Can Visual Function Be Affected by an Open Foramen Ovale?

The authors present a relatively rare finding of pathological changes in the visual field, the emergence of homonymous hemianopia, in connection with trauma and paradoxical embolism in a subsequently diagnosed open foramen ovale in a 56-year-old otherwise healthy patient. Cardiac source of embolism is a significant etiology of vascular embolization. The important group is the so-called paradoxical embolism, which occurs when a blood clot (embolus) is carried from the venous side of circulation to the arterial side via foramen ovale patens, what can manifests as ischemic stroke. Foramen ovale patens becomes a risk factor for the stroke development only if there is a peripheral source of embolism and at the same time there is a hemodynamically significant right-left short circuit. Therefore, screening for the causes of cryptogenic stroke should include not only the detection of foramen ovale patens but also evaluation of the peripheral venous system, coagulation parameters and hemodynamic severity of a right-left shunt. Neuroophthalmological aspects related to the described issues are discussed.

The optic nerve drusen and haemodynamics.

PURPOSE: The optic nerve drusen (DON) are precisely described in many papers. But fewer papers evaluate real haemodynamics parameters (HP) in DON. Clinically, it has been shown, that the development and progression of visual field changes in DON is closely related to the hemodynamics of the ocular vascular supply - the optic nerve. DON can visually overlap the excavation optic disc, making it difficult to evaluate scotomas of the visual field in glaucoma. METHODS: HP was prospectively evaluated in 54 patients with compensated intraocular pressure and DON. The drusen at the optic nerve head have been detected by fundus examination and B-scan ultrasonography (USG). DON were divided into 3 groups according to the size of the individual drusen or the drusen complex. I. Group: area size up to 1.9 mm. II. Group: area size: 1.9 - 3.9 mm. III. Group: area size: 4,0 mm. HP - maximum systolic velocity (MSV), minimal diastolic velocity (MDV) and resistance indices (IR) and index pulsatility (IP) - were recorded at the central retinal artery (CRA), at the central retinal vein (CRV), at ciliares posteriores arteries breves (CPAb) and at the ophthalmic artery (AO). The values were divided into 3 groups: 1 - Physiological: CRA: 8.7 ± 0.9 / 2.9 ± 0.6 cm/s or RI: 0.70 ± 0.05. 2 - Slightly impaired: CRA: 6.6 ± 0.8 / 2.0 ± 0.5 cm/s, or RI: 0.75 ± -0.04. 3 - Significantly impaired: CRA: 5.2 ± 1.2 / 1.9 ± 0.7 cm/sec or RI: 0.79 ± 0.03. RESULTS: There was no linear relationship between size of DON and HP. Slight worsening of HP at the CRA was in I. Group (28.6 %), II. Group (48.3 %) and III. Group (62.4 %). Significant worsening of HP at the CRA was I. group (28.6 %), II. Group (48.3 %) and in III. Group (62.4 %). HP of the CPA and of the OA were not significant due to the presence and size of drusen. The relationship between individual variables was evaluated using the Pearson correlation coefficient 0.213. I. Group P: 0.354, II. Group P: 0.073, III. Group P: 0.287. CONCLUSIONS: HP is more often impaired in „large“ DON (Group III), rarely in Group I, but this is not a rule. HP cannot be predicted according to the size of the druse formation at the optic nerve. It seems that the deterioration of HP depends not only on the DON size but also on the location (the distance from the lamella cribriformis) and also to the vascular system intrapapillary.

[Translaminar Gradient and Glaucoma]. / Translaminárny gradient a glaukóm.

