Leah Levi

Increased Light Exposure Consolidates Sleep and Strengthens Circadian Rhythms in Severe Alzheimer's Disease Patients

Sleep in the nursing home environment is extremely fragmented, possibly in part as a result of decreased light exposure. This study examined the effect of light on sleep and circadian activity rhythms in patients with probable or possible Alzheimers disease. Results showed that both morning and evening bright light resulted in more consolidated sleep at night, as measured with wrist actigraphy. Evening light also increased the quality of the circadian activity rhythm, as measured by a 5-parameter extended cosine model (amplitude, acrophase, nadir, slope of the curve, and relative width of the peak and trough). Increasing light exposure throughout the day and evening is likely to have the most beneficial effect on sleep and on circadian rhythms in patients with dementia. It would behoove nursing homes to consider increasing ambient light in multipurpose rooms where patients often spend much of their days.

Graded orbital decompression based on severity of proptosis

OBJECTIVE To study the results of orbital decompression based on the severity of preoperative proptosis. DESIGN A retrospective noncomparative interventional case series. PARTICIPANTS Thirty-nine orbits in 23 patients with thyroid-related orbitopathy at a university-based referral center. INTERVENTION Graded orbital decompression was performed in all patients based on the severity of preoperative exophthalmometry. MAIN OUTCOME MEASURES Exophthalmometry, visual acuity, margin-to-reflex distance, prism cover testing, and intraocular pressure. RESULTS Mean proptosis reduction in all orbits was 6.4 +/- 2.7 mm (P < 0.01). In group 1 (preoperative exophthalmometry <22 mm), proptosis decreased with a mean of 4.8 +/- 1.3 mm (P < 0.01); mean proptosis reduction was 6.0 +/- 2.3 mm (P < 0.01) and 8.9 +/- 3.4 mm (P < 0.01) in group 2 (exophthalmometry between 22-25 mm) and group 3 (exophthalmometry >25 mm), respectively. In four of five eyes with compressive optic neuropathy there was an improvement of best-corrected visual acuity of 2 lines or more. Margin-to-reflex distance of the upper and lower lids and intraocular pressure were reduced in all groups. New-onset diplopia developed in two patients (8.7%); 13 of 15 patients (86.7%) who had diplopia preoperatively had persistent diplopia postoperatively. Two patients (13.3%) had relief of diplopia postoperatively. CONCLUSIONS Graded orbital decompression based on the severity of preoperative exophthalmometry is useful to determine the type and amount of orbital surgery to be performed.

Optic disk edema associated with peripapillary serous retinal detachment: an early sign of systemic Bartonella henselae infection☆

PURPOSE To describe optic disk edema associated with peripapillary serous retinal detachment as an early sign of systemic Bartonella henselae infection. METHODS Multicentered, retrospective case series. RESULTS Five women and two men presented with optic disk edema producing peripapillary serous retinal detachment. Each patient had a markedly elevated serum anti-B. henselae antibody titer. Patient age ranged from 11 to 44 years, with a mean and median of 26.6 and 28 years, respectively. The time from the onset of systemic symptoms to the onset of visual symptoms varied from 3 days to 1 month. The peripapillary serous retinal detachment resolved within 1 to 3 weeks in each case, producing a macular star in four of seven patients. Initial vision was 20/200 or worse in five of seven patients and improved in four of these five patients to 20/30 or better. CONCLUSIONS Systemic B. henselae infection should be considered in patients who develop optic disk edema associated with a peripapillary serous retinal detachment, even in the absence of classic neuroretinitis with a macular star.

Systemic toxicity of topical and periocular corticosteroid therapy in an 11-year-old male with posterior uveitis.

PURPOSE To report a case of systemic corticosteroid toxicity resulting from topical and periocular therapy. METHODS Treatment and follow-up of an 11-year-old male with uveitis are illustrated. Initial presentation of the patient was bilateral iridocyclitis, for which he was treated with prednisolone acetate 1% every 2 hours for 6 months. Subsequently, posterior uveitis developed, necessitating posterior subtenon injections. RESULTS After initial topical corticosteroid therapy, the patient developed a cushingoid habitus accompanied by increased lanugo hair, acanthosis nigricans, posterior subcapsular lens opacities, and increased intraocular pressure. Cushingoid stigmata worsened after administration of posterior subtenon injection of corticosteroids. The patients truncal obesity worsened, and his linear growth stopped. CONCLUSIONS Systemic toxic effects may develop as a result of topical and local use of ophthalmic corticosteroid preparations in susceptible patients.

