Anthony C. Arnold

The Effect of Aspirin on the Visual Outcome of Nonarteritic Anterior Ischemic Optic Neuropathy

PURPOSEnTo examine the effect of aspirin use on the visual outcome of nonarteritic anterior ischemic optic neuropathy.nnnMETHODSnThis retrospective case-controlled study included 23 patients who used aspirin regularly before and during the course of nonarteritic anterior ischemic optic neuropathy and 55 control patients with nonarteritic anterior ischemic optic neuropathy. Snellen visual acuity in logMAR and mean deviation on automated perimetry were compiled from the initial and final follow-up examinations.nnnRESULTSnThe comparisons of patients who took aspirin with control patients disclosed that neither initial logMAR (P = .36) nor the follow-up logMAR (P = .95) data differed significantly. There was no significant difference between the groups for the initial (P = .60) and the follow-up mean deviation (P = .41).nnnCONCLUSIONSnAspirin use does not improve the visual outcome of patients with nonarteritic anterior ischemic optic neuropathy. Additional studies are needed to further elucidate this issue.

Isolated metastasis to the optic nerve

A case of isolated optic nerve metastasis from breast carcinoma is described. Intraocular tumor was discovered three months following a radical mastectomy and was confined to the optic nerve head and distal optic nerve. Following X-irradiation treatment, central retinal vascular occlusion, rubeosis, and neovascular glaucoma developed during the fifteen months before enucleation. The clinicopathologic features of this case are discussed and the literature reviewed.

Ischemic Optic Neuropathies

Ischemia of the optic nerve may occur in several forms, usually associated with vasculopathic risk factors or vasculitis, and may present with various patterns of optic disc appearance and dysfunction. Though a proven therapy is not available for the most common syndromes, correct identification may present severe visual loss or systemic complications in some cases.

Abducens nerve ocular neuromyotonia following non-sellar or parasellar tumors.

Ocular neuromyotonia is an uncommon disorder resulting from episodic involuntary discharge of ocular motor nerves producing sustained contraction of their respective ocular muscles. Ocular neuromyotonia manifests in brief spells of diplopia occurring spontaneously or after eccentric gaze holding. In most cases, ocular neuromyotonia follows months or years after radiotherapy to the sellar and parasellar region and involves the oculomotor nerve. We report two unusual cases of abducens nerve ocular neuromyotonia that followed radiation therapy of tumors in areas other than the sellar or parasellar region.

The Next Accreditation System in ophthalmology

The accreditation of graduate medical education through the evaluation of residency programs and the teaching hospitals that offer them in the United States is the primary mission of the Accreditation Council for Graduate Medical Education (ACGME). In 1999, the ACGME formulated the six ACGME competencies and, ten years later, developed a multi-year plan to restructure the accreditation process in order to assess educational outcomes. The result of these evolving efforts has been termed the Next Accreditation System (NAS). The stated goals of the NAS are 1) to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century; 2) to accelerate the ACGMEs movement toward accreditation on the basis of educational outcomes; and 3) to reduce the burden associated with the current structure and process-based approach. The NAS is an interesting and novel approach to re-engineer the GME accreditation process to become more equitable, fair, and transparent and less costly and burdensome, and to improve resident education and ultimately patient care. The new process will rely upon measurable and meaningful outcomes rather than simply structure and process assessments. Instead of the episodic program biopsies with site visitor reports, detailed program information forms, and formal residency review committee evaluations that characterized the old accreditation system, the NAS will be based upon annual reports of specific quantitative, trended, performance benchmarks; the ACGME milestones; and an institutional clinical competency committee. In addition, a separate but related specialty-specific Clinical Environment Learning Review (CLER) will be a more detailed examination of the learning environment and infrastructure. The CLER, however, will not have a direct role in the accreditation decision-making process of the NAS.

Aggressive Low-Grade Optic Nerve Glioma in Adults

Abstract Primary optic nerve gliomas are most commonly benign pilocytic astrocytomas (World Health Organization [WHO] Grade I) occurring in childhood and following an indolent course. Malignant optic gliomas occur in adulthood and follow an extremely aggressive course, with rapid infiltration of the chiasm, blindness, and death typically within months. A third category of optic glioma, occurring in adulthood, histopathologically benign (WHO Grade I–II) but following an aggressive course, has been rarely reported. The authors describe clinical and histopathologic features of clinically aggressive but histopathologically benign optic nerve gliomas of adulthood. Retrospective review of cases of biopsy-proven optic nerve glioma in the neuro-ophthalmology division of the Jules Stein Eye Institute from 1990 to 2011 was carried out. Cases following an aggressive course were selected for review of clinical, neuroradiologic, and histopathologic features. Three cases were selected for detailed study. Ages ranged from 31 to 45 years. All were initially diagnosed with optic nerve inflammation or benign neoplasm based on clinical and neuroradiologic features, but all suffered neuroradiologic extension and rapid deterioration of vision in the affected eye to no light perception over 3–8 weeks. Optic nerve biopsies were undertaken for the suspicion of malignancy. Features ranged from WHO Grade I (pilocytic astrocytoma, ganglioglioma) in two cases, to WHO Grade II in one case (diffuse astrocytoma, histopathologically benign, but associated with aggressive features such as high p53 [13–21%] and Ki-67 [40%]). The diffuse astrocytoma case subsequently developed extensive intracranial extension suspicious for malignant transformation. These findings indicate that benign optic nerve glioma in adults may be initially misdiagnosed as inflammation, be clinically aggressive, and require excision to prevent further intracranial involvement.

Cavernous Sinus Syndrome Resulting from Contiguous Spread of Adenoid Cystic Carcinoma: A Systematic Analysis of Reported Cases

Purpose:u2002The aim of this review is to analyze all reported cases of histologically confirmed adenoid cystic carcinoma (ACC) with cavernous sinus involvement identified in the literature in order to elucidate the clinical symptoms, neuro-ophthalmic and neuro-imaging findings. Methods:u2002A systematic electronic database search (Medline, Biosis and Cochrane) and a literature review were used to identify reported cases which were assessed for demographic information; primary tumour site; pattern of spread; extent and timing of cranial nerve involvement; and neuro-imaging findings. Conclusions:u2002Neuro-ophthalmologic evaluation is extremely important in the diagnosis of this disease which has a propensity for perineural and direct orbital invasion.

Ophthalmic Manifestations of Multiple Sclerosis

ULTIPLE SCLEROSIS (MS) is a disM ease of undetermined etiology in which a multifocal demyelinative process affects the white matter of the CNS. Neurologic symptoms usually occur acutely and last several weeks or longer, followed by a variable degree of resolution. Most often there is an exacerbating/remitting pattern, but occasionally the course is one of progressive deterioration. The disease attacks young adults most frequently, with peak incidence at age 20 to 40 years; females are affected more often than males, with a ratio of about 1.5 to 1. For reasons that are unclear, the disease has a predilection for certain regions of the CNS, including the corticospinal tracts and posterior columns of the spinal cord, the brainstem and cerebellum, and the anterior visual pathway, particularly the optic nerves. Thus, the most common presenting features are weakness, numbness, and paresthesias of the extremities, urinary disturbance, ataxia, bulbar signs, and