OBJECTIVE: The cribriform plate is a threshold of the intraocular pressure (VOT) and of the intracranial pressure (IKT). The difference between the VOT and IKT is referred to as translaminar gradient (TLG). The goal was to evaluate the Glaucoma progression (visual field, fundus examination, HRT) with / without topical anti-glaucomatous therapy) in relation to the TLG. PATIENTS AND METHODS: the significance of TLG has been studied in two groups. I. Group: 57 patients diagnosed and treatment of Primary Open-Angle Glaucoma (PGOU), 10 patients with Ocular hypertension (OH), 7 patients with Normal-Tension Glaucoma (NTG), and 75 healthy without glaucoma. The examinations of TLG were carried out once and retrospectively. In II. group there were prospectively studied 14 patients with OH and 24 patients with newly detected PGOU without local therapy. The examinations were performed 4 times at intervals of 10 to 11 months. All tests included a basic eye examination, ORA tonometry, HRT examination, gonioscopy, Color Doppler sonography of blood vessels of the eye and orbit. Venous pulsation pressure (VPT) has been recorded by the Ophthalmodynamometer Meditron (D-ODM). In case of spontaneous retinal venous pulsation, VPT was considered as the same pressure as the VOT. The TLG was calculated with formula of Querfurth: ICT = 0.29 + 0.74 (VOT / PI (AO)). [PI(AO) - Pulsatility index of the Ophthalmic artery (AO)]. RESULTS: I. group: TLG was in the control group without Glaucoma: 12.2 ± 2.0 torr. The NTG group: 9.0 ± 1.70 mm Hg. PGOU: 11.1 ± 1.91 mm Hg. OH: 12.6 ± 0.85 mm Hg. IKT alone does not show a significant relationship to the presence of glaucoma, ocular hypertension. II. Group: The average TLG in Ocular Hypertension (14 patients) has been 3.8 ± 1.2 torr. 2 patients (OH) had TLG 10 torr. and 15 torr. After 4 years in one of them (TLG = 15 torr.) there was recorded Glaucoma progression. In the PGOU group before antiglaucoma therapy, TLG was 15.0 ± 4.8 torr for all patients. After setting up local anti-glaucoma therapy and decreasing VOT, the TLG in 20 patients reduced to 3.6 ± 1.3 mm Hg. CONCLUSION: TLG showed a significant relationship to the Glaucoma progression. The risk of glaucomatous damage increases proportionally with increasing Translaminar gradient. Translaminar gradient can be use to refine the so-called. "Target VOT". TLG has a role in ocular damage (ocular hypertension, glaucoma, vascular occlusion, optic neuropathy), intracranial damage, orbitopathy, selection of appropriate antiglaucomatous therapy.Key words: color Doppler ultrasonography, glaucoma, ocular hypertension, ophthalmodynamometry, translaminar gradient, venous pulsation pressure, venous pulsation.

[Intracranial Pressure Evaluation by Ophthalmologist]. / Hodnotenie intrakraniálneho tlaku oftalmológom.

The value of ICT is important in diagnosis of the diseases of the eye and orbit Methods for direct measurement of intracranial pressure (ICT) are exact, but they are invasive and there is some risk of infection and damage of the tissue. Currently there are 2 valid indirect methods of mesurement of IKT. Digital Ophthalmodynamometry (D-ODM) and Transcranial Doppler ultrasonography (TDU). D-ODM is a non-invasive method for measuring of the Pulsating Venous Pressure (VPT). We can measure VPT by the pulse phenomena. Physiologically (to be maintained blood flow) VPT not be less than the ICT and intraorbital pressure (IorbitT). If we raise the VPT to compensate the current IKT (or IorbitT) - there is a pulsation VCR. We can calculate aproxymative IKT with the formula: IKT = 0.903 - (VPT) - 8.87, or IKT = 0.29 + 0.74 (VOT / PI (AO)). [VOT = intraocular pressure. PI - pulsatility index arteriae ophthalmic from Color Doppler ultrasonography.] IKT can be approximate calculate with mathematical formulas: IKT = 0:55 × BMI (kg / m2) + 0.16 × KTD (mmHg) - 0:18 x age (years) - 1.91. [KTD - diastolic blood pressure, BMI - Body master index] or: IKT = 16.95 x 0.39 x OSASW09 + BMI + 0.14 + TKS - 20.90. [OSASW095: width of the orbital arachnoid space at a distance of 9 mm behind the eyeball (nuclear magnetic resonance). BMI: Body Mass Index. TKS: mean arterial pressure]. Normal values of VPT are under 15 torr. The risk of increased intracranial pressure is above 20 torr. Under physiological conditions, there is intraocular pressure lower in about 5 torr than VPT. CONCLUSION: D-ODM is a useful screening method in the evaluation of IKT for hydrocephalus, brain tumors, cerebral hemorrhage after brain trauma and also in ocular diseases: Glaucoma, Ocular hypertension, orbitopathy (endocrine orbitopathy), ischemic / non-ischemic occlusion of blood vessels of the eye, indirect detection ICT carotid artery-cavernous fistula, amaurosis fugax, optic neuropathy. D-ODM is suitable for immediate evaluation of IKT, but is not suitable for continuous monitoring. As it can be repeated, it is useful for a patient suspected of having an increased ICT.Key words: central retinal artery, central retinal vein, colour Doppler ultrasonography, digital ophthalmodynamometry, intracranial pressure, pressure of cerebrospinal fluid, transcranial Doppler ultrasonography, intraocular pressure, venous pulsation pressure, venous outflow pressure, retinal venous pressure.

