Big red flags in neuro-ophthalmology

Optociliary shunt vessels in multiple sclerosis

BACKGROUND/INTRODUCTION

Optociliary shunt vessels develop as a result of chronic retinal venous obstruction. Optic neuritis has never been reported as a causative influence.

OBJECTIVE

To determine whether optic neuritis predisposes to the development of optociliary shunts in patients with multiple sclerosis.

CASES

This case series follows two patients with multiple sclerosis from August 1st, 2019 to April 24th, 2024, who developed optociliary shunt vessels after attacks of optic neuritis. A 43-year-old female presented with left visual loss and bilateral superior optociliary shunt vessels. Perimetry showed bilateral peripheral visual field loss. Optical coherence tomography showed bilateral retinal thinning and ganglion cell complex loss. Optical coherence tomography angiography showed reduced capillary density bilaterally. We investigated her and eventually diagnosed her with multiple sclerosis. The second, a 49-year-old female, developed right-sided optociliary shunt vessels after an episode of neuroretinitis. Perimetry revealed bilateral central scotomata; optical coherence tomography showed disc and retinal nerve fiber layer edema, and serous retinal detachment; later, ganglion cell complex loss; and reduced capillary density on optical coherence tomography angiography. Neuroimaging revealed demyelination in both, leading to a diagnosis of multiple sclerosis, and therapy was instituted.

CONCLUSIONS

We hypothesize, that demyelinating optic neuritis due to multiple sclerosis causes chronic retinal hypoperfusion, leading to subsequent optociliary shunt development in affected eyes. Our case series reveals that eyes with optic neuritis, both previous episodes and fresh cases, can contribute to sufficient retinal vein hypoperfusion to cause the development of optociliary shunts, which should be reported in the literature.

Long-Term Visual Function After Fractionated Stereotactic Radiotherapy for Primary Optic Nerve Sheath Meningioma: A Retrospective Analysis of 34 Subjects

Objective

To evaluate long-term visual function after fractionated stereotactic radiotherapy (FSRT) for primary optic nerve sheath meningioma (PONSM).

Methods

This 22-year retrospective study included 34 subjects (34 affected eyes) with PONSM who were treated with FSRT exclusively. Subjects with a history of biopsy/resection were excluded. Visual function, including visual acuity (VA) and visual field mean deviation (VF MD), was evaluated at presentation (pre-radiotherapy; pre-RT) and at the final follow-up (post-radiotherapy; post-RT); treatment complications were also evaluated. Treatment success was defined as either stabilization or improvement of visual function.

Results

The median pre-RT VA and pre-RT VF MD were 0.70 logarithm of the minimum angle of resolution (logMAR; range: 0.0–2.9 logMAR) and −15.4 decibels (dB) (range: −31.4 to −3.2 dB), respectively. The median total dose of FSRT was 50 Gy (range: 45–54 Gy) and the median number of fractions was 25 (range: 25–30). The median follow-up interval was 89 months (range: 6–251 months). The median post-RT VA and post-RT VF MD were 0.48 logMAR (range: 0.0–2.9 logMAR) (p = 0.010) and −6.8 dB (range: −20.6 to −1.6 dB) (p = 0.005), respectively. Among the 34 included eyes, VA was successfully treated in 29 eyes (85.3%) and worsened in 5 eyes (14.7%). Of the 14 eyes with both VA and reliable VF MD at pre-RT and post-RT time points, VF MD was successfully treated in 13 eyes (92.8%) and worsened in one (7.2%); overall visual function was successfully treated in 13 eyes (92.8%) and worsened in 1 eye (7.2%). Complications occurred in one subject (2.9%; radiation retinopathy).

Conclusion

Approximately 90% of PONSM subjects exhibited long-term treatment success in terms of VA, VF MD, and overall visual function after FSRT. Additionally, the incidence of complications was low. Therefore, FSRT is effective and safe treatment for PONSM.

Primary and Secondary Optic Nerve Sheath Meningioma

Objective  This study was aimed to review issues relating to the recognition, radiographic diagnosis, monitoring, and management of primary and secondary optic nerve sheath meningioma (ONSM). Design  This study is a review of peer-reviewed literature combined with illustrative case studies. Participants and Methods  A literature search was conducted via the PubMed database using pertinent search terms. Selected articles were limited to those written or translated into English. Additional works cited within articles were also included. Individual cases were drawn from the experience of a tertiary academic neuroophthalmic and orbital practice. Tables summarize radiotherapeutic and surgical studies, excluding single case reports and studies focusing on meningioma of intracranial origin. Main Outcome Measurements  Review of reported surgical and radiotherapeutic series is the primary measurement. Results  The natural history of optic nerve sheath meningiomas is primarily characterized by progressive ipsilateral vision loss. Diagnosis is typically based on radiographic imaging findings, with biopsy remaining indicated in some patients. Management strategies may include observation, radiation, and/or surgical intervention, or a combination of these approaches. The role of surgery, especially with respect to primary ONSM (pONSM), remains controversial. Advancement of radiotherapy techniques has shifted modern treatment paradigms in pONSM toward radiation as primary treatment, as surgical outcomes are inferior in major studies. Although radiation remains the treatment of choice in many cases, selected patients may benefit from surgery, especially in the setting of secondary ONSM (sONSM). Conclusion  A wide variety of radiotherapeutic and surgical treatment modalities for ONSM exist. The specific indications for each management strategy continue to be redefined.

Neuro-Ophthalmology at the Bedside: A Clinical Guide

Neuro-ophthalmological signs and symptoms are common in the emergency department but are a frequent source of diagnostic uncertainties. However, neuro-ophthalmological signs often allow a precise neuro-topographical localization of the clinical problem. A practical concept is presented how to perform a neuro-ophthalmological examination at the bedside and to interpret key findings under the aspect of emergency medicine with limited resources.

