Suprasellar germinoma and late perioptic seeding.

PURPOSE: To report an unusual case of optic nerve seeding 12 years following treatment of a suprasellar germinoma. METHODS: Observational case report. RESULTS: A 34-year-old woman presented with a 3-week history of subjective right eye visual loss. She had been diagnosed with a suprasellar germinoma at 22 years of age, which had been partially excised and radiated (5400 cGy). The tumor had shown complete radiographic regression without neurologic sequelae. Pertinent findings on current examination included right eye visual acuity of 20/150, right relative afferent papillary defect, and optic nerve pallor in the right eye. In addition, partial left facial paralysis was noted. Examination was otherwise unremarkable including 20/20 acuity in the left eye. Magnetic resonance imaging demonstrated abnormal enhancement and thickening of both optic nerves and along the course of the left V and VII cranial nerves. Serum levels of alpha-fetoprotein and beta-HCG were abnormal, consistent with metastatic germinoma. Following two cycles of chemotherapy (VIP-etoposide, ifosfamide, and cisplatin), visual acuity returned to 20/20 bilaterally, with corresponding radiographic improvement and normal cerebrospinal fluid cytology. CONCLUSIONS: Perioptic subarachnoid seeding may occur over a decade after presumed successful treatment of germinomas, suggesting the importance of lifelong observation.

Severe surfing-related ocular injuries: the Stanford Northern Californian experience.

There is a growing body of literature describing severe surfing-related ocular injuries that result in permanent vision loss. We describe three severe surfing-related ocular injuries that occurred on beaches in northern California. One particular case stresses the need to tailor treatment to the patient and injury because of the possibility of good outcomes despite severe injury. Attention should also be directed towards commercially available safety gear and providing additional safety measures to prevent other orbital and ocular injuries.

Estimating visual acuity by character counting using the Snellen visual acuity chart.

PURPOSE: This study examines visual acuity estimation with character counting, which can be used in subjects with nonorganic visual loss. METHODS: The right eyes of 35 healthy subjects were fogged with plus lenses and tested with the Snellen visual acuity chart (Reichert 11180). Visual acuity and counting level were assessed under various degrees of fogging, up to a maximal fogged acuity of 20/200. Counting level was defined as the smallest line that subjects could count the number of characters correctly. For each counting level, the visual acuity that 95% of subjects could see equal to or better than was determined. RESULTS: A counting level of 20/10 estimates (ie 95% chance) a visual acuity equal to or better than 20/30. Counting levels 20/15, 20/20, and 20/25 estimate visual acuities of at least 20/50, 20/80, and 20/80, respectively. Counting levels 20/30-20/60 estimate a visual acuity of at least 20/200. CONCLUSIONS: Character counting appears to be a useful technique of obtaining a rough estimate of visual acuity in subjects unable to be tested by standard methods, such as those with non-organic visual loss.

Aniridia and optic nerve hypoplasia.

BACKGROUND: This study evaluates, in patients with aniridia, the prevalence of optic nerve hypoplasia and its association with foveal hypoplasia. METHODS: The medical records of 56 patients with aniridia (31 female, 25 male, mean age 33 years, range 2-74 years) were retrospectively evaluated for optic nerve and foveal hypoplasia. The difference in prevalence of foveal hypoplasia in patients with and without optic nerve hypoplasia was compared using Fisher's exact test. RESULTS: Six of 56 patients, 10.7% (95% CI: 4.8-21.5%), had optic nerve hypoplasia; hypoplasia was found in both eyes of five binocular patients and in one monocular patient. The prevalence of foveal hypoplasia was higher in aniridia patients with optic nerve hypoplasia than in those without (50.0 vs 6.0%); this difference did not achieve statistical significance (P=0.10). CONCLUSIONS: Clinically apparent optic nerve hypoplasia is found in roughly 10% of patients with aniridia and may occur independently or in association with foveal hypoplasia.

Medial rectus muscle incarceration in pediatric medial orbital wall trapdoor fractures.

PURPOSE: We describe two cases of orbital trapdoor fractures with medial rectus muscle incarceration. METHODS: Small interventional case series. RESULTS: This is a retrospective university based report of two healthy males (11 and 14 years old) who developed diplopia following blunt orbital trauma. Both patients had decreased horizontal ocular motility of the involved eye with minimal additional evidence of trauma. Computed tomography (CT) demonstrated no significant bony displacement; however, the left medial rectus muscle was located within the ethmoid sinus in the first and had an abnormal size and shape in the second case. In both cases, during urgent surgical repair, the incarcerated medial rectus muscle was gently released from linear non-displaced medial wall fractures and ocular motility normalized postoperatively. CONCLUSIONS: In pediatric patients sustaining blunt orbital trauma, medial rectus incarceration should be considered and managed accordingly.

Acute effects of sildenafil on the electroretinogram and multifocal electroretinogram.

