Robert S. Hepler

Retinal Periphlebitis and Retinitis in Multiple Sclerosis: I. Pathologic Characteristics

Eyes from 47 autopsy cases of multiple sclerosis were studied pathologically. Lymphocytic or granulomatous retinal periphlebitis was found in four cases (seven eyes); focal lymphocytic or granulomatous retinitis was present in three cases (five eyes). These findings were correlated with optic nerve changes (periphlebitis, neuritis, leptomeningitis, and atrophy), retinal venous sclerosis, uveitis, central nervous system involvement, clinical activity of disease at death, and with ultrastructural and immunopathological retinal findings.

Management of limited rhino-orbital mucormycosis without exenteration.

Eight cases of rhino-orbital mucormycosis managed successfully without exenteration were reviewed. The favorable outcome was attributable to early diagnosis and management of focal areas of fungus infection. Treatment included: correction of diabetic ketoacidosis or other concomitant metabolic derangement; wide local excision and debridement of all involved and devitalized oral, nasal, sinus, and orbital tissue, while establishing adequate sinus and orbital drainage; daily irrigation and packing of the involved orbital and paranasal areas with amphotericin B; and intravenous amphotericin B. This represents the largest reported series of rhino-orbital mucormycosis survivors without mutilating surgery and with unaltered visual acuity.

Hyperbaric oxygen therapy for nonarteritic anterior ischemic optic neuropathy.

PURPOSE To evaluate the effectiveness of hyperbaric oxygen therapy in reducing optic nerve damage in acute nonarteritic anterior ischemic optic neuropathy. METHODS Twenty-two eyes in 20 patients with acute nonarteritic anterior ischemic optic neuropathy were treated with hyperbaric oxygen (100% oxygen, 2.0 absolute atmospheres of pressure) in two 90-minute inhalation sessions per day for ten days. Changes in mean visual acuity and mean sensitivity loss were compared with those of 27 untreated control patients with acute nonarteritic anterior ischemic optic neuropathy, and proportions of patients with a change in acuity or mean sensitivity loss were compared with controls. Similar analysis was performed on subgroups based on time delay from symptom onset to therapy. RESULTS Mean values for visual acuity were increased at final examination in both groups; although the increase was greater in controls, the difference was not statistically significant. Mean visual field sensitivity loss was minimally increased; although the increase was smaller in controls, the difference between groups was not significant. There was no significant difference between groups in proportions of patients with change in acuity score or mean sensitivity loss. Stratification by time delay to therapy did not suggest that treatment within nine days produced better visual results than that for either controls or those treated later. CONCLUSIONS Hyperbaric oxygen therapy using 100% oxygen and 2.0 absolute atmospheres of pressure did not produce a significant improvement in visual acuity or visual field for patients with acute nonarteritic anterior ischemic optic neuropathy.

Results of Inpatient and Outpatient Cataract Surgery: A Historical Cohort Comparison

PURPOSE The transition from inpatient to outpatient cataract surgery during the last decade was not accompanied by prospective investigation of its effect on visual outcomes or surgical complications. The authors performed this study to assess the impact of this transition on surgical results. METHODS The authors reviewed 600 extracapsular cataract extractions performed by 4 experienced ophthalmic surgeons during a 36-month period; in 300 cases, patients were hospitalized after surgery (inpatient group), and, in 300 cases, patients were never hospitalized (outpatient group). The same surgical techniques were used in all cases. Visual outcome and rates for operative and postoperative complications were compared. RESULTS There were no statistically significant differences between the inpatient and outpatient groups for visual acuity. Excluding patients with pre-existing nonlenticular ocular disease, a best-corrected visual acuity of 20/40 or better was achieved in 93.1% of inpatient cases and in 97.2% of outpatient cases 6 months after surgery. Postoperative, clinically apparent cystoid macular edema was more common in the inpatient group (P = 0.03); however, after exclusion of patients with diabetes, hypertension, age younger than 65 years, and eyes with pre-existing nonlenticular disease, there was no statistically significant difference between groups. No significant differences in rates for other operative and postoperative complications were identified, including wound dehiscence, unplanned postoperative filtering blebs, infectious endophthalmitis, retinal detachment, persistent iridocyclitis, glaucoma, and corneal edema. CONCLUSION This study does not demonstrate that the transition to outpatient cataract extractions has had an adverse effect on surgical outcomes.

