Treatment of nonarteritic anterior ischemic optic neuropathy

Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common clinical presentation of acute ischemic damage to the optic nerve. Most treatments proposed for NAION are empirical and include a wide range of agents presumed to act on thrombosis, on the blood vessels, or on the disk edema itself. Others are presumed to have a neuroprotective effect. Although there have been multiple therapies attempted, most have not been adequately studied, and animal models of NAION have only recently emerged. The Ischemic Optic Neuropathy Decompression Trial, the only class I large multicenter prospective treatment trial for nonarteritic anterior ischemic optic neuropathy, found no benefit from surgical intervention. One recent large, nonrandomized controlled study suggested that oral steroids might be helpful for acute NAION. Others recently proposed interventions are intravitreal injections of steroids or anti-vascular endothelial growth factor (anti-VEGF) agents. There are no class I studies showing benefit from either medical or surgical treatments. Most of the literature on the treatment of NAION consists of retrospective or prospective case series and anecdotal case reports. Similarly, therapies aimed at secondary prevention of fellow eye involvement in NAION remain of unproven benefit.

Pain in ischaemic ocular motor cranial nerve palsies

AIM

Pain is a common feature of microvascular ischaemic ocular motor cranial nerve palsies (MP). The natural history of pain in this condition has not been studied. The purpose of this report is to define the spectrum of pain in isolated MP, with special reference to diabetic versus non-diabetic patients.

DESIGN AND METHODS

Retrospective and prospective chart review was performed on 87 patients with acute-onset MP of a single cranial nerve (CN III, oculomotor; CN IV, trochlear; CN VI, abducens) that progressively improved or resolved over 6 months.

RESULTS

Five of the 87 patients had two events, making the total number events 92. There were 39 (42.4%) CN III palsies, five (5.4%) CN IV palsies and 48 (52.2%) CN VI palsies. Thirty-six (41%) patients had diabetes. Pain was present in 57 (62%) events. The majority of diabetic and non-diabetic patients had pain. Pain preceded diplopia by 5.8 (SD 5.5) days in one-third of events. There was a trend towards greater pain with CN III palsies, but this was not statistically significant. Patients who experienced severe pain tended to have pain for a longer duration (26.4 (SD 21.7) days compared with 10.8 (SD 8.3) and 9.5 (SD 9) days for mild and moderate pain, respectively). There was no correlation between having diabetes and experiencing pain.

CONCLUSIONS

The majority of MP are painful, regardless of the presence or absence of diabetes. Pain may occur prior to or concurrent with the onset of diplopia. Non-diabetic and diabetic patients presented with similar pain characteristics, contrary to the belief that diabetic patients have more pain associated with MP.

Clinicopathologic correlations in giant cell arteritis: a retrospective study of 107 cases

OBJECTIVE

To correlate the pathologic findings of temporal artery biopsies in patients clinically defined as positive, presumed, or negative for giant cell arteritis (GCA).

DESIGN

Retrospective case series.

PARTICIPANTS AND CONTROLS

Patients evaluated for GCA.

METHODS

Temporal artery biopsies examined between 1989 and 2007 were studied. Clinical information and residual tissue for immunohistochemical staining was identified in 107 patients. Clinical information was used to make a diagnosis of "positive," "presumed," or "negative" GCA. The biopsies were reviewed in a masked fashion and classified as "positive," "indeterminate," or "negative" based on published, classic pathologic diagnosis (CPD) criteria. All biopsies were immunostained for CD3 and CD68 and graded as "negative," "mildly" (+), "moderately" (++), or "markedly" (+++) positive. Clinical and pathologic results were correlated and a modified pathologic diagnosis classification (MPD) scheme was developed. The modified scheme was compared in a masked fashion with the final clinical diagnosis and positive and negative predictive values (PVs) were calculated.

MAIN OUTCOME MEASURES

Pathologic diagnosis and final clinical diagnosis.

