Unrecognized visual field deficits in children with primary central nervous system brain tumors.

Visual field deficits can be a consequence of brain tumor location or treatment. The prevalence of unrecognized visual field deficits in children diagnosed with brain tumors is not known. All children at a single tertiary care pediatric children's hospital diagnosed with a primary brain tumor were tested for visual field deficits by a child neurologist and neuro-ophthalmologist over 16 months. Children with reproducible visual field deficits on two separate occasions were included in the analysis. Patients with optic glioma, craniopharyngioma, or previously known visual field deficits were excluded. Fourteen of 92 (15.2%) children (average 8.9 years, 8 girls) had undiagnosed visual field deficits. Average time between diagnosis of tumor and unrecognized visual field deficit was 3.7 years (range 0-13 years). Unrecognized visual field deficits were not associated with age (P = 0.27) or gender (P = 0.38). Visual field deficits were attributed to direct tumor infiltration (n = 8), postoperative complications (n = 5) and post-radiation edema (n = 1). Deficits included bitemporal hemianopsia (n = 2), homonymous hemianopsia (n = 9), quadrantanopsia (n = 2), and concentric visual field loss (n = 1.) Tumor location included temporal lobe (n = 9), parietal lobe (n = 2), posterior fossa (n = 2), hypothalamic-chiasmatic (n = 2) and multifocal areas (n = 4). Children with temporal lobe tumors were more likely to have unrecognized visual field deficits (P = 0.004). In all 14 patients, visual field deficits were determined by examination only and were not reported by either the patient or caregiver regardless of age. The prevalence of unrecognized visual field deficits in children with brain tumors can be surprisingly high. Serial neuro-ophthalmologic evaluation of children with brain tumors is often required to diagnose a visual field deficit since patient or caregiver reporting may be limited.

Acute multifocal placoid pigment epitheliopathy and central nervous system involvement: nine new cases and a review of the literature.

OBJECTIVE: The authors describe nine new cases of acute multifocal placoid pigment epitheliopathy (AMPPE) with associated central nervous system (CNS) involvement and permanent visual sequelae. The study includes a review of the literature and discussion of evaluation, management, and treatment options. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Nine patients were identified with AMPPE and CNS involvement in addition to 22 patients reviewed in the literature. MAIN OUTCOME MEASURES: A review of nine patients with AMPPE and CNS involvement was performed. Charts were reviewed for age, gender, preceding viral prodromes, visual acuity, ophthalmologic examination findings, CNS findings, and treatment. RESULTS: Thirty-one patients (nine new patients) were diagnosed with AMPPE and various degrees of CNS involvement. Ages ranged from 8 to 54 years, with an average of 27 years. Twenty-one males (68%) and 10 females (32%) were identified. Eleven patients (35%) had antecedent viral illnesses. Visual acuity was variable and ranged from 20/20 to count fingers. The spectrum of CNS findings ranged from headaches to sagittal sinus thrombosis. CONCLUSIONS: Acute multifocal placoid pigment epitheliopathy can be associated with CNS abnormalities and permanent visual deficits. Neuroimaging, lumbar puncture, and cerebral angiography analysis provide useful diagnostic tools when CNS involvement is suspected. Intravenous corticosteroids and collaboration with neurovascular colleagues should be considered in these situations. In cases complicated by CNS arteritis, immunosuppressive agents can be a beneficial adjunct to corticosteroids.

Decreased incidence of retinopathy of prematurity, 1995-1997.

