Psoriatic arthritis treatment and the risk of herpes zoster.

OBJECTIVES: To study the association between traditional disease-modifying antirheumatic drugs (c-DMARD) or anti-TNF-α agents and herpes zoster (HZ) in patients with psoriatic arthritis (PsA). METHODS: A retrospective cohort study was conducted in patients with PsA between 2002 and 2013. Patients were grouped as follows: no DMARDs (Group A); c-DMARDs (Group B); anti-TNF-α agents (Group C); anti-TNF-α agents in combination with c-DMARDs (Group D). Crude incidence rates (IR) were calculated as number of HZ episodes per 1000 patient-years. A Cox regression model was used to adjust for HZ risk factors (age, gender, steroid use, Charlson Comorbidity Index score, and previous treatment) in order to estimate their contribution to the risk of the first HZ event. RESULTS: The study included 3128 patients, mean age 50.26±14.54 years; 46.2% male. During a period of 20 096 person-years 182 HZ events were observed. The crude IR (95% CI) of HZ in the study population was 9.06 per 1000 patient-years, and in Groups A-D 7.36 (5.41 to 9.79), 9.21 (7.5 to 11.21), 8.64 (4.84 to 14.26), 17.86 (10.91 to 27.58), respectively. In a multivariate analysis, age (HR 1.01, 95% CI 1.00 to 1.02), treatment with steroids (HR 1.08, 95% CI 1.04 to 1.13), and a combination of anti-TNF-α agents and c-DMARDs (HR 2.37, 95% CI 1.32 to 4.22) were significantly associated with HZ events. CONCLUSIONS: In our database, the risk of HZ was significantly increased with age, treatment with steroids, and combination of anti-TNF-α agents and c-DMARDs, but not with c-DMARDs or anti-TNF-α therapy alone. Time to HZ event was shorter in patients treated with anti -TNF-α agents.

Sustained motion perception deficit following optic neuritis: Behavioral and cortical evidence.

OBJECTIVE: To assess the recovery process in patients after an acute optic neuritis (ON) attack, comparing static and dynamic visual functions. METHODS: In this prospective controlled study, 21 patients with unilateral, first-ever ON were followed over the course of 1 year. Standard visual tests, visual evoked potentials, and optical coherence tomography were assessed repeatedly. In addition, we developed a novel set of motion perceptual tasks to test dynamic visual deficits. fMRI examinations were performed to study the neuronal correlates for the behavioral findings. RESULTS: Four months after the acute phase, the affected eyes had returned to normal performance levels in the routine visual testing. However, motion perception remained impaired throughout the 12-month period. In agreement with the clinical findings, fMRI studies showed recovery in cortical activation during static object recognition, as opposed to sustained deficit in tasks that require motion perception. CONCLUSIONS: Sustained motion perception deficit following ON may explain the continued visual complaints of patients long after recovery of visual acuity. Cortical activation patterns suggest that if plastic processes in higher visual regions contribute to the recovery of vision, this may be limited to static visual functions. Alternatively, cortical activation may reflect the visual percept (intact for visual acuity and impaired for motion perception), rather than demonstrating plastic processes. We suggest that motion perception should be included in the routine ophthalmologic tests following ON.

Normal form from biological motion despite impaired ventral stream function.

We explored the extent to which biological motion perception depends on ventral stream integration by studying LG, an unusual case of developmental visual agnosia. LG has significant ventral stream processing deficits but no discernable structural cortical abnormality. LG's intermediate visual areas and object-sensitive regions exhibit abnormal activation during visual object perception, in contrast to area V5/MT+ which responds normally to visual motion (Gilaie-Dotan, Perry, Bonneh, Malach, & Bentin, 2009). Here, in three studies we used point light displays, which require visual integration, in adaptive threshold experiments to examine LG's ability to detect form from biological and non-biological motion cues. LG's ability to detect and discriminate form from biological motion was similar to healthy controls. In contrast, he was significantly deficient in processing form from non-biological motion. Thus, LG can rely on biological motion cues to perceive human forms, but is considerably impaired in extracting form from non-biological motion. Finally, we found that while LG viewed biological motion, activity in a network of brain regions associated with processing biological motion was functionally correlated with his V5/MT+ activity, indicating that normal inputs from V5/MT+ might suffice to activate his action perception system. These results indicate that processing of biologically moving form can dissociate from other form processing in the ventral pathway. Furthermore, the present results indicate that integrative ventral stream processing is necessary for uncompromised processing of non-biological form from motion.