RESULTS

Using the MPD classification, there were 25%, 16%, and 61% positive, indeterminate, and negative biopsies, respectively. There was excellent correlation between the modified pathologic criteria and final clinical diagnosis (correlation coefficient 0.997; P<0.0001; kappa = 0.81). The positive PVs for CPD and MPD were 85% and 96%, respectively. The negative PVs for CPD and MPD were 64% and 61%, respectively. Positive and negative biopsies strongly correlated with clinical diagnoses of positive and negative for GCA, respectively, whereas indeterminate cases moderately correlated with presumed GCA. The diagnosis did not change from the original biopsy in 11 patients who had a second biopsy. Immunostaining for CD 68 was helpful in several indeterminate cases.

CONCLUSIONS

We recommend using the modified histologic classification of temporal artery biopsies. There are indeterminate cases that cannot be further defined using current pathologic classification criteria. A second biopsy has very limited value. Immunostaining for CD68 may be helpful in indeterminate cases, although the diagnosis in these cases is based on clinical judgment.

Idiopathic intracranial hypertension: a comparison between French and North-American white patients

OBJECTIVE

To compare French and American white patients with idiopathic intracranial hypertension (IIH), and to determine prognostic factors associated with visual loss.

METHODS

Medical records of all consecutive white patients with definite IIH seen between 2001 and 2006 in three French tertiary care medical centers and one American tertiary medical center were reviewed. Demographics, associated clinical features, and visual function at presentation and follow-up were collected. French white patients were compared to American white patients.

RESULTS

One hundred and thirty-four patients (66 French, 68 American) were included. American patients were 8.7 times more likely than French patients to have visual acuity 20/60 or worse or visual field constriction (95% CI: 2.1-36.1, p=0.0001). American patients were treated more aggressively than French patients. French patients were older (31 vs. 28 years, p=0.02) and more likely to have anemia (20 vs. 2%, p<0.001). American patients had a longer duration of symptoms prior to diagnosis (12 vs. 4 weeks, p=0.01) and longer follow-up than French patients (26 vs. 11 months, p=0.001). Multivariable analysis found that nationality was an independent risk factor for visual loss. French and American patients did not differ regarding gender proportion, frequency of obesity, sleep apnea, endocrine diseases, or systemic hypertension. Cerebrospinal fluid (CSF) opening pressures were similar in both groups.

CONCLUSION

American patients with IIH had worse visual outcomes than French patients despite more aggressive treatment. These differences are not explained by differences in previously known risk factors.

Headaches, rapidly progressive visual loss, and bilateral disc edema

The diagnosis and management of a 28-year-old obese woman who presented with neck pain, headache, and rapidly progressive visual loss is discussed here. Results of her initial general examination were normal. Thorough medical follow-up resulted in a rare diagnosis.

Neurologic and ophthalmic manifestations of fetal alcohol syndrome

Fetal alcohol syndrome (FAS) is a leading cause of preventable birth defects and developmental disability with numerous neurologic and ophthalmic manifestations. FAS is identified by the presence of a characteristic facies, growth deficiency, and central nervous system abnormalities. A wide variety of ocular and neuro-ophthalmic conditions occur in FAS and result in lifelong visual impairment. Neurologists are frequently called upon to evaluate and recommend treatment for children with developmental delay or neurologic manifestations of FAS. We review the neuro-ophthalmic literature on FAS to alert neurologists to the ocular disease seen in patients with this condition. Timely ophthalmic referral and early intervention for treatable ophthalmic conditions, such as refractive errors, strabismus, and amblyopia, can prevent irreparable harm to the developing visual system and improve the overall neurologic development, long-term functioning, and quality of life for these patients.

Multiple brain infarcts after orbital inflammation

A 75-year-old woman developed trigeminal varicella-zoster virus infection complicated by ophthalmoplegia, and visual loss followed by recurrent cerebral infarctions involving small and large intracranial arteries. Medical therapy improved her ophthalmoplegia, but she developed a right hemiparesis and aphasia.

