The effects of nasal lavage with betamethasone cream post-endoscopic sinus surgery: clinical trial.

BACKGROUND: Steroid nasal irrigation for chronic rhinosinusitis patients following endoscopic sinus surgery reduces symptom recurrence. There are minimal safety data to recommend this treatment. This study evaluated the safety of betamethasone nasal irrigation by measuring its impact on endogenous cortisol levels. METHODS: Participants performed daily betamethasone nasal irrigation for six weeks. The impact on pre- and post-intervention serum and 24-hour urinary free cortisol was assessed. Efficacy was evaluated using the 22-item Sino-Nasal Outcome Test. RESULTS: Thirty participants completed the study (16 females and 14 males; mean age = 53.9 ± 15.6 years). Serum cortisol levels were unchanged (p = 0.28). However, 24-hour urinary free cortisol levels decreased (47.5 vs 41.5 nmol per 24 hours; p = 0.025). Sino-Nasal Outcome Test scores improved (41.13 ± 21.94 vs 23.4 ± 18.17; p < 0.001). The minimal clinical important difference was reached in 63 per cent of participants. CONCLUSION: Daily betamethasone nasal irrigation is an efficacious treatment modality not associated with changes in morning serum cortisol levels. The changes in 24-hour urinary free cortisol levels are considered clinically negligible. Hence, continued use of betamethasone nasal irrigation remains a viable and safe treatment option for chronic rhinosinusitis patients following functional endoscopic sinus surgery.

Acute otitis media associated bilateral sudden hearing loss: case report and literature review.

BACKGROUND: Sudden sensorineural hearing loss is a rare otological condition with potential for dire outcomes including permanent hearing loss. Although the majority of cases are deemed idiopathic, bilateral sudden sensorineural hearing loss represents a rare subset typically related to systemic conditions, with higher morbidity and mortality. A controversial association with acute otitis media has been reported, with few bilateral cases published in the literature. CASE REPORT: A very rare case of bilateral sudden sensorineural hearing loss associated with acute otitis media is described, with a review of the literature. CONCLUSION: The limited evidence available suggests that acute otitis media with tinnitus and/or bacterial pathology may have an increased risk of sudden sensorineural hearing loss, which is consistent with the case described. Although there is no sufficiently powered published evidence to provide definitive treatment guidelines, the literature reviewed suggests that early myringotomy and antibiotics may greatly improve treatment outcomes.

The prevalence and symptoms of migraine in a consecutive series of patients attending an optometric practice.

The purpose of the investigation was to determine the prevalence of migraine in optometric practice and to document the variety of presentation. One thousand consecutively presenting patients of a suburban optometric practice were asked questions to establish whether they experience migraine or have experienced it in the past. Those with a history of migraine were asked further questions to establish the type of migraine and to document the variety of the symptoms they experienced. Eleven percent of male and 23% of female patients currently had migraine or had experienced it in the past. When corrected for the age distribution of the population of the state from which the sample was drawn, it is estimated that the general population prevalence of migraine is 9.5% for men and 19.7% for women. Half of the sample of migraineurs had not experienced a migraine within the last 12 months. A third had a known family history of migraine. Nearly half had not had a formal medical diagnosis of their migraine but only 7 had attended for optometric examination because of their migraine symptoms. Four of these patients had single migraine-like episodes and three had migraine equivalents (acephalic migraine, experiencing the visual aura without headache). Optometrists must be thoroughly familiar with migraine and its varied presentation because of its high prevalence, the explanatory value in offering a formal diagnosis of migraine, and the risk that headache or visual aura may be wrongly ascribed to migraine when there is some more sinister cause of the symptoms.

Keratoconus associated with continual eye rubbing due to punctal agenesis.

PURPOSE: To highlight a possible causal effect of eye rubbing in the etiology of keratoconus. METHODS: A 43-year-old man presented to the practice of one of the authors (I.F.G.) with the complaint of gradual onset reading difficulty. History revealed the patient to have experienced constant epiphora in the right eye throughout his life as a result of punctal agenesis, which necessitated frequent wiping of this eye. Vision in the patient's right eye had been reduced for approximately 20 years. RESULTS: Based on ocular examination, the patient was diagnosed as having unilateral keratoconus in the right eye. CONCLUSION: It is thought by some that keratoconus is associated with, or indeed caused by, persistent rubbing of the anterior eye. While a number of studies support a genetic basis for keratoconus in some patients, it is possible that mechanical factors play a role in the development of this condition in other patients. This paper presents a case of unilateral keratoconus, where there is a confirmed history of habitual eye rubbing and wiping of excess tears as a result of punctal agenesis in the ipsilateral eye, thereby suggesting a possible causal relationship of eye rubbing in the etiology of keratoconus.

Spontaneous internal jugular vein thrombosis and venous-stasis retinopathy.

A case is presented in-which the detection of venous-stasis retinopathy in one eye led to investigation of the carotid circulation. There were no neurologic symptoms of carotid insufficiency, and noninvasive tests failed to reveal significant carotid pathology. Digital subtraction angiography and carotid angiography demonstrated a carotid plaque of doubtful significance. At carotid endarterectomy, the venous-stasis retinopathy was found to be associated with venous thrombosis distant from the eye and in the internal jugular vein. This site is beyond the range over which isolated ocular vascular effects would be expected and was thought to be unrelated to the hemodynamically insignificant, nonulcerated carotid artery plaque. The possibility of this association being causal is discussed.

