James D. Kim

Clinical experience with a novel glaucoma drainage implant.

Purpose:To retrospectively evaluate the safety and efficacy of an Ahmed glaucoma valve (AGV) modified with a polyethylene shell (M4) to reduce the fibrotic reaction around the drainage plate compared with the S2 and FP7 models in patients with glaucoma. Methods:The medical records of patients who underwent implantation of the AGV FP7, S2, and M4 were reviewed. The primary outcome measure was cumulative probability of success, defined as an intraocular pressure (IOP) between 5 and 18 mm Hg and >20% reduction of IOP without loss of light perception, need for additional IOP-lowering surgical procedures, or removal of AGV. Results:Seventy-six, 38, and 40 eyes received the FP7, S2, and M4 with a mean follow-up time of 578±157, 662±186, and 504±158 days, respectively. The mean IOP was reduced from 31.0±10.6 to 13.9±5.5 mm Hg in the FP7 group, 33.5±12.1 to 15.8±8.1 mm Hg in the S2 group, and 27.0±12.0 to 15.0±4.0 mm Hg in the M4 group at 1 year (P=0.31). At 1 year, the cumulative probability of success was 70%, 66%, and 80% and at 18 months, 61%, 53%, and 52% in the FP7, S2, and M4 groups, respectively (P=0.99). Complications were similar among groups. Conclusions:No significant difference was observed between the AGV M4, FP7, and S2 at 1 year. Additional follow-up is required to determine its long-term safety profile and efficacy.

Neuroimaging in ophthalmology

In the past three decades, there have been countless advances in imaging modalities that have revolutionized evaluation, management, and treatment of neuro-ophthalmic disorders. Non-invasive approaches for early detection and monitoring of treatments have decreased morbidity and mortality. Understanding of basic methods of imaging techniques and choice of imaging modalities in cases encountered in neuro-ophthalmology clinic is critical for proper evaluation of patients. Two main imaging modalities that are often used are computed tomography (CT) and magnetic resonance imaging (MRI). However, variations of these modalities and appropriate location of imaging must be considered in each clinical scenario. In this article, we review and summarize the best neuroimaging studies for specific neuro-ophthalmic indications and the diagnostic radiographic findings for important clinical entities.

Conjugal giant cell arteritis.

While the pathogenesis of giant cell arteritis (GCA) remains unclear, a number of factors may be contributory, including genetic, environmental, and immune. There have been few reports of GCA occurring in a conjugal pair, all originating from Northern Europe or the Northern United States. We document GCA occurring in a husband and wife from the southern Gulf Coast of the United States and discuss the implications of this, as well as the current understanding of the pathogenesis of GCA.

Post-traumatic amaurosis secondary to paraophthalmic internal carotid artery pseudoaneurysm treated with pipeline embolization device

During evaluation for monocular visual loss, a 48-year-old woman was found to have a posttraumatic paraophthalmic internal carotid artery (ICA) pseudoaneurysm. She underwent reconstruction of the ophthalmic segment of the right ICA with a Pipeline embolization device but her vision did not return.

Correlation and Agreement Between Cirrus HD-OCT "RNFL Thickness Map" and Scan Circle Retinal Nerve Fiber Layer Thickness Measurements.

Purpose:To evaluate the correlation and agreement between optical coherence tomography (Cirrus HD-OCT) retinal nerve fiber layer (RNFL) thickness map and scan circle RNFL thickness measurements. Methods:ImageJ and custom Perl scripts were used to derive RNFL thickness measurements from RNFL thickness maps of optic disc scans of healthy and glaucomatous eyes. Average, quadrant, and clock-hour RNFL thickness of the map, and RNFL thickness of the areas inside/outside the scan circle were obtained. Correlation and agreement between RNFL thickness map and scan circle RNFL thickness measurements were evaluated using R2 and Bland-Altman plots, respectively. Results:A total of 104 scans from 26 healthy eyes and 120 scans from 30 glaucomatous eyes were analyzed. RNFL thickness map and scan circle measurements were highly reproducible (eg, in healthy eyes, average RNFL thickness coefficients of variation were 2.14% and 2.52% for RNFL thickness map and scan circle, respectively) and highly correlated (0.55⩽R2⩽0.98). In general, the scan circle provided greater RNFL thickness than the RNFL thickness map in corresponding sectors and the differences tended to increase as RNFL thickness increased. The width of the 95% limits of agreement ranged between 5.28 and 36.80 &mgr;m in healthy eyes, and between 11.69 and 42.89 &mgr;m in glaucomatous eyes. Conclusions:Despite good correlation between RNFL thickness map and scan circle measurements, agreement was generally poor, suggesting that RNFL thickness assessment over the entire scan area may provide additional clinically relevant information to the conventional scan circle analysis. In the absence of available measurements from the entire peripapillary region, the RNFL thickness maps can be used to investigate localized RNFL thinning in areas not intercepted by the scan circle.