Management of acute optic neuritis: a survey of neurologists and ophthalmologists in Australia and New Zealand

Recent studies suggest that evidence-based medicine is not well translated into everyday practice. Studies of optic neuritis (ON) have generated clear treatment guidelines. Therefore, a survey was mailed to all Australian and New Zealand neurologists and ophthalmologists to evaluate the impact of recent studies on clinical practice. The response rate was 38.9%. Neurologists were more likely to use high dose corticosteroids and disease modifying agents (DMAs), and were more likely to be aware of relevant literature concerning DMAs. Both groups contained a significant minority of practitioners who would use corticosteroids for reasons not substantiated by available evidence. We conclude that most practitioners manage optic neuritis according to existing evidence and guidelines, but many do not. It is essential to instigate high-quality training programs to keep practitioners up-to-date, thereby optimising patient care and justifying the time and expense of large-scale clinical trials.

Management of optic neuritis and impact of clinical trials: an international survey

OBJECTIVE

1) To evaluate the management of acute isolated optic neuritis (ON) by ophthalmologists and neurologists; 2) to evaluate the impact of clinical trials; 3) to compare these practices among 7 countries.

METHODS

A survey on diagnosis and treatment of acute isolated ON was sent to 5,443 neurologists and 6,099 ophthalmologists in the southeast-USA, Canada, Australia/New Zealand, Denmark, France, and Thailand. USA data were compared to those of other countries.

RESULTS

We collected 3,142 surveys (1,449 neurologists/1,693 ophthalmologists) (29.8% response rate). In all countries, ON patients more frequently presented to ophthalmologists, and were subsequently referred to neurologists or subspecialists. Evaluation and management of ON varied among countries, mostly because of variations in healthcare systems, imaging access, and local guidelines. A brain MRI was obtained for 70-80% of ON patients; lumbar punctures were obtained mostly in Europe and Thailand. Although most patients received acute treatment with intravenous steroids, between 14% and 65% of neurologists and ophthalmologists still recommended oral prednisone (1 mg/kg/day) for the treatment of acute isolated ON. In all countries, steroids were often prescribed to improve visual outcome or to decrease the long-term risk of multiple sclerosis.

INTERPRETATION

Although recent clinical trials have changed the management of acute ON around the world, many neurologists and ophthalmologists do not evaluate and treat acute ON patients according to the best evidence from clinical research. This confirms that evaluation of the impact of major clinical trials ("translational T2 clinical research") is essential when assessing the effects of interventions designed to improve quality of care.

Idiopathic intracranial hypertension in men

OBJECTIVE

To compare the characteristics of idiopathic intracranial hypertension (IIH) in men vs women in a multicenter study.

METHODS

Medical records of all consecutive patients with definite IIH seen at three university hospitals were reviewed. Demographics, associated factors, and visual function at presentation and follow-up were collected. Patients were divided into two groups based on sex for statistical comparisons.

RESULTS

We included 721 consecutive patients, including 66 men (9%) and 655 women (91%). Men were more likely to have sleep apnea (24% vs 4%, p < 0.001) and were older (37 vs 28 years, p = 0.02). As their first symptom of IIH, men were less likely to report headache (55% vs 75%, p < 0.001) but more likely to report visual disturbances (35% vs 20%, p = 0.005). Men continued to have less headache (79% vs 89%, p = 0.01) at initial neuro-ophthalmologic assessment. Visual acuity and visual fields at presentation and last follow-up were significantly worse among men. The relative risk of severe visual loss for men compared with women was 2.1 (95% CI 1.4-3.3, p = 0.002) for at least one eye and 2.1 (95% CI 1.1-3.7, p = 0.03) for both eyes. Logistic regression supported sex as an independent risk factor for severe visual loss.

CONCLUSION

Men with idiopathic intracranial hypertension (IIH) are twice as likely as women to develop severe visual loss. Men and women have different symptom profiles, which could represent differences in symptom expression or symptom thresholds between the sexes. Men with IIH likely need to be followed more closely regarding visual function because they may not reliably experience or report other symptoms of increased intracranial pressure.