PURPOSE: To report a significant decrease in the incidence of retinopathy of prematurity (ROP), both in our neonatal intensive care unit (NICU) and internationally, and review factors in patient care that may be contributory. METHODS: We retrospectively reviewed the records of all neonates weighing less than 1251 g admitted to our NICU from 1995 to 1997 and evaluated the incidence and stage of ROP. These data on 191 neonates were compared with an international NICU database of 9989 similar neonates, which represents all infants who received an ophthalmologic examination in the Vermont-Oxford Network Database (VOND) in 1997, except those from our institute (the University of Kentucky). In addition to investigating the incidence of ROP, we looked at the use of antenatal corticosteroids given 1 to 7 days prepartum, the use of oxygen at 36 weeks' postconceptional age, and the use of oxygen at home upon discharge. RESULTS: In our center, we had a 36.1% incidence of ROP compared with an international incidence of 57.2% for the VOND in 1997 (P <.0001). Antenatal corticosteroids were given to 62.6% of infants in our center compared with 48.6% in the VOND (P <.005). In addition, 48.5% of our infants weighing less than 1500 g received oxygen at 36 weeks' postconceptional age versus 29.5% of the VOND infants (P <.001). Upon discharge to home, 37.5% of our infants were on oxygen compared with 15.6% of infants from all VOND centers, excluding the University of Kentucky (P <.001). CONCLUSION: The incidence of ROP in our center from 1995 to 1997 and in the VOND in 1997 show a significant decrease from the 65.8% incidence from 1986 to 1987 reported by the Multicenter Trial of Cryotherapy for ROP.

Airbags and bilateral eye injury: five case reports and a review of the literature.

We report five cases of bilateral eye injuries from airbag deployment in motor vehicle crashes and review the world's literature on ocular injuries associated with airbags. The cases in the literature were identified by cross-referencing Medline searches from airbags and ocular injuries. Additional cases were identified after review of references from each article in the search. An additional 89 cases from the literature were identified and are included for discussion. Patients were treated individually in a noncontrolled, nonrandomized fashion according to the nature of each injury with regular follow-up examinations in clinic. Of the 94 cases studied, 24 (27%) were bilateral eye injuries, and 15 (16%) patients were wearing spectacles at the time of the accident. The most common injuries included corneal abrasions, eyelid trauma, and hyphemas. Outcomes ranged from complete resolution of symptoms and return of normal visual acuity to primary enucleation. This report describes the wide spectrum of eye injuries that may occur after airbag deployment. We suggest a management plan for the evaluation and treatment of the ocular complications of airbag-related trauma.

Facial reanimation surgery utilizing the Mitek anchor system: A case report.

A flaccid hemi-face is frequently the most noticeable and cosmetically unacceptable consequence of facial nerve palsy, whether due to trauma, Bell's palsy or other etiologies. A variety of face-lift and reanimation techniques have been utilized in the past, but with time, these frequently require further surgery. We describe the use of Mitek (Norwood, MA) suture anchors for cheek resuspension in a patient with facial palsy. This system is composed of a drill guide, drill, inserter, and anchor. Although the titanium alloy anchors come in multiple sizes, the Mini GII Anchor is typically most appropriate for use in facial procedures. The actual size of the Mini GII Anchor is 1.8 mm in diameter and 5.4 mm in length. Two small arched prongs extend from the body of the anchor, and an eyelet at the superior surface is used for suture placement. When placed into a pre-drilled hole with the insertion tool, the prongs extend, effectively fixing the anchor in place. The drill guide protects adjacent soft tissues during the drilling process and allows drilling to a predetermined fixed depth. Sutures attached to the anchor may then be used for soft tissue fixation to bone.

Carcinoid metastasis to extraocular muscles: case reports and review of the literature.

Carcinoid tumors are slow growing, low-grade malignant neoplasms that are believed to originate from neuroendocrine cells, usually in the gastrointestinal mucosa. Metastasis of carcinoid tumor to the orbit is a rare occurrence. When metastasis does occur, the choroid is the most common ocular structure involved. We report two cases of unique involvement of extraocular muscles.

Optic nerve edema as a consequence of respiratory disease.

The authors describe a patient with bilateral papilledema, visual field abnormalities, poorly reactive pupils, meningeal enhancement on cranial MRI, and diffuse brain parenchymal hypervascularity. The opening pressure at the time of lumbar puncture was normal, and results of other CSF studies were normal. All abnormalities resolved with home oxygen therapy.