[The cooperation between the ophthalmologist and the endocrinologist in the treatment of the endocrine orbitopathy]. / Spolupráca oftalmológa a endokrinológa pri liecbe endokrinnej orbitopatie.

Authors of this study emphasize the requirement of the cooperation between the ophthalmologist and the endocrinologist in diagnostics and treatment of moderate and severe forms of endocrine orbitopathy (EO). Examinations necessary for diagnosis and possibilities of the systemic treatment are reported. Twenty patients within the group of 70 patients with EO, who had severe form of disease and underwent different combinations of corticosteroid therapy, immunosuppressive therapy, radiotherapy (RA) and orbital decompression were followed up. Authors recommend a dosage of Methylprednisolon (7-9 g) divided into pulses of 1000mg followed by pulses of 500 mg given during 3 to 4 weeks (2-3 infusions per week). They recommend administering Prednison in 60-90 mg doses per day depending on weight of a patient. After daily maximum dose during the first two weeks, the authors recommend to decrease gradually the dose with the total treating period of minimum of a half a year. Decrease of visual acuity depending on EO appeared by 7 patients. It has been stabilized in 6 patients after the treatment of EO. Hand movement remained in one patient with severe neuropathy in spite of urgent orbital decompression. The intraocular pressure has been stabilized in 16 patients after treatment of EO (six patients do not require further antiglaucomatic therapy). The decrease of protrusion occurred in 8 patients after corticosteroid therapy (1-5 mm) and in 5 patients after orbital decompression (6-10 mm). Severe adverse events (herpetic infection, osteoporosis, steroid DM) were reported in 3 patients after repeated courses of corticosteroid therapy. Authors recommend early administration of intensive systemic corticosteroid therapy in active stage of the moderate forms of EO.

[The color Doppler ultrasonography in glaucoma diagnosis]. / Farebná dopplerovská diagnostika pri glaukóme.

UNLABELLED: The insufficiency of the autoregulation at the optic nerve's head may cause the glaucoma optic neuropathy (GON). If the long-term stressing exists and an additional endurance arises, the autoregulation may fail and significant changes of the resistance index (RI) at the central retinal artery (CRA) and at the posterior ciliar artery (PCA) can be detected by color flow ultrasonography. Resistivity index represents peripheral resistance. It is displayed in numerical value 0-1. 0 indicates none peripheral resistance, 1 indicates maximal peripheral resistance. The goal of this paper was to determine a risk value of the RI at the CRA and PCA that could suggest possible damaging of the optic nerve. Two groups of the patients were evaluated in the course of 4 years duration of the study. In the I. Group were 72 patients (144 eyes) with GON and with intraocular pressure (IOP) 14-24 mm Hg. The II. Group consisted of 25 healthy men (48 eyes) without diagnosis of GON and with IOP values 14-20 mm Hg. There were RI measurements at all patients at the CRA and CPA at the idle mode and immediately after ordinary addition endurance (performing squatting--Master test). The statistical analysis by T test was evaluated with value: 0.05. CONCLUSION: According to our findings, the difference between RI: 0.12 +/- 0.03 at the CRA at the idle mode and immediately after ordinary addition endurance is significant for damaging of the autoregulation at the optic nerve's head. For assessment of the insufficiency of the autoregulation at the optic nerve's head RI from PCA is not significant.

