[Early symptoms and findings in optic nerve meningiomas]

PURPOSE OF THE STUDY

While evaluating radiotherapy results in patients with primary and secondary optic nerve sheath meningiomas (ONSM) treated between 1993 and 2002, a large amount of data about early signs and symptoms has been collected which might be helpful for establishing an early diagnosis.

METHODS

We have reviewed the charts of the patients available at the Centre of Ophthalmology, collecting especially pretreatment data.

RESULTS

112 patients, 4 with bilateral tumours, 83 % female were included. Mean age was 51.7 years. Visual acuity loss with relative afferent pupillary defect was the main symptom and sign in primary ONSM (38 patients). Median interval between first symptoms and diagnosis was 12 months. Optic discs were in approximately one half atrophic, the other half were swollen, and only rarely normal (3 cases only). Retinociliary shunt vessels were seen in 10 cases. Nerve fibre bundle defects were the major visual field finding (including constriction and central scotoma). Visual acuity was better than 0.5 (20 / 40) in 46 % and worse than 0.1 (20 / 200) in 30 %. In secondary ONSM, the interval to diagnosis was with a median of 6 months shorter than in primary ONSM. Approximately half of the optic discs were atrophic, only 6 % were swollen. Even here nerve fibre bundle defects were dominating, only 7 % had vertical hemianopic defect. Visual acuity was better than 0.5 (20 / 40) in 30 % and in worse than 0.1 (20 / 200) 22 %. 45 % had ocular motility disorders.

DISCUSSION

Vertical hemianopic defects were surprisingly rare. The high rate of nerve fibre bundle defects and the relatively high number of patients with good visual acuity might explain why this disorder is occasionally mistaken for glaucoma. A typical clinical appearance can be outlined: mainly mid-aged women, slowly progressing visual loss, frequently motility disorders, relative afferent pupillary defect, nerve fibre bundle defects and atrophic or--mainly in primary ONSM--swollen optic disc form the characteristic picture.

[Afferent pupillary disorders in postchiasmal lesions of the visual pathways]

Classically, the pupillary pathway is considered as a simple reflex arc comprising retinal ganglion cells, midbrain interneurons, oculomotor nerve and short ciliary nerves. However, there are some specialties in the construction of the pupillary pathways that have to be kept in mind when dealing with diseases involving pupillary disorders. This may help to localise lesions. Additionally, studies in patients with lesions of the retrogeniculate pathways have shown that pupillary disorders are possible even with lesions not involving the classical reflex arc. The pupil is therefore not only controlled subcortically, some components are influenced by the visual cortex. The aim of this article is to clarify various findings and terms such as relative afferent pupillary defect and pupillary hemihypokinesia.

[Higher visual disorders]

Higher visual disorders as discussed in this paper comprise visual hallucinations, palinopsy, hemineglect, Balint Holmes syndrome, prosopagnosia, visual objectagnosia, alexia without agraphia and cerebral achromatopsia. Such disorders are frequently caused by ischemia, but tumors, trauma and intoxication are possible as well. As a rule, higher visual disorders are a transient phenomenon. It is important to inform the patient and his family about the nature of the disorder and consider persisting disorders during rehabilitation.

First Synthesis of Dimethyl-1H-Isochromeno[3,4-b]Carbazoles

The first synthesis of isochromene fused carbazols, (4a S, 13b R)-2,5,5-trimethyl-3,4,4a,5,8,13b-hexahydroisochromeno[3,4-b]carbazole (2) and its epi-isomer 3 by condensation of citral and 2-hydroxycarbazole using Ti(OEt)4 and MeAlCl2 as catalysts is described.

First synthesis of dimethyl-1H-isochromeno[3,4-b]carbazoles

The first synthesis of isochromene fused carbazols, (4aS, 13bR)-2,5,5-trimethyl-3,4,4a,5,8,13b-hexahydroisochromeno[3,4-b]carbazole (2) and its epi-isomer 3 by condensation of citral and 2-hydroxycarbazole using Ti(OEt)4 and MeAlC12 as catalysts is described.

