Hyperbaric oxygen therapy for nonarteritic anterior ischemic optic neuropathy.

PURPOSE: To evaluate the effectiveness of hyperbaric oxygen therapy in reducing optic nerve damage in acute nonarteritic anterior ischemic optic neuropathy. METHODS: Twenty-two eyes in 20 patients with acute nonarteritic anterior ischemic optic neuropathy were treated with hyperbaric oxygen (100% oxygen, 2.0 absolute atmospheres of pressure) in two 90-minute inhalation sessions per day for ten days. Changes in mean visual acuity and mean sensitivity loss were compared with those of 27 untreated control patients with acute nonarteritic anterior ischemic optic neuropathy, and proportions of patients with a change in acuity or mean sensitivity loss were compared with controls. Similar analysis was performed on subgroups based on time delay from symptom onset to therapy. RESULTS: Mean values for visual acuity were increased at final examination in both groups; although the increase was greater in controls, the difference was not statistically significant. Mean visual field sensitivity loss was minimally increased; although the increase was smaller in controls, the difference between groups was not significant. There was no significant difference between groups in proportions of patients with change in acuity score or mean sensitivity loss. Stratification by time delay to therapy did not suggest that treatment within nine days produced better visual results than that for either controls or those treated later. CONCLUSIONS: Hyperbaric oxygen therapy using 100% oxygen and 2.0 absolute atmospheres of pressure did not produce a significant improvement in visual acuity or visual field for patients with acute nonarteritic anterior ischemic optic neuropathy.

Fluorescein angiography in nonischemic optic disc edema.

OBJECTIVE: To determine whether nonischemic optic disc edema is associated with significant delay in fluorescein angiographic optic disc filling. METHODS: Fluorescein angiograms from 16 patients with acute papillitis, five with papilledema, and one with optic disc edema from orbital cavernous hemangioma were compared with those of age-matched controls. Early views of the optic disc were evaluated for onset of central retinal artery dye filling and both onset and completion of choroidal and prelaminar optic disc dye filling. Data were compared with our previously published figures for patients with nonarteritic anterior ischemic optic neuropathy (NAION) and a new group of patients aged 46 years and younger with NAION (NAIONy). Subgroup analysis was performed on data from patients with papillitis. RESULTS: Mean onset or completion of filling was not significantly delayed compared with controls for the central retinal artery, choroid, or prelaminar optic disc in patients with nonischemic optic disc edema, including the subgroup of patients with papillitis. In comparison, significant delay had been detected for onset and filling of prelaminar disc in typical NAION; similar significant delay was noted in this study for patients with NAIONy. No patients with nonischemic optic disc edema (including those with papillitis) demonstrated delay of disc filling by at least 5 seconds, while this feature was detected in 76% of patients with typical NAION and 62% of those with NAIONy. CONCLUSIONS: Optic disc filling delay is common in typical NAION and NAIONy; it is not a feature of nonischemic optic disc edema. This characteristic may aid in the differentiation of NAION from papillitis.

Magnetic resonance imaging of the brain in nonarteritic ischemic optic neuropathy.

We wished to determine whether the number of central nervous system (CNS) white matter lesions on magnetic resonance imaging (MRI) is increased in patients with nonarteritic ischemic optic neuropathy (NAION). T2-Weighted axial images of the brain in 13 patients with acute NAION and 16 age-matched controls were used to tabulate the number of subcortical and periventricular white matter lesions. Groups were compared by t test for means, the Wilcoxon-Mann-Whitney rank-sum test, and chi-square test for proportions with at least one lesion. The mean number of CNS white matter ischemic lesions in the NAION group was 4.0 (range 0-20) as compared to 1.4 (range 0-7) in the control group. The difference in these samples suggested a significant increase in NAION (p = 0.069, rank-sum test). The proportions of patients with at least one lesion were not significantly different (53.8% NAION vs. 56.3% controls). The data suggest an increased number of CNS white matter lesions in patients with NAION.

Metastasis of adenocarcinoma of the lung to optic nerve sheath meningioma.

A 71-year-old woman developed chronic progressive visual loss in the right eye and computed tomographic scan showed enlargement of the intraorbital optic nerve consistent with optic nerve sheath meningioma. Over 12 years, the contralateral optic nerve was not clinically affected, and serial neuroradiologic imaging showed no evidence of intracranial tumor extension. Death occurred from metastatic adenocarcinoma of the lung 14 years after initial visual loss. Examination of the postmortem specimen of optic nerve and chiasm revealed extradural extension of meningioma with spread to the region of the optic chiasm and hypothalamus. A large focus of metastatic adenocarcinoma was present within the intraorbital portion of the meningioma. Carcinoma metastatic to intracranial meningioma is rare; to our knowledge, this is the first reported case in an optic nerve sheath meningioma. Neuroimaging may be inadequate to predict the value of tumor excision in preventing intracranial spread of optic nerve sheath meningioma.

