Prognostic Value of the Neurological Pupil Index in Patients With Acute Subarachnoid Hemorrhage.

BACKGROUND: The Neurological Pupil index (NPi) provides a quantitative assessment of pupil reactivity and may have prognostic value in patients with subarachnoid hemorrhage (SAH). We aimed to explore associations between the NPi and clinical outcomes in patients with SAH. METHODS: A retrospective analysis of 79 consecutive patients with acute SAH. Age, sex, Acute Physiology and Chronic Health Evaluation-II score, and respiratory failure and NPi in each eye were recorded at admission. The primary outcomes included death and poor clinical outcome (defined as inpatient death, care withdrawal, or discharge Glasgow Outcome Score <4). Groups were compared using the Fisher exact test, and predictive models developed with fast-and-frugal trees (FFTs). RESULTS: A total of 53 patients were included: 21 (40%) had poor clinical outcomes and 2 (4%) died. Univariate analysis found that only APACHE-II score (P < 0.001) and respiratory failure (P = 0.04) were significantly associated with poor clinical outcomes. NPi was lower among patients with poor clinical outcomes (mean 4.3 in the right eye and 4.2 in the left eye) vs those without (mean 4.5 in the right eye and 4.5 in the left eye), but neither was significant. However, the most accurate FFTs for death and poor clinical outcome included NPi after accounting for age in the death FFT and APACHE-II score in the poor outcome FFT (sensitivity [sn] = 100%, specificity [sp] = 94%, and accuracy (ac) = 94% in a model for death; sn = 100%, sp = 50%, and ac = 70%) in a model for poor clinical outcome. CONCLUSIONS: Our study supports the NPi as a useful prognostic marker for poor outcomes in acute SAH after accounting for age and APACHE-II score.

Optic Nerve Angle in Idiopathic Intracranial Hypertension.

BACKGROUND: The tortuosity of the optic nerve can be quantified radiologically by measuring the angle of optic nerve deformation (the "optic nerve angle" [ONA]). In patients with idiopathic intracranial hypertension (IIH), lowering the intracranial pressure (ICP) to a normal range by lumbar puncture leads to straightening of the optic nerve and an increase in the measured sagittal ONA on MRI. It is uncertain whether there is any correlation between ONA and cerebrospinal fluid (CSF) opening pressure or visual function. METHODS: Retrospective study of patients with and without IIH who had MRI of the brain followed by lumbar puncture with CSF opening pressure within 24 hours of MRI. Before LP and within 24 hours of MRI of the brain, all patients with IIH had neuro-ophthalmologic assessment including visual acuity, Humphrey Visual Field (HVF), and fundus photography. Sagittal ONA was measured on multiplanar T2-SPACE images on a DICOM viewer. Papilledema on the fundus photographs was graded using the Frisén scale. RESULTS: Fifty-four patients with IIH and 30 unmatched controls were included. The IIH group was 6.3 years younger (95% CI 2.4-10.3, P = 0.002), had 8.7 kg/m2 higher body mass index (4.9-12.5, P < 0.001), and 26.3% more women (P = 0.011) compared with controls. In both eyes, the ONA was significantly smaller in patients with IIH by 12° compared with controls (7°-17°, P < 0.00001). In the IIH group, no correlation between ONA and the CSF opening pressure was present in either eye (right eye r = 0.19, P = 0.15; left eye r = 0.18, P = 0.19) The ONA did not correlate with logarithm of the minimum angle of resolution visual acuity (right eye r = 0.26, P = 0.063; left eye r = 0.15, P = 0.27), HVF mean deviation (right eye r = 0.0059, P = 0.97; left eye r = -0.069, P = 0.63), or Frisén grade (Spearman's rho right eye 0.058, P = 0.67; left eye 0.14, P = 0.30). CONCLUSIONS: The ONA is significantly smaller in patients with IIH compared to controls, but does not correlate with CSF opening pressure, severity of papilledema, or visual function. The ONA may be useful in identifying patients with raised ICP, but not necessarily those with a poor visual prognosis.

Patient Harm Due to Diagnostic Error of Neuro-Ophthalmologic Conditions.