Alteration of the visual evoked potential by macular holes: Comparison with optic neuritis

Nine patients with maculopathy (macular holes, macular cysts, and lamellar holes) and ten patients with optic neuritis were examined in order to determine changes in the visual evoked potential (VEP) in response to pattern-reversal stimulation. Eyes with lamellar holes had normal P100 latency, but eyes with macular cysts and macular holes had prolonged P100 latency. Eyes with optic neuritis exhibited greater prolongation of the P100 latency than eyes with macular holes. In contrast, eyes with macular holes had a greater reduction in the steady-state VEP amplitude than eyes with optic neuritis. The prolonged latency occurring in maculopathy may be due to a peculiar amplitude summation noted with half-field VEP, rather than to a true conduction delay like that seen in eyes with optic neuritis. The amplitude slope, which is usually positive in normal controls, was negative for 85.7% of eyes with macular holes and 69.2% of eyes with optic neuritis. The negative amplitude slope may represent a subtle defect in retinal ganglion X cells. Eyes with significantly lower values for four or more of the nine central test points on quantitative automated perimetry had negative amplitude slopes and prolonged P100 latency.

Magnetic resonance imaging of craniopharyngioma.

Craniopharyngiomas are common tumors located in the suprasellar region. Contrast enhancement, cyst formation, and calcification are the three characteristic features of craniopharyngiomas on computed tomographic scan. More than 90% of suprasellar craniopharyngiomas exhibit at least two of these three features, thus providing easy radiologic detection. We treated a 41-year-old man in whom a large suprasellar craniopharyngioma producing severe visual loss was not detected by computed tomography but was easily identified with magnetic resonance imaging. Thus, despite high-resolution computed tomographic scan, large suprasellar craniopharyngiomas can be missed. Magnetic resonance imaging may be superior to computed tomography in detecting these tumors.

Management of optic neuritis

To improve understanding and effectiveness of therapy in optic nerve disease, various causes of so-called optic neuritis should be identified when possible. The clinical characteristics of demyelinating optic neuropathy can be contrasted with those of ischemic optic neuropathy, nutritional optic neuropathy, true optic nerve inflammation (e.g., luetic), optic nerve infiltration with tumor, and compression neuropathy caused by adjacent tumor. Radiologic studies and other means of investigating patients with optic neuritis are reviewed. Arguments in favor of, and against, treatment of presumed demyelinating optic neuritis are presented along with representative corticosteroid treatment regimens. The natural tendency toward spontaneous improvement of optic neuritis makes the effect of treatment difficult to assess.

Hemianopia respecting the vertical meridian and with foveal sparing from retinal degeneration

lumbosacral ganglia, which have only interganglia and postganglionic fibers. When sympathetic ganglia or postganglionic fibers along the lumbosacral plexus or the peripheral nerves are damaged below the segment L3, autonomic disturbances appear, which are not preeent with lesions of the nerve roots or cauda equina.l.2 However, clinically it is difficult to differentiate LSP from lesions of the spinal cord, cauda equina, or nerve mot. Our patient’s myelogram was normal, as were CSF studies. Additionally, epidural metastasis, usually below the conus medullaris, has been demonstrated in 45% of patients with neoplastic LSP by myelography.3 Furthermore, myelography might help delineate radiation porta because the epidural tumor may be at the fringe of or outside the conventional pelvic port. In cancer patients, along with the classic quintet of leg pain, weakness, edema, rectal mass, and hydronephrosis, which are strongly suggestive of neoplastic LSP? look for vegetative symptoms in the neurologic examination. The spontaneous onset of a warm and dry foot in a cancer patient is a valuable diagnostic clue to retroperitoneal metastasis. Furthermore, motor or sensory disturbances at lumbosacral segments indicate LSP. rather than a radiculopathy or cauda equina syndrome.lJ

Trends in Clinical Neuroendocrinology

Excerpt Clinical neuroendocrinology can be practiced most effectively by a multidisciplinary team that should include basic investigators as well as clinicians. This conference illustrates this tea...

Microphthalmia and Arachnoidal Brain Cyst

Conditions associated with microphthalmia are many but, to the best of our knowledge, there have been no reports of arachnoidal brain cyst. Arachnoidal cysts are benign intracranial cysts that are occasionally confused with porencephalic cysts. 1 Arachnoidal cysts are filled with colorless or xanthochromic fluid. Their origin is for the most part unknown; some appear to be developmental and others to be the result of infection or trauma. Some of these cysts remain asymptomatic throughout life. 1 Associated ocular conditions include ocular motor disorders, 2 unilateral blepharoptosis, 3 ipsilateral glaucoma, exophthalmos, visual field loss, and chronic papilledema. 4 Optimal treatment in a symptomatic patient is surgical excision; if the cysts recur and the patient is symptomatic, shunting the lesion to the peritoneal cavity can be effective. 1