[Epidemiology of the endocrine orbitopathy]. / Endokrinná orbitopatia-- epidemiologické súvislosti.

The goal of this paper was to evaluate epidemiological data of the endocrine orbitopathy in a group of 126 patients (250 eyes) during the 5-years period (1999-2004). The prevalence of endocrine orbitopathy was at the age 46.5 +/- 11.4 years, predominantly in females: 5.3 times more often than in males. In most cases (94%) and independently on the sex, hyperthyroidism accompanied the endocrine orbitopathy. Hyperthyroidism mostly (91%) preceded the appearance of the endocrine orbitopathy. Most patients with endocrine orbitopathy had eyelid signs (91% females and 85% males respectively), protrusion or exophtalmos (77% females, 75% males). 69% patients (68% females, 70% males) had elevated intraocular pressure (pseudoglaucoma, primary glaucoma). During the active stage of the endocrine orbitopathy with protrusion (52% patients), pseudoglaucoma was detected in 7% of patients. During the inactive stage of the endocrine orbitopathy with protrusion (34% patients), pseudoglaucoma was detected in 4% of patients. Primary glaucoma was found in 2% (active stage) and 1% (inactive astage).

[Diagnosis of swollen optic disks using color Doppler ultrasonography] . / Diagnostika opuchov zrakového nervu pomocou farebnej dopplerovskej ultrasonografie.

The Goal of this study was prospective evaluation of the blood flow parameters-maximal systolic velocity (MSV), minimal diastolic velocity (MDV) and Pourcelot's resistivity index (RI) in patients with swollen optic dis. 63 patients (79 eyes) were examined with swollen optic disc-10 patients (17 eyes) with intracranial hypertension, 12 patients (14 eyes) with pseudoedema of disk of the optic nerve, 7 patients (7 eyes) with inflammation swollen optic disc, 3 patients (6 eyes) with pseudotumor cerebri, 8 patients (12 eyes) with arteritic anterior ischemic optic neuropathy (A-AION) and 23 patients (23 eyes) with nonarteritic anterior ischemic optic neuropathy (N-AION) and 23 patients (23 eyes) with nonarteritic anterior ischemic optic neuropathy (N-AION). All patients had ophthalmological examinations and Color Doppler ultrasonography in central retinal artery (CRA), posterior ciliary artery (PCA), ophthalmic artery (OA) and in central retinal vein (CRV). The blood flow parameters of the swollen optic disc and normal optic disc were not significant changed at intracranial hypertension, pseudooedema cerebri, inflammation swelling, and at pseudotumour od the optic disc. A-AION and N-AION acallocated significant changes of the blood velocities and resistivity index. A-AION: significant increasing resistivity index at CRA, CPA, significant decrease of MSV and MDV and difficult mapping of the CPA in Color doppler mapping. At the fellow eye (without swollen optic disc) was significant decreasing of the blood velocities of the CRA, CPA, but not so much as at the defective eye with swollen optic nerve disk. N-AION: defective eye with swollen optic disc--there were: nonsignificant decreasing of MSV, MDV, significant decreasing of MSV, MDV and increasing of resistivity index of the CRA, CPA at the fellow eye. AO was without significant changes. Color Doppler information allowed to specify diagnosis of A-AION and N-AION.

[Tonic pupil]. / Pupilotonia.

Authors evaluated the group of 21 patients (22 eyes) with pupillotonia. There were 2 postraumatic pupillotonias, 1 bilateral pupillotonia with systematic polyneuropathy in alcoholism, 6 Adie's pupillotonias and 9 postviral pupillotonias. In 4 one-sided pupillotonias there were finded no traumatic, viral or neurological cause. 2 patients (2 eyes) with traumatic cause, 2 patients with Adie's pupillotonia and 9 patients with viral cause had indicated the marked subjective difficulties in the eyes with pupillotonia--blurred vision, cephalea. After local application of Pilocarpin in 0.05%-0.1% concentration, these patients were indicating the marked improvement of their subjective troubles of the eyes.

[Evaluation of the retrobulbar space in Graves' orbitopathy using color Doppler ultrasonography]. / Hodnotenie retrobulbárneho priestoru pri Gravesovej orbitopatii pomocou farebnej Dopplerovskej ultrasonografie.