Natural history of nonarteritic anterior ischemic optic neuropathy.

Visual acuity and quantitative perimetry (Octopus Program 32) testing was performed in the acute (< 30 days after onset) and convalescent (> 3 months after onset) phases of disease in 27 patients with untreated NAION. Initial group mean acuity and sensitivity loss were compared to final values using the t test. Proportions of patients demonstrating a change of > 2 lines acuity or > 2 dB mean sensitivity were calculated. Patients were classified as either "progressive" (n = 6) or "stable" (n = 21) for purposes of additional subgroup analysis. There was no significant change in group mean visual acuity or field over time. Overall, significant worsening occurred in 11.1% for visual acuity and 22.2% for visual field; improvement occurred in 23.8% for acuity and 24.0% for field. Of 21 "stable" patients, none worsened for acuity and 4.7% showed late worsening of field; 31.3% showed significant improvement for acuity and 31.6% for field. No "progressive" patients demonstrated worsening or improvement after the initial progressive phase.

Fluorescein angiography in acute nonarteritic anterior ischemic optic neuropathy.

Fundus fluorescein angiograms from 41 patients with nonarteritic anterior ischemic optic neuropathy of less than three weeks' duration were compared with those from 43 age-matched control subjects. Patients with disease showed statistically significant delay in both the onset and the time to completion of prelaminar optic disk filling. Neither onset nor completion of peripapillary choroidal filling were markedly delayed when compared with control subjects. Frequency of occurrence of delayed filling within peripapillary choroidal watershed zones was not increased in patients with disease. There was no consistent correlation by quadrant between optic disk filling delay, choroidal filling delay, optic disk swelling or hyperfluorescence, and visual field deficit. No trend for change in characteristics was found with increasing time interval from onset of symptoms to performance of angiography. Fluorescein angiography in nonarteritic anterior ischemic optic neuropathy demonstrates delayed optic disk filling without consistent relation to adjacent peripapillary choroidal filling delay or other disease findings.

Results of inpatient and outpatient cataract surgery. A historical cohort comparison.

PURPOSE: The transition from inpatient to outpatient cataract surgery during the last decade was not accompanied by prospective investigation of its effect on visual outcomes or surgical complications. The authors performed this study to assess the impact of this transition on surgical results. METHODS: The authors reviewed 600 extracapsular cataract extractions performed by 4 experienced ophthalmic surgeons during a 36-month period; in 300 cases, patients were hospitalized after surgery (inpatient group), and, in 300 cases, patients were never hospitalized (outpatient group). The same surgical techniques were used in all cases. Visual outcome and rates for operative and postoperative complications were compared. RESULTS: There were no statistically significant differences between the inpatient and outpatient groups for visual acuity. Excluding patients with pre-existing nonlenticular ocular disease, a best-corrected visual acuity of 20/40 or better was achieved in 93.1% of inpatient cases and in 97.2% of outpatient cases 6 months after surgery. Postoperative, clinically apparent cystoid macular edema was more common in the inpatient group (P = 0.03); however, after exclusion of patients with diabetes, hypertension, age younger than 65 years, and eyes with pre-existing nonlenticular disease, there was no statistically significant difference between groups. No significant differences in rates for other operative and postoperative complications were identified, including wound dehiscence, unplanned postoperative filtering blebs, infectious endophthalmitis, retinal detachment, persistent iridocyclitis, glaucoma, and corneal edema. CONCLUSION: This study does not demonstrate that the transition to outpatient cataract extractions has had an adverse effect on surgical outcomes.

Accuracy of papilledema and pseudopapilledema detection: a multispecialty study.

BACKGROUND: Present trends in medical care suggest that primary care physicians will exert increasing control over patient access to medical specialty consultation and diagnostic testing. Therefore, it is important to determine whether primary care physicians can reliably identify papilledema. METHODS: A prospective study involving 429 physicians was undertaken to assess the accuracy of papilledema and pseudopapilledema detection by five groups of physicians, family practice physicians, neurologists, neuro-ophthalmologists, neurosurgeons, and ophthalmologists. RESULTS: Neuro-ophthalmologists and ophthalmologists did better than family physicians, neurologists, and neurosurgeons in identifying both papilledema and pseudopapilledema (P less than .05). Neuro-ophthalmologists more accurately identified pseudopapilledema than all other groups in the study (P less than .05). Family physicians did as well as, or better than, neurologists and neurosurgeons in identifying all classifications of acute and chronic papilledema defined in the study. Family physicians did not perform as well as the other four groups in differentiating pseudopapilledema from papilledema (P less than .05). CONCLUSIONS: Although the sensitivity of detecting papilledema was high (84.5%) for family physicians, the specificity was low (59.3%). Preliminary data indicate that family physicians with prior exposure to clinical ophthalmology in medical school did better than those who had not had training. It is possible that additional exposure to clinical ophthalmology during residency training might yield improved performance.