Evaluation and classification of pediatric ocular trauma.

PURPOSE: To offer to the pediatric emergency physician consistent and unambiguous terms for the description of pediatric ocular trauma, based upon an adapted version of a standardized classification system. To show the potential effect of this reclassification system in a tertiary care emergency department. METHODS: The authors reviewed a new classification system of ocular trauma and adapted it for use by pediatric emergency physicians. In addition, a retrospective analysis of the records of pediatric patients presenting over a 2-year period to a tertiary emergency department with ocular complaints was performed. The diagnoses related to ocular trauma were reclassified according to the new classification system. RESULTS: Over a 2-year period, 117 pediatric patients were evaluated for ophthalmic complaints. Sixty-seven (57%) of these cases involved an ocular contusion or ruptured globe; however, six disparate diagnoses were given. The cases were reclassified into an adapted, unambiguous, classification system. In some cases, the reclassification altered the indication for immediate ophthalmologic referral. CONCLUSION: There is currently no standardized system of terminology to describe pediatric ocular trauma. This may lead to confusion in communication among the pediatric emergency physician, the pediatrician, and the ophthalmologist. Consistent, unambiguous, terminology will assist in this communication, facilitate the writing of peer-reviewed articles and case reports, and increase the level of accurate documentation in the medical record.

Orbital pachymengitis secondary to Pseudomonas aeruginosa.

Pachymengitis is a very rare disorder that can present with multiple cranial neuropathies. The etiology can be inflammatory, infective or a combination of both, resulting in a thickening of the cranial dura and an obliteration of the individual layers of the meninges. We present a rare case of Pseudomonas aeruginosa pachymeningitis in the orbit that resulted in severe and permanent visual loss, in a patient after extensive sinus surgery.

Ophthalmoplegic migraine with unusual features.

We report the details of a patient with an unusual form of ophthalmoplegic migraine resulting in permanent vertical misalignment of the affected eye. The presentation, history, and ophthalmologic examination are reported as well as disease course and follow-up complications. We review the literature on ophthalmoplegic migraine with discussion regarding typical presentation, methods of diagnosis, and other diseases which may cause diagnostic confusion. In light of current case reports on ophthalmoplegic migraine, this is the first documented example with a permanent deficit.

Microangiopathy of the brain, retina, and cochlea (Susac syndrome). A report of five cases and a review of the literature.

OBJECTIVE: This study reports five new cases of microangiopathy of the brain, retina, and cochlea (Susac syndrome) and reviews the world's literature. DESIGN: Five cases were systematically studied by the authors. The cases in the literature were identified through Medline searches for Susac syndrome; microangiopathy of the brain, retina, or ear; and cross-referencing the indexes of each retrieved article. PARTICIPANTS: The number of new patients studied in this report was five. An additional 41 patients were culled from the literature. INTERVENTION: Patients were treated with corticosteroids, antineoplastic agents, and other methods in a noncontrolled, nonrandomized fashion. MAIN OUTCOME MEASURES: With respect to therapeutic intervention, the main clinical outcome measures were return of vision, improvement of neurologic and psychiatric manifestations, and recovery of auditory function. Alterations of abnormalities observed by cranial magnetic resonance imaging also were monitored. RESULTS: Of 46 identified patients, 39 were women. The mean age of the patients was 30 years. Forty-one patients (89%) had arterial occlusions, which were bilateral in 60%. Thirty-one patients (67%) reported hearing loss. Twenty patients (44%) had a global encephalopathy, but other neurologic manifestations were common. The mean duration of the illness was 46.7 months. CONCLUSION: This rare syndrome is more common than previously thought, has a strong female preponderance, and often can be identified at an early stage with a careful history and physical examination. Magnetic resonance imaging of the brain often shows lesions suggestive of multiple sclerosis. Fluorescein angiography may show arteriolar wall hyperfluorescence. Early treatment with corticosteroids often is, although not invariably, associated with a good prognosis. The disease appears to be self-limited in most patients.