[Traumatic optic neuropathy]

Traumatic optic neuropathy is a severe complication of a head or face trauma. Diagnosis is established by analyzing pupillary responses to light. Fundus examination and orbital CT scan help to localize the site of the lesion and may show a fracture involving the optic canal. Surgical decompression or megadose steroids are therapeutic options. No therapeutic approach has proven with sufficient evidence to be effective. Spontaneous improvement is definitely possible. Based on experiences in single cases direct compression of the optic nerve by bone fragments or optic nerve sheath haemorrhage are as a rule treated surgically. In all other cases usually high dose steroids are given without proven effectiveness.

Disability Glare in the Aging Eye. Assessment and Impact on Driving☆

Purpose

To compare different methods for the assessment of disability glare sensitivity in the elderly, to arrive at an objective assessment of the condition of the eye. To delineate the importance of straylight values in vision.

Methods

Three groups of subjects were studied: 1) Young subjects without any eye disease, 2) elderly subjects without any eye disease and 3) elderly subjects with (early) cataract in at least one eye. All subjects underwent 2 glare tests, 2 straylight tests, ETDRS visual acuity test, Pelli Robson contrast sensitivity test, refraction, LOCS III cataract classification. Straylight was quantified by means of the straylight parameter s.

Results

Repeatability, discriminative ability, and added value as compared to visual acuity were low for the glare tests and good for the straylight measurements. For young normal subjects, with log(s)=0.9, the standard glare situation with low beams gives a contrast reduction of 1.3, whereas for the healthy 77 year olds this increases to 2. With cataract hardly affecting visual acuity, log(s) can be as high as 1.8, resulting in a contrast reduction of 3.4.

Conclusion

Straylight measurement is of relevance for the assessment of the glare-related hindrance during driving, and can be used to objectify complaints and aid in the decision-making regarding cataract surgery.

1-O-Substituted derivatives of murrayafoline A and their antifungal properties

The synthesis of some 1-oxygenated derivatives of murrayafoline A (1) and their antifungal properties is reported. Three derivatives, 1-hydroxy-3-methyl-9H-carbazole (2), 1-(3-methylbut-2-enyloxy)-3-methyl-9H-carbazole (3) and 1-(2,3,4,6-tetra-O-acetyl-alpha-D-O-glucopyranosyl)-3-methyl-9H-carbazole (4) of murrayafoline A were synthesized. Compounds 1 and 2 exhibited strong fungicidal activity against Cladosporium cucumerinum at the dose of 12.5 microg.

Metallic state in cubic FeGe beyond its quantum phase transition

We report on results of electrical resistivity and structural investigations on the cubic modification of FeGe under high pressure. The long-wavelength helical order (T(C) = 280 K) is suppressed at a critical pressure p(c) approximately 19 GPa. An anomaly at T(X)(p) and strong deviations from a Fermi-liquid behavior in a wide pressure range above p(c) suggest that the suppression of T(C) disagrees with the standard notion of a quantum critical phase transition. The metallic ground state persisting at high pressure can be described by band-structure calculations if zero-point motion is included. The shortest FeGe interatomic distance display discontinuous changes in the pressure dependence close to the T(C)(p) phase line.

[Multiple sclerosis. An update with practical guidelines for ophthalmologists]

Multiple sclerosis (MS) is the most frequent chronic inflammatory disease of the central nervous system. Mostly young adults present with a variety of different symptoms due to the multiple localisations of the inflammatory lesions. Up to one-third of MS patients experience symptoms of optic neuritis as the initial symptom. That is the reason why the ophthalmologist often is the first physician contacted by patients later on diagnosed with MS. Today, it is known that there is already a significant irreversible axonal loss in MS patients progressing from the beginning of the disease. Therefore early, diagnosis and application of available therapeutic options are necessary for the patient's benefit. The therapeutic aim in early immunomodulatory treatment is to decrease the number of relapses and to slow down the development of clinical disability. This interdisciplinary overview presents guidelines for the clinical routine: how to assess the individual risk of each patient and how to treat the patient in accordance with current pathogenic, diagnostic and therapeutic knowledge.

