Georgia Antonakou Chrousos

A Randomized, Controlled Trial of Corticosteroids in the Treatment of Acute Optic Neuritis

Background and Methods. The use of corticosteroids to treat optic neuritis is controversial. At 15 clinical centers, we randomly assigned 457 patients with acute optic neuritis to receive oral prednisone (1 mg per kilogram of body weight per day) for 14 days; intravenous methylprednisolone (1 g per day) for 3 days, followed by oral prednisone (1 mg per kilogram per day) for 11 days; or oral placebo for 14 days. Visual function was assessed over a six-month follow-up period. Results. Visual function recovered faster in the group receiving intravenous methylprednisolone than in the placebo group; this was particularly true for the reversal of visual-field defects (P = 0.0001). Although the differences between the groups decreased with time, at six months the group that received intravenous methylprednisolone still had slightly better visual fields (P = 0.054), contrast sensitivity (P = 0.026), and color vision (P = 0.033) but not better visual acuity (P = 0.66). The outcome in the oral-prednisone group did ...

Incidence of Chronic Glaucoma, Retinal Detachment and Secondary Membrane Surg ery in Pediatric Aphakic Patients

The eyes of 392 consecutive childhood cataract aspiration procedures were analysed for frequency of the development of chronic glaucoma and retinal detachment and the performance of secondary membrane surgery. Three different modifications of the aspiration procedure were employed: the standard needle and syringe procedure leaving the posterior capsule intact (304 eyes), rotoextraction with small opening of the posterior capsule (34 eyes) and Ocutome aspiration with wide excision of the posterior capsule (54 eyes). The mean postoperative follow-up was 5.5 years. Chronic glaucoma was found in 6.1% of the eyes. Coexisting ocular anomalies and retained lens cortex increased the risk for this complication. Retinal detachment was found in 1.5% of the cases. Coexisting ocular anomalies and uncontrolled vitreous disturbance increased the possibility of retinal detachment. Secondary membrane procedures were performed in 62% of the eyes in which the aspiration procedure left the posterior capsule intact, in nearly 12% of those in which the posterior capsule was minimally opened and in none of those which had the posterior capsule widely excised. The secondary membrane surgery itself appeared to increase the risk for both glaucoma and retinal detachment. The aspiration procedure with the lowest incidence for all three complications was the Ocutome aspiration with wide excision of the posterior capsule.

Spasm of the Near Reflex Associated with Organic Disease

Spasm of the near reflex is characterized by transient attacks of convergence, accommodation, and miosis. It is usually observed in young individuals and considered functional. We studied seven patients with spasm of the near reflex who had associated neurologic disorders or head trauma. Two patients had posterior fossa abnormalities (cerebellar tumor, Arnold-Chiari malformation), two patients had pituitary tumors, one patient had a vestibulopathy, and two patients had a history of antecedent head trauma.

Anterior ischemic optic neuropathy in Churg-Strauss syndrome.

A patient with a history of chronic rhinitis, sinusitis, and bronchial asthma developed a unilateral anterior ischemic optic neuropathy and a mild sensory motor neuropathy as the initial manifestation of systemic vasculitis. We made a probable diagnosis of Churg-Strauss syndrome. Fluorescein angiography showed delayed choroidal perfusion in both eyes. Marked eosinophilia, increased sedimentation rate, and elevated perinuclear anti-neutrophil cytoplasmic antibody and anti-myeloperoxidase antibody titers were the main laboratory abnormalities that supported this diagnosis. Therapy with high-dose methylprednisolone and cyclophosphamide may have preserved vision in the better seeing eye, improved its choroidal circulation, and reversed the laboratory abnormalities except for a mild persistent eosinophilia. The neuropathy is gradually improving.

Accommodation deficiency in healthy young individuals

Ten patients, ages 10 to 19, with accommodation insufficiency are reported. All patients were in good health and asymptomatic, except for asthenopia during near visual activities. Each patients amplitude of accommodation was measured and found to be considerably below the minimal normal for their respective ages (an average of 6 diopters). Only three patients had associated convergence insufficiency. No etiology for the diminished accommodation was suggested by history or could be identified by careful examination. All patients were successfully managed optically with bifocals or reading glasses, although three required the addition of base-in prisms for the near exodeviation. Near vision testing and determination of the near point of accommodation should be part of the pediatric ophthalmologic examination in all patients with complaints referable to their reading and visual performance at near.

