injections reduce the inflammatory signs of moderate GO, as measured by the CAS, and could also be used as an alternative treatment for ON. Randomized clinical trials are needed to compare the results of triamcinolone peribulbar injections to those of other treatment modalities.

[Fisher syndrome with optic neuropathy]

Fisher syndrome with optic neuropathy has been rarely reported. We report a 78-year-old Frenchman with Fisher syndrome. The patient complained of dizziness and bilateral blurred vision. His corrected visual acuity was 0.03 in the right eye, and 0.02 in the left eye. Deep tendon reflexes were absent. A few days later, bilateral complete external ophthalmoplegia appeared. Both pupils were dilated and pupillary reflexes were absent. Serum anti-GQlb antibodies and anti-GT1a antibodies were detected. After intravenous immunoglobulin treatments, all neurological symptoms including optic neuropathy and external ophthalmoplegia disappered except for pupillary dilatation associated with light-near dissociation. Tonic pupil indicated disorder of the peripheral nervous system.

CONCLUSION

Fisher syndrome may complicate optic neuropathy.

Longterm visual prognosis of patients with ocular Adamantiades-Behçet's disease treated with interferon-alpha-2a

OBJECTIVE

Relapsing ocular involvement is one of the major manifestations in Adamantiades-Behçet's disease (ABD). Combining systemic corticosteroids with cyclosporin A is currently the treatment of choice. Interferon-alpha (IFN-alpha) has proven to be effective in mucocutaneous ABD and has been reported to improve ocular lesions. We examined the longterm effects of IFN-alpha-2a in a case series of 45 patients with ocular involvement.

METHODS

Since 1988, 45 patients (79 eyes of 90 eyes) with ocular involvement in ABD have been treated with IFN-alpha (3 x 6-9 Mio IU per wk). In the initial acute phase of the disease, patients additionally received short-term corticosteroids (oral prednisolone 100 mg/day), tapered to a maintenance dose of 10 mg/day within 2 weeks. IFN-alpha-2a was administered as longterm therapy with a mean duration of 30 months (range 1.1-101 mo).

RESULTS

IFN-alpha-2a/prednisolone treatment was effective against vasculitis, optic nerve neuropathy, and iritis. Sixty-four eyes had no recurrence under therapy. To date, recurrences have been seen in 26 eyes under IFN-alpha treatment. Flu-like symptoms were recorded in nearly all patients (n = 43). Further side effects were dose-dependent reversible thrombocytopenia (n = 1), psychosis (n = 3), depression (n = 13), thyroiditis (n = 1), and reversible diffuse alopecia (n = 7). In our series, 92% of all eyes showed stable or improved visual acuity in longterm followup.

CONCLUSION

Longterm remission of ocular inflammation can be achieved with the combination of IFN-alpha and low-dose corticosteroids.

Disease progression and the need for neuroprotection in glaucoma management

Glaucoma, the second leading cause of worldwide blindness, is a progressive optic neuropathy characterized by a loss of retinal ganglion cells and their axons beyond typical age-related baseline loss. Diagnosis is defined by optic disc and visual field changes, and the primary goal of glaucoma treatment is to preserve vision. Proven existing therapies (ie, pharmacotherapy, laser, and surgical) focus on reduction of intraocular pressure (IOP), although elevated IOP is no longer a diagnostic feature of glaucoma. New neuroprotectant drugs are being investigated, with the goal of reducing retinal ganglion cell loss, either prophylactically or after the insult has occurred. Various treatment strategies are being evaluated, and include a neuroprotectant only, or a complete therapy approach comprised of both a neuroprotectant supplemented by an IOP-lowering therapy. Dually targeted complete therapy may directly preserve the optic nerve, decrease the risk factors that cause glaucoma damage, and reduce glaucoma-related morbidities. Neuroprotectant therapy outcomes should include functional and structural effects of disease progression and neuroprotectant therapies, as well as patient functioning and economic impact.