PURPOSE: To prospectively examine diagnostic error of neuro-ophthalmic conditions and resultant harm at multiple sites. DESIGN: Prospective, cross-sectional study. PARTICIPANTS: A total of 496 consecutive adult new patients seen at 3 university-based neuro-ophthalmology clinics in the United States in 2019 to 2020. METHODS: Collected data regarding demographics, prior care, referral diagnosis, final diagnosis, diagnostic testing, treatment, patient disposition, and impact of the neuro-ophthalmologic encounter. For misdiagnosed patients, we identified the cause of error using the Diagnosis Error Evaluation and Research (DEER) taxonomy tool and whether the patient experienced harm due to the misdiagnosis. MAIN OUTCOME MEASURES: The primary outcome was whether patients who were misdiagnosed before neuro-ophthalmology referral experienced harm as a result of the misdiagnosis. Secondary outcomes included appropriateness of referrals, misdiagnosis rate, interventions undergone before referral, and the primary type of diagnostic error. RESULTS: Referral diagnosis was incorrect in 49% of cases. A total of 26% of misdiagnosed patients experienced harm, which could have been prevented by earlier referral to neuro-ophthalmology in 97%. Patients experienced inappropriate laboratory testing, diagnostic imaging, or treatment before referral in 23%, with higher rates for patients misdiagnosed before referral (34% of patients vs. 13% with a correct referral diagnosis, P < 0.0001). Seventy-six percent of inappropriate referrals were misdiagnosed, compared with 45% of appropriate referrals (P < 0.0001). The most common reasons for referral were optic neuritis or optic neuropathy (21%), papilledema (18%), diplopia or cranial nerve palsies (16%), and unspecified vision loss (11%). The most common sources of diagnostic error were the physical examination (36%), generation of a complete differential diagnosis (24%), history taking (24%), and use or interpretation of diagnostic testing (13%). In 489 of 496 patients (99%), neuro-ophthalmology consultation (NOC) affected patient care. In 2% of cases, neuro-ophthalmology directly saved the patient's life or vision; in an additional 10%, harmful treatment was avoided or appropriate urgent referral was provided; and in an additional 48%, neuro-ophthalmology provided a diagnosis and direction to the patient's care. CONCLUSIONS: Misdiagnosis of neuro-ophthalmic conditions, mismanagement before referral, and preventable harm are common. Early appropriate referral to neuro-ophthalmology may prevent patient harm.

Conservative treatments for acute nonarteritic central retinal artery occlusion: Do they work?

Acute central retinal arterial occlusion has a very poor visual prognosis. Unfortunately, there is a dearth of evidence to support the use of any of the so-called "conservative" treatment options for CRAO, and the use of thrombolytics remains controversial. In this review, we address a variety of these "conservative" pharmacologic treatments (pentoxifylline, isosorbide dinitrate, and acetazolamide) and nonpharmacologic approaches (carbogen, hyperbaric oxygen, ocular massage, anterior chamber paracentesis, laser embolectomy, and hemodilution) that have been proposed as potential treatments of this condition. We conclude that the available evidence for all treatments is insufficient to conclude that any treatment will influence the natural history of this disorder. Management of CRAO patients should instead focus on reducing the risk of subsequent ischemic events, including cerebral stroke. Certain patients may be considered for acute treatment with thrombolytics, although further research must clarify the efficacy, safety, and optimal use of these therapies.

Optic disc edema due to peripapillary choroidal neovascularization.

A 35-year-old myopic woman developed right-eye optic disc edema with normal visual function. The presence of a subtle crescent-shaped peripapillary subretinal hemorrhage in addition to the disc edema raised concern for a peripapillary choroidal neovascular membrane, which was confirmed by enhanced depth optical coherence tomography.

Unilateral Isolated Paucisymptomatic Optic Disc Edema.

BACKGROUND: Unilateral isolated optic disc edema (UIODE) represents a challenging clinical presentation that frequently precipitates an extensive diagnostic work-up. Patients without an apparent diagnosis despite appropriate investigations are often categorized as having "papillophlebitis," an entity that is poorly defined in the existing literature. Our aim was to describe the characteristics of a series of patients with paucisymptomatic UIODE, determine the optimal diagnostic approach to such cases, and clarify the clinical features of presumed papillophlebitis. METHODS: We retrospectively identified 29 patients with UIODE who were seen by neuro-ophthalmologists at a single center between 2005 and 2019. Each patient presented with isolated, unilateral disc edema that was either entirely asymptomatic or associated with minimal visual symptoms. Patients underwent a comprehensive neuro-ophthalmic evaluation and several ophthalmic and systemic investigations. Data from the initial visit and all subsequent clinical visits were collected, including patient demographics, examination findings, and details of the diagnostic work-up. RESULTS: Our 29 patients with UIODE were found to have a variety of underlying diagnoses including unilateral papilledema due to idiopathic intracranial hypertension (10 patients), optic nerve sheath meningioma (5), incipient nonarteritic anterior ischemic neuropathy (4), vitreopapillary traction (3), orbital masses (2), a peripapillary choroidal neovascular membrane (1), and presumed papillophlebitis (4). The duration of disc edema varied considerably based on the etiology, but most patients had favorable visual outcomes. CONCLUSIONS: A systematic approach to the evaluation of UIODE, combined with long-term follow-up, led to a definite diagnosis in a majority of patients, with only 4 patients presumed to have papillophlebitis, a diagnosis the actual existence of which remains controversial.

