Optic disk edema in a patient with non-Hodgkin's lymphoma: is there a metastasis to the brain?

BACKGROUND: The manifestation of bilateral disk swelling raises the suspicion of papilledema and mandates that an etiology for increased intracranial pressure be discovered. This case report will present the manifestations and treatment of non-Hodgkin's lymphoma and review the differential diagnoses of bilateral disk edema. CASE REPORT: A 51-year-old black man manifested symptoms of dizziness and intermittent loss of vision in the left eye for one week. Dilated funduscopy revealed early left optic disk edema; edema of the right optic nerve head was questionable. The patient had pulmonary nodules noted on a recent chest x-ray that were thought to be cancerous; this raised the suspicion of a metastasis to the brain or orbit. The patient did not return until about 10 weeks later, at which time he presented with a history significant for newly-diagnosed intermediate-grade non-Hodgkin's lymphoma. He had begun chemotherapy one month before the second examination at our clinic; methotrexate therapy for CNS metastasis had been provided at the time of the spinal taps. At the second visit, there was marked progression of the swelling of the left optic disk and mild swelling of the right disk. At the third visit, six weeks later, the disk edema had improved remarkably. The patient's disk swelling resolved completely by the end of his six months of chemotherapy. CONCLUSION: This is a unique presentation of a patient at high risk for brain metastasis, in which laboratory and radiologic studies failed to provide adequate supportive evidence for the conclusions drawn from clinic observations. Bilateral disk edema in a patient with a history of non-Hodgkin's lymphoma is strongly suggestive of a metastatic tumor to the brain causing increased intracranial pressure.

Case presentations of retinal artery occlusions.

BACKGROUND: Retinal artery occlusions typically result in sudden, unilateral painless loss of vision and may have varying presentations. They are associated with systemic diseases such as atherosclerosis, hypertension, and valvular heart disease. Additional risk factors include diabetes mellitus, cigarette smoking, giant-cell arteritis, and hyperlipidemia. They most often occur in persons 60 to 80 years of age. METHODS: Four patients have come to our clinics with varying degrees of visual loss as a result of retinal artery occlusions. The types of arteriolar occlusions presented include: precapillary arteriole occlusion, cilioretinal artery occlusion, branch retinal artery occlusion, and central retinal artery occlusion. RESULTS: Patients were followed for their ocular involvement, but also included was medical management of the underlying systemic disease condition. Workup of retinal artery occlusion included laboratory testing, carotid duplex scans, and echocardiograms to uncover the possible systemic etiologies of the artery occlusion. CONCLUSION: Optometrists should recognize the signs and symptoms of the various arterial obstructions and refer patients for systemic treatment as indicated. Patients who manifest retinal or pre-retinal artery occlusions should undergo thorough systemic evaluations for vascular disease, including: atherosclerotic disease, hypertension, and valvular heart disease.

Hypovolemic ischemic optic neuropathy.

BACKGROUND: Ischemic optic neuropathy refers to an acute event of ischemia, or decreased blood flow, to the optic nerve resulting in varying degrees of vision loss and visual field defects. Typically this disease affects the elderly population who experience systemic diseases that compromise the blood flow efficiency of the optic nerve head (e.g., giant-cell arteritis, hypertension, diabetes, etc.). However, cases of blood loss to the optic nerve, secondary to traumatic injuries or surgeries, have also been shown to result in ischemic optic neuropathy, regardless of age. It seems that in these cases, the resulting anemia and hypotension play contributing roles in the development of ischemic optic neuropathy. METHODS: A 41-year-old black man came to us with optic nerve head pallor O.S., count-fingers vision O.S., positive afferent pupillary defect O.S., and a central scotoma O.S. after being hospitalized and treated for a stab wound to his left neck that severed his left carotid artery at the bifurcation. RESULTS: This patient had been seen in the Optometry Clinic two years before the stab-wound incident. At that time, he had 20/20 vision in his left eye and no remarkable neurological deficits. His ocular presentation after the traumatic hypovolemic event was probably a direct result of the hypoperfusion to the left optic nerve head. This patient was diagnosed with a hypovolemic, or blood loss-related, ischemic optic neuropathy (O.S.). CONCLUSIONS: Patients who experience large amounts of blood loss due to trauma, surgery, internal bleeding, etc. and report vision loss should be screened for possible optic nerve ischemia. As eye care providers, when we are presented with patients who have optic nerve head atrophy, we should inquire about events that may have precipitated blood loss, potentially triggering ischemic optic neuropathy.

Acute vision loss resulting from complications of ethanol abuse.

