Mitchell Drucker

Tilted Optic Disks

Tilted optic disks are a common finding in the general population. An expression of anomalous human development, the tilted disk appears rotated and tilted along its axes. Visual sequelae described with tilted optic disks include myopia, astigmatism, visual field loss, deficient color vision, and retinal abnormalities. Although the natural course of tilted optic disks is nonprogressive, the anomaly can be mistaken for tumors of the anterior visual pathway, edema of the optic nerve head, or glaucoma. A thorough examination of patients with tilted disk includes refraction, dilated fundus examination, and visual field testing. At times, neuroimaging may be necessary to arrive at the correct diagnosis. Until normative data are validated for tilted disks, the role of new imaging technologies for the optic nerve head is limited. Familiarity with the spectrum of ophthalmoscopic appearance and the clinical manifestations of tilted disks may be the most critical factors in avoiding misdiagnosis.

Pain in anterior ischemic optic neuropathy

Purpose The diagnoses of both anterior ischemic optic neuropathy (AION) and optic neuritis are clinical ones with significant overlap of symptoms and signs. This study investigates the presence and character of pain at the onset of AION, in order to evaluate this symptom as a differentiating diagnostic feature between optic neuritis and AION. Methods Forty-one consecutive patients over 45 years of age with a clinical syndrome consistent with AION were questioned about the presence and character of associated pain. Methods Pain was reported by 12% (5 of 41) of the patients with AION. This is contrasted with data compiled on 448 patients enrolled in the optic neuritis treatment trial, of whom 92.2% complained of pain. Methods While there is overlap in the incidence and character of pain in AION and optic neuritis, its presence/absence remains a useful differentiating feature.

Sudden blindness as a complication of percutaneous trigeminal procedures: mechanism analysis and prevention

The authors describe the case of a 76-year-old man in whom reversible sudden blindness developed after a percutaneous balloon compression rhizotomy for trigeminal neuralgia. His eye became tense and swollen with intraocular pressures of 66 mm Hg. Acetazolamide was administered, and visual acuity (20/50) returned within several months. Despite correct needle placement, the intraocular pressure rose acutely because of transient occlusion of the orbital venous drainage through the cavernous sinus; this was reversed with aggressive medical treatment. In cadaveric studies (dried skull and formalin-fixed head), the authors studied the mechanism of optic nerve penetration. Their findings showed that excessive cranial angulation of the needle with penetration of the inferior orbital fissure can directly traumatize the optic nerve in the orbital apex. Direct trauma to the optic nerve can therefore be prevented by early and repeated confirmation of the needle trajectory with lateral fluoroscopy before penetration of the foramen ovale.

Spontaneous resolution of ophthalmologic symptoms following bilateral traumatic carotid cavernous fistulae.

A 38-year-old woman developed bilateral carotid cavernous fistulae (CCF) following a motor vehicle collision. Her initial ophthalmologic findings included periorbital edema, palsies of the left oculomotor and abducens nerves, and residual dilated pupils. She subsequently developed significant optic disc edema and retinal vascular dilation bilaterally. Patients with similar injuries typically require neurosurgical or vascular intervention. In this case, the patients signs resolved spontaneously by 21 months after onset, leaving no residual ocular deficits.

The role of lumbar puncture and pressure-lowering therapy for transverse dural sinus thrombosis.

Transverse (lateral) sinus thrombosis is a well-known complication of acute otitis media and mastoiditis in the pediatric and adult population. Thrombosis involving the transverse sinus can ultimately cause elevation of intracranial pressure (ICP) as a result of decreased cerebrospinal fluid absorption. If treatment to lower ICP is not undertaken, it can lead to ophthalmological complications including irreversible vision loss. The following case report describes an 11-year-old girl who was diagnosed with AOM by her pediatrician and subsequently presented to the emergency department complaining of nausea, vomiting, headache, and diplopia.

Bariatric surgery and its impact on pseudotumor cerebri: A case report

Purpose Pseudotumor cerebri is a debilitating condition that causes severe headaches and progressive visual field loss. In this report, we present a patient with Class III obesity, with pseudotumor cerebri who failed medical management and attempted weight loss via diet and exercise. Observations After undergoing bariatric surgery, the patient had significant weight loss and improvement of visual field defects. Conclusion and importance These results suggest that bariatric surgery may be an effective option for patients with rapidly progressing visual loss due to pseudotumor cerebri.

Craniopharyngioma causing bilateral vision loss 4 months after unremarkable magnetic resonance imaging of the brain

A 65-year-old man developed bilateral vision loss 4 months after magnetic resonance imaging demonstrated no lesion in the vicinity of the optic chiasm, hypothalamus, and suprasellar tissues. Repeat computed tomography 3 months later showed a predominantly cystic mass of the suprasellar cistern with extension into the anterior third ventricle, which histologically was a craniopharyngioma. The clinical course of this case fuels the controversy whether craniopharyngiomas arise from embryonic rests or can be acquired. From a clinical perspective, it raises questions about when to obtain imaging studies dedicated to the chiasm and the appropriate interval in which a scan should be repeated to exclude structural causes of bilateral vision loss.

The blind photographer. Observations on the bewildering nature of feigned vision loss.

The diagnosis of feigned vision loss in adults taxes the doctor-patient relationship because the relationship should be based on trust, honesty, and the mutual desire to improve the medical condition. Even under ideal circumstances, physicians rarely have a complete understanding of the factors that lead patients to simulate disease they do not have. We describe the historical figure of John Howard Griffin (1920-1980) who likely perpetuated feigned vision loss for a decade. His writings provide a unique perspective on motivation (or inspiration) behind factitious disease.