Visual function at baseline and 1 month in acute optic neuritis: Predictors of visual outcome

Objective: To identify cutpoints for visual measures at baseline and 1 month predictive of abnormal 6-month vision that could be used as eligibility criteria in a clinical trial to test potential neuroprotection or myelin repair agents in patients with optic neuritis. To determine whether moderate-to-severe dysfunction in one or more visual measures at baseline or 1 month correlates with having major vision loss at 6 months. Methods: We used the Optic Neuritis Treatment Trial database to evaluate various cutpoints for baseline and 1-month vision levels that predicted abnormal 6-month vision. For selected cutpoints, we computed a 95% CI for positive predictive value and the required sample size if the cutpoint was to be used for clinical trial eligibility. We evaluated whether the degree of visual loss at baseline, 1 month, or change in visual function from baseline to 1 month correlated with 6-month visual acuity, contrast sensitivity, or threshold visual field. Results: The best cutpoints for baseline and 1 month were visual acuity ≤ 20/50, contrast sensitivity < 1.0 log units, and visual field mean deviation ≤ −15 dB. The same levels of visual dysfunction at 1 month, but not at baseline, correlated with having 6-month moderate-to-severe loss for each of these measures (p = 0.01). A trial could require as few as 100 subjects for an outcome variable of one or more abnormal measures. Cutpoints at 1 month were highly predictive of abnormal 6-month vision, but the proportion of patients who would be eligible for a trial would be small. Conclusion: Provided data can be used either for the clinician to counsel patients on expected visual outcome or for designing studies to test therapies that might reduce the amount of permanent optic nerve damage due to optic neuritis in high-risk patients.

Weill-Marchesani Syndrome With Bilateral Angle-Closure Glaucoma

To our knowledge this is the first reported case of cyclopentolate induced bilateral acute angle-closure glaucoma associated with the Weill-Marchesani syndrome without lens subluxation. The diagnosis of Weill-Marchesani syndrome was not initially suspected, and Pilocarpine was used in an attempt to break the acute attack. Treatment with Pilocarpine-induced myosis only worsened the glaucoma by causing a severe pupillary block. This case is important because it demonstrates that mid-dilatation and cycloplegia can induce acute glaucoma in patients with the Weill-Marchesani syndrome and points out the importance for considering the diagnosis of Weill-Marchesani syndrome in any case of acute glaucoma in childhood.

Two Cases of Downbeat Nystagmus and Oscillopsia Associated With Carbamazepine

Downbeat nystagmus is often associated with structural lesions at the craniocervical junction, but has occasionally been reported as a manifestation of metabolic imbalance or drug intoxication. We recorded the eye movements of two patients with reversible downbeat nystagmus related to carbamazepine therapy. The nystagmus of both patients resolved after reduction of the serum carbamazepine levels. Neuroradiologic investigations including magnetic resonance imaging scans in both patients showed no evidence of intracranial abnormality. In patients with downbeat nystagmus who are taking anticonvulsant medications, consideration should be given to reduction in dose before further investigation is undertaken.

Bilateral Orbital Involvement in Fatal Giant Cell Polymyositis

The case of a young woman with giant cell polymyositis is described. She had bilateral, severe, midly painful proptosis and ophthalmoplegia. Extensive pharyngeal, laryngeal, and cardiac muscle involvement occurred 18 months later coincident with fatal cardiac arrhythmia. At autopsy, extensive muscle necrosis and giant cells were noted in extraocular, pharyngeal, laryngeal, and cardiac muscle with only minimal involvement of other striated muscles.

Chorioretinal Lacuna in the Amniotic Band Syndrome

The malformations in the amniotic band syndrome (ABS) are due to entrapment of fetal parts by fibrous band in the amniotic sac. Limbs are most commonly affected followed by craniofacial defects in one third of patients. Ocular defects include corneal leukomas and lid colobomas often contiguous with facial clefts, strabismus, hypertelorism, and microphthalmos. Unilateral chorioretinal defects or lacunae are rare findings in the ABS. We report a female infant with such a lacunar defect along with central nervous abnormalities, and discuss the differential diagnosis and the embryopathic implications.