History of neuroprotection and rationale as a therapy for glaucoma

Neuroprotection is any therapy that prevents, retards, or reverses apoptosis-associated neuronal cell death resulting from primary neuronal lesions. Although more than 500 products have been investigated for neuroprotective effects, there has been a low rate of success in human trials. Reasons include failure of the animal model to simulate human disease, human disease variability, brain size and development differences, variations in the ratio of axonal to neuronal damage, and lack of efficacy of the compound under study. Other reasons include narrow drug therapeutic index, drug molecular size, the small treatment window after cellular injury, multiple comorbidities of test subjects causing recruitment and statistical challenges, and insufficiently valid and reliable end points. Glaucoma is a neurodegenerative disease for which the neuropathic pathology has been studied since 1972. There have been recent significant advances in understanding the mechanisms for death of retinal neurons, and numerous agents are under development. Memantine, currently approved for Alzheimer's disease and in phase 3 trials for glaucoma progression, is one of the most studied neuroprotectants in glaucoma. Therapies that prevent death of the retinal ganglion cell (neuroprotection), its axon (axoprotection), or both, theoretically should be useful in treating glaucoma.

[Optic neuropathy in multiple sclerosis]

The inflammation of the optic nerve called optic neuropathy could be an onset marker of multiple sclerosis. The authors review the place of optic neuropathy (neuritis) in the inflammatory demyelinating disease continuum, especially as the onset symptom of multiple sclerosis. We present the clinical symptoms, the aetiology of optic neuritis and the adjacent methods used to investigate optic neuritis. In the article are presented the actual criteria used to establish the multiple sclerosis diagnosis and the revised criteria for optic neuromyelitis, with emphasis on the differential diagnosis between these diseases.

Emerging syphilitic optic neuropathy: critical review and recommendations

BACKGROUND

Infection with Treponema pallidum causes multiorgan manifestations including isolated optic nerve involvement at any stage of the disease. This is of particular interest for resulting in severe visual impairment, which is reversible if treated adequately.

PURPOSE

To review clinical and diagnostic findings in patients with optic nerve affection in neurosyphilis and to focus on the visual outcome after administering adjunctive cortisone to the standard therapy regimes with penicillin G.

METHODS/PATIENTS

The review is based on a retrospective case serial of 4 patients (three males: mean age 40 years, range 37-42 years; one female: mean age 62 years) with optic nerve involvement in neurosyphilis treated in our hospital, and on a literature review of recent publications. Patients were treated with systemic penicillin either with or without adjunctive cortisone. The major outcome measure of therapy was improvement of visual acuity.

RESULTS

Visual outcome in our case serial showed total restoration if cortisone was also administered. The bibliographic survey, which was based on 60 patients, also revealed a better improvement of vision when antibiotic medication was combined with cortisone.

CONCLUSIONS

The data show that the causal therapy of choice is undoubtedly penicillin G, with adjunctive steroids playing a crucial role in improvement of optic nerve functional outcome. Physicians should consider the use of cortisone in SON whenever clinically harmless, although prospective randomized multicenter studies are required to support this recommendation.

Visual field damage and progression in glaucomatous myopic eyes

PURPOSE

To make a visual field retrospective analysis on a group of patients with primary open angle glaucoma (POAG) and to evaluate whether different refractive errors could have different progression of the 30 degrees central sensitivity.

METHODS

A total of 110 patients with POAG (52 men and 58 women) were included in the study. All the patients were divided into four subgroups based on the refractive error. The visual field of all the included patients was assessed by an Octopus 30 degrees central visual field every 6 months, for a total of 837 visual fields examined. The resulting data were analyzed by PERIDATA for Windows 1.7 TREND function. Mean defect (MD) and loss variance (LV) were considered for the analysis.

RESULTS

At the first examination, 82% of eyes showed a global decrease of differential light sensitivity (MD >2 dB) and in 67% the distribution of the defect was nonhomogeneous (LV >6 dB). The analysis of variance for subgroups showed a more significant decrease of MD in highly myopic patients. A linear regression analysis highlighted a statistically significant change in time of MD in 36% and of LV in 34% of the eyes studied. Highly myopic patients had the highest (p<0.01) percentage of change of MD and LV (46% and 42%, respectively). Among the four subgroups, there was no difference in progression of MD decrease in time.

CONCLUSIONS

These results showed that after 5 years of glaucoma, the visual field was altered in most of the eyes examined (82%) and that in 67% of cases, its defect was nonhomogeneous and worsened with the increase of myopia. The regression linear analysis of visual field changes in time showed a progressive increase of MD and LV in approximately one third of all the eyes examined.