Severe Vision Loss and Neovascular Glaucoma Complicating Superior Ophthalmic Vein Approach to Carotid-Cavernous Sinus Fistula

PURPOSE To report a patient with unilateral vision loss and neovascular glaucoma after attempted superior ophthalmic vein embolization in the treatment of a carotid-cavernous sinus fistula. METHODS A 69-year-old man with a history of a left dural carotid-cavernous sinus fistula underwent attempted treatment with superior ophthalmic vein embolization. The procedure was unsuccessful, and the left superior ophthalmic vein was ligated. RESULTS Uncontrolled left proptosis and intraocular pressure necessitated urgent orbital decompression with severe vision loss and neovascular glaucoma. CONCLUSION Superior ophthalmic vein embolization in the management of carotid-cavernous fistula may be associated with vision-threatening complications.

Botulinum A toxin injection for restrictive myopathy of thyroid-related orbitopathy: effects on intraocular pressure

PURPOSE To study the effect of extraocular muscle injections of botulinum A toxin on intraocular pressure in patients with thyroid-related orbitopathy. DESIGN Retrospective observational case series. METHODS The medical records of eight consecutive patients with restrictive myopathy secondary to thyroid related orbitopathy (TRO) who underwent botulinum A toxin injection from December 1997 to December 1998 were reviewed and analyzed retrospectively. All patients were seen at the University of California, San Diego (UCSD) Thyroid Eye Center, a university-based tertiary referral center. The main outcome measure was intraocular pressure (IOP) readings taken before and after injection in both primary gaze and upgaze (involving one eye in seven of the patients and both eyes in one patient). Intraocular pressure readings were measured by an unmasked physician using a Goldmann applanation tonometer. RESULTS A statistically significant decrease in IOP in upgaze was noted 2 to 6 weeks following botulinum A toxin injection and in both fields of gaze (primary and upgaze) after 2 to 4 months. The mean IOP before injection was 21.4 +/- 3.0 mm Hg in primary gaze and 29.9 +/- 9.7 mm Hg in upgaze. The mean IOP, following injection at 2 to 6 weeks, was 19.2 +/- 4.2 mm Hg (P <.095) in primary gaze and 25.1 +/- 5.9 mm Hg (P <.023) in upgaze. At 2 to 4 months following injection, the mean IOP was 19.3 +/- 3.9 mm Hg (P <.044) in primary gaze and 27.7 +/- 8.5 mm Hg (P <.024) in upgaze. Six patients indicated improved ocular deviation, which was associated with a lowering of IOP. Two patients indicated no change in IOP or strabismic deviation following botulinum A toxin injection. CONCLUSIONS Botulinum A toxin injections cause a secondary effect to lower IOP in patients with restrictive strabismus associated with thyroid-related orbitopathy.

A Masked Prospective Evaluation of Outcome Parameters for Cytomegalovirus-related Retinal Detachment Surgery in Patients with Acquired Immune Deficiency Syndrome

PURPOSE The management of cytomegalovirus (CMV)-related rhegmatogenous retinal detachments in patients with acquired immune deficiency syndrome (AIDS) has been the subject of recent attention and controversy because of the high degree of variability in visual outcome, as well as significant differences in the reported incidence of profound postoperative optic atrophy. This study was designed to evaluate the various parameters affecting postoperative visual outcome, and to quantitate the degree of postoperative optic disc pallor. METHODS The results of 65 consecutive surgeries for CMV-related retinal detachments in 51 patients with AIDS were prospectively studied. Postoperative vision, survival, optic disc pallor, and retinitis extent were analyzed. Serial photographs of optic discs underwent masked evaluation. RESULTS Mean postoperative survival was 30 weeks (range, 2-146 weeks). Mean best postoperative visual acuity was 20/66 (range, 20/20-2/200) and mean final postoperative visual acuity was 20/100 (range, 20/25-no light perception). Analysis of visual outcome for eyes with no macular or papillo-macular retinitis showed a best postoperative visual acuity of 20/60 (range, 20/25-2/200) and mean final postoperative visual acuity of 20/80 (range, 20/25-no light perception). Postoperative vision was not affected by the presence of a preoperative macular detachment, with both groups (macula on or off detachments), achieving a best postoperative visual acuity of 20/60 in the absence of macular retinitis. Mild postoperative optic disc pallor was observed in 30% of surgical eyes at the final postoperative visit, and moderate pallor was noted in 13%. The mean degree of optic disc pallor was not different from the degree of optic disc pallor seen in fellow, nonsurgical eyes with CMV retinitis (surgical versus fellow nonsurgical eyes, 29% +/- 23% versus 26% +/- 30%; P = 0.64). CONCLUSION In this largest reported series of reattachment surgery for CMV-related retinal detachments, patients are experiencing increased postoperative survival, good vision, and relative optic nerve health.