BACKGROUND: Alcoholism affects about 10% of men and 3% to 5% of women in their lifetime. It is a primary chronic disease with genetic, psychosocial, and environmental factors that influence its development and manifestations. METHODS: A 47-year-old alcoholic male manifested mild nutritional optic atrophy, chronic anemia, pancreatitis, and previous gastrojejunostomy and pancreaticojejunostomy. After an acute episode of hypovolemic blood loss from peptic ulceration, there was increased bi-temporal optic nerve head pallor with permanent vision loss, central scotoma, and an acquired red-green color vision defect. RESULTS: The genetic, psychosocial, and systemic effects of ethanol abuse--including anemia, cardiomyopathy, gastric/duodenal ulceration, pancreatitis, and neurologic deficits--are reviewed. Appropriate treatment and management of ocular manifestations and complications from alcoholism are discussed. Prophylactic topical therapy may be indicated to restore the balance between intraocular tension and optic nerve head perfusion in an attempt to prevent further axonal loss. CONCLUSION: Alcohol-induced nutritional optic neuropathy should not be viewed as an isolated ocular entity, but rather as a potentially treatable neurologic problem. An interdisciplinary approach is essential optimal in the management of the alcoholic patient.

Weber's syndrome secondary to subarachnoid hemorrhage.

BACKGROUND: Since a large intracranial hemorrhage is a space-occupying mass, it may cause the brain to shift, resulting in neurologic deficits both at the location of the bleeding and at a site distal to the hemorrhage. A parietal lobe hemorrhage may push the brain downward, causing the uncus of the temporal lobe to herniate through the tentorial notch, compressing the midbrain. The signs of parietal lobe damage, uncal herniation, and several midbrain syndromes that effect ocular motility are discussed. CASE REPORT: A 66-year-old Hispanic man came to us with a history of a subarachnoid hemorrhage that involved the right parietal lobe. Several signs of damage to both the right parietal lobe and midbrain were evident, including an ipsilateral third nerve paresis with contralateral hemiplegia, Weber's syndrome. CONCLUSION: A patient who survives a subarachnoid hemorrhage may demonstrate permanent residual neurologic deficits subsequent to the acute event. The presentation is particularly complex when the hemorrhage is large and damage occurs at multiple locations. Damage at the level of the midbrain is evident when the findings include Weber's syndrome, which is one of several syndromes that involves the oculomotor nerve.

Optometric management of patients with Alzheimer's disease.

BACKGROUND: The earliest symptoms of Alzheimer's disease (AD) may be visual. AD is an age-related, progressive dementia. At least 7% of Americans over 65 years of age are afflicted, and it ranks as the fourth leading cause of death in the United States. A review of the literature was performed to delineate the visual manifestations of Alzheimer's disease. RESULTS: Abnormal visual perception and visuospatial processing are common among patients with AD Visual acuity, pupillary light reflexes, and the ocular fundus do not appear to be specifically affected by AD. Whether AD impairs color vision is controversial. Stereopsis may also be affected. True visual-field defects are rarely found. Although not universally reported, some studies of contrast sensitivity functions show abnormal sensitivity possibly at low spatial frequencies. The electroretinogram is normal, while the visual evoked response is frequently abnormal. CONCLUSIONS: As primary eye care providers, optometrists must properly identify and refer individuals with suspected Alzheimer's disease to the appropriate specialist, as well as manage their visual welfare.

Traumatic porencephalic cyst of the brain.

BACKGROUND: A porencephalic cyst is a cavity within the cerebral hemisphere, filled with cerebrospinal fluid, that communicates directly with the ventricular system. It is a rare condition probably caused by vascular occlusion resulting from an insult during fetal development or an injury occurring later in life. Porencephaly is often associated with various ophthalmic and neurologic signs, including visual-field defects, abnormal pupillary responses, optic nerve hypoplasia, decreased vision, nystagmus, strabismus, hemi-inattention, seizures, and mental deficiencies. CASE REPORTS: Two cases are presented of patients in whom porencephalic cysts developed as a result of traumatic head injuries. Both had demonstrable visual-field defects, with diagnosis of porencephaly verified by computed tomography scans of the head. CONCLUSIONS: Visual-field defects resulting from porencephalic cysts can mimic those observed with strokes or brain tumors. A thorough case history and complete neurologic workup can assist with differential diagnosis. The clinical features of porencephaly, different theories of brain recovery after trauma, and treatment options are discussed.

Presumed ocular tuberculosis in an AIDS patient.

BACKGROUND: Prior to the advent of anti-tuberculosis medications, ocular manifestations of tuberculosis, including choroidal tubercles, were common. METHODS: A 46-year-old Hispanic male with a history of AIDS, tuberculosis and treated neurosyphilis presented for examination complaining of decreased vision in the left eye. Ophthalmoscopy revealed a large, elevated, juxtapapillary lesion consistent with a choroidal tubercle or an intraocular lymphoma. RESULTS: During follow-up, the lesion responded well to systemic anti-tuberculosis therapy. CONCLUSIONS: With the recent increase in incidence of tuberculosis in both th general population and AIDS patients, ocular manifestations of tuberculosis once thought to be rare may be increasing. Ocular tuberculosis should be considered in the differential diagnosis of patients presenting with intraocular masses, especially in individuals at high risk for exposure.