The Acute Morphologic Changes That Occur at the Optic Nerve Head Induced by Medical Reduction of Intraocular Pressure

PURPOSE

The mechanical theory of glaucoma postulates that raised intraocular pressure (IOP) causes laminar distortion resulting in damage to axons at the optic nerve head. There is some evidence that the change in morphology may occur over a short time course. The aim of this paper was to detail the acute morphologic changes at the optic nerve head when IOP was lowered with medical therapy in a clinical population.

METHODS

Subjects referred to the glaucoma clinic that had a documented IOP of over 28 mm Hg, on no treatment, in one or both eyes were included. Tonometry, pachymetry, and scanning laser ophthalmoscopy were performed before and after lowering IOP with topical apraclonidine and oral acetazolamide. The significance of change in outcome variables was assessed using a paired t test allowing for dependence within subjects and, for sensitivity, with a nonparametric Wilcoxon signed-rank test.

RESULTS

Data were obtained from 38 eyes of 19 patients with a mean age of 67 years. After lowering IOP for only 1 hour, there was a significant decrease in mean cup volume (mean change in volume below surface 26.8 microm3, P< or =0.001) and mean cup depth (13.8 microm, P<0.01), there being a corresponding increase in mean rim area (37.3 microm2, P<0.034). There was no statistically significant change in central corneal thickness after administration of the IOP lowering medications.

CONCLUSIONS

In the present study, it was shown that acute and statistically significant alterations in optic disc morphology occur when IOP is lowered medically with a combination of topical apraclonidine and systemic acetazolamide. The technique, therefore, may be useful to further investigate subgroups of glaucomatous eyes and test etiologic hypotheses.

Intravitreal triamcinolone acetonide for the management of papillophlebitis and associated macular edema

BACKGROUND

To investigate the efficacy of intravitreal injection of triamcinolone acetonide in the management of papillophlebitis and associated cystoid macular edema.

METHODS

This study was a retrospective medical records review of four eyes of four patients (three males and one female) who had approximately 2-4 months history of papillophlebitis and associated persistent cystoid macular edema. These patients were treated with a single intravitreal injection of 4 mg triamcinolone acetonide. Mean follow-up time was 15 +/- 4 months. The outcome measures included best corrected visual acuity (BCVA), intraocular pressure (IOP), and central retinal thickness by optical coherence tomography (OCT).

RESULTS

The BCVA ranged from 20/100 to 20/60 pre-operation. The mean gain in BCVA was 7 +/- 1 Snellen lines. All eyes had BCVA of 20/20 at the last visit. The mean baseline central retinal thickness as measured by OCT was 529 +/- 53 microm. The mean central retinal thickness by OCT was 235 +/- 15 microm at 1-week follow-up examination. At the last visit the mean central retinal thickness by OCT was 161 +/- 7 microm. One patient experienced an increase in IOP after the first injection and another patient had IOP elevation after the second injection. Both were well controlled with single topical anti-glaucoma medication.

CONCLUSION

Intravitreal injection of triamcinolone acetonide appears to be an effective treatment for patients with papillophlebitis and associated cystoid macular edema.

Unilateral Blastomyces dermatitidis optic neuropathy case report and systematic literature review

OBJECTIVE

To describe the clinical and histopathologic findings of a unique case of isolated optic nerve Blastomyces dermatitidis infection and to summarize the ophthalmic blastomycosis literature.

DESIGN

Case report and systematic literature review.

METHODS

A 70-year-old healthy man experienced impaired vision in his left eye. Magnetic resonance imaging (MRI) showed an enhancing process of the left optic nerve sheath. Although vision initially improved with oral dexamethasone, visual acuity subsequently decreased from 20/25 to no light perception over 8 weeks. An optic nerve biopsy revealed blastomycosis. Because ophthalmic blastomycosis infections are unusual, the Cochrane Library, PubMed, OVID, and UpToDate databases were searched using the term blastomycosis with the limits English and humans. Articles that predated the databases were gathered from current references.

MAIN OUTCOME MEASURES

Visual acuity of the left eye and MRI of the orbits and brain.