Mitochondrial oxidative phosphorylation in autosomal dominant optic atrophy

Background

Autosomal dominant optic atrophy (ADOA), a form of progressive bilateral blindness due to loss of retinal ganglion cells and optic nerve deterioration, arises predominantly from mutations in the nuclear gene for the mitochondrial GTPase, OPA1. OPA1 localizes to mitochondrial cristae in the inner membrane where electron transport chain complexes are enriched. While OPA1 has been characterized for its role in mitochondrial cristae structure and organelle fusion, possible effects of OPA1 on mitochondrial function have not been determined.

Results

Mitochondria from six ADOA patients bearing OPA1 mutations and ten ADOA patients with unidentified gene mutations were studied for respiratory capacity and electron transport complex function. Results suggest that the nuclear DNA mutations that give rise to ADOA in our patient population do not alter mitochondrial electron transport.

Conclusion

We conclude that the pathophysiology of ADOA likely stems from the role of OPA1 in mitochondrial structure or fusion and not from OPA1 support of oxidative phosphorylation.

Racial differences in idiopathic intracranial hypertension

OBJECTIVE

To evaluate racial differences in idiopathic intracranial hypertension (IIH).

METHODS

Medical records of all consecutive patients with definite IIH seen between 1989 and 2006 were reviewed. Demographics, associated factors, and visual function at presentation and follow-up were collected. Black patients were compared to non-black patients.

RESULTS

We included 450 patients (197 black, 253 non-black). Obesity, systemic hypertension, anemia, and sleep apnea were more common in black patients than in non-black patients (p </= 0.01). CSF opening pressure was higher in black patients (40 vs 34 cm CSF, p < 0.001). Visual acuity, visual field loss, and degree of papilledema at presentation and follow-up were worse in black patients (p </= 0.01). Diagnostic and therapeutic measures were similar between black patients and non-black patients, except for optic nerve sheath fenestration (p = 0.01) and lumbar puncture (p = 0.03), both more commonly performed on black patients. The relative risk of severe visual loss for black patients compared with non-black patients was 3.5 (95% CI 2.0 to 5.8, p < 0.001) in at least one eye and 4.8 (95% CI 2.1 to 10.9, p < 0.001) in both eyes. Logistic regression analysis supported race, anemia, body mass index, and male gender as independent risk factors for severe visual loss and suggested that racial differences may be partially accounted for by differences in CSF opening pressure, body mass index, and frequency of anemia.

CONCLUSION

Black patients with idiopathic intracranial hypertension (IIH) were more likely than non-black patients with IIH to have severe visual loss in at least one eye. This difference did not appear to result from diagnosis, treatment, or access to care, but may partially relate to differences in other risk factors. Black patients have a more aggressive disease and may need closer follow-up and lower thresholds for early intervention.

Perioperative visual loss after nonocular surgeries

PURPOSE

To review the current knowledge of persistent visual loss after nonocular surgeries under general anesthesia.

DESIGN

Perspective.

METHODS

Literature review.

RESULTS

The incidence of perioperative visual loss after nonocular surgeries ranges from 0.002% of all surgeries to as high as 0.2% of cardiac and spine surgeries. Any portion of the visual pathways may be involved, from the corneas to the occipital lobes, but the most common site of permanent injury is the optic nerves, and the most often presumed mechanism is ischemia. Anterior ischemic optic neuropathy (AION) is more prevalent among cardiac surgery patients and posterior ischemic optic neuropathy (PION) predominates among those who have had spine and neck procedures. Patients range from age five to 81 years and typically awake with severe bilateral visual loss. Multiple factors have been proposed as risk factors for perioperative ION, including long duration in the prone position, excessive blood loss, hypotension, anemia, hypoxia, excessive fluid replacement, use of vasoconstricting agents, elevated venous pressure, head positioning, and a patient-specific vascular susceptibility that may be anatomic or physiologic. However, the risk factors for any given patient or procedure may vary and are likely multifactorial.