Rhino-orbital Mucormycosis Treated Successfully with Posaconazole without Exenteration

Abstract Mucormycosis is a rare and often fatal opportunistic angioinvasive infection seen mostly in immunocompromised patients, such as those with diabetes mellitus, cancer, or renal failure. Ophthalmic manifestations of orbital mucormycosis include ocular pain, periocular oedema, visual loss, ophthalmoplegia, proptosis, and ptosis. Although therapy for orbital mucormycosis consists of maximally tolerated doses of antifungal agents (e.g., amphotericin B) and extensive surgical debridement, treatment remains ineffective in up to 20% of cases. We describe two patients with rhino-orbitalmucormycosis who were successfully treated with posaconazole in conjunction with intravenous (IV) amphotericin B and sinus surgical debridement. These cases highlight several unusual early manifestations of orbital mucormycosis, including disc oedema and amaurosis fugax, as well as the applicability of a new extended-spectrum antifungal agent in management of orbital zygomycosis.

Orbital apex syndrome

A 70-year-old woman presented with a one-month history of progressive, painful loss of vision in the right eye (OD), a droopy right upper eyelid, and horizontal binocular diplopia. Past medical history was significant for hypertension, diabetes mellitus type II, and breast cancer (status post-mastectomy and -chemotherapy). Review of systems was significant for nausea, vomiting, and malaise. On examination, visual acuity was light perception OD and 20/25 in the left eye (OS). The right pupil measured 5 mm in the dark and was non-reactive to light or accommodation with a relative afferent pupillary defect (RAPD) OD (by reverse testing). The left pupil measured 4 mm in the dark and 3 mm in the light with no light-near dissociation. Ocular motility revealed complete ophthalmoplegia OD but full extraocular movements OS (Fig. 13.1). Anterior segment examination and intraocular pressure measurements were normal in both eyes (OU). External exam showed complete ptosis OD. Hertel exophthalmometry showed 3mm of proptosis OD (23mm OD compared with 20mm OS). Dilated fundus exam revealed diffuse optic disc pallor OD and a normal fundus OS. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast showed a dural-based extra-axial lesion located within the sella and extending into the right-sided cavernous sinus, superior orbital fissure, planum sphenoidale, and infundibulum (Fig. 13.2). Trans-sphenoidal biopsy revealed diffuse large B-cell lymphoma. The patient underwent staging and was treated with systemic chemotherapy and radiotherapy.

Cup-to-disc ratio in idiopathic intracranial hypertension without papilloedema

Abstract This study seeks to characterise potential differences in the cup-to-disc ratio (CDR) of patients with idiopathic intracranial hypertension (IIH) with papilloedema (IIHWP) compared with IIH without papilloedema (IIHWOP). The medical charts, optical coherence tomography (OCT), and digital optic disc photos of 30 patients (59 eyes) with IIHWP and 4 patients (8 eyes) with IIHWOP were reviewed retrospectively. The CDR values of the two groups were analysed using the Wilcoxon-Mann-Whitney test. Results showed a statistically significant smaller CDR in patients with IIHWP as compared with IIHWOP. These findings suggest that structural factors of the optic disc may play a role in the development of or lack thereof of papilloedema in patients with IIH.

Down But Not Out

A 20-year-old Hispanic man with Down syndrome presented with progressively worsening headache, fluctuating decreased vision, and bilateral optic disk edema. Magnetic resonance imaging of the head showed an empty sella, and magnetic resonance venography showed thrombosis of left transverse and sigmoid sinuses. Catheter angiography angiogram showed a dural arteriovenous fistula in the wall of left transverse and sigmoid sinuses. The patient underwent Onyx endovascular embolization of the fistula, resulting in its angiographic obliteration, followed by resolution of his clinical signs and symptoms.