Visual failure and recovery after thrombosis of a giant carotid ophthalmic aneurysm following vascular bypass and carotid artery ligation.

Thrombosis via Hunterian ligation, with or without high-flow bypass, is the definitive treatment for unclippable giant aneurysms; however, secondary deterioration may occur. We present a 67-year-old woman with an unclippable giant (33mm) carotid ophthalmic aneurysm. High-flow external carotid artery to middle cerebral artery bypass and proximal cervical internal carotid artery Hunterian ligation achieved complete thrombosis. Subsequent expansion of the thrombosed aneurysm created mass effect with hydrocephalus, leading to marked cognitive and visual decline. Aneurysmal decompression led to improved vision and near-normal neurological function.

Differing causal roles for lateral occipital cortex and occipital face area in invariant shape recognition.

The human extrastriate visual cortex contains functionally distinct regions where neuronal populations exhibit signals that are selective for objects. How such regions might play a causal role in underpinning our ability to recognize objects across different viewpoints remains uncertain. Here, we tested whether two extrastriate areas, the lateral occipital (LO) region and occipital face area (OFA), contained neuronal populations that play a causal role in recognizing two-dimensional shapes across different rotations. We used visual priming to modulate the rotation-sensitive activity of neuronal populations in these areas. State-dependent transcranial magnetic stimulation (TMS) was applied after the presentation of a shape and immediately before a subsequent probe shape to which participants had to respond. We found that TMS applied to both the LO region and OFA modulated rotation-invariant shape priming but, whereas the LO region was modulated by TMS for small rotations, the OFA was modulated for larger rotations. Importantly, our results demonstrate that a node in the face-sensitive network, the OFA, participates in causally relevant encoding of non-face stimuli.

Elevated healthcare utilisation in young adult males with obstructive sleep apnoea.

The aim of the present study was to explore morbidity and healthcare utilisation among young adult males with obstructive sleep apnoea (OSA) compared with middle-aged OSA patients over the 5-yr period preceding diagnosis. A prospective case-control study was performed; 117 young (22-39-yr-old) males with OSA were matched with 117 middle-aged (40-64-yr-old) OSA males for body mass index, apnoea/hypopnoea index, arterial oxygen saturation, arousal and awakening index, and Epworth Sleepiness Scale score. Each OSA patient was matched with controls by age, geographic area and physician. Young adult males with OSA showed no increase in specific comorbidity compared with controls. Middle-aged OSA patients exhibited increased risk of cardiovascular disease. Healthcare utilisation for the 5-yr period was >or=1.9 times higher among young and middle-aged male OSA patients than among controls. Multiple logistic regression analysis revealed that hyperlipidaemia in young adults and a body mass index of >37 kg x m(-2) and cardiovascular disease in middle-aged adults are the only independent determinants of the upper third, most costly, OSA patients. Compared with middle-aged males with obstructive sleep apnoea, in whom increased expenditure was related to cardiovascular disease and body mass index, utilisation was not related to any specific disease in younger cases.

Rathke's cleft cyst abscess.

Pituitary abscesses are rare. Occasionally they will arise in pre-existing pituitary pathology. We report such an occurrence within a Rathke's cleft cyst. On the basis of history and imaging, this was indistinguishable from more commonly encountered pituitary pathology.

Minocycline treatment and pseudotumor cerebri syndrome.

PURPOSE: To demonstrate the association between minocycline treatment and development of the pseudotumor cerebri syndrome. METHODS: A retrospective study was conducted of 12 patients from five neuro-ophthalmic referral centers who developed pseudotumor cerebri syndrome after being treated with standard doses of minocycline for refractory acne vulgaris. The main outcome measures included resolution of headaches, transient visual obscurations, diplopia, papilledema, and visual fields static thresholds after withdrawal of minocycline and treatment for increased intracranial pressure. RESULTS: Nine (75%) of the 12 patients developed symptoms of the pseudotumor cerebri syndrome syndrome within 8 weeks of starting minocycline therapy; six were not obese. Two patients developed symptoms only after a year had elapsed because of commencement of treatment with minocycline. One patient was asymptomatic, and pseudotumor cerebri syndrome was diagnosed by finding papilledema on routine examination 1 year after minocycline was started. None of the patients developed recurrences for at least 1 year after the discontinuation of minocycline and treatment for increased intracranial pressure, but three (25%) of the 12 patients had substantial residual visual field loss. CONCLUSION: Minocycline is a cause or precipitating factor in pseudotumor cerebri syndrome. Although most patients have prominent symptoms and are diagnosed promptly, others are asymptomatic and may have optic disk edema for a long period of time before diagnosis. Withdrawal of minocycline and treatment for increased intracranial pressure lead to resolution of the pseudotumor cerebri syndrome, but visual field loss may persist.