Idiopathic Intracranial Hypertension in Pregnancy.

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by elevated intracranial pressure without an identifiable underlying cause. Pregnancy has unique and important diagnostic and therapeutic implications for patients with IIH. Despite these implications, there are no guidelines to assist clinicians in managing IIH during pregnancy. Our review aims to summarize the key considerations related to the diagnosis and management of IIH during pregnancy, to optimize the care of these patients and mitigate the risk of disease-related complications. The optimal management of IIH in pregnancy should include a multidisciplinary team, including an obstetrician (or maternal-fetal medicine specialist), a neurologist, and an ophthalmologist (or neuro-ophthalmologist).

Ocular Fundus Abnormalities in Acute Subarachnoid Hemorrhage: The FOTO-ICU Study.

BACKGROUND: Ocular fundus abnormalities, especially intraocular hemorrhage, may represent a clinically useful prognostic marker in patients with acute subarachnoid hemorrhage (SAH). OBJECTIVE: To evaluate associations between ocular fundus abnormalities and clinical outcomes in acute SAH. METHODS: Prospective evaluation of acute SAH patients with ocular fundus photography at bedside. Multivariable logistic models were used to evaluate associations between fundus abnormalities and poor outcome (inpatient death, care withdrawal, or discharge Glasgow Outcome Score <4) and intensive care unit (ICU) and hospital lengths-of-stay, controlling for APACHE II score, respiratory failure at ICU admission, Hunt & Hess score, aneurysmal etiology, age, and sex. RESULTS: Fundus abnormalities were present in 29/79 patients with acute SAH (35.4%), and 20/79 (25.3%) had intraocular hemorrhage. In univariate analyses, poor outcomes were more likely among patients with fundus abnormalities vs without (15/28 [53.6%] vs 15/51 [29.4%], P = .03); median length of ICU stay was longer in patients with intraocular hemorrhage than without (18 d [interquartile range (IQR) 12-25] vs 11 [IQR 7-17], P = .03). Logistic regression with fundus abnormality as predictor of interest showed that male sex (odds ratio [OR] 5.33 [95% CI 1.09-26.0], P = .045), higher APACHE II (OR, per 1-point increase, 1.35 [95% CI 1.08-1.78], P = .01), and aneurysmal etiology (OR 4.35 [95% CI 1.01-22.9], P = .048), but not fundus abnormalities (OR 1.56 [95% CI 0.43-5.65], P = .49) or intraocular hemorrhage (OR 1.28 [95% CI 0.26-5.59], P = .75) were associated with poor outcome. CONCLUSION: Although ocular fundus abnormalities are associated with disease severity in SAH, they do not add value to patients' acute management beyond other risk factors already in use.

Ophthalmic adverse effects of lithium.

Lithium is the current mainstay treatment for both acute and maintenance management of bipolar disorders. However, its narrow therapeutic index and array of side effects, although well-documented, can be challenging to manage. Comparatively, the side effects of lithium that involve the ophthalmic structures are not as well established in the literature and only partially appreciated, which can potentially lead to noncompliance. In this article, an extensive literature review of lithium and its ophthalmic adverse effects were performed and comprehensively summarized. Based on the search, documented ophthalmic adverse effects of lithium include: exophthalmos; abnormal eye movements; ocular myasthenia gravis; papilledema; photophobia; and abnormal tear film, contributing to dry eye disease. Additional studies are anticipated to be helpful in expanding the current understanding of lithium and its adverse ophthalmic side effects and certainly warranted to fill the knowledge gap. Close interprofessional management between psychiatrists and ophthalmologists is expected to be beneficial in patient care.

New concepts on acute ocular ischemia.