High throughput production of mouse monoclonal antibodies using antigen microarrays

Recent advances in proteomics research underscore the increasing need for high-affinity monoclonal antibodies, which are still generated with lengthy, low-throughput antibody production techniques. Here we present a semi-automated, high-throughput method of hybridoma generation and identification. Monoclonal antibodies were raised to different targets in single batch runs of 6-10 wk using multiplexed immunisations, automated fusion and cell-culture, and a novel antigen-coated microarray-screening assay. In a large-scale experiment, where eight mice were immunized with ten antigens each, we generated monoclonal antibodies against 68 of the targets (85%), within 6 wk of the primary immunization.

[Idiopathic hypertrophic cranial pachymeningitis]

BACKGROUND

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a chronic inflammatory disease of unknown origin that is morphologically characterized by a local fibrotic thickening of the dura mater with a sterile lymphocytic infiltrate. Patients usually present with chronic headache, ataxia and cranial nerve palsies. Because of the great diversity of symptoms and the fact that IHCP can be associated with many other disorders, there is often a long time between the occurrence of clinical features and making the diagnosis. During this time symptoms can further increase. In addition, this is the third case report describing bone involvement in this disorder.

CASE REPORT

In May 2000, a 51-year-old woman presented with reduced visual acuity on both eyes, complete palsies of the fourth and sixth cranial nerve, a partial palsy of the third cranial nerve and numbness and pain concerning the area of the fifth cranial nerve on the left side, painful eye movement on the left side, headache, and numbness and palsies on the left side of her body. Magnetic resonance imaging of the brain showed a focal gadolinium-enhanced small thickening of the dura mater close to the left hemisphere and a homogeneous bone thickening in the same area close to the thickened dura mater. Cerebrospinal fluid analysis revealed an elevated cell count (lymphocytic pleocytosis), routine blood counts and serum chemistry showed an elevated white blood count, an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Therapy with corticosteroids resulted in a complete remission in November 2000 except for a persistent numbness of the left side of her face and body and reduced visual acuity on both sides. The following three years were characterized by repeated clinical deteriorations followed by a temporary increase of the daily steroid dose. Altogether, daily oral steroid therapy could slow down the progression of disease and improve the visual acuity when compared with the first examination.

CONCLUSIONS

Chronic headache, ataxia and cranial nerve palsies in combination with inflammation and dural thickening should call to mind idiopathic hypertrophic cranial pachymeningitis. In principle, every ophthalmological or neurological symptom can be associated with IHCP.

Bose-Einstein condensation of magnons in Cs2CuCl4

We report on results of specific heat measurements on single crystals of the frustrated quasi-2D spin-1/2 antiferromagnet Cs2CuCl4 (T(N)=0.595 K) in external magnetic fields B<12 T and for temperatures T>30 mK. Decreasing B from high fields leads to the closure of the field-induced gap in the magnon spectrum at a critical field Bc approximately = 8.51 T and a magnetic phase transition is clearly seen below Bc. In the vicinity of Bc, the phase transition boundary is well described by the power law Tc(B) proportional, variant (Bc-B)(1/phi), with the measured critical exponent phi approximately =1.5. These findings are interpreted as a Bose-Einstein condensation of magnons.

Pupil campimetry in patients with visual field loss

Pupil campimetry is an objective test of the visual field. In pupil campimetry, the pupil light response elicited by focal light stimuli at different locations within the visual field is measured. Pupil campimetry was performed in patients with visual field loss because of different pathologies. The match between reduced pupil response and visual field loss was assessed. The pupil field of 23 patients was recorded by infrared video-pupillography with light stimuli generated on a computer screen. A visual field was obtained on the same day with the Tuebingen Automated Perimeter. Both fields were compared by subjective judgement. Six of nine patients with large, two of five patients with incomplete, and three of six patients with minor field loss showed matching defects in their pupil and their visual fields. In functional loss of visual field sensitivity, no pupil field defect was seen (three patients). In most patients, the loss of visual field sensitivity could be revealed objectively by pupil campimetry.