RESULTS

Histopathologic examination of the nerve specimen showed B. dermatitidis infection. Needle biopsy and culture results of a suspicious lung scar were positive for Blastomyces. The patient was treated with intravenous amphotericin B followed by oral itraconazole for 6 months. The left eye remained blind 23 months after the biopsy. Approximately 40 articles describing ophthalmic infection were found in the literature search.

CONCLUSIONS

Ophthalmic blastomycosis infections can cause rapid, complete vision loss. Prompt treatment is required, but infections are uncommon and usually are misdiagnosed, often because of lack of biopsy results. Tissue must be biopsied, cultured, or both for a definitive diagnosis. Because virtually all blastomycosis cases begin in the lungs, a chest radiograph or computed tomographic scan should be obtained. Any questionable lung lesion should be biopsied to corroborate possible ophthalmic disease.

Special considerations in low-tension glaucoma

Low-pressure (low-tension) glaucoma is reviewed in relation to neuroprotection, that is, the therapeutic strategy to keep neurons living and functionally connected to targets within the brain. Baseline results of the Low-Pressure Glaucoma Treatment Study (LoGTS) are reviewed.

Is this neuroprotective drug good for my glaucoma patients? Some key factors in clinical decision-making

Neuroprotection protects neurons from death after a primary insult, independent of that insult. Important clinical considerations include minimal interference with physiological processes, possible simultaneous or sequential treatment strategies, and most effective method of drug delivery. Clinicians' assessment of the neuroprotective value of any agent hinges on demonstration of efficacy by prospective randomized controlled trials. Use of a neuroprotectant will depend on the glaucomatous threat to a patient's visual function, as well as the agent's therapeutic index and its cost.

Should we treat the brain in glaucoma?

The loss of retinal ganglion cells in glaucoma may lead to blindness, and current therapies are directed at reducing pressure within the eye. Most of the retinal ganglion cell axon lies outside the eye, and evidence from experimental primate and human glaucoma suggests that axon injury extends from the optic nerve to visual pathways in the brain. Neurodegenerative changes in the central visual system may contribute to the pathology of glaucomatous progression. Thus, intraocular pressure-lowering strategies combined with neuroprotective therapies to protect visual neurons in the retina and brain may help to preserve vision in patients with glaucoma.

Retrobulbar cysticercosis masquerading as optic nerve glioma

Extra ocular muscles are the most common site of involvement in orbital cysticercosis. We present a case of retrobulbar cysticercosis masquerading clinically as optic nerve glioma.

Rapamycin for treatment of refractory dysthyroid compressive optic neuropathy

We report a patient with dysthyroid optic neuropathy refractory to steroids and orbital decompression treated with rapamycin, a fibroblast and T cell inhibitor. Symptoms, visual acuity, color plate testing, and visual fields improved. Aside from hypercholesterolemia, no complication related to this therapy was observed. By addressing the pathogenesis of thyroid eye disease, rapamycin may represent an alternative when standard treatments fail. Further investigation of rapamycin for treatment of dysthyroid orbitopathy is warranted.

Assessment of the optic disc to measure neuroprotection

In early glaucoma, axonal loss and optic disc change occur in the absence of detectable changes in psychophysical measurements, such as those obtained from standard automated perimetry. Accurate assessment of the anatomy of the optic disc is therefore necessary to document change. The measurement of optic disc topography with scanning laser ophthalmoscopy has been shown to be accurate, reproducible, diagnostically valid, and an accurate reflection of the underlying anatomic status of the optic disc and retinal nerve fibre layer. Validated techniques have been developed to detect change over time in the surface topography of the optic disc. Ultimately, real-time in vivo analysis of the health of retinal ganglion cells should provide the best method of assessing the advisability and adequacy of treatment and the potential value of neuroprotective therapies.

Effect of lowering intraocular pressure on optical coherence tomography measurement of peripapillary retinal nerve fiber layer thickness

PURPOSE

To assess, with optical coherence tomography (OCT), any changes in peripapillary retinal nerve fiber layer (RNFL) thickness in glaucoma patients after reduction of intraocular pressure (IOP).

DESIGN

Prospective observational case series.

PARTICIPANTS

Twenty-one eyes of 21 glaucoma patients who underwent medical or surgical intervention to lower IOP.