The swollen optic nerve: an approach to diagnosis and management

The differential diagnosis of swollen optic nerves differs according to whether the swelling is unilateral or bilateral, or whether visual function is normal or affected. Patients with a unilaterally swollen optic nerve and normal visual function most likely have optic nerve head drusen. Patients with abnormal visual function most likely have demyelinating optic neuritis or non-arteritic anterior ischaemic optic neuropathy. Patients with bilaterally swollen optic nerve heads and normal visual function most likely have papilloedema, and require neuroimaging followed by lumbar puncture. However, if their visual function is affected, the most likely causes are bilateral demyelinating optic neuritis, neuromyelitis optica spectrum disorder and anti-myelin oligodendrocyte glycoprotein optic neuritis: these patients require investigating with contrast-enhanced MRI of the orbits.

Unilateral recurrent periorbital pain: the role of the neuro-ophthalmologist

Unilateral recurrent periorbital pain is an aspecific symptom that may have originated from different orbital and ocular regions and structures that share the same innervation and can be provoked by different pathological disease. Since in some cases the patient is unable to associate with certainty the pain to a specific structure or region, a neuro-ophthalmological evaluation may be addressed to highlight signs useful to suspect the involvement of the eye, the optic nerve, the extra-ocular muscles, or intraorbital tissue or the cavernous sinus. This review describes the clinical patterns of periocular pain related to common ocular disease, orbital, or intracranial diseases.

Headaches attributed to visual disturbances

Ocular pain due to ophthalmological diseases is most commonly associated with redness and inflammation of the ocular surface and surrounding tissues. Pain in a quiet eye can be referred as headache and can be the first sign of a number of ocular or orbital conditions. Painful symptoms may be considered non-specific if signs of targeted diseases are not identified. Collection of appropriate history of pain around the eye and associated symptoms or signs should be considered to recognize when ophthalmological examination is needed. Some painful diseases such as intermittent angle closure glaucoma, uveitis or optic neuritis, can lead to severe and permanent visual loss and require a prompt diagnosis and treatment.

MRI in the Evaluation of Acute Visual Syndromes

Acute visual symptom emergencies occur commonly and present a challenge to both clinical and radiologic facets. Although most patients with visual complaints routinely require clinical evaluation with direct ophthalmologic evaluation, imaging is rarely necessary. However, there are highly morbid conditions where the prompt recognition and management of an acute visual syndrome (AVS) requires an astute physician to probe further. Suspicious symptomatology including abrupt visual loss, diplopia, ophthalmoplegia, and proptosis/exophthalmos require further investigation with advanced imaging modalities such as magnetic resonance imaging and magnetic resonance angiography. This review will discuss a variety of AVSs including orbital apex syndrome, cavernous sinus thrombosis, cavernous carotid fistula, acute hypertensive encephalopathy (posterior reversible encephalopathy syndrome), optic neuritis, pituitary apoplexy including hemorrhage into an existing adenoma, and idiopathic intracranial hypertension. A discussion of each entity will focus on the clinical presentation, management and prognosis when necessary and finally, neuroimaging with emphasis on magnetic resonance imaging. The primary purpose of this review is to provide an organized approach to the differential diagnosis and typical imaging patterns for AVSs. We have provided a template for radiologists and specialists to assist in early intervention in order to decrease morbidity and provide value-based patient care through imaging.

Foster Kennedy Syndrome: An Atypical Presentation

PURPOSE

To describe an unusual presentation of Foster Kennedy syndrome (FKS; unilateral optic nerve atrophy with optic nerve edema in the other eye) with optic nerve atrophy and retinal vein occlusion. It is an example of how common clinical features can hide a rare condition or presentation of a disease. Foster Kennedy syndrome is uncommon. Therefore, a space-occupying lesion should be suspected when there is optic atrophy associated with acute pathology of the other eye.

CASE REPORT

A 56-year-old man presented with hemiretinal retinal vein occlusion in his right eye. He had previous optic nerve atrophy in his left eye attributed to nonarteritic anterior ischemic optic neuropathy. He lacked cardiovascular or prothrombotic risk factors. Consideration was given whether the presence of contralateral optic atrophy was associated with the retinal vein occlusion. A computed tomographic scan revealed a suprasellar mass. The tumor was excised and identified as meningioma.

CONCLUSIONS

Although typical FKS would present with optic nerve atrophy and contralateral optic nerve edema secondary to an intracranial mass, in this case, edema was replaced by a hemiretinal vein occlusion. In optic atrophy that does not show characteristic visual field alterations, typical symptoms, or the classic evolution of a given disease, diagnostic imaging may reveal the etiology. As FKS is uncommon, when there is optic atrophy associated with acute pathology of the other eye, a space-occupying lesion should be suspected.

The application of optical coherence tomography in neurologic diseases

Optical coherence tomography (OCT) has become an increasingly popular tool in various disciplines of medicine, particularly ophthalmology and neurology. It is an imaging technology that has revolutionized the practice of ophthalmology by providing anatomic detail of pathologic changes in the retina and optic nerve. OCT is routinely used as an ancillary test that can aid in the diagnosis and monitoring of neuro-ophthalmic diseases such as papilledema, optic neuritis, and neuroretinitis. OCT measurements have also been shown to predict visual prognosis in compressive optic neuropathies. Changes in OCT measurements have been used to study the course of particular neurologic diseases such as multiple sclerosis, suggesting that the data obtained may be useful as a biomarker in diagnosing and treating neurodegenerative disease. We present an up-to-date review of the OCT findings in several diseases of neurologic interest and provide clinical examples pertinent to the general neurologist.