Acute Idiopathic Blind Spot Enlargement and Acute Zonal Occult Outer Retinopathy: Potential Mimics of Neuro-Ophthalmic Disease.

In 1988, William Hoyt, MD, et al described "acute idiopathic blind spot enlargement" (AIBSE) in 7 symptomatic patients who had no apparent abnormalities of the optic disc or surrounding retina. With the use of multifocal electroretinography, they showed that the scotoma was caused by occult retinal dysfunction. In 1992, J. Donald Gass, MD, described "acute zonal occult outer retinopathy" (AZOOR) in 13 patients who had sudden loss of often large zones of visual field without fundus abnormalities. Most patients developed zonal atrophy of retinal pigment epithelium and had no improvement in vision. Gass believed that AZOOR, multiple evanescent white dot syndrome, multifocal choroiditis, and AIBSE were all variants of the same disorder. Despite over 3 decades of numerous reports, the classification of these entities, their pathogenesis, and treatment remain controversial. AIBSE and AZOOR may be mistaken for an acute optic neuropathy, so it behooves the neuro-ophthalmologist to be familiar with these disorders. This review describes the initial recognition of AIBSE and its relationship to AZOOR.

Obesity and Weight Loss in Idiopathic Intracranial Hypertension: A Narrative Review.

BACKGROUND: Most patients with idiopathic intracranial hypertension (IIH) are obese. Weight loss is felt to be an important factor in improving IIH. The mechanism by which weight loss leads to a reduction in elevated intracranial pressure is unclear. Evidence from prospective studies evaluating the role of weight loss in IIH is lacking. EVIDENCE ACQUISITION: We performed a detailed review of the published literature regarding the association of IIH and obesity, including proposed pathogenetic mechanisms, and the effect of weight loss and weight-loss interventions in IIH. References were identified by searching PubMed with the terms idiopathic intracranial hypertension and weight loss. Additional citations were found in the identified references. RESULTS: Over 90% of IIH patients are obese or overweight. The risk of IIH increases as a function of body mass index (BMI) and weight gain over the preceding year. The risk of IIH-induced vision loss also increases with increasing BMI, especially with BMI >40 kg/m. Several mechanisms have been proposed linking obesity to the development of IIH but the pathophysiology remains unknown. Published studies and clinical observations strongly support weight loss as an effective treatment, although there are no prospective controlled trials. Weight loss in the range of 6%-10% often leads to IIH remission. Weight loss of ≥5% at 1 year is achieved in roughly 50%-70% of patients if they are enrolled in a high-intensity lifestyle modification program and in 20%-35% of patients if they direct their own weight loss. Weight is typically regained over 1-3 years but about a third of patients maintain ≥5% weight loss over the long term. Patients treated initially with lifestyle modification therapy show a modest persisting benefit over self-directed patients. Selected commercial weight loss programs also may improve long-term maintenance of weight loss. New antiobesity drugs significantly improve the proportion of obese patients who have ≥5% loss of weight at 1 year. CONCLUSIONS: Obesity is an important contributing factor for the development of IIH, although the pathophysiological mechanism linking obesity to IIH is unknown. The risk of developing IIH and associated visual loss increases with increasing BMI. Weight loss is an effective treatment for IIH. Long-term maintenance of initial weight loss is helped modestly by lifestyle modification programs and possibly by selected commercial weight loss programs. New antiobesity drugs may provide further options for IIH therapy in the future.

Risk factors for poor visual outcome in patients with idiopathic intracranial hypertension.

OBJECTIVES: Determine potential risk factors for progressive visual field loss in the Idiopathic Intracranial Hypertension Treatment Trial, a randomized placebo-controlled trial of acetazolamide in patients with idiopathic intracranial hypertension and mild visual loss concurrently receiving a low sodium, weight reduction diet. METHODS: Logistic regression and classification tree analyses were used to evaluate potential risk factors for protocol-defined treatment failure (>2 dB perimetric mean deviation [PMD] change in patients with baseline PMD -2 to -3.5 dB or >3 dB PMD change with baseline PMD -3.5 to -7 dB). RESULTS: Seven participants (6 on diet plus placebo) met criteria for treatment failure. The odds ratio for patients with grades III to V papilledema vs those with grades I and II was 8.66 (95% confidence interval [CI] 1.65-∞, p = 0.025). A 1-unit decrease in the number of letters correct on the ETDRS (Early Treatment Diabetic Retinopathy Study) chart at baseline was associated with an increase in the odds of treatment failure by a factor of 1.16 (95% CI 1.04-1.30, p = 0.005). Compared with female participants, the odds ratio for male participants was 26.21 (95% CI 1.61-433.00, p = 0.02). The odds of treatment failure were 10.59 times higher (95% CI 1.63-116.83, p = 0.010) for patients with >30 transient visual obscurations per month vs those with ≤30 per month. CONCLUSIONS: Male patients, those with high-grade papilledema, and those with decreased visual acuity at baseline were more likely to experience treatment failure. All but one of these patients were treated with diet alone. These patients should be monitored closely and be considered for aggressive treatment of their idiopathic intracranial hypertension.

