Carotid-cavernous fistula: A potential treatable cause of bilateral abducens palsy and conjunctival hyperemia

OBJECTIVE

Carotid cavernous fistulas (CCFs) represent uncommon and anomalous communications between the carotid artery and the cavernous sinus.

MATERIALS AND METHODS

Case report RESULTS: We present the clinical details and successful management of a previously healthy 44-year-old patient who presented with one-month worsening headache, bilateral abducens palsy and conjunctival injection. Imaging modalities including magnetic resonance imaging (MRI) with contrast and digital subtraction angiography (DSA) facilitated the diagnosis of CCF. The patient underwent endovascular coiling of the CCF, leading to neurological recovery and symptom remission.

CONCLUSION

This case highlights the importance of promptly CCF diagnosis in patients with multiple cranial nerve palsies and conjunctival hyperemia. Moreover, it emphasizes the efficacy of endovascular coiling in achieving symptom remission.

Telltale Signs of Idiopathic Intracranial Hypertension With Normal Opening Cerebrospinal Fluid Pressure

Introduction

Idiopathic Intracranial Hypertension (IIH) with normal opening cerebrospinal fluid (CSF) pressure comprises a rare IIH variant.

Case Report

We report the case of a non-obese Caucasian woman, who presented with asymmetrical papilledema, typical IIH-findings on optic nerve sonography and brain magnetic resonance imaging (MRI), and was diagnosed with IIH despite normal opening CSF pressure. Following treatment with acetazolamide, a complete remission of her symptoms was achieved, accompanied by significant improvement of the fundoscopy findings.

Conclusion

Although normal opening CSF pressure in IIH patients is rare, clinicians should be aware of this IIH variant and promptly indicate IIH treatment in patients presenting with typical clinical symptoms and neuroimaging findings suggestive of IIH.

The influence of mild posterior capsular opacification on spectral domain optical coherence tomography retinal nerve fiber layer thickness

PURPOSE

Τo investigate whether Yag laser capsulotomy, in addition to restoring ocular media transparency, may also significantly alter retinal nerve fiber layer (RNFL) thickness analysis and spectral domain optical coherence tomography (SD OCT) indices and quality parameters, such as signal strength (SS), in patients with mild, diffuse posterior capsular opacification (PCO).

METHODS

Prospective interventional case series study which enrolled 28 patients with mild PCO and good baseline best-corrected visual acuity (BCVA). All patients underwent a complete ophthalmologic examination, including SD OCT RNFL thickness measurement prior to Yag laser capsulotomy. Following laser intervention, all patients repeated the same complete ophthalmic examination and results were recorded and analysed.

RESULTS

Mean RNFL thickness showed a significant postoperative increase from 89.6 to 94.1 μm (p = 0.01), which was also confirmed for superior (p = 0.041), nasal (p = 0.011) and inferior quadrants (p = 0.032). SS and BCVA were also significantly increased after laser treatment (p < 0.01). A significant positive correlation was observed between SS and mean RNFL thickness postoperatively (p = 0.043) but not preoperatively (p = 0.059). Similarly, a significant relationship was found between BCVA and average RNFL thickness after (p = 0.017) but not before (p = 0.457) laser intervention.

CONCLUSIONS

Our study suggests that the presence of even mild PCO may alter the sensitivity of SD-OCT acquisition and lead to inadvertent RNFL thickness underestimation. Clinicians should be alerted to this contingency and take it into consideration when evaluating various optic neuropathies with SD OCT, in pseudophakic eyes.

Optic disc drusen mimicking Idiopathic Intracranial Hypertension (IIH): rely on ultrasound

Optic nerve ultrasound is an established routine supplementary diagnostic tool for idiopathic intracranial pressure but it can also be helpful in avoiding misdiagnoses. We describe a case of an obese 15- year-old girl with persistent headaches, fundoscopic findings suggesting papilledema, normal brain imaging who underwent two lumbar punctures with unremarkable cerebrospinal fluid findings before ultrasound revealed optic disc drusen as the cause of the optic disc elevation.

Visual loss after treatment for idiopathic intracranial hypertension with lumboperitoneal shunting

Both idiopathic intracranial hypertension and intracranial cerebrospinal fluid hypotension, spontaneous or iatrogenic, display visual disturbances, including visual loss, visual field deficit, transient visual obscurations, and diplopia. We present a case of a long-standing idiopathic intracranial hypertension, primarily manifesting with visual disturbances and documented pre-existing concentric visual field deficit, treated with a lumboperitoneal shunt after conservative treatment failure, leading to an unexpected exacerbation of visual field deficit and acute visual loss, probably due to shunt catheter malfunction and subsequent intracranial hypotension. We provide a step-by-step documentation of cerebrospinal fluid volume and consequent intracranial pressure fluctuations effect on visual field alterations over a significant period of time, attempting an insight on pathogenetic mechanisms implicated in the relationship between intracranial pressure and optic nerve functionality. Interdepartmental collaboration in such cases could ensure prompt diagnosis and treatment, leading to the possibility of either halting the progression or even reversing established visual loss, sparing our patients from a lifetime disability and improving their quality of life.

