Bradley K. Farris

Pseudotumor cerebri and Optic nerve sheath decompression

OBJECTIVE To determine the efficacy and safety of optic nerve sheath decompression in a large population of patients with pseudotumor cerebri with visual loss despite medical treatment and to suggest a treatment algorithm on the basis of these data. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS One hundred fifty-eight eyes in 86 patients with pseudotumor cerebri. INTERVENTION Optic nerve sheath decompression. MAIN OUTCOME MEASURES Visual acuity, visual fields, and surgical complications. RESULTS After optic nerve sheath decompression for pseudotumor cerebri, visual acuity stabilized or improved in 148 of 158 (94%) eyes, and visual fields stabilized or improved in 71 of 81 (88%) eyes. Surgical complications, most of which were transient and benign, were seen in 39 of 86 patients. Only one eye in one patient had permanent severe visual loss secondary to an operative complication. CONCLUSIONS In patients with pseudotumor cerebri with progressive visual loss despite maximum medical therapy, optic nerve sheath decompression is a safe and effective means of stabilizing visual acuity and the visual fields of those tested.

Ophthalmic complications of sinus surgery

Seven patients with orbital complications of sinus surgery seen over a 10-year period are reported. Severe intraoperative orbital hemorrhage occurred in three patients while undergoing external or intranasal ethmoidectomy. In one patient, an avulsed anterior ethmoidal artery was identified as the source of bleeding, whereas in two others bleeding was due to snaring of orbital tissues. In two of these three cases, intraoperative recognition and prompt treatment of the expanding hematoma resulted in preservation of vision. Motility disturbances due to extraocular muscle injury occurred in two patients after intranasal ethmoidectomy and in one patient after a Caldwell-Luc procedure. Bilateral blindness resulted from transection of both optic nerves in one patient during bilateral intranasal endoscopic ethmoidectomies. Recommendations for prevention, intraoperative recognition, and management of such ophthalmic complications of sinus surgery are given.

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.

Bilateral postinfectious optic neuritis and intravenous steroid therapy in children.

Six patients presented with acute, simultaneous, bilateral optic neuritis. Five of the six patients admitted to a recent history of a brief upper respiratory or gastrointestinal illness, presumably viral in nature. Visual acuity was severely reduced in all patients. Five of the six patients also demonstrated marked neurologic deficits, including seizure activity and cerebellar dysfunction. Three patients demonstrated enhancing intracranial lesions on magnetic resonance imaging (MRI) consistent with demyelinative plaques, whereas lumbar puncture was abnormal in three patients. HLA tissue typing was performed on five of the six patients. All patients were treated with intravenous methylprednisolone, followed by a 2-month tapering course of oral prednisone. Each patient experienced a rapid and nearly complete recovery of vision during treatment.

The Efficacy of Radiotherapy in the Treatment of Orbital Pseudotumor

PURPOSE To review institutional outcomes for patients treated with external-beam radiotherapy (EBRT) for orbital pseudotumor. METHODS AND MATERIALS This is a single-institution retrospective review of 20 orbits in 16 patients diagnosed with orbital pseudotumor that received EBRT at the University of Oklahoma, Department of Radiation Oncology. Treated patients had a median follow-up of 16.5 months. RESULTS Fifteen patients (93.7%) were initially treated with corticosteroids. Eight had recurrence after steroid cessation, six were unable to taper corticosteroids completely or partially, and one experienced progression of symptoms despite corticosteroid therapy. Fourteen patients (87.5%) initially responded to radiotherapy indicated by clinical improvement of preradiation symptoms and/or tapering of corticosteroid dose. Mean EBRT dose was 20 Gy (range, 14-30 Gy). Thirteen patients (81.2%) continued to improve after radiation therapy. Patient outcomes were complete cessation of corticosteroid therapy in nine patients (56.3%) and reduced corticosteroid dose in four patients (25%). Radiotherapy did not achieve long-term control for three patients (18.7%), who still required preradiation corticosteroid dosages. Three patients received retreatment(s) of four orbits, of which two patients achieved long-term symptom control without corticosteroid dependence. One patient received retreatment to an orbit three times, achieving long-term control without corticosteroid dependence. No significant late effects have been observed in retreated patients. CONCLUSIONS Radiotherapy is an effective treatment for acute symptomatic improvement and long-term control of orbital pseudotumor. Orbital retreatment can be of clinical benefit, without apparent increase in morbidity, when initial irradiation fails to achieve complete response.

Optic nerve sheath decompression: a surgical technique with minimal operative complications.

