Joseph G. Chacko

Review of Giant cell arteritis

Giant-cell arteritis (GCA) is a systemic autoimmune disease affecting primarily the elderly. Giant cell arteritis can cause sudden and potentially bilateral sequential vision loss in the elderly. Therefore, it is considered a medical emergency in ophthalmology and a significant cause of morbidity in an increasingly aging population. Ophthalmologists need to be able to recognize the classic symptoms and signs of this disease, and then be able to work-up and treat these patients in an efficient manner. An in-depth review of GCA from the literature as well as personal clinical experience follows.

Spontaneous postpartum resolution of vision loss caused by a progesterone receptor-positive tuberculum sellae meningioma.

A 27-year-old pregnant woman reported progressive loss of vision. Brain MRI disclosed an intracranial mass compressing the optic nerves and chiasm with imaging features suggestive of meningioma. Because delivery was imminent, surgical removal was deferred. Within a few days after delivery, the patient noted improvement in vision. Subsequent neuro-ophthalmological evaluations documented almost complete visual recovery within 2 months postpartum. The mass was removed surgically at 10 months postpartum. It was a grade I meningioma with progesterone cell surface receptors. The patients visual function has remained stable during a follow-up of 14 months. This is the first reported case with full visual function and MRI documentation of spontaneous postpartum visual recovery in a progesterone receptor-positive meningioma compressing the anterior visual pathway.

Visual recovery after direct traumatic optic neuropathy.

Direct traumatic optic neuropathy is a rare complication of endoscopic sinus surgery and can result in irreversible damage to the optic nerve. We report a case of direct traumatic optic neuropathy after transnasal endoscopic orbital decompression for Gravess disease in a patient who experienced near-complete recovery of vision. We discuss possible mechanisms.

Multicentric malignant glioma of adulthood masquerading as optic neuritis

Malignant optic nerve glioma of adulthood is a rare tumour that can mimic optic neuritis in its initial presentation.1 2 At onset, unilateral decreased vision occurs in 70% of patients; however, a rapid progression to total blindness is usually seen within 3 months and death within 1 to 2 years.3 MRI often shows diffuse enhancement and, later, enlargement of the affected optic nerves, chiasm and tracts. We report a unique, multicentric case of malignant optic nerve glioma involving two exceptionally rare sites, the corpus callosum and cerebellum. A previously healthy 48 year-old man was referred for blurry vision of the right eye with pain on eye movement for 1 week. …

Bilateral optic neuritis due to malaria.

Malaria is a mosquito-borne infectious disease caused by protists of the genus Plasmodium. Malaria is widespread in tropical regions around the equator, including much of sub-Saharan Africa, Asia, and the Americas, and uncommonly seen in the developed world. Although a variety of ocular manifestations have been linked to malaria, optic neuritis is rare. We report a patient who developed bilateral optic neuritis after he was treated successfully for acute falciparum malaria.

Nutritional Optic Neuropathy Status Post Bariatric Surgery

A 31-year-old woman who had lost 240 lbs following bariatric surgery 3 years ago presented with decreased vision. The patient was found to have deficiencies of folate and vitamin B1, and to a lesser degree vitamins B6 and B12. The patient was treated with vitamin supplementation but without improvement. Bariatric surgery is known to cause B vitamin and folate deficiencies, which can lead to both serious ocular and neurological complications. This is important as the incidence of obesity increases and thus the number of bariatric procedures. It is paramount that patients undergoing these procedures and their physicians be made aware of the need for vitamin supplementation to prevent nutritional optic neuropathy.

Diplopia is better than no plopia

Idiopathic intracranial hypertension often presents with cranial nerve VI paresis. Infrequently, other cranial nerve dysfunction may occur. We report a case of idiopathic intracranial hypertension that presented with bilateral cranial nerve III paresis. Review of the literature suggests that severe elevation of intracranial pressure may predispose patients with idiopathic intracranial hypertension to cranial nerve III dysfunction.

Cryptococcal Meningitis in a Young Obese Female with Takayasu Arteritis and Idiopathic Intracranial Hypertension

A 30-year-old African-American obese female, with hypovitaminosis D, was diagnosed with idiopathic intracranial hypertension and Takayasu arteritis 2 years before; symptoms improved with acetazolamide and immunosuppressive therapy. She then presented with headaches, photophobia, tinnitus, facial paraesthesiae, fatigue, and subjective night fevers. Brain imaging was normal. Lumbar puncture was performed, and spinal fluid fungal cultures grew Cryptococcus neoformans. Antifungal therapy was instituted with relief of symptoms. Immunosuppressive treatment for Takayasu arteritis was tapered. The authors report a unique case in the medical literature and would like to raise awareness of cryptococcal meningitis, as it can simulate idiopathic intracranial hypertension and cause a non-specific neurological syndrome. Risk factors, detection, and management are discussed.

Blurred vision and eye pain in a middle-aged woman

Dr. Chacko: A 48-year-old white woman complained of worsening blurry vision in both eyes lasting 1 year and pain in both eyes for the previous month, which worsened with eye movements. She had experienced frequent headaches and transient visual obscurations during the preceding month, but she denied nausea, vomiting, and diplopia. Her medical history was significant for hypertension, acid reflux, anemia, and retroperitoneal fibrosis requiring ureteral stenting in the past year. She had undergone hysterectomy 13 years earlier. Her family history was significant for leukemia in her father. Social history revealed that she was an 18 pack-year smoker, but had quit 16 years earlier. Her only medication was valsartan. She denied any use of methysergide. On examination, the patient’s blood pressure was 160/ 88 and her weight was 216 pounds. Visual acuity with correction was 20/20 in each eye. Color vision was normal, and pupils were brisk in each eye without a relative afferent pupillary defect. Intraocular pressure measured 18 mm Hg in each eye. Visual fields were full to confrontation, and slitlamp examination was unremarkable. There was slight ptosis of the left upper lid, and xanthelasmae were present (Fig. 1). There was no proptosis. Ocular motility revealed mild bilateral limitation of upgaze. The optic discs were mildly swollen (Fig. 2), and the fundi otherwise were normal. Neuroimaging was obtained (Fig. 3A–E).