Optic neuropathy and chiasmopathy in the diagnosis of systemic lupus erythematosus.

PURPOSE: To report the clinical presentation of acute visual loss in six patients who were ultimately diagnosed with systemic lupus erythematosus (SLE). METHODS: Retrospective case series. RESULTS: All patients had a positive antinuclear antibody and elevated anti-double stranded DNA titers. Five of six patients demonstrated gadolinium enhancement of the optic nerve and/or chiasm on magnetic resonance imaging (MRI). Most patients showed initial improvement after treatment with high-dose systemic corticosteroids, but five experienced recrudescences during steroid taper, requiring further treatment with immunosuppressive or cytotoxic medications. CONCLUSIONS: Visual loss owing to optic neuropathy or chiasmopathy may be the presenting sign of SLE or the event that leads to this diagnosis. Gadolinium-enhanced MRI is useful for identifying anterior visual pathway lesions in these patients. Corticosteroids are effective in the treatment of this condition; however, relapses requiring further treatment are common.

Laser in situ keratomileusis-induced optic neuropathy.

OBJECTIVE: To report a case of bilateral optic neuropathy after bilateral laser-assisted in situ keratomileusis (LASIK) surgery. DESIGN: Observational case report. METHODS: Complete eye examination with detailed evaluation of the optic nerve, detailed medical history, stereo disc photographs, GDx Nerve Fiber Analyzer testing, Humphrey 24-2 SITA visual field testing, diurnal intraocular pressure measurement, serologic evaluation, and magnetic resonance imaging of the brain and orbits. MAIN OUTCOME MEASURES: Optic nerve status, visual field status, and visual acuity. RESULTS: A subject with previously healthy optic nerves had bilateral optic neuropathy develop after LASIK surgery. This neuropathy manifested with a subjective decrease in visual field, normal visual acuity, normal color vision, relative afferent pupillary defect, increased cupping of the optic nerve with focal neuroretinal rim defects, decreased nerve fiber layer thickness, and nerve fiber bundle-type visual field defects. The subject had no other risk factors for optic neuropathy. No other cause of neuropathy was identified. CONCLUSIONS: Optic neuropathy is a potential vision-threatening complication of LASIK surgery. This complication may be due to barotrauma or ischemia related to extreme elevation of intraocular pressure by the suction ring. Careful examination of the optic nerve before and after LASIK surgery is warranted.

Wall-eyed bilateral internuclear ophthalmoplegia in central nervous system cryptococcosis.

Only one case of wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) has been described in central nervous system cryptococcosis. The disorder was initially unilateral, then became bilateral with skew deviation and vertical upgaze deficit. We report a case of WEBINO in central nervous system cryptococcosis in a patient with acquired immune deficiency syndrome. Magnetic resonance imaging revealed high signal on T2 images in the right midbrain, left frontal vertex, left splenium, and cerebellum. With treatment, the internuclear ophthalmoplegia improved; however, the convergence insufficiency remained. Disruption of input from cortical supranuclear locations or the region of the rostral interstitial nucleus of the medial longitudinal fasciculus has been proposed as a mechanism in the absence of convergence. This correlates in our patient with the lesions seen on magnetic resonance images.

Comparison of anterior transposition and recession of the inferior oblique muscle in unilateral superior oblique paresis.

PURPOSE: Both anterior transposition and graded recession have been shown to be effective procedures in weakening the inferior oblique muscle. Anterior transposition may work in part by converting the inferior oblique muscle from an elevator to a depressor of the globe. In theory, this would be useful in treating the inferior oblique overaction associated with superior oblique paresis. We compared inferior oblique recession and anterior transposition for the surgical correction of Knapp's class III unilateral superior oblique paresis. METHODS: Four patients underwent 14 mm recession, and five underwent anterior transposition of the inferior oblique muscle for the hypertropia in superior oblique paresis. Prism cover test measurements were made in all cardinal fields of gaze and were compared before and after operation between the two groups. RESULTS: The mean preoperative hyperdeviation in the primary position was 12 prism diopters in the recession group and 15 prism diopters in the anterior transposition group. The mean postoperative hyperdeviation was 1 prism diopter in the recession group and 3 prism diopters in the anterior transposition group. Postoperative results in the inferior oblique field of action demonstrated a mean 3 prism diopter hypertropia in the recession group and a 2 prism diopter hypotropia in the anterior transposition group. CONCLUSIONS: Anterior transposition and graded recession gave similar results in correcting the primary position hyperdeviation in Knapp's class III superior oblique paresis. Both procedures also markedly improved the hyperdeviation in the field of action of the inferior oblique muscle and superior oblique muscle. However, anterior transposition was more likely to result in postoperative hypodeviation in upgaze.