Background: The purpose of this study was to determine the safety and efficacy of optic nerve sheath decompression (ONSD) with a medial transconjunctival approach for a variety of indications in a larger population of patients than has previously been reported. Methods: A retrospective chart review was performed on consecutive patients who underwent ONSD between January 1992 and December 2010. Before ONSD, all patients had documented evidence of progressive loss of visual acuity or visual field, or both. Postoperative follow-up visits were scheduled at 1 week, 1 month, and then every 3–6 months. Main outcome measures were visual acuity, visual fields, and surgical complications. Results: Five hundred seventy-eight eyes of 331 patients underwent ONSD for progressive vision loss due to various indications, which included but were not limited to idiopathic intracranial hypertension (IIH), progressive nonarteritic ischemic optic neuropathy, and optic nerve drusen (OND). During a mean follow-up of 18.7 months (range, 1 week to 10 years), postoperative visual acuity remained stable or improved in 536 of 568 eyes (94.4%) and progressively worsened in 32 of 568 eyes (5.6%). Visual fields remained stable or improved in 257 of 268 eyes (95.9%) and progressive visual field loss occurred in 11 of 268 eyes (4.1%). There were no reported intraoperative complications. The most common postoperative complication was diplopia (6.0%). Conclusions: To our knowledge, this review represents the largest series of patients who have undergone ONSD for any indication. Our data are consistent with current literature supporting ONSD as a safe and effective procedure for IIH. Other indications for ONSD, such as progressive visual field loss associated with OND, warrant further study. Regardless of the indication, complications following ONSD with the technique described in this report are infrequent.

Surgical Management of Skew Deviation

There are no published data on the outcomes of realignment surgery for skew deviation. A retrospective chart review disclosed 10 patients who had undergone surgical correction of skew deviation by three surgeons at a single institution between 1991 and 2002. Nine of 10 patients had satisfactory relief of diplopia with an acceptable field of single binocular vision. Vertical rectus recession or resection was the most common procedure. Four patients required more than one procedure. For nonalternating hypertropias, resection of the inferior rectus muscle or recession of the superior rectus muscle of the hypertropic eye was successful. For alternating hypertropia, resection of both inferior rectus muscles was successful. Oblique muscle surgery was not associated with good outcomes.

Patients' Perception of Physician-Initiated Prayer Prior to Elective Ophthalmologic Surgery

Background: Prayer is an important part of many patients’ and physicians’ lives. There is little data in the literature regarding patients’ perception of prayer from or with their doctors. Objective: To assess in a masked fashion patients’ impression of prayer’s role in a medical setting, and their perception of being offered and receiving prayer from their physician. Design, Setting, and Participants: Confidential survey of 567 consecutive patients who were offered prayer by their physician before elective eye surgery. Main Outcome Measures: Proportion of patients favoring physician-initiated prayer and weighted Likert responses to various positive and negative sentiments regarding their experience. Results: Survey response rate was 53% (300 patients). Ninety-six percent of patients identified themselves as Christian. At least 90% of Christian patients responded favorably toward their prayer experience to each Likert question. Among the non-Christian patients, the proportion of negative impressions to the prayer experience ranged from 0 to 25%. Conclusions: Physician-initiated Christian-based prayer before surgery is well-received by a strong majority of Christian patients. Although the data are few, only a minority of non-Christians felt negatively regarding this experience.

The Relationship Between Optic Nerve Sheath Decompression Failure and Intracranial Pressure in Idiopathic Intracranial Hypertension

Background: To our knowledge, there are no studies of patients with idiopathic intracranial hypertension (IIH) that address the relationship between level of intracranial pressure (ICP) and likelihood of progressive visual loss despite uncomplicated optic nerve sheath decompression (ONSD). This study investigated whether patients with IIH undergoing ONSD had a higher risk of surgical failure if opening pressure (OP) on lumbar puncture was ≥50 cm H2O compared to those with OP <50 cm H2O. Methods: We conducted a retrospective chart review of consecutive patients with IIH who failed maximal medical therapy and underwent ONSD between January, 1992 and November, 2014, and were followed at least 3 months postoperatively. The main outcome measure was the relationship between OP on lumbar puncture and ONSD failure. We also investigated the relationship of OP with visual acuity, visual fields, age, and gender. Results: During this period, 174 patients met inclusion criteria. Of the 40 patients who had an OP ≥50 cm H2O, 6 (15%) had progressive visual loss after uncomplicated ONSD, vs 6 (4.5%) of 134 patients with an OP <50 cm H2O (P = 0.032, Fisher exact test). Patients with worse visual acuity at presentation also had a higher risk of progressive visual loss after ONSD (P < 0.001, Cochran–Armitage trend test), as did men (P = 0.048, Fisher exact test). Conclusions: Patients with IIH and an OP ≥50 cm H2O had a 3-fold increased risk of failure of ONSD to prevent progressive visual loss, requiring a shunting procedure when compared to those with OP <50 cm H2O. Visual acuity at presentation and male sex also were associated with progressive visual decline after ONSD. These risk factors merit closer follow-up in the postoperative period when signs of further visual deterioration would indicate an urgent need for neurosurgical shunting.

Mickey Mouse aneurysm presenting with cranial bruit: case report.

The production of a bruit associated with intracranial aneurysms is very rare. A patient with a bilobed aneurysm of the middle cerebral artery who was otherwise asymptomatic was admitted with both a subjective and an objective bruit. The bruit resolved with elective clipping of the aneurysm. After a thorough review of the literature, a total of 12 cases of proved intracranial aneurysms were found with associated bruit. Five of those were carotid artery aneurysms within the cavernous sinus. Most (67%) of those patients reviewed were admitted with hemorrhage that was present either into the cavernous sinus or in the form of subarachnoid hemorrhage, with the bruit only secondarily noted. A possible explanation for the production of bruits caused by intracranial aneurysms is discussed. We conclude that, although an audible bruit as the presenting symptom of an intracranial aneurysm is quite rare, it deserves serious surgical considerations.