CONCLUSIONS

If, when an ophthalmologist is consulted for a patient with perioperative visual loss, an obvious ocular cause is not apparent, urgent neuroimaging should be obtained to rule out intracranial pathology. Anterior and posterior ION should be considered and careful documentation is essential. Currently, the pathogenesis of perioperative ION remains unclear, and preventive and therapeutic measures remain elusive.

The "sunglasses sign" predicts nonorganic visual loss in neuro-ophthalmologic practice

OBJECTIVE

The aim of our study was to evaluate whether wearing sunglasses (the "sunglasses sign") can be used by neuro-ophthalmologists to predict nonorganic visual loss (NOVL) in their patients.

METHODS

We prospectively collected information on all new patients seen by us over 13 months. We included all patients who ultimately received a diagnosis of NOVL, and all patients wearing sunglasses in our clinic. We recorded demographics, iris color, number of positive review of systems, ocular examination, precipitating event or trauma, workers' compensation claims, disability and lawsuit related to the visual loss, and the reason for wearing sunglasses.

RESULTS

Among the 1,377 consecutive new patients seen in our clinic during the study, 34 patients wore sunglasses, among whom 7 (20.6%) had organic visual loss. During the study period, 59 patients were diagnosed with NOVL, among whom 27 (45.8%) wore sunglasses. The sensitivity of wearing sunglasses for NOVL was 0.46 (95% CI 0.33 to 0.59). The probability that a patient walking into our clinic had NOVL was 0.043 (95% CI 0.033 to 0.055); it increased to 0.79 (95% CI 0.62 to 0.91) in sunglasses patients. The specificity of sunglasses for the diagnosis of NOVL was 0.995 (95% CI 0.989 to 0.998). At least one of the following characteristics (highly positive review of systems, workers' compensation claim, disability, and lawsuit) was found in 26 of 27 (96.3%) of NOVL patients wearing sunglasses and in none of the sunglasses patients with organic neuro-ophthalmic disorders. All 7 sunglasses patients with organic neuro-ophthalmic disorders had reasonable ophthalmic explanations for wearing sunglasses.

CONCLUSION

The "sunglasses sign" in a patient without an obvious ophthalmic reason to wear sunglasses is highly suggestive of nonorganic visual loss.

The treatment of giant cell arteritis

Although giant cell arteritis (GCA) is a well-known vasculitis sensitive to corticosteroid-mediated immunosuppression, numerous issues of long-term therapeutic management remain unresolved. Because GCA encompasses a broad spectrum of clinical subtypes, ranging from devastating visual loss and neurological deficits to isolated systemic symptoms, the treatment of GCA must be adjusted to each case, and recommendations vary widely in the literature. This article systematically reviews the treatment options for patients with neuro-ophthalmic and neurological complications of GCA, as well as the evidence for possible adjuvant therapies for patients with GCA. Although there is no randomized controlled clinical trial specifically evaluating GCA patients with ocular and neurological complications, we recommend that GCA patients with acute visual loss or brain ischemia be admitted to the hospital for high-dose intravenous methyl-prednisolone, close monitoring, and prevention of steroid-induced complications. Aspirin may also be helpful in these cases. The evidence supporting the use of steroid-sparing immunomodulatory agents such as methotrexate for long-term management remains debated.

Post-traumatic visual loss

Visual loss following head trauma is common, and the diagnosis can be challenging for the neurologist called to perform an emergency room assessment. The approach to the patient with post-traumatic visual loss is complicated by a wide range of potential ocular and brain injuries with varying pathophysiology. In addition to direct injuries of the eye and orbit, traumatic optic neuropathies, carotid cavernous fistulas, and damage to the intracranial visual pathways are classic causes of visual loss after head trauma. This review provides an update on the diagnosis and management of these conditions.

A patient with headache and increased intracranial pressure

These 2 cases presented with acutely raised intracranial pressure and had characteristic CT and MRI changes.