METHODS

Patients with elevated IOP underwent fast peripapillary RNFL measurements with the Stratus OCT (model 3000, software version 4.04; Carl Zeiss Meditec, Dublin, CA) before and after the IOP was lowered by medical or surgical therapy.

MAIN OUTCOME MEASURES

Changes in overall and quadrant RNFL thickness with respect to change in IOP.

RESULTS

The OCT scans were performed before intervention (range, 0-38 days before; mean+/-standard deviation [SD], 9.8+/-9.3 days) and after intervention (range, 32-74 days; mean+/-SD, 46.8+/-11.2 days) to measure peripapillary RNFL thickness. Mean IOP (mean+/-SD) decreased from 31.5+/-8.2 mmHg to 12.8+/-4.6 mmHg with the intervention (P<0.001). Twenty of 21 eyes had an IOP reduction of more than 30%. There was no significant change in the overall RNFL thickness associated with the lowering of IOP (mean+/-SD, 1.02+/-10.3 microm; P = 0.653). Quadrant analysis did not show a significant change in the RNFL thickness of any of the 4 quadrants (superior, -1.71+/-14.5 microm, P = 0.593; inferior, 2.38+/-16.8 microm, P = 0.523; temporal, 2.19+/-9.50 microm, P = 0.303; and nasal, 1.24+/-12.5 microm, P = 0.655). No relationship was found between any of the changes in OCT parameters or percent change in OCT parameters and the extent of IOP reduction, or whether IOP was lowered medically or surgically, with or without adjusting for preintervention OCT measurements as an indication of disease severity (P values ranged from 0.331 to 0.985).

CONCLUSIONS

No significant change in the RNFL thickness was associated with the lowering of IOP by medical or surgical therapy, as measured by OCT.

Bilateral Sequential Optic Neuropathy as the Initial Manifestation of Sjögren Syndrome

BACKGROUND

Neuro-ophthalmic findings are uncommon in the setting of Sjögren syndrome. We report the case of a patient with bilateral, sequential optic neuropathy as the initial manifestation of Sjögren syndrome.

HISTORY AND SIGNS

A 38-year-old male presented with sudden painless visual loss in his left eye in May 2005. Fundus examination revealed a left swollen optic disk. Magnetic resonance imaging (MRI) revealed a left optic nerve lesion. Elevated titres of autoantibodies (ANA, anti-SSA, anti-SSB) were found, suggestive of Sjögren syndrome. In January 2006, he presented with painful sudden visual loss in the right eye. Fundus examination revealed a right swollen optic disk and left optic nerve atrophy. MRI was normal. Other aetiologies were ruled out.

THERAPY AND OUTCOME

Each episode was treated with intravenous methylprednisolone (1 g/day during 3 days), followed by oral prednisone (1 mg/kg/day). Moderate improvement of vision ensued in both eyes.

CONCLUSIONS

Atypical presentation of an optic neuropathy must raise the suspicion of an unusual aetiology. Our case illustrates how a bilateral sequential optic neuropathy in an otherwise healthy patient can result from an unusual inflammatory aetiology: primary Sjögren syndrome.

Optic neuropathy in refractory neurosarcoidosis treated with TNF-alpha antagonist

CASE REPORT

To report a rare case of optic neuropathy in refractory neurosarcoidosis treated with tumour necrosis factor-alpha antagonist (infliximab) perfusion. A 41-year-old man with diabetes presented with an abrupt, painless, unilateral visual loss. Thoracic computed tomography disclosed mediastinal lymphadenopathy, and evidence from histopathology confirmed sarcoidosis.

COMMENTS

Corticosteroids alone and with immunosuppressive agents failed to suppress the active disease. Alternative therapy of infliximab perfusions resulted in disease remission and relative visual improvement, and this treatment may warrant further clinical studies.