Large-angle exotropia corrected by intraoperative botulinum toxin A and monocular recession resection surgery.

PURPOSE: Surgical correction of large-angle exotropia, greater than 70 PD, traditionally requires operating on three or four horizontal muscles. However, in secondary exotropia from monocular visual loss, it is advisable to operate only on the eye with poor vision. We used intraoperative botulinum toxin as an adjunct to the monocular recession-resection procedure for large-angle sensory exotropia, therefore operating only on the visually impaired eye. METHODS: Three patients underwent monocular recession (10 mm) and resection (10 mm) along with intraoperative botulinum toxin A injection of 10 units into the recessed muscle. All had desired cosmetic repair of long-standing large-angle exotropia (range 100 to 110 PD) with amblyopia and vision worse than 20/200 in the deviated eye. RESULTS: Within 4 days after operation all patients demonstrated maximal paresis of the lateral rectus muscle. This lasted 8 to 12 weeks and resulted in stable orthotropia at 2.5 years in case 1 and stable 8 PD exotropia at 4 years in case 2. The third case demonstrated a stable 18 PD exotropia by 7 months with a satisfactory cosmetic result. CONCLUSION: This technique provides an alternative for the surgical correction of large-angle exotropia by operating only on two horizontal muscles. In sensory exotropia it also avoids subjecting a normal eye to an operative risk.

Sarcoid optic neuropathy: a case report.

BACKGROUND: Sarcoidosis is frequently overlooked as a cause of optic neuropathy. A cascade of immune interactions has been cited in the pathogenesis. Optic nerve involvement can be the initial manifestation of systemic disease, making the diagnosis even more elusive. Compatible clinicoradiographic and abnormal laboratory findings along with histologic evidence of noncaseating granuloma are necessary to secure the diagnosis of sarcoidosis. METHODS: A case report is presented of a 41-year-old patient with severe papillitis and a junctional scotoma as the first declaration heralding neurosarcoidosis (NS). Co-management with a neuroophthalmologist at an academic teaching hospital prompted the necessary diagnostic studies to preserve vision. RESULTS: Sarcoidosis was diagnosed on the basis of the patient's clinical presentation of rapid vision loss, enlarging mass in the anterior visual pathway revealed by CT and MRI, as well as increased uptake of gallium in the lungs and lacrimal glands. Also considered in the differential diagnosis were glioblastoma, lymphoma, and demyelinating disease. CONCLUSIONS: This case represents an example of triage referral involving optometry and academic ophthalmology. Rapid intervention with intravenous corticosteroids should be considered in the face of atypical optic neuritis with a suspected inflammatory etiology.

Optic disk swelling and abducens palsies associated with OKT3.

PURPOSE/METHODS: Orthoclone OKT3 is a monoclonal murine IgG immunoglobulin used to treat acute cellular rejection of allografted organs. Aseptic meningitis and meningoencephalopathy are known adverse side effects from the drug. OKT3 caused additional ophthalmologic and neurologic complications in an 18-year-old woman who was treated for transplanted kidney graft rejection. Papilledema and bilateral abduction deficits developed. RESULTS/CONCLUSIONS: Results of magnetic resonance imaging and magnetic resonance angiography were unremarkable. Lumbar puncture disclosed increased intracranial pressure and sterile meningeal inflammation. Most of the symptoms resolved by one week after discontinuation of OKT3. Ophthalmologists and neurologists should be aware that optic disk swelling and abducens palsies can be associated with OKT3 when used in the treatment of transplanted kidney graft rejection.

Transient worsening of optic neuropathy as a sequela of the Jarisch-Herxheimer reaction in the treatment of Lyme disease.

A 58-year-old woman developed neurologic and neuroophthalmologic manifestations of Lyme disease, including a radiculomyelitis, cranial neuritis and mild right optic neuropathy. Upon treatment with intravenous ceftriaxone a Jarisch-Herxheimer reaction occurred with encephalopathy, mild fever, worsening radiculomyelitis, and deterioration of her visual acuity. Intravenous methylprednisolone was given, and the visual acuity recovered over 72 hours. This case suggests that transient worsening of optic neuropathy can develop as a sequela of the Jarisch-Herxheimer reaction in the treatment of Lyme disease.

