Case Series: Glioblastoma Highlighting the Eye Care Provider's Role.

SIGNIFICANCE: Although the incidence of glioblastoma is relatively low, patients presenting with this malignant central nervous system tumor will typically experience visual symptoms. Eye care providers are uniquely positioned to assist with the diagnosis of glioblastoma and to manage its associated visual symptoms. PURPOSE: This case series will review the pathophysiology, diagnosis, treatment, and management of glioblastoma while highlighting the eye care provider's role over the course of the disease process. CASE REPORTS: Three patients with glioblastoma are presented: a 63-year-old White man with new onset of headache and blurred vision upon awakening, a 65-year-old White man with a weeklong history of peripheral vision deficit and neurological symptoms, and a 65-year-old White woman with visual field deficit and visual perception difficulties related to a known history of glioblastoma. CONCLUSIONS: It is incumbent upon eye care providers to recognize examination findings such as new neurological symptoms and/or visual field defects that may warrant additional workup. In addition, eye care providers can serve a palliative role by maximizing the patient's remaining visual function and thereby quality of life.

Case Report: Atraumatic Orbital Emphysema after Bronchoscopy with Endobronchial Biopsy.

SIGNIFICANCE: Orbital emphysema is a well-documented condition where air enters the orbital soft tissue typically because of direct or indirect trauma; however, atraumatic cases can be encountered. The following is a novel case report of acute unilateral atraumatic orbital emphysema 24 hours after bronchoscopy with endobronchial biopsy. PURPOSE: To the best of the authors' knowledge, this is the first known case report of atraumatic orbital emphysema as a postprocedure complication of bronchoscopy with endobronchial biopsy in the literature. CASE REPORT: A 74-year-old man presented with painless swelling of the left upper and lower eyelids upon awakening. The patient had a history of bronchoscopy and endobronchial biopsy with conscious sedation for a right upper lobe lung mass 24 hours before the visit. Slit-lamp examination revealed air entrapment in the left upper and lower lids with enlarged subconjunctival air pockets of the left eye. Head and maxillofacial computed tomography without contrast revealed extensive emphysema tracking and dissecting along the subcutaneous and deep soft tissue spaces of the neck and face that was more pronounced along the left side. The patient was admitted for overnight observation and prescribed a prophylactic oral course of 250 mg of azithromycin daily for 2 days by the attending hospitalist. The subsequent follow-up visit 3 days later revealed complete resolution of signs and symptoms. CONCLUSIONS: This case report demonstrates the importance of considering orbital emphysema in patients with a history of recent bronchoscopy with endobronchial biopsy. Clinicians should be aware of this potential complication and refer for appropriate testing and comanagement.

Anoxic Brain Injury Secondary to Metabolic Encephalopathy.

PURPOSE: To discuss the clinical case of a patient suffering visual dysfunction secondary to a metabolic brain injury, the patient's visual rehabilitative treatment, and outcomes. CASE REPORT: A 24-year-old Caucasian male presented to the Southern Arizona Veteran's Affairs Healthcare System's Traumatic Brain Injury (TBI) eye clinic for evaluation and treatment of visual dysfunction secondary to an anoxic brain injury suffered 4 months before. Symptoms included persistent right homonymous hemianopia, oculomotor dysfunction, and a visual information processing deficit. After 5 weeks of vision rehabilitation, the patient was reassessed and displayed significant improvement in both signs and symptoms. CONCLUSIONS: The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a metabolic syndrome that causes hyponatremia and, in severe cases, encephalopathy and anoxic brain injury. Damage to the visual pathways can produce visual field, ocular motility, and binocular vision deficits. Comprehensive treatment including rehabilitative vision therapy bolstering the natural neuroplasticity process can provide improvements in patients' quality of life.

Arteriole tortuosity associated with diabetic retinopathy and cholesterol.

PURPOSE: Earlier identification of diabetic eye disease is an important research effort. Retinopathy is widely acknowledged but retinal vessel changes are not evaluated as stringently. Here, we create a multivariate model for the association between retinal vessel tortuosity (RVT) and other health factors in patients with diabetes. METHODS: Three hundred eyes of 150 patients with diabetes were included. Three investigators independently reviewed telemedicine fundus photographs and scored the level of diabetic retinopathy (DR) and RVT. These scores were evaluated for agreement and averaged. Also collected were age, duration of diabetes, presence or absence of diabetic nephropathy or neuropathy, blood pressure, total cholesterol, and hemoglobin A1c. A regression model evaluating the association of tortuosity with other factors was created. RESULTS: There was very high agreement between the three graders for level of DR (κ = 0.84). Agreement between the three graders for RVT varied substantially: poor for venous tortuosity (κ = 0.23) and fair for arteriole tortuosity (κ = 0.44) and overall gut tortuosity (κ = 0.42). The overall gut tortuosity was the most reproducible for the graders with a correlation coefficient of 0.923. There were univariate associations between arteriole tortuosity and venous tortuosity, DR level, and cholesterol. The selected best multivariate model found arteriole tortuosity to be associated with DR and cholesterol levels. CONCLUSIONS: First, RVT, particularly for venules, is difficult to grade consistently; therefore, future studies examining tortuosity should focus on arterioles. Second, the model indicates that there is an association between vessel changes, DR, and systemic cholesterol levels. Although DR and RVT are readily available to assess concurrently on a photograph, the addition of cholesterol to this model indicates that patients with RVT may warrant further follow-up on health factors, such as cholesterol levels.

Bevacizumab in conjunction with panretinal photocoagulation for neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a type of secondary angle-closure glaucoma that can result from severe retinal ischemia, such as proliferative diabetic retinopathy. Vascular endothelial growth factor (VEGF) plays a role in ocular neovascularization, which can result in NVG. The use of bevacizumab, an anti-VEGF antibody, has been shown to lead to the rapid resolution of ocular neovascularization and may be used off-label in conjunction with panretinal photocoagulation in the treatment of neovascular glaucoma. CASE REPORT: A 71-year-old man presented with neovascular glaucoma in both eyes secondary to proliferative diabetic retinopathy and was treated with both panretinal photocoagulation and an intravitreal injection of bevacizumab, which led to the rapid resolution of his iris neovascularization. A follow-up examination after 12 months showed that there was no recurrence of neovascularization. CONCLUSION: This case shows the possible beneficial effects of bevacizumab in conjunction with panretinal photocoagulation as a treatment option for neovascular glaucoma.