Optic Neuropathy Associated With Periostitis in Relapsing Polychondritis

Optic neuropathy is an uncommon manifestation of relapsing polychondritis (RPC), a rare systemic disease affecting cartilaginous and proteoglycan-rich structures. The optic neuropathy has been attributed to ischemia, intrinsic inflammation of the optic nerve, or spread of inflammation to the nerve from adjacent intraconal orbital tissues. We report a case of recurrent corticosteroid-responsive optic neuropathy in which MRI did not show ocular, optic nerve, or intraconal orbital abnormalities but did show periosteal thickening and enhancement in the apical orbit and adjacent intracranial space consistent with periostitis. The periostitis, which is a manifestation of a systemic vasculitis or an autoimmune reaction to progenitors of cartilage, probably caused the optic neuropathy by compression or inflammation. It is important to recognize this mechanism of optic neuropathy as its imaging features may be a subtle yet critical clue to an underlying systemic condition that can be life-threatening if not properly managed.

Optic Neuropathy Associated With Botulinum A Toxin in Thyroid-related Orbitopathy

PURPOSE

To report the development of optic neuropathy after botulinum A toxin injection for restrictive myopathy from thyroid-related orbitopathy (TRO).

METHODS

We retrospectively reviewed the records of three patients with TRO who underwent botulinum A toxin injection for restrictive myopathy and subsequently developed optic neuropathy. Development of optic neuropathy was measured by visual acuity, color vision testing, visual field testing, and relative afferent pupillary testing.

RESULTS

At 3 week follow-up after botulinum A toxin injection, three patients were noted to have clinical signs and symptoms of optic neuropathy in the ipsilateral eye following injection of botulinum A toxin for restrictive myopathy. Treatment with oral steroids followed by orbital wall decompression reversed the optic neuropathy.

CONCLUSIONS

To our knowledge, this is the first report of optic neuropathy associated with botulinum A toxin injection in TRO. Clinicians should be aware of this potential vision threatening complication.

Optic neuropathy related to hydrogen peroxide inhalation

Optic neuropathy related to toxins is a complex, multifactorial disease potentially affecting individuals of all ages. We report a case of presumed toxic optic neuropathy secondary to H2O2 exposure. This has not been previously reported, and the temporal relationship of the exposure to the optic neuropathy is compelling, although not definite, evidence of a causal relationship.

Anti-VEGF bevacizumab (Avastin) for radiation optic neuropathy

PURPOSE

To evaluate intravitreal bevacizumab treatment for radiation optic neuropathy (RON).

DESIGN

Interventional case report.

METHODS

At The New York Eye Cancer Center, a patient symptomatic of decreased vision because of RON was treated with intravitreal bevacizumab (1.25 mg). Main outcome measures included visual acuity, appearance of the optic nerve, fundus photography, angiography, and optical coherence tomography/scanning laser ophthalmoscopy (OCT/SLO).

RESULTS

Within one week, her vision improved from 20/32 to 20/20 with a reduction in optic disk hemorrhage. At six weeks, evidence of both decreased hemorrhage and optic disk edema was documented by photography, angiography, and OCT/SLO. At the three and five-month follow-up visits, the hemorrhages resolved, and her disk margins were sharp. There were no ocular or systemic side effects.

CONCLUSIONS

Intravitreal bevacizumab was tolerated, improved vision, and reduced hemorrhage as well as optic disk edema (angiographic leakage). Anti-VEGF therapy (e.g. bevacizumab) should be investigated for both ocular and nonocular radiation neuropathy.

Successful treatment of cancer-associated retinopathy with alemtuzumab

We herein report a patient with cancer-associated retinopathy who experienced multiple bouts of paraneoplastic retinopathy and optic neuropathy but responded to treatments with alemtuzumab and was able to maintain useful vision over the course of 8 years of follow-up.

[Retinal ganglion cells death in glaucoma--mechanism and potential treatment. Part I]

Glaucoma is a kind of optic neuropathy where selective retinal ganglion cell loss is the major hallmark. Frequently glaucoma is associated with elevated intraocular pressure, but this condition is neither necessary nor sufficient for onset and progression of the disease. The exact mechanism of ganglion cell death in glaucoma and fully effective treatment of glaucomatous neuropathy still remain unknown. This article is a review of the recent researches relevant to IOP independent risk factors, mechanisms of RGC death and modern potential therapeutic strategies in glaucoma. Part one includes review of blood flow changes, neurotrophic factors deprivation and apoptotic dysregulation findings in glaucoma.

