Authors' Reply to “Neuro-Ophthalmologic Complications of SARS-Cov-2 Infections and Vaccinations” [J Ophthalmic Vis Res 2024;19:140–141]

Postoperative visual loss (POVL) is a very rare but devastating event that can occur post-cardiac surgery. The most common cause of POVL is vascular occlusion. We present a case of a 39-year-old male with severe mixed aortic valve disease, who had to undergo double valve replacement (mechanical) due to extensive calcification. On postoperative day 7, he complained of sudden painless loss of vision in the right eye. He was diagnosed with right eye central retinal artery occlusion and was discharged home with permanent right eye blindness. Neuro-ophthalmologic complications following non-ocular surgery occur rarely. POVL occurs more likely when there are calcified heart valvular lesions, higher perioperative blood loss, hypotension, low systolic blood pressure, anaemia, hypothermia, prolonged surgery time and age >50 years old. In our case report we have encountered a couple of risk factors for ischaemia which are heavily calcified aortic and mitral valves, lower mean arterial pressure and bypass time >5 hours. Postoperative blindness can be avery serious and devastating problem with no known or established treatment. Stroke is a well-known and established complication of cardiac surgery, but central retinal artery occlusion causing loss of vision is rarely covered and explained.

The devastating, blinding effects of diabetic retinopathy have been well publicized. Although individually less common, many neuro-ophthalmologic complications are also associated with diabetes. The vascular effects of diabetes contribute to nonarteritic ischemic optic neuropathy, vasculopathic cranial neuropathies, and strokes affecting both afferent visual function and ocular motility. The neuropathic effects of diabetes primarily affect pupillary function, and the immunosuppressive effects of diabetes predispose to certain infections, such as mucormycosis. Diabetes is also associated with numerous congenital syndromes. This paper reviews the literature published in the past year on the neuro-ophthalmologic effects of diabetes.

Sixth-nerve palsy in a patient with uncontrolled type 1 diabetes

Background and purposeTopiramate (TPM) is a sulfa-derivative monosaccharide that is used mainly for treating epilepsy and preventing migraine. Within the gamut of side effects attributable to this drug, ophthalmologic manifestations are of crucial importance. In this study, for the first time, the aim was to provide a systematic literature review regarding this issue.MethodsFor the time period 1996–2011, a PubMed search was made for the studies concerning the adverse/beneficial effects of TPM on vision. Overall, 404 citations out of a total of 2756 TPM-related studies were examined for relevance.ResultsA total of 74 relevant studies were reviewed, 65 of which comprise small observational studies describing the ophthalmic side effects of TPM in 84 patients. Of these patients, 66 were affected by ciliochoroidal effusion syndrome as the cardinal ocular side effect of TPM (17 cases of myopic shift and 49 cases of angle closure glaucoma). A comprehensive statistical analysis is provided on these 66 subjects. Other rare side effects of TPM on the vision were also reviewed, including massive choroidal effusion, ocular inflammatory reactions, visual field defects, probable effects on retina, cornea, and sclera, and neuroophthalmologic complications. In addition, a framework is provided to classify these results.DiscussionDue to the expanding spectrum of indications for the administration of TPM, neurologists and psychiatrists should be aware of its diverse ocular side effects. In conclusion, ocular complications following this drug should be taken seriously and be subjected to ophthalmic counseling.

Background:To review the literature and provide a summary of COVID-19–related neurologic and neuro-ophthalmic complications.Methods:The currently available literature was reviewed on PubMed and Google Scholar using the following keywords for searches: CNS, Neuro-Ophthalmology, COVID-19, SARS-CoV-2, coronavirus, optic neuritis, pseudotumor cerebri, Acute Disseminated Encephalomyelitis, posterior reversible encephalopathy syndrome (PRES), meningitis, encephalitis, acute necrotizing hemorrhagic encephalopathy, and Guillain–Barré and Miller Fisher syndromes.Results:Neuroradiologic findings of neurologic and neuro-ophthalmologic complications in relationship to COVID-19 infection were reviewed. Afferent visual pathway–related disorders with relevant imaging manifestations included fundus nodules on MRI, papilledema and pseudotumor cerebri syndrome, optic neuritis, Acute Disseminated Encephalomyelitis, vascular injury with thromboembolism and infarct, leukoencephalopathy, gray matter hypoxic injury, hemorrhage, infectious meningitis/encephalitis, acute necrotizing hemorrhagic encephalopathy, and PRES. Efferent visual pathway–related complications with relevant imaging manifestations were also reviewed, including orbital abnormalities, cranial neuropathy, Guillain–Barré and Miller Fisher syndromes, and nystagmus and other eye movement abnormalities related to rhombencephalitis.Conclusion:COVID-19 can cause central and peripheral nervous system disease, including along both the afferent and efferent components of visual axis. Manifestations of disease and long-term sequela continue to be studied and described. Familiarity with the wide variety of neurologic, ophthalmic, and neuroradiologic presentations can promote prompt and appropriate treatment and continue building a framework to understand the underlying mechanism of disease.