[Neuro-ophthalmologic complications of disseminated lupus erythematosus]. / Complications neuro-ophtalmologiques du lupus érythémateux disséminé.

BACKGROUND: Systemic lupus erythematosus (SLE) is a multisystemic inflammatory disease of unknown etiology. Physiopathology includes small vessel occlusion and auto-antibody production. Neuro-ophthalmic complications can be detected in 10-30% of SLE cases. Further, some patients can present with neuro-ophthalmic complications prior to diagnosis of SLE. PATIENTS AND METHODS: We report seven cases of neuro-ophthalmic complications of SLE demonstrating lesions from the retina to the brain. The other possible manifestations of SLE will be reviewed. RESULTS: Two cases were not yet diagnosed with SLE when neuro-ophthalmic disease occurred. Anti-double stranded DNA antibodies were detected at a very high titer, suggesting SLE, later confirmed by rheumatologists. CONCLUSIONS: Ophthalmologists should be aware of the unusual patient presenting with a neuroophthalmic disorder prior to the diagnosis of SLE. In such cases, autoantibodies should be sought. Antinuclear antibodies are very sensitive but non specific for SLE. Anti-double stranded DNA antibodies are specific for SLE and elevated titer should raise the suspicion of undiagnosed SLE.

Asymptomatic unilateral papilledema in pseudotumor cerebri.

A 32-year-old asymptomatic woman was found to have unilateral papilledema on routine ophthalmological examination. Subsequent visual field, neuroimaging, and cerebrospinal fluid examinations were consistent with the diagnosis of pseudotumor cerebri. This case demonstrates that pseudotumor cerebri may present as unilateral papilledema in any asymptomatic patient and illustrates the need for thorough neuro-ophthalmological evaluations to allow early detection of cases with atypical presentations to increase the efficacy of therapeutic intervention and prevent progressive visual loss.

Bilateral internuclear ophthalmoplegia with absence of convergent eye movements. Clinicopathologic correlation.

A case of bilateral internuclear ophthalmoplegia of long duration with autopsy confirmation is reported. The main features of the syndrome included paresis of ocular adduction upon attempted lateral gaze, horizontal nystagmus in the abducting eye, and an absence of converging eye movements. Examination of Weil-stained sections revealed multiple plaques of demyelination. The medial longitudinal fasciculus was demyelinated bilaterally in the upper pons-caudal midbrain. The oculomotor, trochlear, and abducens nuclei appeared relatively well preserved. The internal capsule was severely damaged. Large cyst-like structures were centered in the anterior limb bilaterally and extended caudally to the level of the genu. Plaques of demyelination were present bilaterally in the posterior limb. The left side of the internal capsule was more severely affected than the right. It is thought that convergence in this case may have been eliminated by interruption of fibers from the frontal eye fields and/or other cortical areas in their descent through the internal capsule.

Isolating and sequencing the predominant 5'-ends of a specific mRNA in cells. I. Purification by filter hybridization.

Procedures are considered for purification of a specific procaryotic RNA by successive hybridizations to DNA immobilized to nitrocellulose with special consideration of problems associated with subsequent end-labeling in the T4 polynucleotide kinase reaction. (1) Inhibitors of the kinase can be associated with the plasmid but were removed by electrophoresis of the DNA fragment through polyacrylamide. (2) Residual soluble acrylamide, contaminating the DNA and preventing its efficient retention to nitrocellulose, could be removed by DE52 chromatography. (3) Short denatured DNA required high salt (0.9 M) to bind to nitrocellulose but reannealed quickly at those salt concentrations unless applied at less than or equal to 0.3 micrograms/ml at 4 degrees C with a flow rate of 1 ml/min. (4) The kinetics of the hybrid reaction were a function of DNA length, concentration, and temperature. (5) Formamide was a more effective denaturing agent to remove hybrid RNA from the filter than either 12 M urea or 8 M guanidine-HCl, but caused significant release of DNA from the nitrocellulose as well as another potent inhibitor of the kinase reaction. The release of DNA and other kinase inhibitors was greatly reduced by eluting in boiling water.

Electron microscope studies of conditional spore cortexless mutants of Bacillus sphaericus.

Spore cortex of conditional cortexless mutants of Bacillus sphaericus 9602 was not detectable by electron microscopy unless the medium was supplemented with meso-alpha,epsilon-diaminopimelic acid during sporulation. Other spore structures appeared normal. Spore shape was quite irregular in the absence of meso-alpha,epsilon-diaminopimelic acid.