Langerhans cell histiocytosis of the optic chiasm

Langerhans cell histiocytosis (LCH) is a rare disease with clonal proliferation of dendritic histiocytes forming a pseudotumoral growth. LCH occurs most frequently in infancy or early childhood. It can present either as a localized self-limiting form or as a diffuse form with multisystem involvement. Herein an unusual case of LCH involving the optic chiasm is presented. To the authors' knowledge, this is the first reported case of LCH presenting with visual disturbance. The clinical, radiological and histopathological findings are discussed.

[Simultaneous defect of visual fields and loss of libido--a coincidence?]

We present the case of a 60 year old male patient with incidentally detected visual abnormalities. Detailed personal history revealed a hypogonadism that had been present for several years. Further investigations established the diagnosis of an infiltrative macroadenoma. Medical treatment with cabergoline led to a rapid regression of ophthalmologic symptoms and, subsequently, of tumor size. In male subjects symptoms of hypogonadism are often reported only late in the course of the disease, thereby leading to a generally larger tumor size at the point of diagnosis. In contrast to other pituitary tumors that are mainly treated by surgery, medical treatment with dopamine agonists is the principal therapeutic option in prolactinomas.

Acute Optic Neuropathy in Patients with Behçet’s Disease

Although acute optic neuropathy has been rarely reported in patients with Behçet's disease, a detailed description of its clinical course is lacking. We report in detail the course of acute optic neuropathy in two patients with Behçet's disease. Our experience suggests that it can be bilateral, can affect both eyes simultaneously, and can be recurrent. The severity of the visual loss and its recovery can be very variable even in the same patient. Early recognition of this entity and treatment with high-dose systemic corticosteroids may limit the degree of permanent visual loss. However, the optimal treatment has not been established.

Mitigation of radiation-induced optic neuropathy in rats by ACE inhibitor ramipril: importance of ramipril dose and treatment time

PURPOSE

Radiation-induced optic nerve damage was reduced by ramipril, a prodrug angiotensin-converting enzyme inhibitor (ACEI). This study was to determine the optimum dose and administration time of ramipril for mitigating radiation-induced optic neuropathy.

MATERIALS AND METHOD

Adult Fischer 344 male rats were treated with a single dose radiation 30 Gy by using radiosurgical technique. After irradiation, the animals were randomly assigned into groups of different ramipril doses and administration time; control (no treatment), radiation alone, radiation+ramipril in different doses and starting times of drug. Ramipril was given 0.5-1.5 mg/kg/day and AT1R blocker Losartan 20 mg/kg/day in drinking water for 180 days. Functional endpoint with visual evoked potential (VEP) and anatomical endpoint with gross and histological analysis with immunohistochemical (IHC) stain were used.

RESULTS

Normal VEP measurements in un-irradiated rats were 46.2+/-7.9 ms. There was no change of VEP value until 4 months, but was lengthened to 188.1+/-58.7 ms at 6 months after radiation. By ramipril treatment with the dose of 1.5 mg starting at 2 weeks after radiation, VEP was significantly shortened to 105.7+/-88.5 ms at 6 months. Gross and microscopic structure of the irradiated optic nerve was well preserved in the ramipril-treated group.

CONCLUSION

Ramipril can mitigate the radiation-induced optic nerve damage and preserve the functional integrity of the nerve. The results support early treatment with a high dose of ramipril after radiation.

Triamcinolone Acetonide–Induced Ocular Hypertension

PURPOSE

The aim of this study is to report on the clinical course of a patient showing markedly increased intraocular pressure (IOP) caused by intravitreal triamcinolone acetonide.

METHODS

A 33-year-old patient received an intravitreal injection of approximately 20 mg of triamcinolone acetonide (TA) as treatment of otherwise therapy-resistant uveitis. She experienced an IOP rise to values over 40 mmHg for a period for more than 3 months, despite maximal antiglaucomatous medical therapy. Peak IOP was 55 mmHg.

RESULTS

Neither confocal scanning laser tomography nor qualitative assessment of optic disc photographs nor perimetry showed development of glaucomatous changes. Scanning laser polarimetry of the retinal nerve fiber layer suggested a slight loss in the nasal upper fundus quadrant.

CONCLUSIONS

Relatively young patients with a pronounced TA-induced rise in IOP, unresponsive to maximal antiglaucomatous medication, may not necessarily undergo antiglaucomatous surgery if the rise in IOP does not last longer than approximately 3 months.

