Edward Margolin

Spontaneous Resolution of Two Dural Carotid-cavernous Fistulas Presenting With Optic Neuropathy and Marked Congestive Ophthalmopathy

Two patients with dural carotid-cavernous fistulas (CCFs) presented with optic neuropathy and marked congestive ophthalmopathy, including 1 patient with a narrowed anterior chamber angle due to choroidal effusions. Endovascular intervention was planned but deferred for logistic reasons. While the patients awaited the procedures, the clinical features markedly improved, and time-resolved imaging of contrast kinetics (TRICKS) MRA was consistent with closure of the CCFs. These patients serve as a reminder that spontaneous resolution may occur in dural CCFs even when presenting clinical features are florid and vision appears to be threatened. In fact, a rapid worsening of clinical manifestations may be a sign that a dural CCF is about to close spontaneously.

Prevalence of Retinal Hemorrhages in Perpetrator-Confessed Cases of Abusive Head Trauma

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Bilateral pseudohypopyon as a presenting feature of recurrent diffuse large B-cell lymphoma.

A 55-year-old man with Gaucher disease and B-cell lymphoma developed a white meniscus along the inferior portion of the anterior chamber of both eyes. In one eye, the meniscus was also temporal, reflecting the fact that he had just been lying on his left side. Aspiration of aqueous fluid confirmed that the meniscus was made up of lymphoma cells, indicating that it was a pseudohypopyon. (A true hypopyon is made up of reactive white blood cells.) Despite intensive chemotherapy, the patient expired within 14 weeks of the discovery of the pseudohypopyon. This is the first report of binocular pseudohypopyon confirmed as lymphomatous by flow cytometric immunophenotyping analysis in a patient with diffuse large B-cell lymphoma.

A review of specialties performing temporal artery biopsies in Ontario: a retrospective cohort study

BACKGROUND Temporal artery biopsy is the gold standard for the diagnosis of giant cell arteritis, but the numbers and types of surgical specialists performing temporal artery biopsies are unknown. The goal of this study was to determine which surgical specialists performed temporal artery biopsies and how geographic location influenced this trend over a period of 10 years. METHODS This retrospective cohort study included all physicians practising in Ontario from 2002 to 2013. Using comprehensive physician services data from the IntelliHEALTH Medical Services database, physicians performing temporal artery biopsies were identified by the Ontario Health Insurance Plan billing code submitted for remuneration. Physicians were categorized by specialty and geographic Local Health Integration Unit. RESULTS A total of 9958 patients underwent a temporal artery biopsy during the study period: the biopsies were performed by 11 different subspecialties. The number of patients undergoing a temporal artery biopsy declined over the 10-year study period. Most procedures were performed by general surgeons (38.1%), followed by ophthalmologists (31.0%) and plastic surgeons (23.6%). Ophthalmologists performed more temporal artery biopsies per person compared with general surgeons, but significantly more general surgeons performed at least 1 biopsy. There was significant variation based on geographic location: plastic surgeons performed the most biopsies in regions with a population of more than 1 million people, and general surgeons performed most of the biopsies in rural areas. INTERPRETATION Geographic location heavily influenced which specialty was most likely to perform temporal artery biopsies. General surgery, ophthalmology and plastic surgery emerged as leaders in this area, and their residency programs should include formal training in this procedure in their curricula.

Paraneoplastic Optic Neuropathy Associated With Purkinje Cell Antibody-2 in a Patient With Small Cell Lung Cancer.

Paraneoplastic optic neuropathy (PON) is a rare cause of vision loss usually associated with small cell lung cancer. Patients with this condition usually test positive for anti-collapsin response mediating protein-5 (CRMP-5). We describe a case of a 57-year-old woman with bilateral vision loss with the characteristic features of CRMP-5 PON including bilateral optic disc edema and vitreous cells. However, she was negative for anti-CRMP-5 including a negative Western blot on two occasions, but positive for Purkinje Cell Antibody (PCA)-2. Although paraneoplastic antibodies are more predictive of an underlying cancer than a specific syndrome, previously PON has not been associated with PCA-2. Based on this observation, we recommend that the workup should include PCA-2 antibodies in patients who present with bilateral optic neuropathy and vitreous cells.

Development of Dural Arteriovenous Fistulas After Cerebral Venous Sinus Thrombosis.

A 57-year-old man presented with papilledema due to partially recanalized dural sinus thrombosis and was treated with anticoagulation and acetazolamide. One year after treatment and resolution of his symptoms, he had an increase in his optic disc edema accompanied by headaches. Subsequent neuroimaging indicated development of arteriovenous fistulas resulting in cortical and deep venous reflux. Given the high risk of mortality from intracranial hemorrhage, the patient underwent urgent treatment with a liquid embolic agent, which resulted in the resolution of his optic disc edema. Our case is unique in that recurrence of bilateral optic disc edema led to discovery of the rare complication of dural arteriovenous fistulas developing after dural sinus thrombosis. Ongoing monitoring of patients after cerebral venous sinus thrombosis is, therefore, important.