Efficacy of intravitreal dexamethasone implant for the treatment of macular oedema after pars plana vitrectomy for rhegmatogenous retinal detachment: long-term outcomes

Purpose: To investigate the efficacy and safety of intravitreal dexamethasone implant as initial and only treatment for macular oedema after pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD).Methods: This study included 14 patients, who were diagnosed with macular oedema after PPV for RRD and who were treated with intravitreal dexamethasone implant. Patients were examined at the time of macular oedema diagnosis (baseline) and 1, 6 and 12 months after treatment, using best corrected visual acuity (BCVA) measurement and optical coherence tomography (OCT).Results: The mean BCVA at baseline was 0.72 ± 0.29 logMAR and improved significantly to 0.37 ± 0.21, 0.42 ± 0.19 and 0.35 ± 0.22 logMAR at month 1, 6 and 12 after treatment with dexamethasone implant. The mean central retinal thickness (CRT) was 623 ± 142 μm at baseline and decreased significantly to 339 ± 163 μm, 428 ± 131 μm and 356 ± 147 μm at month 1, 6 and 12 after treatment. Total resolution of macular oedema was observed in 10 out of 14 patients (71.4%) at month 12. Ellipsoid zone was intact in 71.4% of patients at the end of the follow-up, while 71.4% of patients received only one implant until the end of the 12-month follow-up. No adverse events were observed.Conclusions: Intravitreal dexamethasone implant was found to be effective and safe as initial treatment for macular oedema after PPV for RRD.

Follow-up of the retinal nerve fiber layer thickness of diabetic patients type 2, as a predisposing factor for glaucoma compared to normal subjects

PURPOSE

To evaluate and follow-up the retinal nerve fiber layer (RNFL) thickness in patients with diabetes mellitus type 2 compared to a group of healthy individuals with similar demographic characteristics.

PATIENTS AND METHODS

This is a prospective, noninvasive, observational case series study. For the purposes of the study, 27 eyes of diabetic patients without diabetic retinopathy, 24 eyes of patients with mild retinopathy, and 25 normal age-matched subjects (control group [CG]) were examined. All participants underwent complete ophthalmological examination and imaging with GDx variable corneal compensation scanning laser polarimetry. Follow-up was 2 years for all three groups.

RESULTS

The mean inferior average was statistically significantly lower in both diabetic groups compared to CG at baseline examination and during follow-up. The nerve fiber indicator (NFI) was higher in both diabetic groups compared to CG, both at baseline examination and during follow-up. The NFI was 21.7±11.9 and 22.0±11.8 for the diabetic group without retinopathy, 20.8±9.6 and 21.9±9.8 for the group with mild retinopathy, and 15.3±5.4 and 15.9±5.5 for the normal subjects, at baseline and 24 months, respectively. There was no statistically significant reduction of the RNFL thickness in all three groups compared to baseline examination.

CONCLUSION

This is the first long-term study documenting the RNFL thickness in diabetic patients in comparison with normal controls. Although the lower RNFL was found thinner in diabetics, the 2-year follow-up showed no significant reduction of RNFL thickness in all groups, indicating that RNFL damage may occur early in diabetic patients.

Comparison of the nerve fiber layer of type 2 diabetic patients without glaucoma with normal subjects of the same age and sex

BACKGROUND

The retinal nerve fiber layer (RNFL) thickness in patients with diabetes mellitus type 2 was compared to normal subjects of similar age and sex, having first excluded any risk factors for glaucoma. The correlation between the RNFL thickness and the severity of diabetic retinopathy was investigated at its primary stages and with other ocular and diabetic parameters.

METHODS

A prospective, case series study was carried out. Twenty-seven diabetic patients without diabetic retinopathy, 24 diabetic patients with mild retinopathy, and 25 normal, age-matched subjects underwent a complete ophthalmological examination and imaging with scanning laser polarimetry for the evaluation of the RNFL. Multivariate analysis was applied in order to investigate the correlation between RNFL and diabetic parameters, such as age, duration of diabetes, insulin therapy, levels of glycosylated hemoglobin; and ocular parameters, such as cup to disc ratio, levels of normal intraocular pressure, and central corneal thickness.

RESULTS

The mean inferior average of RNFL and the temporal-superior-nasal-inferior-temporal standard deviation were statistically significantly lower in both diabetic groups, and the nerve fiber index was higher (P=0.04) compared to the normal group. There was no statistically significant difference between the diabetic groups. The factor analysis showed no significant correlation between the RNFL and the previously mentioned diabetic and ocular parameters.

CONCLUSION

The existence of diabetes should be seriously considered in evaluating the results of scanning laser polarimetry. Multivariate analysis for RNFL was used for the first time.

New optical coherence tomography fundus findings in a case of beta-thalassemia

Patients with beta-thalassemia may present with an acquired diffuse elastic tissue defect due to degeneration of elastic tissue along with vaso-occlusive findings in the retinal microvasculature. Here we report the case of a patient with granular-like accumulation presenting as black sunburst lesions detected by optical coherence tomography (OCT). A 38-year-old man with beta-thalassemia intermedia associated with angioid streaks complained of deterioration of vision in both eyes. Funduscopic examination revealed small, round, hyperpigmented lesions bilaterally. During the early and late phases of fluorescein angiography, granular hyperfluoresence was present, associated with pigment decompensation and mottled-like hypofluorescence. The main OCT finding was the presence of granuloid-like accumulations at the retinal pigment epithelium level. Granule penetration was also noticed at the photoreceptor layer, while isolated granuloid-like accumulations were found in the inner layers of the macula and choroid. In this case, the new OCT finding was the granular-like hyperpigmented accumulations in the macula located at the level of the retinal pigment epithelium. To the best of our knowledge, our OCT findings show for the first time granuloid-like accumulations representing black sunburst lesions.