Spontaneous dural carotid-cavernous fistula with central retinal vein occlusion and iris neovascularization.

Spontaneous dural carotid-cavernous fistulas are dural vascular malformations that usually run a benign course. We present a case of a spontaneously occurring dural carotid-cavernous fistula complicated by central retinal vein occlusion and iris neovascularization that led to progressive visual failure.

Internuclear ophthalmoplegia in the Chiari type II malformation.

We describe 3 cases of Chiari type II malformation presenting with bilateral internuclear ophthalmoplegia (INO). Although prominent, the INO was not an isolated sign in any of the patients; superimposed abduction paresis was present in 2, and deficits in smooth pursuit, optokinetic nystagmus, and vestibulo-ocular responses were present in 3. Two had hydrocephalus: 1 was clinically unchanged without therapy after 5 years; the other did not improve with shunting. Findings in our 3 patients, along with the 4 previously reported, confirm that INO is 1 manifestation of widespread brainstem or cerebellar dysfunction. Its origin is probably multifactorial, related to hydrocephalus, vascular compromise, direct neuronal distortion, or congenital neural malformation.

Ophthalmology personnel in risk management. What office personnel need to know to keep you out of trouble.

The performance of staff in the ophthalmologist's office will influence the risk that an individual patient may someday file a medical malpractice complaint. Areas of identified risk include improper triage of emergency patients, abandonment, problems in confidentiality, improper maintenance of medical records, and perceived lack of compassion and skill on the part of staff members.

Reversible visual loss caused by fibrous dysplasia.

Fibrous dysplasia is a developmental anomaly of bone, often affecting the facial bones. We treated a patient who had fibrous dysplasia involving the right maxillary and sphenoid bones. The patient had a sudden loss of visual acuity to R.E.: counting fingers. Visual fields demonstrated a central scotoma, and retrobulbar neuritis was diagnosed. When vision failed to improve spontaneously, however, radiologic studies were performed. These showed compromise of the optic canal by bony proliferation and an apparent mucocele at the orbital apex. Surgical exploration disclosed fibrous dysplastic bone and a cystic structure overlying the optic nerve. Successful surgical excision of the cyst and debulking of the fibrous dysplasia resulted in visual acuity returning to R.E.: 20/25.

Orbital inflammation and optic neuropathies associated with chronic sinusitis of intranasal cocaine abuse. Possible role of contiguous inflammation.

Three cases of long-standing intranasal cocaine abuse were associated with orbitopathy or optic neuropathy. All three cases were characterized by chronic sinusitis. Histopathologic examination of involved sinus and orbital tissues revealed chronic and acute nonspecific inflammation, with no evidence of unusual infections or of idiopathic midline destructive disease. In two of the cases, there was radiographic evidence of contiguous orbital inflammation associated with sinusitis. The inflammatory orbital process in these two cases was steroid responsive, but in one case recurrent inflammation occurred in response to steroid tapering. One patient suffered a complete loss of vision in the involved eye due to fulminant orbital inflammation and optic nerve dysfunction.

Corectopia and lipoid proteinosis.

Lipoid proteinosis (Urbach-Wiethe disease) is a rare autosomal recessive disorder associated with deposition of hyalinised material in the skin, mucous membrane, and brain. Corectopia has not been described in this disorder. A case is presented of lipoid proteinosis with bilateral corectopia.

Contact-lens correction of aphakic infants and children: early behavioral and VEP results.

We studied 11 infants and young children fitted with contact lenses for correction of unilateral or bilateral aphakia. The visual-acuity estimates obtained from behavioral cues (alternate-cover test and central-fixation monitoring) were compared with results obtained from pattern-reversal visual-evoked potentials (VEP). We conclude that VEP may be more sensitive than behavioral observation for monitoring the visual progress in certain aphakic children.

The Rieger syndrome and a chromosome 13 deletion.

The Rieger syndrome, characterized by a prominent Schwalbe line, iris strands to the cornea, iris hypoplasia, dental abnormalities, facial malformations, and umbilical defects, is inherited in an autosomal dominant pattern. We studied a boy with the ocular features of the Rieger syndrome, micrognathia, and redundancy of the periumbilical skin. Chromosome analysis revealed an interstitial deletion of the long arm of chromosome 13 involving the distal region of band q14 through band q31. As there was a previous report of the Rieger syndrome in a child with an interstitial deletion of chromosome 13 (q12,q22), we suggest that a gene for this disorder may be located in the segment q14 to q22.