PURPOSE OF REVIEW: To review recent advances in the management of acute ocular ischemic events, including: transient monocular vision loss, central and branch retinal artery occlusions, and nonarteritic anterior ischemic optic neuropathy. RECENT FINDINGS: Transient monocular vision loss and acute retinal arterial occlusions require immediate diagnosis and management, with recognition of these events as transient ischemic attack or stroke equivalents, respectively. Patients should undergo an immediate stroke workup in a stroke center, similar to patients with acute cerebral ischemia. The treatment of central retinal artery occlusions remains limited despite the growing use of thrombolytic treatments. The indication for these treatments remains under debate. No quality evidence exists to support any therapy, including corticosteroids, in the treatment of nonarteritic anterior ischemic optic neuropathy. The highest priority in management is to rule-out giant cell arteritis. SUMMARY: Effective therapies for the treatment of ischemic events of the retina and optic nerve remain elusive. Clinicians should focus on the prompt recognition of these events as ocular emergencies and immediately refer patients with vascular transient visual loss and acute central and branch retinal arterial occlusions to the nearest stroke center.

Status of Canadian undergraduate medical education in ophthalmology.

OBJECTIVE: To use the perspectives of undergraduate program directors to assess the current structure and adequacy of undergraduate ophthalmology curricula at Canadian medical schools. DESIGN: Cross-sectional survey. PARTICIPANTS: Undergraduate ophthalmology program directors at each English-speaking Canadian medical school. METHODS: Program directors were identified and invited to participate in an online survey. The 18-question survey focused on key areas of undergraduate ophthalmology curricula, including length, timeline, setting, and nature of medical students' exposure to ophthalmology. A period of 4 months was allowed for responses. Information from medical school web sites was combined with survey responses. RESULTS: Responses were obtained from 7 of the 14 (50%) program directors. All of the respondents represented metropolitan institutions of greater than 100 seats. After combining survey and web site data, only 5 of 14 (35.7%) schools were found to have a mandatory clinical clerkship ophthalmology rotation. In each case, the mandatory rotation is less than 2 weeks. A core curriculum based on the International Council of Ophthalmology (ICO) guidelines is used in only 20% of schools. Extracurricular ophthalmology exposure in the form of research opportunities and interest groups exists in 100% and 71.4% of schools, respectively. CONCLUSIONS: The proportion of schools requiring mandatory clerkship ophthalmology rotations is only 35.7%. However, most departments use strategies to optimize the limited time allotted to ophthalmology rotations during medical school. A greater degree of adherence to the ICO curriculum guidelines may help to ensure that medical students develop an appropriate level of proficiency in managing patients with eye disease.

Association between positive corneal rim cultures and microbiology screening protocols in Ontario.

OBJECTIVE: (i) To assess the rate of positive microbiological cultures of corneas prepared by the Eye Bank of Canada (Ontario Division) between January 1, 2012, and December 31, 2013; (ii) to review the microbiology protocols at the 5 major transplant centres in Ontario; and (iii) to assess the incidence of endophthalmitis during the study period. DESIGN: Retrospective chart review. PARTICIPANTS: A total of 4186 consecutive cultured corneal tissues prepared by the Eye Bank from January 1, 2012, to December 31, 2013. METHODS: Rates of culture-positive cornea rims and incidence of postkeratoplasty endophthalmitis at 5 surgical centres in Ontario were determined, and the protocols used to culture rims at each site were concurrently reviewed. Culture results were analyzed via logistic regression for positive cultures. RESULTS: The rate of positive cultures at each sites were as follows: centre A, 3.74%; centre B, 3.26%; centre C, 0.51%; centre D, 0.48%; and centre E, 0.04%. Centres A, B, and D were noted to have significantly higher positive rates than centre E. In comparing microbiology protocols, longer incubation period (11 days) was 12 times more likely to be associated with higher positive culture rates than shorter period (4-5 days). Six-month follow-up of all keratoplasties revealed zero reported cases of endophthalmitis. CONCLUSIONS: A literature review regarding the predictive value of routine culturing reveals conflicting data. Our findings suggest that differences in the microbiology protocols directly influence the rates of positive rim cultures. Without a standardized protocol, it is not possible to evaluate the predictive value of routine corneal rim culturing in predicting postkeratoplasty endophthalmitis.

Treatment of Nonarteritic Acute Central Retinal Artery Occlusion.

