Albert D. Woods

An uncommon presentation of Bartonella-associated neuroretinitis.

Background. This article documents a case of neuroretinitis initially presenting with ocular pain, 20/20 visual acuities, optic disc edema, and macular serous detachment without macular star formation in the absence of a history of exposure to pets or cats or symptoms suggestive of Bartonella infection. This initial clinical presentation appeared unilateral, but later became bilateral. Case Report. Physical and neuroophthalmologic consultation, neuroimaging studies, blood chemistry, and serologic analysis were requested. Positive serologic (IGG) titers to Bartonella henselae and Bartonella quintana were detected. Treatment was instituted initially with oral tetracycline (250 mg) qid and subsequently with doxycycline (100 mg) bid and prednisone (20 mg) qd. Conclusion. Bartonella infection may cause optic disc edema and serous detachment without macular star formation. This presentation may occur without the generally characteristic signs and symptoms of Bartonella-associated neuroretinitis. A bilateral involvement may follow an initial unilateral presentation during the affliction period of this disorder.

Pupil sparing incomplete third nerve palsy secondary to a cavernous sinus meningioma: challenges in management

Background:  The diagnosis of incomplete third nerve palsy can be clinically challenging because the aetiologies, as well as presentations, can be variable and subtle. The optometric clinician should be familiar with the association of third nerve palsy with compressive lesions, including the clinical presentations and management of these patients.

Topographical analysis of the optic nerve in migraine patients.

Purpose. Vascular dysfunction appears related to the development of migraines and has been associated with pressure-independent glaucoma. The purpose of this study is to investigate possible topographical differences in the optic nerve between migraine sufferers and normal age-matched control subjects. The identification of optic disc topographical differences between migraine and non-migraine sufferers may help clinicians determine if the presence of migraine influences the development and progression of glaucoma. Methods. Sixty consecutively seen patient-volunteers (30 subjects in migraine group: mean age 37.7 years, range from 19 to 66 years, 28 females and 2 males; 30 subjects in the control group: mean age 37.6 years, range from 19 to 61 years, 29 females and 1 male) were categorized as either migraine patients or control group subjects. All migraine subjects had been medically diagnosed with a migraine syndrome and were being treated with prophylactic medication. Optic nerve head topographical analysis was performed using a confocal scanning laser ophthalmoscope. The data was evaluated using generalized estimating equations, a priori and post hoc power analysis. Results. No significant differences were found in any of the optic nerve parameters examined between the two groups. Conclusions. This study indicates that the optic nerve parameters as measured by the Heidelberg retinal tomograph II do not differ between migraine sufferers and age-matched control subjects.

Use of multifocal ERG and OCT for diagnosing Stargardt's disease

Stargardt’s disease (Stargardt’s macular dystrophy, juvenile macular degeneration) was originally described by Stargardt in the early 1900s and is known as the most common congenital macular dystrophy, with an incidence of one in every 10,000. Stargardt’s disease (STGD) is characterised as a widespread lipofusin storage disease of the retinal pigment epithelium (RPE). Typically, it presents between the first to third decades of life and is associated with a progressive, bilateral decrease in visual acuity leading to legal blindness and central visual acuity of 6/60 to 6/120. Though it is typically associated with an autosomal recessive (AR) inheritance pattern, autosomal dominant (AD) cases have been reported with later onset and less severe acuity loss. Classic findings include bilateral macular changes that begin as granular mottling with progression toward a ‘beaten bronze’ maculopathy. The late stage of the disease is associated with macular atrophic degeneration. Yellow-white flecks in the posterior pole may be noted; they are described as tri-radiating ‘fish tail’ (pisciform) flecks. Traditionally, Stargardt’s disease has been diagnosed through clinical evaluation and fluorescein angiography (IVFA), which demonstrates a dark or ‘silent’ choroid due to the blockage of the fluorescein by the lipofusin deposition in the RPE. Though fluorescein angiography has been considered the ‘gold standard’ in verifying the presence of the disease, the characteristic dark choroid pattern is seen in only 85 per cent of patients with Stargardt’s disease. There have been reports of patients with autosomal dominant inheritance pattern who fail to demonstrate this classic fluorescein angiography finding. Newer and minimally invasive procedures, such as the multifocal electroretinogram (mfERG) and optical coherence tomography (OCT), may aid in diagnosing and managing patients with the disease. These ancillary tests may be used in the event that fluorescein angiography cannot be performed or used in conjunction with traditional fluorescein angiography as a complementary procedure. Multifocal electroretinography (mfERG) is a minimally invasive procedure that has been shown to be helpful in the diagnosis of Stargardt’s disease. Unlike traditional flash electroretinography (fERG), this technology has proved extremely reliable in diagnosing and monitoring various forms of macular dystrophy. In the case of Stargardt’s disease, the patient presents with significant variation in presentation; from normal to reduced acuity, minimal to significant fundus findings and normal to slightly reduced full field flash electrophysiological findings. Regardless of the presentation, Stargardt’s patients typically have a significant reduction of the foveal response and central approximately 10 degrees in both eyes on mfERG, even early in the disease process with relatively good visual acuity and minimal fundus findings. In addition to electrophysiology, retinal imaging technology such as OCT has proved effective in correlating structural damage with functional visual loss. The OCT findings of patients with Stargardt’s disease include decreased thickness of the retina, most notably in the foveola. The OCT also reveals photoreceptor loss and external nuclear layer changes, as well as abnormalities in the retinal pigment epithelium.

Staging glaucoma using Stratus OCT in a U.S. veteran population.

Purpose This study examines the ability of time domain optical coherence tomography (Stratus OCT) of the retinal nerve fiber layer (RNFL) to discriminate between normal patients and patients with three stages of glaucomatous vision loss in a US veteran population. Methods A review of consecutive patients who underwent automated perimetry and Stratus OCT Fast RNFL scanning within a 6-month period was conducted. Patients with nonglaucomatous ocular disease that might affect the RNFL or perimetry results were excluded. Glaucomatous eyes were staged using the Hodapp-Parrish-Anderson grading system. Average, quadrant, and individual clock hour RNFL thicknesses and normative results between all groups were compared. Results A total of 247 normal subjects and 157 glaucoma subjects were included. Significant differences in RNFL thickness measurements were observed between all groups (p < 0.05). Receiver operating curve analysis of highest area under the curve showed average RNFL for normal versus mild glaucoma (0.86), inferior quadrant for mild versus moderate glaucoma (0.80), and superior quadrant for moderate versus severe disease (0.86). Normative results for individual parameters demonstrated high specificity but low sensitivity for mild disease versus normal control subjects with increasing sensitivity and decreasing specificity in subsequent stages of disease. The number of OCT parameters classified as borderline or abnormal increased with advancing disease, but a combination of high sensitivity and specificity was not detected for any stage. Conclusions Optical coherence tomography RNFL thickness measurements, individual parameter normative results, and the number of parameters classified as borderline or abnormal poorly distinguished between severities of disease. Significant RNFL thickness overlap and lack of normative parameters demonstrating both high sensitivity and specificity between consecutive stages of disease highlighted the wide variability of structural findings using time domain OCT in the staging of glaucoma.