Multiple concomitant cranial nerve palsies secondary to preeclampsia.

A 32-year-old primigravid woman developed pre-eclampsia after delivery of twins along with left fifth, sixth, and seventh cranial neuropathies. She also had evidence of hepatic and renal involvement. Results of patient evaluation were otherwise unremarkable, and the palsies completely resolved over 3 months after treatment with valacyclovir and systemic corticosteroids.

Multiple brain infarcts after orbital inflammation.

A 75-year-old woman developed trigeminal varicella-zoster virus infection complicated by ophthalmoplegia, and visual loss followed by recurrent cerebral infarctions involving small and large intracranial arteries. Medical therapy improved her ophthalmoplegia, but she developed a right hemiparesis and aphasia.

Clinicopathologic correlations in giant cell arteritis: a retrospective study of 107 cases.

OBJECTIVE: To correlate the pathologic findings of temporal artery biopsies in patients clinically defined as positive, presumed, or negative for giant cell arteritis (GCA). DESIGN: Retrospective case series. PARTICIPANTS AND CONTROLS: Patients evaluated for GCA. METHODS: Temporal artery biopsies examined between 1989 and 2007 were studied. Clinical information and residual tissue for immunohistochemical staining was identified in 107 patients. Clinical information was used to make a diagnosis of "positive," "presumed," or "negative" GCA. The biopsies were reviewed in a masked fashion and classified as "positive," "indeterminate," or "negative" based on published, classic pathologic diagnosis (CPD) criteria. All biopsies were immunostained for CD3 and CD68 and graded as "negative," "mildly" (+), "moderately" (++), or "markedly" (+++) positive. Clinical and pathologic results were correlated and a modified pathologic diagnosis classification (MPD) scheme was developed. The modified scheme was compared in a masked fashion with the final clinical diagnosis and positive and negative predictive values (PVs) were calculated. MAIN OUTCOME MEASURES: Pathologic diagnosis and final clinical diagnosis. RESULTS: Using the MPD classification, there were 25%, 16%, and 61% positive, indeterminate, and negative biopsies, respectively. There was excellent correlation between the modified pathologic criteria and final clinical diagnosis (correlation coefficient 0.997; P<0.0001; kappa = 0.81). The positive PVs for CPD and MPD were 85% and 96%, respectively. The negative PVs for CPD and MPD were 64% and 61%, respectively. Positive and negative biopsies strongly correlated with clinical diagnoses of positive and negative for GCA, respectively, whereas indeterminate cases moderately correlated with presumed GCA. The diagnosis did not change from the original biopsy in 11 patients who had a second biopsy. Immunostaining for CD 68 was helpful in several indeterminate cases. CONCLUSIONS: We recommend using the modified histologic classification of temporal artery biopsies. There are indeterminate cases that cannot be further defined using current pathologic classification criteria. A second biopsy has very limited value. Immunostaining for CD68 may be helpful in indeterminate cases, although the diagnosis in these cases is based on clinical judgment.

A case of acute posterior multifocal placoid pigment epitheliopathy with recurrent stroke.

A 43-year-old man who had visual loss from acute posterior multifocal placoid pigment epitheliopathy (APMPPE) developed a right middle cerebral artery territory infarction a few weeks after the visual loss occurred and shortly after corticosteroid therapy was tapered. He was then treated continuously with oral low-dose prednisone and cyclophosphamide but presented with recurrent cerebral infarction 6 months later, shortly after cyclophosphamide was replaced with azathioprine. Neurologic complications of APMPPE are exceedingly rare, with only 18 other well-documented cases of APMPPE in the English and French literature. Cerebral vasculitis was the presumed mechanism in most patients, but only 2 patients had pathologic confirmation. There have been only 3 reported cases of recurrent cerebral infarction, all occurring during corticosteroid taper. Because neurologic complications of APMPPE are rare, it is reasonable to reserve neuroimaging for patients who have unusual headaches or other new neurologic manifestations.

Ischemic optic neuropathies.

Anterior ischemic optic neuropathy (AION) is the most common cause of acute optic neuropathy after age 50, but may also occur in younger patients. The diagnosis is clinical and includes painless visual loss associated with a relative afferent pupillary defect and disc edema. In almost all cases, there is an underlying crowded optic nerve with a small cup-to-disc ratio. The visual prognosis is usually poor, although up to 43% of patients may improve over time. The fellow eye is involved in up to 15% of patients within 5 years, but the risk of recurrence in the same eye is less than 5%. There is no treatment for acute nonarteritic AION but it is essential to evaluate these patients for underlying treatable atheromatous vascular risk factors. A coagulation workup should also be considered in younger patients. It is essential to rule out giant cell arteritis in all patients over the age of 50 with ischemic optic neuropathies. Posterior ischemic neuropathy (in which the optic nerve is normal acutely) is rare and should be considered a diagnosis of exclusion.

Familial cold-induced transient diplopia.

BACKGROUND: The major precipitants of intermittent diplopia secondary to a phoria breakdown include fatigue and illness. PURPOSE: To describe cold-induced vertical diplopia in a mother and daughter. METHODS: Retrospective report. RESULTS: Mother and daughter both developed vertical diplopia after exposure to cold ambient temperatures. These symptoms remained stable over many years. Ocular motility examination suggested that the diplopia resulted from breakdown of a small vertical phoria. CONCLUSIONS: Familial cold-induced vertical diplopia is a rare disorder of unclear etiology that need not be associated with underlying systemic disease.

Using the CanMEDS roles when interviewing for an ophthalmology residency program.

BACKGROUND: To improve the admissions process for the Université de Montréal (UdeM) ophthalmology residency program, the interview structure was modified to encompass the seven CanMEDS roles introduced by the Royal College of Physicians and Surgeons of Canada (RCPSC). These roles include an applicant's abilities as a communicator, collaborator, manager, health advocate, professional, scholar, and medical expert. METHODS: In this retrospective pilot study, the records of all applicants were reviewed by 8 members of the admissions committee, with a high intraclass correlation coefficient of 0.814. Four 2-person interview teams were then formed. The first 3 groups asked the applicants specific questions based on 2-3 of the CanMEDS roles, marking their impressions of each candidate on a visual analogue scale. The last group answered candidates' questions about the program but assigned no mark. RESULTS: The intraclass correlations for the teams were 0.900, 0.739, and 0.585, demonstrating acceptable interrater reliability for 2 of the teams. Pearson correlation coefficients between groups of interviewers were considered adequate at 0.562, 0.432, and 0.417 (p < 0.05). For each interviewer, the Pearson correlation coefficient between record marking and interview scoring was either not statistically significant or very low. INTERPRETATION: By basing the 2006 interview process on the CanMEDS roles defined by the RCPSC, information was obtained about the candidates that could not have been retrieved by a review of the medical students' records alone. Reliability analysis confirmed that this new method of conducting interviews provided sound and reliable judging and rating consistency between all members of the admissions committee.