["Do you have a remedy for macular degeneration?" A field study about the advice given on dietary supplementation in 60 German pharmacies]

PURPOSE

Since completion of the AREDS study, evidence has accumulated to suggest that some form of dietary supplementation may be of value in special individuals who are at risk of progressive age-related macular degeneration (ARMD). We wanted to find out which of the many supplements available are recommended in practice and which instructions, promises, and purchasing arguments are used by German pharmacies.

METHODS

A blinded consultation following a standardized protocol was carried out in 60 pharmacies.

RESULTS

In 36 pharmacies specific products for dietary supplementation were recommended, but the dosage never complied with the AREDS study, and in 24 pharmacies, the necessity for a medical examination or consultation with an ophthalmologist was not mentioned. Possible interactions with other drugs or side effects were generally excluded.

CONCLUSIONS

Potential risks of supplement intake were underestimated. Medical knowledge of the most frequent cause of blindness in the Western world was insufficient. A clear policy of recommendations according to evidence-based criteria is needed.

Measurement of stray light and glare: comparison of Nyktotest, Mesotest, stray light meter, and computer implemented stray light meter

AIM

To evaluate the properties of devices for measuring stray light and glare: the Nyktotest, Mesotest, "conventional" stray light meter and a new, computer implemented version of the stray light meter.

METHODS

112 subjects, divided in three groups: (1) young subjects without any eye disease; (2) elderly subjects without any eye disease, and (3) subjects with (early) cataract in at least one eye. All subjects underwent a battery of glare and stray light tests, measurement of visual acuity, contrast sensitivity, refraction, and LOCS III cataract classification. Subjects answered a questionnaire on perceived disability during driving.

RESULTS

Repeatability values were similar for all glare/stray light tests. Validity (correlation with LOCS III and questionnaire scores), discriminative ability (ability to discriminate between the three groups), and added value (to measurement of visual acuity and contrast sensitivity) were all superior for both stray light meters. Results of successive measurements are interrelated for the conventional but not the new stray light meter. This indicates a better resistance to fraud for the latter device.

CONCLUSIONS

The new computer implemented stray light meter is the most promising device for future stray light measurements.

Cerebellar agenesis II: motor and language functions

In a former study of a patient with cerebellar agenesis (HK) mild motor deficits, problems in delay eyeblink conditioning and mild to moderate deficits in IQ, planning behavior, visuospatial abilities, visual memory, and attention were found. The present study reports additional findings in the same patient. In the motor domain, impairments in fine motor manipulations, trace eyeblink conditioning and motor imagination in a functional magnetic resonance (fMRI) study were found. Based on fMRI findings; however, cortical areas involved in a tapping task did not significantly differ from a healthy control group. In the cognitive domain, deficits in speech comprehension as well as verbal learning and declarative memory were present. No significant affective symptoms were observed. Although problems in executive, visuospatial and language tasks are in agreement with the so-called cerebellar cognitive affective syndrome-other possibilities remain. Non-motor impairments in HK might also be a consequence of lacking motor abilities in development and motor deficits may interfere with the performance of parts of the cognitive tasks. In addition, lack of promotion and learning opportunities in childhood may contribute and mental retardation based on extracerebellar dysfunction cannot be excluded.

[Potentially fatal orbital disorder]

Fulminant processes of the orbit can cause considerable diagnostic difficulties with regards to the clinical, radiological and microbiological appearance. Rhino-orbito-cerebral mucormycosis is a rare but, when untreated, fatal orbital disease capable of destructive infiltration of soft tissue and bone. It occurs preferably in the ill adjusted diabetic or in the course of an immunodeficiency. The following case report describes a leukaemia patient developing a severe rhino-orbito-cerebral mucormycosis which was initially not recognised. Since untreated mucormycosis is fatal, an aggressive surgical approach with excision of the whole necrotic area is necessary even if the diagnosis cannot be confirmed with certainty.