Colloid cyst of the third ventricle.

BACKGROUND: Colloid cyst of the third ventricle has rarely been reported in the ophthalmic literature. The incidence is about one per 1000 in asymptomatic patients and accounts for 0.55 to 2 percent of all intracranial tumors. Although it is an uncommon benign tumor, nearly half of symptomatic patients present with papilledema and hydrocephalus. Consideration of this intracranial tumor should be included in the differential diagnosis of papilledema and apparent unilateral disc edema. METHODS: A patient with highly asymmetrical papilledema and vague visual symptomatology involving the right eye was studied. Computer axial tomography (CT) without contrast enhancement revealed a colloid cyst of the third ventricle. Typical symptoms of the condition include headaches, nausea, vomiting, visual obscuration, transient diplopia and weakness of the lower extremities, which are due to acute hydrocephalus caused by increased intracranial pressure from cystic obstruction of the foramen of Monro. Intermittency of symptoms is characteristic of this lesion. RESULTS: The patient underwent frontal craniotomy with total tumor excision and reopening of the cerebrospinal fluid pathway. CONCLUSIONS: Colloid cyst of the third ventricle discovered incidentally on CT in asymptomatic patients with no evidence of hydrocephalus can be monitored periodically. If symptomatic, neurosurgery is usually indicated since prolonged increased intracranial pressure can lead to mental and physical deterioration as well as sudden death.

Retinal nerve fiber layer defects and microtalc retinopathy secondary to free-basing "crack" cocaine.

BACKGROUND: There have been several reports in the literature documenting ocular manifestations of cocaine abuse. None have discussed the potential retinal complications stemming from cocaine inhalation. METHODS: Approximately 60 patients with a history of free-basing "crack" cocaine were examined at the Optometry Clinic. Threshold visual field testing and fundus photographs were obtained and later reviewed. RESULTS: Microtalc retinopathy and associated retinal nerve fiber layer "rake" or "slit" defects were detected exclusively in patients who had free-based "crack" cocaine. Some of these patients manifested visual field changes that mimic glaucoma. Several cases are presented that demonstrate the findings typical of those observed in the patients examined at the Optometry Clinic. CONCLUSIONS: Microtalc retinopathy and associated glaucoma-like retinal nerve fiber layer defects indicate the presence of permanent microvascular changes in the eyes, as well as the lungs, brain, and probably other peripheral organs. Optometrists should be aware of these new findings in order to properly manage patients who free-base "crack" cocaine.

Superior quadrant visual field loss secondary to temporoparietal craniectomy for brain abscess.

BACKGROUND: Visual field defects occur from a variety of causes. As a result, the differential diagnosis of visual field defects and their etiology is important. METHODS: A 64-year old white male was examined in follow up related to the surgical removal of a right temporal lobe abscess secondary to a childhood right side mastoidectomy. The patient underwent ophthalmic examination, which suggested possible changes in his field of vision, and neurobehavioral evaluation related to his visual field defect, a left homonymous superior quadrant defect. RESULTS: Computed tomography (CT) scan of the head without contrast enhancement confirmed the ophthalmic diagnosis and correlated with the patient's medical history. However, neurobehavioral evaluation revealed a number of deficits that were believed to be associated with alcohol abuse. CONCLUSIONS: Visual field loss with changing vision symptoms and a complex history can confound the differential diagnosis of visual field defects. Frequently careful and complete evaluation can confirm and reveal subsequent diagnoses.

Support for the vasogenic theory of glaucoma: case reports and literature review.

BACKGROUND: The influence of systemic disease, vascular abnormalities, hematologic and rheologic factors, pulsatile ocular blood flow, perfusion pressure, autoregulation, optic disc hemorrhage and the results of optic nervehead fluorescein angiographic studies are reviewed in the context of supporting evidence for the vasogenic theory of glaucoma. METHODS: Two case reports of patients with confirmed carotid artery occlusive disease and one case report of a patient with a history of hypovolemic blood loss are presented. RESULTS: These cases illustrate the importance of hypotensive crisis, perfusion pressure, collateral blood flow and the optic nerve head vascular autoregulatory mechanism in the pathogenesis of glaucoma and the differential diagnosis of pseudoglaucoma. CONCLUSIONS: Evaluation and consideration of both mechanical and vasogenic causes of the glaucomas is essential in the management of the glaucomas. It is also necessary to differential diagnose the "pseudo-glaucomas," and to manage them correctly.

Malignant melanoma of the choroid with literature review.

A 67-year-old white male presented for an eye examination with history of difficulty reading. Upon routine dilation, an unsuspected malignant melanoma of the choroid was discovered. Binocular indirect ophthalmoscopy, B-scan ultrasonography, and visual field testing helped confirm the initial diagnosis. Uveal malignant melanoma is the most common primary intraocular malignant tumor occurring in adults. Controversial issues regarding proper management of choroidal malignant melanoma are discussed.