Recurrent abducens nerve palsy caused by dolichoectasia of the cavernous internal carotid artery.

PURPOSE: To describe a 59-year-old patient who had seven recurrent, self-limited episodes of isolated ipsilateral abducens nerve palsy in the previous 4 years. Each episode lasted between 2 and 5 weeks. METHODS: Systemic examination and neuroimaging studies were performed. RESULT: Repeated comprehensive examination failed to demonstrate any ocular or systemic condition apart from a lateral protrusion by dolichoectasia of the posterior portion of the cavernous left internal carotid artery, compressing the posterior left cavernous sinus. CONCLUSION: Numerous self-limited episodes of sixth nerve palsy may be associated with structural abnormalities of the intracranial carotid vasculature.

Control of Colletotrichum acutatum in Strawberry Under Laboratory, Greenhouse, and Field Conditions.

Various fungicides and a heat treatment were assessed for their ability to control strawberry anthracnose caused by the fungus Colletotrichum acutatum under laboratory, greenhouse, and field conditions. The effective dose causing 50% inhibition of mycelial growth (ED50) was 30.5, 12.2, 0.2, 0.15, 0.05, 0.07, and 0.05 µg/ml for the fungicides folpet, captan, propiconazole, difenoconazole, combined prochloraz-Zn/folpet, prochloraz-Zn, and prochloraz-Mn, respectively. In laboratory experiments, infection in segments of strawberry runners treated with pro-chloraz-Zn reached 60%, which was significantly reduced as compared to combined prochloraz-Zn/folpet (90%), captan, folpet, and water controls (100%). In the greenhouse, numbers of naturally infected transplants killed were significantly reduced by all fungicides and the heat treatment (5 min at 49°C) as compared to the non-treated control. Prochloraz-Zn was the most effective chemical control treatment but did not differ significantly from the heat treatment. In field experiments conducted during 1995 and 1996, numbers of naturally infected strawberry transplants killed were significantly reduced by all fungicide treatments relative to the non-treated control. Percent reduction of transplant mortality in the field was 93.3, 93.1, 66.7, 37.7, and 29.1 for prochloraz-Mn, prochloraz-Zn, combined prochloraz-Zn/folpet, propiconazole, and difenoconazole, respectively.

Varied clinical spectrum of necrobiotic xanthogranuloma.

Four cases are presented that illustrate a wide spectrum of ophthalmologic and systemic features of necrobiotic xanthogranuloma (NXG). Case 1 initially had signs of Cogan syndrome, and then developed chronic lymphocytic leukemia. Case 2, the first case of NXG to undergo autopsy, had progressive cicatricial lid retraction and corneal perforation. Case 3 had a more typical presentation of diplopia and blepharoptosis caused by orbital and periorbital infiltrative masses. Case 4 had nondeforming periocular skin lesions over a 6-year period. In all four cases, the diagnosis was made on the basis of characteristic histopathologic and laboratory findings. Although the cause of NXG is still obscure, in many cases it appears to be a forerunner of lymphoproliferative diseases.

Visual loss in tuberous sclerosis.

Of 11 patients with tuberous sclerosis complex (TSC) treated from 1980 to 1990 for obstructive hydrocephalus secondary to subependymal giant-cell astrocytoma, four had adequate documentation to determine visual outcome. Despite surgical relief of elevated intracranial pressure in all cases, two patients sustained further visual loss. In one patient, visual loss was arrested, and in one patient, it was prevented. Although hydrocephalus is uncommon in TSC, its effects on the optic nerves are serious and eventually irreversible. Because TSC patients may not be able to express early symptoms of increased intracranial pressure, periodic ophthalmologic examination and brain imaging may be advisable when a subependymal lesion has been identified.