Central retinal artery occlusion (CRAO) is an event most often caused by an embolus originating in the ipsilateral carotid artery, aortic arch, or heart. CRAO may result from partial or complete occlusion of the central retinal artery (CRA), which acts as the primary blood supply to the inner neurosensory retina, and typically results in profound vision loss and permanent visual disability. No consensus has emerged regarding the optimal treatment of CRAO. All proposed treatments are of questionable efficacy and many have uncertain risk profiles. In certain circumstances, thrombolysis may be attempted as a treatment option; however, the evidence to support broad use of thrombolytics in the treatment of acute CRAO remains elusive. It is known that the risk factors that predispose to other cardiovascular and cerebrovascular events are often present in CRAO. Accordingly, identification of patients at highest risk of stroke and secondary prevention of ischemic events remains the primary focus of management. This review offers a summary of the clinical presentation, diagnosis, and prognosis of CRAO, with an emphasis on treatment options.

Barriers to electronic medical record implementation: a comparison between ophthalmology and other surgical specialties in Canada.

OBJECTIVE: In the present study, the barriers limiting widespread adoption of electronic medical records (EMRs) among Canadian ophthalmologists were evaluated in comparison with physicians from other surgical specialities. The published literature regarding EMR use in ophthalmic practice was also reviewed. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 1199 Canadian surgeons participating in the 2014 National Physician Survey (NPS). METHODS: Data regarding speciality surgeons' adoption of EMR programs were extracted from the 2014 NPS, a nationwide survey of practicing physicians in Canada. The data were entered into a spreadsheet, and basic statistical analyses, including χ2 analyses, were performed to compare the responses of ophthalmologists to other surgeons. RESULTS: Compared with other surgeons, ophthalmologists surveyed were significantly more likely to identify the following barriers to EMR adoption: "no suitable product for my practice" (p = 0.01), "too costly" (p = 0.0006), "too time consuming" (p < 0.0001), and "planning to retire soon" (p = 0.001). No statistically detectable differences were found between ophthalmologists and other surgeons for the following barriers: privacy concerns, reliability concerns, and lack of training. CONCLUSIONS: The barriers that limit increased EMR adoption among Canadian ophthalmologists are different from those of other surgeons. This may be attributed to unique features of the field, including heavy reliance on hand-drawn figures in documentation, high patient volume, and the high costs associated with independent practice. Given the well-established benefits of EMR technology, consideration should be given to implementing strategies to mitigate these barriers. Additional research may help determine which specific improvements can be made to increase the use of EMR systems by ophthalmologists.

Comparison of intraocular pressure post penetrating keratoplasty vs Descemet's stripping endothelial keratoplasty.

OBJECTIVE: To compare the effect of Descemet's stripping endothelial keratoplasty (DSEK) with penetrating keratoplasty (PKP) on intraocular pressure (IOP) and use of ocular antihypertensives. DESIGN: Retrospective cohort study. PARTICIPANTS: Thirty-five eyes in 33 patients undergoing PKP and 43 eyes in 38 patients undergoing DSEK were included in the analysis. Fifteen eyes undergoing PKP and 12 undergoing DSEK had diagnosed glaucoma. Patients undergoing corneal transplant because of trauma, keratoconus, pellucid marginal degeneration, or prior failed transplant were excluded. METHODS: Charts were obtained for all patients who underwent PKP or DSEK by a single surgeon at the Ivey Eye Institute between 2003 and 2010. IOP and all IOP-lowering medications were recorded preoperatively and at 1, 4, 8, 12, and 24 weeks postoperatively. Complications, graft survival, and glaucoma surgeries were noted. RESULTS: There was no significant difference in preoperative IOP between the 2 groups (p = 0.30). Postoperatively, IOP was significantly higher in the PKP group at 1 week (p < 0.01), 4 weeks (p < 0.01), and 8 and 12 weeks (p < 0.05), but not at 24 weeks (p = 0.62). Mean IOP increased significantly post-transplant in all groups (p < 0.05). In patients without glaucoma, postoperative IOP elevation requiring treatment occurred in 68% of PKP eyes and 23% of DSEK eyes. In patients with prior glaucoma, an increased requirement for ocular antihypertensives occurred in 60% of PKP eyes and 20% of DSEK eyes. Three trabeculectomies and 1 tube shunt were performed in the cohort with glaucoma undergoing PKP. No glaucoma surgery was required in the DSEK cohort. CONCLUSIONS: Elevation of IOP requiring treatment occurred at a lower rate after DSEK compared with PKP. This difference was significant during the early postoperative course but nonsignificant at 24 weeks. Additional long-term studies on the effect of DSEK on glaucoma and IOP control are warranted.