Visual loss secondary to acquired immunodeficiency virus–related progressive multifocal leukoencephalopathy demonstrating clinical improvement with highly active antiretroviral therapy

Behavioral Consequences and Cortical Reorganization in Homonymous Hemianopia

The most common visual defect to follow a lesion of the retrochiasmal pathways is homonymous hemianopia (HH), whereby, in each eye, patients are blind to the contralesional visual field. From a behavioral perspective, in addition to exhibiting a severe deficit in their contralesional visual field, hemianopic patients can also present implicit residual capacities, now usually referred to collectively as blindsight. It was recently demonstrated that HH patients can also suffer from a subtle deficit in their ipsilesional visual field, called sightblindness (the reverse case of blindsight). Furthermore, the nature of the visual deficit in the contralesional and ipsilesional visual fields, as well as the pattern of functional reorganization in the occipital lobe of HH patients after stroke, all appear to depend on the lesion side. In addition to their contralesional and ipsilesional visual deficits, and to their residual capacities, HH patients can also experience visual hallucinations in their blind field, the physiopathological mechanisms of which remain poorly understood. Herein we review blindsight in terms of its better-known aspects as well as its less-studied clinical signs such as sightblindness, hemispheric specialization and visual hallucinations. We also discuss the implications of recent experimental findings for rehabilitation of visual field defects in hemianopic patients.

Progressive Multifocal Leukoencephalopathy: Recent Advances and a Neuro-Ophthalmological Review

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) is a severe often fatal opportunistic infection of the central nervous system caused by reactivation of a ubiquitous polyoma virus, JC virus. Although typically characterized by multifocal asymmetric subcortical white matter lesions, it may be monofocal and affect the cortical gray matter. Among the broad spectrum of clinical manifestations that occurs with PML, visual complaints are common.

EVIDENCE ACQUISITION

Combination of representative personally observed cases of PML and comprehensive review of case series of PML from 1958 through 2014.

RESULTS

Neuro-ophthalmic signs and symptoms were reported in approximately 20%-50% of patients with PML and can be the presenting manifestation in half of these. A majority of these presentations occur from damage to cerebral visual pathways resulting in visual field defects, cortical blindness, and other disorders of visual association. Given the decreased frequency of infratentorial and cerebellar involvement, ocular motility disorders are less common.

CONCLUSIONS

Visual complaints occur in patients with PML and are often the presenting sign. Awareness of this condition is helpful in avoiding unnecessary delays in the diagnosis of PML and management of the underlying condition. Recent guidelines have established criteria for diagnosis of PML in the high-risk patient population and strategies to mitigate the risk in these populations.

Rehabilitation of homonymous hemianopia: insight into blindsight

Strong evidence of considerable plasticity in primary sensory areas in the adult cortex, and of dramatic cross-modal reorganization in visual areas, after short- or long-term visual deprivation has recently been reported. In the context of patient rehabilitation, this scientifically challenging topic takes on urgent clinical relevance, especially given the lack of information about the role of such reorganization on spared or newly emerged visual performance. Amongst the most common visual field defects found upon unilateral occipital damage of the primary visual cortex is homonymous hemianopia (HH), a perfectly symmetric loss of vision in both eyes. Traditionally, geniculostriate lesions were considered to result in complete and permanent visual loss in the topographically related area of the visual field (Huber, 1992). However, numerous studies in monkeys, and later, in humans, have demonstrated that despite destruction of the striate cortex, or even following a hemispherectomy, some patients retain a certain degree of unconscious visual function, known as blindsight. Accordingly, there have recently been attempts to restore visual function in patients by stimulating unconscious preserved blindsight capacities. Herein we review different visual rehabilitation techniques designed for brain-damaged patients with visual field loss. We discuss the hypothesis that explicit (conscious) visual detection can be restored in the blind visual field by harnessing implicit (unconscious) visual capacities. The results that we summarize here underline the need for early diagnosis of cortical visual impairment (CVI), and the urgency in rehabilitating such deficits, in these patients. Based on the research precedent, we explore the link between implicit (unconscious) vision and conscious perception and discuss possible mechanisms of adaptation and plasticity in the visual cortex.

Histological effects of chronic administration of efavirenz on lateral geniculate body of adult Wistar rats

Background:

The effects of chronic administration of efavirenz commonly used as part of highly active antiretroviral therapy (HAART) for the treatment of Human Immunodeficiency Virus (HIV) type-1 on the weight of the brain and inferior colliculus of adult Wistar rats was carefully studied.

Methods and Materials

The rats of both sexes (n = 24), with average weight of 200g were randomly assigned into two treatment (A & B) (n=16) and Control (c) (n=8) groups. The rats in the treatment group received 600mg/70kg bogy weight of efavirenz dissolved in distilled water daily for 30days through the orogastric tube. The control group received equal volume of distilled through the same route. All rats were fed with grower's mash and given water liberally. The rats were sacrificed by cervical dislocation method on the thirty-first day of the experiment and the lateral geniculate body was carefully dissected out and quickly fixed in 10% formal saline for histological study.

Results

The findings indicate that rats in the treated group showed some cellular degenerative changes like sparse cellular population, pyknotic nuclei with some microcystic changes and edema in the stroma of the lateral geniculate body as compared to the control group.

Conclusion

Chronic administration of efavirenz may have an adverse effect on the visual sensibilities by affecting the microanatomy of the lateral geniculate body of adult Wistar rats. It is recommended that further studies aimed at corroborating these observations be carried out.

Central nervous system infections in immunocompromised patients: update on diagnostics and therapy

Infections of the central nervous system (CNS) are increasingly reported in patients with malignancies. Heavily immunocompromised patients like those after allogeneic stem cell transplantation (SCT) or previous T cell depleting treatment regimens (e.g. with fludarabine or alemtuzumab) are at highest risk for cerebral infections. The spectrum of causative organisms may vary greatly, depending on the underlying malignancy, its treatment and various other factors. Toxoplasma gondii and fungi are the leading causative organisms in patients after allogeneic SCT, but also viruses such as herpes simplex virus or JC virus may be detected in these patients. Definitive diagnosis of cerebral infection still remains a high challenge, although diagnostics have improved by the wide availability of imaging techniques and polymerase chain reaction in recent years. Novel therapeutic options are arising, particularly for fungal CNS infections. Here, we summarise aspects on epidemiology, clinical symptoms and prognosis of CNS infections in patients with malignancies. Additionally, we give an overview on the diagnostics and management of cerebral infections in these patients including evidence evaluation of efficacy of treatment.