A 55-Year-Old Man With Severe Papilledema

A 55-year-old man presenting to the emergency department reported blurry vision in his right eye during the past week. He also noticed rhythmic pulsing sounds in both ears during the past month. Past medical history was significant only for well-controlled hypertension treated with irbesartan (300 mg daily) and poor vision in the left eye for many years attributable to presumed inactive ocular histoplasmosis. On presentation, the patient appeared well, with blood pressure of 140/70 mm Hg and a regular heart rate of 75/min. Best corrected visual acuity was 20/200 (right eye) and counting fingers at 1 foot (left eye). Direct ophthalmoscopy revealed severe bilateral optic disc edema, peripapillary hemorrhages, and absent spontaneous venous pulsations (Figure 1). Findings from a full neurologic examination were otherwise normal. Findings from a plain computed tomography (CT) scan of the head were normal apart from multiple bony sclerotic lesions seen in the calvarium, skull base, and C1 vertebra. Quiz at jama.com Left eye Right eye

Computed tomography only useful for selected patients presenting with primary eye complaints in the emergency department

Undifferentiated ophthalmic and visual complaints account for approximately 2 million yearly emergency visits in the United States [1]. Imaging is an important tool in the emergency department (ED) for diagnosis and treatment of visual complaints. Increased speed of testing and wider availability has made CT imaging the most commonly used imaging modality. This, in part, has contributed to a dramatic increase in CT utilization [2,3]. The appropriate use of CT in the ED has been amajor focus for investigation [2-5]. To our knowledge, the incidence of CT head imaging for eye related complaints in the ED has not been investigated to date. This was a retrospective consecutive case series of patients presenting to the ED between January 1, 2010 and September 30, 2014. Triage data and CT reports for patients presenting with eye complaints were included. CT reports for patients with known intracranial pathology or previous neurosurgical procedures, and those referred by an ophthalmologist to the ED for diagnostic imagingwere excluded. Ethics approval was obtained from St. Michaels Hospital research ethics board. Students t, Fishers exact and χ tests were used where appropriate. During the study period a total of 7030 patients presented to the ED with eye complaints; 376 patients received CT imaging, representing 5.3%. The rate of patients receiving CT imaging increased from 4.7% in 2010 to 7.2% in 2013, an increase of 53% (p b 0.01). Length of stay in the ED for patients undergoing imaging was significantly longer than those that did not at 7.25 h vs 2.48 h, respectively (p b 0.001) (Table 1). Of all CT studies included, 94 showed acute findings and 45 showed incidental findings. Visual disturbance was the most common triage complaint, accounting for 59% of patients undergoing CT imaging (Fig. 1). Patients with visual disturbance had a rate of acute findings on CT scan of 12%, a rate significantly lower than other triage complaints (p = 0.02) (Fig. 2). Thematic analysis of triage free-text of patients with visual disturbance elicited 4 common complaints. Blurry vision, visual field loss, diplopia and floaters accounted for 91% of complaints. 27% of CT scans for patients with visual field loss had acute findings, a rate significantly higher than any other complaint within the visual disturbance group (p = 0.012). This study found that the incidence of CT head use in patients with primary eye complaints was similar to rates reported in Ontario but lower than the U.S [4]. Overall utilization of CT imaging in EDs has steadily increased across North America and efforts have been initiated to reduce CT utilization [2-4,6-10]. The high rate of CT findings in patients with eye trauma suggests that imaging of this subgroupwas generally appropriate. In contrast, patients presentingwith a visual disturbance had a significantly lower rate of acute findings while also representing the most common complaint. Patients complaining of visual disturbancemay have less defined symptoms that cannot be captured in other triage complaint codes and our

Severe Intraoperative Orbital Venous Congestion during Resection of a Frontal Meningioma Presenting with Post-operative Vision Loss and Ophthalmoplegia: A Case Report

ABSTRACT We describe a unique case of a middle-aged man who noticed complete vision loss in the right eye after awaking from resection of a large right-sided frontal meningioma. Visual acuity was hand motions, and there were multiple signs of right orbital venous congestion. Magnetic resonance imaging and venography (MRI/V) of the brain and orbits demonstrated expected post-operative findings with no evidence of cavernous sinus thrombosis or fistula. Empiric treatment with intravenous antibiotics and intravenous methylprednisolone were ineffective. Immediate post-operative computerised tomography (CT) images were re-reviewed and revealed right restricted diffusion of the entire intraorbital right optic nerve. Discussion with the neurosurgical team revealed that during craniotomy, a prominent diploic venous plexus in the frontal bone adjacent to the meningioma was identified and coagulated with bone wax. Review of pre-operative imaging revealed large diploid flow voids in the right frontal bone, corresponding to the intraoperative findings. This prominent venous plexus appeared to drain from the meningioma posteriorly into the vein of Labbe. A second pathway drained anteriorly through the right angular vein into the orbit. We hypothesise that the posterior outflow pathway was coagulated intraoperatively, causing redirection of all venous outflow from the meningioma into the right orbit through the anterior pathway. This resulted in significant orbital hypertension with manifest signs and symptoms. Furthermore, sudden rise in intraorbital pressure led to infarction of the optic nerve, leaving the patient with hand motions vision. We suggest that pre-operative vascular imaging should be performed in patients with large meningiomas, as pre-operative embolisation of venous outflow channels may prevent severe post-operative complications.

Two Cases of Segmental Disc Oedema and Normal Visual Acuity in Giant Cell Arteritis

ABSTRACT Giant cell arteritis (GCA) frequently involves the ocular circulation. Arteritic anterior ischemic optic neuropathy (AAION) is the most common presentation, producing severe vision loss with a characteristic waxy pallor of the optic disc. Optic disc ischemia in AAION is related to underlying systemic vasculitis, which must be treated aggressively with systemic steroids in order to minimize the risk of fellow eye involvement. In contrast, non-arteritic AION (NAION) is thought to result from localized hypoperfusion of the posterior ciliary arteries and mainly presents with segmental optic disc oedema. This condition is usually seen in individuals with crowded optic discs as well as predisposing vascular risk factors and does not require specific treatment. Distinguishing these two entities is important and often challenging. We describe two cases of biopsy-confirmed AAION presenting as segmental disc oedema with the absence of pallor, suggesting specific and isolated involvement of the posterior ciliary arteries in GCA affecting the ophthalmic circulation. This emphasizes the importance of maintaining a high index of suspicion for GCA, particularly when atypical features are present or systemic findings accompany acute vision loss.