Radiographic analysis of extraocular muscle volumetric changes in thyroid-related orbitopathy following orbital decompression.

Purpose: To evaluate radiographic volume changes in extraocular muscles (EOM) following orbital decompression for thyroid-related orbitopathy (TRO). Methods: Medical records of 22 orbits in 12 patients undergoing postoperative orbital CT after orbital decompression for TRO were retrospectively reviewed. All orbits demonstrated no signs of clinical reactivation of TRO. EOM volumes were determined by the summation of each EOMs cross-sectional area in the coronal plane of the CT scans and multiplying the sum by the slice thickness. Main outcome measure was a comparison of EOM volumes preoperatively and postoperatively. Results: All orbits demonstrated proptosis reduction postoperatively with a mean of 4.8 mm ± 2.1 mm (p < 0.0001). The significant increase in the medial rectus muscle (p = 0.0010) postoperatively accounted for the primary change in the postoperative enlargement of total EOM volume (p = 0.028). The medial rectus muscle increased 27% from the preoperative volume. The lateral rectus, superior rectus/levator complex, inferior rectus, and superior oblique muscles did not demonstrate a significant volume increase postoperatively (p = 0.23, 0.21, 0.17, 0.40, respectively). Two patients who underwent unilateral orbital decompression demonstrated EOM enlargement postoperatively in the operative orbit only. Conclusions: There is a significant increase in medial rectus muscle volume postoperatively in orbits undergoing orbital decompression for TRO despite lacking clinical evidence of disease reactivation.

Combined eyelid and strabismus surgery: examining conventional surgical wisdom.

PURPOSE To determine whether satisfactory results of both eyelid surgery and strabismus surgery can be obtained when these procedures are performed in the same setting in selected patients. METHODS Nine patients (16 eyelids) who had undergone surgery in the same setting for eyelid malposition and strabismus of the horizontal rectus muscles, with or without concurrent vertical rectus muscle surgery, were retrospectively reviewed. Eyelid malposition surgery success was defined as a postoperative margin reflex distance (MRD1) within 1 mm of the target. Strabismus surgery success was defined as a postoperative deviation within 8 prism diopters of orthophoria or a decrease in binocular diplopia if the patient had a less than 8 prism diopters deviation in primary gaze preoperatively. RESULTS Eyelid retraction repair was performed on 13 upper eyelids, levator advancement was performed on 2 eyelids, and frontalis suspension was performed on 1 eyelid. Four patients underwent bilateral medial rectus recession and the remaining 5 patients received varying strabismus surgery. Four patients received adjustable sutures. Mean follow-up was 11 months. Postoperatively, 13 of 16 eyelids (81%) achieved an MRD1 within 1 mm of the target. Eight of 9 patients (89%) demonstrated satisfactory strabismus correction. CONCLUSION Combined eyelid malposition and strabismus surgery can be successfully performed in selected cases, particularly when the strabismus surgery involves the horizontal rectus muscles. Combined surgery is not recommended in cases that do not involve the horizontal rectus muscles.

Optic neuropathy associated with botulinum A toxin in thyroid-related orbitopathy.

Purpose: To report the development of optic neuropathy after botulinum A toxin injection for restrictive myopathy from thyroid-related orbitopathy (TRO). Methods: We retrospectively reviewed the records of three patients with TRO who underwent botulinum A toxin injection for restrictive myopathy and subsequently developed optic neuropathy. Development of optic neuropathy was measured by visual acuity, color vision testing, visual field testing, and relative afferent pupillary testing. Results: At 3 week follow-up after botulinum A toxin injection, three patients were noted to have clinical signs and symptoms of optic neuropathy in the ipsilateral eye following injection of botulinum A toxin for restrictive myopathy. Treatment with oral steroids followed by orbital wall decompression reversed the optic neuropathy. Conclusions: To our knowledge, this is the first report of optic neuropathy associated with botulinum A toxin injection in TRO. Clinicians should be aware of this potential vision threatening complication.