PURPOSE: To evaluate the acute effects of sildenafil (Viagra; Pfizer, Inc, New York, New York) on the electroretinogram and multifocal electroretinogram. METHODS: Eighteen healthy individuals (ages 21-49 years) were studied; 14 were given 200 mg sildenafil orally and four were given only water. All subjects were tested before sildenafil and 1 hour after sildenafil (or water) with a desaturated Panel D-15 color test, a full-field standard electroretinogram, and a multifocal electroretinogram using the VERIS system; five subjects were also tested 5 hours after sildenafil. RESULTS: Responses from the subjects who received sildenafil were compared with those from the control subjects. At 1 hour after sildenafil, photopic single-flash waveforms were attenuated by 9% and scotopic maximal response amplitudes were increased slightly. Photopic and 30-Hz flicker electroretinogram responses were delayed; multifocal electroretinogram waveforms were delayed (5%-9%) and attenuated (14%-22%) across the posterior pole. These changes did not resolve by 5 hours. Nine of the subjects who had received sildenafil (64%) reported visual or systemic symptoms, including one who reported bluish vision. Ten of those subjects (71%) showed a slight increase in color test errors 1 hour after sildenafil. CONCLUSIONS: For at least 5 hours after taking 200 mg of sildenafil, cone function was slightly depressed in the macula and periphery, as measured by full-field electroretinogram and multifocal electroretinogram recordings. However, the affected electroretinogram and multifocal electroretinogram parameters still remained within normal limits.

Incidence of nonarteritic anterior ischemic optic neuropathy associated with cataract extraction.

OBJECTIVES: To determine the incidence of nonarteritic anterior ischemic optic neuropathy (NAION) after cataract extraction and to use the incidence to evaluate the causal relationship between cataract extraction and NAION. DESIGN: Cohort study. PARTICIPANTS: Five thousand seven hundred eighty-seven cataract extraction cases at the Bascom Palmer Eye Institute (BPEI) in a 5-year period between January 1, 1993 and December 31, 1997. METHODS: During the study period, an estimated 5787 cataract extraction cases were identified that met the following criteria: (1) the patient was 50 years of age or older, (2) surgery was performed by phacoemulsification or phacofracture techniques and not planned in combination with another procedure, and (3) follow-up was at BPEI. Charts of patients diagnosed with NAION from January 1, 1993 to December 31, 1998 were reviewed to detect the occurrence of NAION within 1 year of surgery. The diagnosis of NAION was based on the following: (1) an acute decrease in vision, (2) associated nerve fiber layer defect on visual field testing, (3) associated relative afferent pupillary defect, and (4) observed optic nerve edema. The exact binomial test was used to compare the incidence of NAION after cataract extraction against the expected incidence. MAIN OUTCOME MEASURE: Occurrence of NAION within 1 year after cataract extraction. RESULTS: Of the 5787 cataract extraction cases, three patients experienced NAION within 1 year of the procedure. Each case occurred after surgery on days 29, 36, and 117, giving an estimated 6-month incidence of 51.8 in 100,000 and a 6-week incidence of 34.6 in 100,000. Both were statistically higher than the previously reported overall incidence of NAION. Two of the three patients had a history of NAION in the contralateral eye. CONCLUSIONS: Cataract extraction is associated with an increased incidence of NAION, which is higher than the reported overall incidence. However, the risk of NAION after cataract extraction is low, with approximately one occurrence in every 2000 cases. A history of NAION in the fellow eye may be a risk factor.

Pseudomonas aeruginosa in vitro corneal isolate sensitivity to ofloxacin, ciprofloxacin, and trovafloxacin: a comparative study.

PURPOSE: To compare sensitivity of Pseudomonas aeruginosa corneal isolates to ofloxacin, ciprofloxacin, and trovafloxacin. METHODS: Sensitivities of P. aeruginosa corneal isolates to each antibiotic from the periods 1985 to 1987 (n = 32) and 1995 to 1999 (n = 85) were evaluated in vitro with E tests (AB Biodisk; Remel, Lenexa, Kansas). RESULTS: Overall, the percent of P. aeruginosa corneal isolates sensitive in vitro to ofloxacin (106/117, 90.6%) was significantly less than to ciprofloxacin (113/117, 96.6%, P =.016) and trovafloxacin (113/117, 96.6%, P =.016). We observed trends of decreasing sensitivity to ciprofloxacin and trovafloxacin, which were not statistically significant. Sensitivity to ofloxacin remained unchanged; however, sensitivity to ofloxacin was always less than sensitivity to ciprofloxacin and trovafloxacin. CONCLUSION: Although in vitro susceptibilities may not correlate with in vivo efficacy, our data suggest that ciprofloxacin and trovafloxacin are superior to ofloxacin in the treatment of P. aeruginosa keratitis.

Acute effects of sildenafil (viagra) on blue-on-yellow and white-on-white Humphrey perimetry.

OBJECTIVE: To study the effects of sildenafil on blue-on-yellow and white-on-white Humphrey visual field (HVF). MATERIALS AND METHODS: Healthy subjects, ages 20 to 38 years, were prospectively randomized to active drug (n = 5) or placebo (n = 3) groups. Blue-on-yellow and white-on-white HVF testing was performed before and 1 hour after masked dosing of sildenafil 200 mg or placebo. Changes in mean deviation (MD) were compared between groups. RESULTS: Three of three placebo and four of five sildenafil subjects had no change on HVF. One of five sildenafil subjects had a decrease in MD of 17.9 dB and 4.7 dB on blue-on-yellow and white-on-white HVF testing, respectively. This subject reported more systemic side effects than other subjects. CONCLUSIONS: Sildenafil has no effect on HVF testing in most persons; however, sildenafil caused an acute abnormality of HVF testing in one subject, who experienced pronounced non-visual systemic symptoms; this effect was greater on blue-on-yellow than white-on-white HVF.