UNLABELLED: Authors evaluated B-scan findings, blood flow velocity of orbital vessels. At vena Orbitalis Superior (VOS) they evaluated width of color echo and course of blood flow only too. CONCLUSION: 1. GO significantly influences blood flow only in VOS-alteration of blood flow velocities = 7-25 cm/s, nonconstant changing of course blood flowing and dilatation of color echo of the VOS, 2. Thickening of the extraocular muscles significantly influences dilatation of color echo of the VOS, what is a sign of worsening of venous drainage in orbital apex. 3. Swollen connective tissue is displayed as extensive hyperintensive, homogeneous echo retrobulbar, connecting always with subjective pressure, pain beyond the eye.

[Diagnosis of carotid-cavernous fistula using color Doppler ultrasonography]. / Diagnostika karotido-kavernóznej fistuly pomocou farebnej Dopplerovskej ultrasonografie.

The authors evaluated orbital haemodynamics by Colour Doppler flow Information (CDFI), in 4 cases of carotid-venous fistulas (CCF). Significant changes were demonstrated only in the superior orbital vein (SOV) = 1. Changing of course blood flowing-biodirect (as an alternating orthograde and retrograde) blood flow, or constant retrograde blood flow in SOV, independent from Valsalva manoeuver. 2. Pulsating SOV, in spectral analyse as a retrograde blood flow is synchroned with cordial rhythm on electrocardiography record. 3. Dilatation of color echo of the VOS is a nonconstant sign of CCF.

[Evaluation of circulatory flow in vessels of the eye and orbit using color duplex ultrasonography]. / Hodnotenie krvného toku v niektorých cievach oka a ocnice farebnou duplexnou ultrasonografiou.

Duplex ultrasonography is recent imaging, that allows simultaneous 2-dimensional imaging (B-scan) and Doppler evaluation of the blood flow. Information on blood flow is obtained by pulsed Doppler spectral analysis. The blood flow in vessels of our interest is colour coded. Using this technique we examined 140 eyes. 81 eyes in 48 healthy persons were examined. Based on this examinations, the blood velocity standards were calculated for age groups 19-40 and 41-76 y. There are demonstrated pathologic findings by intraocular tumor, tractional retinal detachment and various failures of blood flow in bulbar and orbital vessels.

[Evaluation of the superior orbital vein using color doppler ultrasonography]. / Hodnotenie veny orbitalis superior pomocou farebnej doplerovskej ultrasonografie.

We examined in collection of 66 patients (116 eyes) vena orbitalis superior (VOS) by Colour Doppler flow imaging (CDFI). In 20% was VOS wider than 3.5 mm in patients without subjective problems and without an orbitopathy, with maximum of width 4.9 mm. In patients with retrobulbar pressure, pain, without orbitopathy was dilatation above 3.5 mm in 31% cases, with maximum 5.4 mm. In patients with orbitopathy was dilatation VOS above 3.5 mm already in 85%, with maximum 7.1 mm. We averaged considerable variability of width in examined VOS.

[Anatomic distribution of anesthetic solutions in the orbit after subconjuctival, parabulbar and retrobulbar administration]. / Anatomická distribúcia anestetického roztoku v orbite pri subkonjunktiválnej, parabulbárnej a retrobulbárnej aplikácii.

Authors evaluated anatomical distribution of 1% Mesocain solution with subconjuctival (SC), parabulbar (PB) and retrobulbar (RB) applications by ultrasonographic orbital examination. At SC application was not expressive mobilization of bolus. At PB and RB applications were observed dependence between bolus dislocation (mm) and quantity injected bolus (ml). At PB and RB applications were recorded expressive mobilization of injected bolus at orbit.

[Ultrasonic imaging of the anterior segment of the eye]. / Zobrazenie predného segmentu bulbu ultrazvukom.

Our survey of the anterior segment of the eye by the ultrasound, is based in the usage of the Kitecko, the eye covering gadget, made by Laboratories 3M. The Kitecko opened a new possibilities for us in the localization of the intraocular, RTG noncontrast foreign bodies of the anterior segment, as well obscure optical medium.