[Cycling with a visual handicap]

PURPOSE OF THE STUDY

To examine bicycling habits of visually handicapped people in order to learn about the visual requirements.

MATERIAL AND METHODS

Survey of patients (age range: 14-60 years) suffering from macular or tapetoretinal degeneration with no additional relevant handicap using a questionnaire.

RESULTS

A total of 232 questionnaires were returned (62% of the questionnaires received by the participants). The results showed that if visual acuity dropped below 0.1, only 15% of the patients were able to ride a bicycle without accidents or near-accidents. This percentage increased for higher acuities between 33% (<0.2 > or = 0.1) and 67% (> or = 0.2 < or = 0.4). For visual field diameters <60 degrees and > or = 20 degrees approximately 18% were able to ride a bicycle safely and only 8% if the visual field diameter was below 20 degrees. For visual fields larger than 60 degrees diameter approximately 40% were able to ride a bicycle without problems. With a central scotoma of more than 10 degrees diameter only 21% of the patients could cycle safely, whereas with a central scotoma of 10 degrees and less this percentage increased to 47%.

CONCLUSIONS

A visual acuity of less than 0.1 is not sufficient to ride a bicycle, and a visual acuity of less than 0.2 leads to a higher accident rate. A visual field diameter of less than 60 degrees or a central scotoma of more than 10 degrees diameter for the vast majority of patients does not allow safe cycling

Traumatische Optikusneuropathie - der aktuelle Stand

Direct or indirect trauma may damage the optic nerve and result in permanent visual loss. The diagnosis of traumatic optic neuropathy is not always straightforward and is complicated by unfavourable circumstances for the examination. The diagnosis should only by established if it can be based on a clear objective finding, a relative afferent pupillary defect or a pathological flash-evoked visual response. Concerning therapy, surgical decompression (even without direct injury to the nerve) or megadose steroids or both in combination have been recommended. But even spontaneous improvement may occur. A large multicentre study could not demonstrate a significant advantage for any of the measures recommended, not even against the spontaneous course. However, the study was not randomised. In animal experiments steroids have shown an unfavourable effect. Currently, therapeutic decisions have to be made on an individual basis, in the absence of any evidence-based recommendations.

Der Kopfschmerzpatient beim Augenarzt

About 50 patients contact an ophthalmologist every month because of headache. Only 20 % can be helped by ophthalmological therapeutic efforts. The vast majority of those patients suffer from migraine. This contribution gives an overview of the most common causes of headache and their therapy. The ophthalmologist should not only exclude an ophthalmological cause of the headache but also contribute to making the correct diagnosis and initiating further treatment.

Cerebellar agenesis: clinical, neuropsychological and MR findings

Cases of cerebellar agenesis are rare. The degree of motor impairment is a matter of discussion. It has been claimed that normal motor function can be observed. Detailed descriptions of neurological findings, however, are lacking. Neuropsychological testing in cerebellar agenesis is of additional interest based on recent findings of impaired non-motor functions in cerebellar disease. The case of an elderly woman with cerebellar agenesis is presented. 3D-MR imaging was used to confirm the diagnosis. Neurological and neuropsychological examination was performed including video documentation (see the authors' own website). To assess deficits of motor learning eyeblink conditioning was investigated. Neurological examination revealed mild to moderate signs of cerebellar dysarthria, upper and lower limb ataxia and ataxia of stance and gait. Motor learning was affected as shown by inability to acquire conditioned eyeblink responses. In addition, neuropsychological testing disclosed mild to moderate deficits in IQ, planning behavior, visuospatial abilities, memory and attention. Cerebellar ataxia, although clearly present, was less than one would expect in almost complete absence of the cerebellum. Neuropsychological deficits, on the other hand, appeared to be more marked than one would expect in cerebellar disease. No conclusion, however, could be drawn whether impaired cognitive development and neuropsychological test performance were directly related to lack of cerebellar function, or caused by impaired motor development and performance.

