Ronit Nesher

Rate of Discordant Findings in Bilateral Temporal Artery Biopsy to Diagnose Giant Cell Arteritis

Objective. To determine to what extent performing simultaneous bilateral temporal artery biopsies might increase the diagnostic sensitivity in giant cell arteritis (GCA). Methods. In total 173 consecutive pathology reports of temporal artery biopsies were reviewed for histological findings by a single pathologist. The rate of discordance of biopsy results was calculated in patients with GCA. Results. Biopsies were performed bilaterally and simultaneously in 132 cases; 51 had positive results. In 38 the biopsy was positive on both sides (concordant results), while in 13 patients only one side was positive (discordant results), reaching a discordance rate of 13/51 = 0.255. Therefore 12.7% of the patients (one-half of the discordance rate) could have been misdiagnosed as biopsy-negative had a biopsy been done only unilaterally in those 51 cases. Conclusion. These data suggest that performing bilateral temporal artery biopsies increases the diagnostic sensitivity of the procedure by up to 12.7%, compared to unilateral biopsies.

Charles Bonnet syndrome in glaucoma patients with low vision.

PurposeTo characterize the nature and frequency of Charles Bonnet syndrome in glaucoma patients with low vision. Patients and MethodsAll patients attending the glaucoma clinic during a period of 10 months who had visual acuity of 20/80 or less in both eyes were included in this study. Each patient was questioned about the occurrence of visual hallucinations. Those who responded positively had a thorough interview relating to the characteristics of the hallucinations. Medical history and social history were taken, followed by a complete ocular examination. ResultsEighty-nine patients met the inclusion criteria. Eleven patients (12.3%), eight men and three women, admitted to having experienced visual hallucinations. Except for one case, the patients did not disclose this experience previously. Eight patients had one repeatable hallucination, and three patients experienced more than one sight. The visions were usually sharp, and the figures were occasionally incomplete. Most hallucinations were chromatic. Frequency of hallucinations varied between daily and weekly, and duration was mostly a few minutes. In addition to glaucoma, nine of the eleven patients had other ocular findings that could have contributed to the reduction of vision. ConclusionVisual hallucinations are not rare in glaucoma patients with low vision. Patients tend to conceal their experience of visual hallucinations, but a discussion of these phenomena with the patient and assurance of their harmless nature will reduce his or her anxiety and concerns.

Frequency doubling technology threshold testing in the pediatric age group.

Purpose:To evaluate the feasibility of performing visual field with the Frequency Doubling Technology (FDT) in children aged 5 to 10 years. Patients and Methods:Forty healthy children and fifteen healthy adults, all with no previous experience with visual field testing, underwent visual field testing with the C20 threshold test of the Carl Zeiss Meditec FDT analyzer in both eyes. The subjects were divided into three groups. Group A (age 5–7), group B (age 8–10), and group C (adults). Results:The mean explanation time for the test was 83 ± 43 seconds for group A, 68 ± 31 seconds for group B, and 37 ± 15 seconds for group C (P < 0.001 for the difference between group C and groups A and B). Test performance time for the right eye was 347 ± 57 seconds, 301 ± 21 seconds, and 298 ± 35 seconds for groups A to C, respectively (P < 0.001 for the difference between group A and groups B and C). Forty percent of the children, but none of the adults required two demonstrations prior to initiation of the test. In children fixation losses for the right and left eye were 10% and 37% respectively. No fixation losses occurred in adults. In both eyes a mean deviation <0.5% occurred significantly more often in group A than in group C (P = 0.013). Conclusion:Visual field testing with FDT in the young age group is feasible. Test reliability was similar between children aged 5 to 7 and 8 to 10. Pre-selection of children is suggested to achieve reliable results.

Headaches as the Main Presenting Symptom of Subacute Angle Closure Glaucoma

The diagnosis of subacute angle closure glaucoma is suspected in patients with narrow angles of the anterior chamber of the eye, presenting with periodic ocular, or periocular pain. However, some patients may present with headaches in the absence of significant ocular discomfort, which often leads to misdiagnosis and delay in specific therapy. The clinical features of 9 such patients are described. Subacute angle closure glaucoma should always be considered in the differential diagnosis of adult‐onset headaches.

Survey of intravitreal injection techniques among retina specialists in Israel.

Purpose The purpose of this study was to describe antivascular endothelial growth factor intravitreal injection techniques of retinal specialists in order to establish a cornerstone for future practice guidelines. Methods All members of the Israeli Retina Society were contacted by email to complete an anonymous, 19-question, Internet-based survey regarding their intravitreal injection techniques. Results Overall, 66% (52/79) completed the survey. Most (98%) do not instruct patients to discontinue anticoagulant therapy and 92% prescribe treatment for patients in the waiting room. Three quarters wear sterile gloves and prepare the patient in the supine position. A majority (71%) use sterile surgical draping. All respondents apply topical analgesics and a majority (69%) measure the distance from the limbus to the injection site. A minority (21%) displace the conjunctiva prior to injection. A majority of the survey participants use a 30-gauge needle and the most common quadrant for injection is superotemporal (33%). Less than half routinely assess postinjection optic nerve perfusion (44%). A majority (92%) apply prophylactic antibiotics immediately after the injection. Conclusion The majority of retina specialists perform intravitreal injections similarly. However, a relatively large minority performs this procedure differently. Due to the extremely low percentage of complications, it seems as though such differences do not increase the risk. However, more evidence-based medicine, a cornerstone for practice guidelines, is required in order to identify the intravitreal injection techniques that combine safety and efficacy while causing as little discomfort to the patients as possible.

Subacute glaucoma masquerading as migraine

Subacute angle~closure glaucoma is a condition that is often mis~ diagnosed. Compared with acute angle~closure glaucoma, subacute angle~closure glaucoma has a much less dramatic presentation. Eye symptoms are usually scarce, and attacks tend to subside sponta~ neously. Thus, persons with subacute angle~closure glaucoma are seldom examined during an attack, and often they are first seen by a primary care physician or a neurologist. Because a delay in diag~ nosis may lead to irreversible vision loss, awareness of subacute an~ gle~closure glaucoma by the treating physician is of utmost impor~ tance. Here, the authors provide several tips to help physicians recognize the subtle symptoms of this disorder and speed its accu~ rate diagnosis and proper treatment.

Digitizing Stereoscopic Optic Nerve Head Photographs for Storage and Viewing Using a Personal Computer

Careful examination and monitoring of optic nerve head changes is essential in the treatment of patients with glaucoma. This often results in accumulation of numerous photographs and required appropriate storage space. A simple, inexpensive, and efficient means of storing and viewing stereoscopic optic nerve head photographs is described. Images were acquired with a fundus camera, on a color slide film. Slides were then scanned and digitized. A handheld stereoscope was used for stereoscopic viewing on a computer monitor. A scanning resolution of 300 dpi appeared optimal. At this resolution, the storage utilization was 16 kilobytes and the scanning time was 160 seconds per patient.