Linear and angular control of circular walking in healthy older adults and subjects with cerebellar ataxia.

Linear and angular control of trunk and leg motion during curvilinear navigation was investigated in subjects with cerebellar ataxia and age-matched control subjects. Subjects walked with eyes open around a 1.2-m circle. The relationship of linear to angular motion was quantified by determining the ratios of trunk linear velocity to trunk angular velocity and foot linear position to foot angular position. Errors in walking radius (the ratio of linear to angular motion) also were quantified continuously during the circular walk. Relative variability of linear and angular measures was compared using coefficients of variation (CoV). Patterns of variability were compared using power spectral analysis for the trunk and auto-covariance analysis for the feet. Errors in radius were significantly increased in patients with cerebellar damage as compared to controls. Cerebellar subjects had significantly larger CoV of feet and trunk in angular, but not linear, motion. Control subjects also showed larger CoV in angular compared to linear motion of the feet and trunk. Angular and linear components of stepping differed in that angular, but not linear, foot placement had a negative correlation from one stride to the next. Thus, walking in a circle was associated with more, and a different type of, variability in angular compared to linear motion. Results are consistent with increased difficulty of, and role of the cerebellum in, control of angular trunk and foot motion for curvilinear locomotion.

Does the cerebellum play a role in podokinetic adaptation?

After sustained stepping in-place on a rotating disc, healthy subjects will inadvertently turn in circles when asked to step in-place on a stationary surface with eyes closed. We asked whether the cerebellum is important for this adaptive phenomenon, called podokinetic after-rotation (PKAR). Subjects with cerebellar degeneration and age-matched control subjects performed 15 min of stepping in-place with eyes open on a rotating disc, then 30 min of attempting to step in-place with eyes closed on a stationary surface. Rotational velocity of PKAR was measured during this 30-min period. All control subjects demonstrated PKAR; average initial rotational velocity for control subjects was 16.4+/-3.5 degrees /s. Five of the eight cerebellar subjects demonstrated impaired PK adaptation, defined as PKAR with an initial velocity more than two standard deviations below the control mean initial velocity. Average initial rotational velocity for cerebellar subjects was 7.8+/-0.2 degrees /s. Impaired PK adaptation was not associated with impaired time constants of decay and was not correlated with variability of PKAR velocity. Our results suggest that the cerebellum is important for regulation of the amplitude of PK adaptation and that reduced PKAR amplitude is not likely the result of dyscoordination or variability of movement in the subjects tested.

Effectiveness of photodynamic ablation for destruction of endometrial explants in a rat endometriosis model.

OBJECTIVE: To evaluate the potential of photodynamic therapy with aminolevulinic acid (ALA-PDT) for ablation of endometrial explants in a rat endometriosis model and to compare the effect of ALA-PDT, electrosurgery, and surgical resection on normal peritoneum. DESIGN: Prospective controlled experimental trial. SETTING: University medical center. ANIMAL(S): Mature Sprague-Dawley female rats. INTERVENTION(S): Induction of endometriosis and subsequent treatment with ALA-PDT; electrosurgery, and simple resection, and ALA-PDT of normal peritoneum. MAIN OUTCOME MEASURE(S): Histopathological assessment. RESULT(S): Systemic ALA followed by exposure to photoactivating light for 10 or 15 minutes resulted in ablation of all explants harvested 3-4 days after treatment. Permanent destruction was confirmed by absence of regrowth by week 3. Exposure of normal peritoneum to ALA-PDT resulted in initial necrosis, with complete recovery by day 16. Adhesions were present on day 16 in 50% of cases after electrosurgery and in 100% of cases after resection. No adhesions were present in ALA-PDT-treated animals. CONCLUSION(S): Systemic ALA followed by exposure to photoactivating light at relatively low power densities for periods as brief as 10 minutes resulted in ablation of endometriotic explants. Exposure of normal peritoneum to ALA-PDT resulted in complete resurfacing. Both electrosurgery and surgical resection resulted in a greater incidence of surface adhesions.