Progression of diabetic retinopathy after cataract extraction.

The course of diabetic retinopathy following cataract extraction was studied retrospectively in 89 patients (89 eyes). Cataract extraction was extracapsular in 12 eyes (13.5%), extracapsular with intraocular lens implantation in 37 (41.6%), and intracapsular in 40 (45%). In 55 eyes (61.8%) there was no change in the retinal status after surgery, and in 34 (38.2%) there was progression of diabetic retinopathy. In the eyes showing progression there was appearance or aggravation of non-proliferative changes in 85.3% and development of proliferative diabetic retinopathy in 14.7%. Most of these eyes (91%) deteriorated within six months of surgery. Risk factors for the progression of diabetic retinopathy were the preoperative existence of diabetic retinopathy (p less than 0.005) and the need for antidiabetic agents in addition to dietary control in the management of diabetes (p less than 0.025).

Course of diabetic retinopathy following cataract surgery.

Five patients with mild to moderate retinopathy to both eyes underwent complication-free cataract surgery in one eye. Within three months of surgery deterioration of the retinopathy was observed in the operated eye only. In four patients there was an increase of intraretinal haemorrhages and hard exudates, accompanied by clinically significant macular oedema manifested as retinal thickening and extensive fluorescein leakage from both the macular and the peripapillary capillary networks. Of these four patients one also developed retinal ischaemia, evident ophthalmoscopically by flame-shaped haemorrhages and cotton-wool spots and angiographically by areas of capillary non-perfusion. The fifth patient showed proliferation of new blood vessels and vitreous haemorrhage. Diabetic patients scheduled for cataract surgery should undergo a thorough preoperative evaluation of any existing retinopathy. Postoperatively they should be followed up at close intervals so that any progression of retinopathy can be promptly detected and considered for laser treatment.

Isolated foveal hypoplasia.

Fifteen patients presented with foveal hypoplasia as an isolated ocular finding. The characteristic findings associated with this entity are a visual acuity of 6/21 or worse, nystagmus, and a typical ophthalmoscopic appearance of the macular area, including absent or abnormal maculofoveal reflexes, unclear definition of the maculofoveal area, and capillaries running abnormally close to the presumed macular area, some of them even crossing the horizontal meridian. Fluorescein angiography revealed a variable and incomplete filtering effect of the choroidal fluorescence in the macular area, suggesting abnormalities in the amount and distribution of macular pigments. The fundal findings of isolated foveal hypoplasia, although typical, are very subtle and often difficult to detect, especially because of the accompanying nystagmus. For this reason we suspect that foveal hypoplasia may be more common than is generally believed.

Eye injuries and ocular protection in the Lebanon War, 1982.

There was a high incidence of ocular trauma (6.8% of all casualties) in the Lebanon War, 1982, which is similar to the rates in previous Arab-Israeli wars. Combat in the Lebanon War consisted of both armored warfare and infantry operations, with much of the fighting taking place in built-up areas. Consequently, there were two main types of ocular injuries: perforating eye injuries caused by the small high-velocity missiles that characterize armored combat, and a wide range of injuries to the eye caused by ricochets during combat in built-up areas. The latter injuries varied in severity from complete destruction of the eye to minor corneal erosions. Not a single eye was injured in soldiers who had ballistic protective goggles properly placed over the eyes at the time of injury. Most of the ocular trauma could have been prevented had the goggles been in universal use. A considerable degree of eye protection is also afforded by ordinary ophthalmic eyeglasses.

Shallow anterior chamber and uveal effusion after nonperforating trauma to the eye.

Three patients (a 51-year-old man, an 8-year-old boy, and a 70-year-old man) developed shallowing of the anterior chamber and uveal effusion after blunt ocular injuries. After treatment with antibiotics (all three patients), corticosteroids (one patient), a mydriatic-cycloplegic solution (two patients), and antiglaucoma drugs (one patient), the shallowing and uveal effusion resolved. Because resolution occurred within two weeks in all three cases, surgical intervention was unnecessary. Both hypotony, which is common after nonpenetrating ocular injuries, and shallowing of the anterior chamber, which is rare, may result from localized uveal effusion that is clinically undetectable.