Intravitreal triamcinolone acetonide for acute radiation papillopathy

OBJECTIVE

To evaluate intravitreal triamcinolone acetonide for patients with visually symptomatic acute radiation-induced papillopathy.

METHODS

In a prospective, nonrandomized, single-center case series, intravitreal triamcinolone acetonide (4 mg/0.1 mL) was injected through the pars plana using sterile technique in 9 patients with radiation papillopathy after plaque radiotherapy for choroidal melanoma. Status of radiation papillopathy and final visual acuity were the main outcome measures.

RESULTS

At the time of diagnosis of the choroidal melanoma, visual acuity was 20/20 to 20/40 (n = 6), 20/60 (n = 2), and 20/100 (n = 1). The mean radiation dose to the optic disk was 6,175 cGy (median, 5,994 cGy; range, 3,571-12,760 cGy). Radiation papillopathy developed a mean of 18 months (median, 17 months; range, 6-33 months) after plaque radiotherapy. In all cases, the choroidal melanoma was regressed, and there was no retinal detachment or neovascularization of the retina, optic disk, or iris. Concomitant radiation maculopathy was found in 8 eyes manifesting as macular edema (n = 8), intraretinal dot hemorrhages (n = 6), intraretinal exudation (n = 6), or nerve fiber layer infarction (n = 3). The radiation papillopathy findings included optic disk hyperemia (n = 9), edema (n = 9), and circumpapillary hemorrhage (n = 8). At the time of diagnosis of radiation papillopathy, visual acuity was 20/70 (n = 1), 20/100 (n = 4), 20/200 (n = 1), and counting fingers (n = 3). At 1 week after injection of triamcinolone acetonide, visual acuity improvement was found in seven patients, and resolution of optic disk hyperemia and edema was noted for four and three patients, respectively. At a mean follow-up of 11 months (median, 9 months; range, 6-19 months), visual acuity was stable or improved in 7 patients, and resolution of optic disk hyperemia and edema was found in all 9 patients. The mean time to improvement in visual acuity by > or =2 lines was 3 weeks (median, 1 week; range, 1-12 weeks). The mean time to complete resolution of radiation papillopathy was 4 months. The two patients with worse final visual acuity also had macular hole and central retinal vein obstruction. The only complication of this therapy was possibly related cataract in three patients.

CONCLUSION

During short-term follow-up, acute radiation-induced papillopathy appears to respond rapidly to intravitreal triamcinolone acetonide injection with resolution of optic disk hyperemia and edema and modest return of visual acuity. The long-term effects remain unknown.

A rat model for acute rise in intraocular pressure: immune modulation as a therapeutic strategy

PURPOSE

To establish a rat model of acute increase in intraocular pressure (IOP) and to investigate the therapeutic window for protection against death of retinal ganglion cells (RGCs) by vaccination with glatiramer acetate (Cop-1) or by treatment with brimonidine or MK-801.

DESIGN

Animal study, laboratory investigation.

METHODS

IOP was transiently increased in anesthetized Lewis rats by infusing normal saline (0.9%) into the anterior chamber of the eye for one hour. RGC survival was assessed one week and two weeks later by counting the RGCs retrogradely labeled with rhodamine dextran.

MAIN OUTCOME MEASURES

RGC survival.

RESULTS

IOP rose to 100 cm H(2)O (76 mm Hg) and returned to baseline after 24 hours. The RGC count decreased by 23% a week after the insult and by a further 7% after the second week. Vaccination with Cop-1 on the day of the insult prevented 50% of the IOP-induced RGC loss. Similar neuroprotection was achieved by daily intraperitoneal injections of brimonidine, but not with MK-801.

CONCLUSIONS

A transient increase in IOP to 100 cm H(2)O causes death of RGCs in rats. A single immunization with Cop-1 or daily injections of brimonidine protected up to 50% of potentially doomed RGCs from IOP-induced death, suggesting that not all of the cell death in the untreated model results from the IOP insult directly, but that some of it is caused by insult-induced environmental cytotoxicity, which is unrelated to glutamate toxicity or at least to NMDA receptors. These findings can be applied immediately as a basis for acute glaucoma therapy.