Should visual field examination be a routine part of ophthalmic practice?

Visual field screening conducted on indication was compared with routine visual field screening to determine the effectiveness of these strategies in identifying patients with normal and abnormal visual fields. The sample consisted of 1,500 consecutively presenting patients. Each patient was screened with the Friedmann Visual Field Analyser Mark II. Visual field defects were detected in 3.0% of eyes. Routine visual field screening detected a very high proportion of these defects. The two indications approaches which were tested achieved only slightly lower sensitivities and specificities, while necessitating that only approximately 20% of patients required screening. The most effective strategy for screening on indication was based on overall clinical assessment of each case, although the optimal criteria relied on low levels of suspicion.

Clinical significance of detecting visual field loss.

The clinical effect of detecting visual field loss was studied in 66 patients with visual field defects. Fifty-two percent of defects were the result of conditions which were themselves considered to be significant. Visual field results were considered to have made vital and important contributions to that diagnosis in 28% and 23% of cases, respectively. The results also brought about a change in the intended management strategy in 39% of cases, but were also helpful in another 35% of cases. It was concluded that the clinical importance of regular perimetric examination is emphasized by these results, which may in turn contribute to the detection of unexpected visual field defects.

An unusual ocular presentation of multiple sclerosis.

An unusual presentation of visual loss in multiple sclerosis is reported. The case is also noteworthy because the patient's presenting complaint appeared to be the result of insufficient or fatiguing accommodation. Had an unsuspected visual loss not been detected, the patient's management may have been inappropriate until more debilitating symptoms of the underlying cause became apparent.

The working threshold approach to Friedmann visual field analyser screening.

Central visual field screening of 2223 eyes without field defects was conducted with the Friedmann Visual Field Analyser Mark II. There was wide variation in the filter setting at which all stimuli were seen and in the working threshold relative to the recommended age filter. The ability to see all stimuli at settings higher than the age filter was found in 803 eyes (36.1%). The difference between mean working threshold and the age filter ranged from 0.22 to 0.40 log units, being greatest in middle age groups. The performance of the screener in correctly identifying normal eyes was thus improved with the working threshold approach, as the criterion for depression of sensitivity was an individually determined threshold.

A clinical comparison of the Friedmann visual field analyser and tangent screen perimetry.

The central visual fields of 44 optometric patients with known or suspected field defects were measured with the Friedmann Visual Field Analyser (FVA) and a 2-m tangent screen. The clinical correlation of visual field characteristics was at least adequate in more than 90% of eyes. Statistically significant correlations were also found between the area of scotoma found on the tangent screen and (1) the number of locations with reduced sensitivity and (2) the average reduction in sensitivity of the stimulated locations as determined by the FVA.

Optic nerve drusen and pseudopapilledema.

A case is presented in which unilateral visible optic nerve head drusen and a contralateral visual acuity loss are associated with moderate hypermetropia and the use of oral contraceptives. Optic nerve drusen are known to be responsible for visual field losses, but a reduction in visual acuity is a rare finding. Extensive investigation of this patient revealed no other cause for the visual acuity loss. However, the possibility of misdiagnosis of papilledema and papillitis is suggested by recent onset headache with unilateral visual acuity loss. A tentative diagnosis of buried drusen of the optic nerve in the affected eye is discussed.

PIP: The reported incidence of visible optic nerve drusen range from 3.4/1000-20.4/1000 in the general population, the discrepancy suggesting that many drusen are buried or are too small to be visible clinically. Drusen of the optic nerve head are an important consideration in the differential diagnosis of papilledema, papillitis, and pseudopapilledema. This case report describes a 22-year old white female patient with previously undetectedoptic nerve head drusen. She presented on June 20, 1979 for optometric examination with symptoms and signs suggestive of increased intracranial pressure or optic neuritis, namely reduced visual acuity, recent onset of severe headaches, central visual field loss, and an elevated right optic disc. The patient reported that her general health was good and she was not under any medical treatment; she was taking oral contraceptives for several years with no apparent side effects. Opthalmological examination and fluorescein angiography confirmed the appearance of both optic discs and the drusen in the right optic disc. Optic nerve drusen can cause visual field losses, but reduction in visual acuity is a rare finding. The pills were discontinued as a precaution. Neurological examination revealed no orbital, cranial, or ventricular abnormalities. The neurologist diagnosed muscle contraction (tension headache) and a tricyclic antidepressant was prescribed. In August 1980, visual acuities were unchanged but there was a reduction in the frequency and intensity of the headaches. This case associates unilateral visible optic nerve and head drusen and a contralateral visual acuity loss with moderate hypermetropia and pill use. Complication of pill use, such as venous thrombosis associated with papilledema was a possible diagnosis. However, there were several indications that the right optic disc elevation was in fact congenital anomalous elevation (pseudopapilledema) with drusen. The important point to remember is that anomalous elevation of disc with drusen and hypermetropia must not only be differentiated from papilldema and optic neuritis, but may also occur in association with these conditions.