The break-up of heavy electrons at a quantum critical point

The point at absolute zero where matter becomes unstable to new forms of order is called a quantum critical point (QCP). The quantum fluctuations between order and disorder that develop at this point induce profound transformations in the finite temperature electronic properties of the material. Magnetic fields are ideal for tuning a material as close as possible to a QCP, where the most intense effects of criticality can be studied. A previous study on the heavy-electron material YbRh2Si2 found that near a field-induced QCP electrons move ever more slowly and scatter off one another with ever increasing probability, as indicated by a divergence to infinity of the electron effective mass and scattering cross-section. But these studies could not shed light on whether these properties were an artefact of the applied field, or a more general feature of field-free QCPs. Here we report that, when germanium-doped YbRh2Si2 is tuned away from a chemically induced QCP by magnetic fields, there is a universal behaviour in the temperature dependence of the specific heat and resistivity: the characteristic kinetic energy of electrons is directly proportional to the strength of the applied field. We infer that all ballistic motion of electrons vanishes at a QCP, forming a new class of conductor in which individual electrons decay into collective current-carrying motions of the electron fluid.

Relation between perceived driving disability and scores of vision screening tests

AIM

To determine the relation between perceived driving disability and vision screening tests.

METHODS

93 subjects, aged 50 years and over, with binocular visual acuity of at least 20/80. Perceived driving disability (PDD) was assessed by a questionnaire. Subtracting daytime from night-time driving question scores revealed PDD at night (PDDN), subtracting scores of questions for driving in familiar places from those in unfamiliar places revealed PDD at unfamiliar places (PDDU).

RESULTS

PDD was strongly related to visual acuity, contrast sensitivity and useful field of view (UFOV). Specific relations existed between PDDN and Nyktotests and Mesotests and between PDDU and UFOV. These associations were enhanced in a subset of subjects with better visual acuities.

CONCLUSIONS

Vision screening tests correlate well with perceived driving disabilities, especially when a subtraction method is used in the questionnaire to reveal condition dependent disabilities. Additional tests for visual acuity are useful, especially in subjects with better visual acuity.

Stereotactic fractionated irradiation of optic nerve sheath meningioma: a new treatment alternative

BACKGROUND

Primary optic nerve sheath meningioma (ONSM) is a rare but almost invariably blinding tumour when its natural history is observed in a "wait and see" strategy. Surgery has hitherto only been advocated in case of progressive disease involving intracranial structures, as it leads to iatrogenic blindness in the overwhelming majority of cases. Therefore, treatment options bearing lesser risk of functional deterioration are highly desirable, both in cases of intracranial involvement as well as during earlier phases of the disease which are currently generally left untreated. The authors report the outcome of the largest series of patients to date treated by stereotactic fractionated irradiation as a new treatment approach in ONSM at all stages.

METHODS

15 patients (16 nerves) underwent stereotactic fractionated conformal irradiation with a total dose of 54 Gy, using standard fractionation. Main outcome parameters included visual acuity and visual field, as well as three dimensional remission as documented by imaging.

RESULTS

Tumour control was confirmed in all 15 patients undergoing stereotactic fractionated conformal irradiation (mean follow up 37 (range 12-71) months). No patient developed functional deterioration during or after treatment. Moreover, visual acuity improved by more than two lines in one patient and the visual field improved in six cases. Visual outcome in the other patients remained unchanged. There were no significant side effects of radiation therapy.

CONCLUSION

These data provide convincing evidence that stereotactic fractionated conformal irradiation is an effective treatment option for primary ONSM with minimal treatment related morbidity. It should therefore be considered as therapeutic option both in early stage ONSM where surgery cannot be justified as well as in later stages, where surgery is so far considered the first line approach.