Strokes with neuro-ophthalmologic complications after cardiac catheterizations have been reported, with potentially debilitating consequences to patients. We present an interesting case of a 55-year-old male who was managed for new-onset heart failure with reduced ejection fraction. He complained of diplopia and became drowsy immediately after a diagnostic coronary angiogram, a concomitant right heart catheterization study, and left ventricular catheterization. Neurological examination showed that he had bilateral vertical gaze palsy. Magnetic resonance imaging of the brain revealed a left paramedian midbrain stroke. His symptoms resolved within 3 days, and he was discharged well on medical therapy after a period of observation.

Lyme borreliosis is a tick-borne spirochetal illness that may involve numerous organs. Multiple ocular manifestations of Lyme disease have been reported, including anterior uveitis, vitritis, episcleritis, conjunctivitis, keratitis, choroiditis, and exudative retinal detachment. 1 Several neuro-ophthalmologic complications have also been recognized. 1 We recently treated a patient with a branch retinal artery occlusion and positive results of serologic tests to detect Lyme disease who responded well to antibiotic therapy. To our knowledge, this is a new ocular manifestation of Lyme disease. Report of a Case. —A 37-year-old white woman awoke with a scotoma above fixation in her left eye. For the previous several months, she had generalized arthralgias and fatigue. Two months before presentation, she developed floaters in both eyes as well as daily, throbbing headaches. She was not pregnant and took no medications or birth control pills. There was no known history of a tick bite or skin rash.

Purpose: To describe the neuro-ophthalmologic complications of sinus surgery. Methods: The charts of seven patients who suffered visual loss and/or diplopia following sinus surgery were retrospectively reviewed. Results: Clinical findings included orbital hematoma, orbital foreign body, extra-ocular muscle dysfunction, optic neuropathy, and a chiasmal hematoma. Conclusions: Sinus surgery may result in significant neuro-ophthalmologic complications.

Chapter 74 - Neurologic manifestations of Henoch–Schönlein purpura

#1412731: Sixth-Nerve Palsy in a Patient with Type 1 Diabetes

Given the ever-increasing number of drugs available for the treatment of a variety of ocular and systemic disorders, it is not surprising that neuro-ophthalmologic complications are being recognized with increasing frequency. In this chapter, we describe both previously unreported (or rarely described) neuro-ophthalmologic complications produced by well known medications and neuro-ophthalmologic complications produced by new medications. The medications discussed include antidepressants, antiepileptic medications, topical antiglaucoma medications, and chemotherapeutic/immunosuppressive agents. Most of the side effects produced by these medications affect visual sensory function; however, some produce disturbances of ocular motility and alignment. Some of these effects are related directly to drug toxicity, whereas others are related to secondary effects of the drug. The heterogeneity of the pathogenesis of side effects from these drugs explains why some of the side effects are reversible, whereas others are not.

Lemierre's syndrome (LS) is a rare disorder that manifests as septic internal jugular thrombophlebitis following a recent oropharyngeal infection. This article details a unique case of LS, where the patient presented to the emergency room with complaints of vomiting, headache, diplopia, and left eye pain. Due to a history of sore throat, headache, neck pain, fever, and nausea five days prior to admission, the patient was initially treated with amoxicillin/clavulanate for suspected tonsillitis. A positive meningeal sign and elevated temperature were observed during the clinical examination. Lumbar puncture (LP) was deferred based on imaging indicating potential increased intracranial pressure (ICP). Nevertheless, the patient received vancomycin, ceftriaxone, and dexamethasone as an initial course of treatment for presumed bacterial meningitis. Significant improvement was observed within the first four days of admission, with no subsequent episodes of fever, nausea, or headache. However, upon discontinuation of corticosteroid therapy, the patient experienced severe headaches and frequent vomiting. An urgent brain CT scan confirmed the extension of the left internal jugular vein (IJV) thrombosis to the ipsilateral sigmoid sinuses. Metronidazole and anticoagulant medication were initiated upon LS diagnosis. There is a paucity of discussions on corticosteroid use in LS, with no definitive statistics in the current literature. This case underscores the importance of recognizing and effectively managing interconnected clinical manifestations.

Cortical blindness is a well described neuro-ophthalmologic complication of angiography due to neurotoxicity following contrast media exposure. A rarer association with retrograde amnesia has also been reported. Since ischemic stroke due to embolism remains the most common aetiology of neurological complications of diagnostic and therapeutic arterial catheterisation, prompt identification of the mechanism responsible for the clinical symptoms is essential for patient management. Although CT and conventional MRI findings have been reported in this condition, experience with diffusion weighted (DW) sequences is lacking especially in cases associated with memory impairment. A 65-year-old man with tinnitus underwent cerebral angiography for suspicion of a dural arteriovenous fistula. During the procedure the patient developed complete loss of vision and rapidly became confused. Brain CT showed bilateral cortical enhancement in the occipital lobes. MR with DWI was performed 3.5 hours after angiography. Early DWI showed no signal abnormalities thereby excluding an ischaemic complication. Gradual improvement of visual function occurred over the next 24 hours. After 48 hours the patient was alert and orientated but profound retrograde amnesia persisted with no memory for the events of the day of angiography. CT follow-up at one year was normal. DWI is invaluable in the evaluation of patients with cortical blindness with or without memory deficits precipitated by angiography and may advance understanding of the pathophysiology. Diffusion-weighted MRI is crucial in differentiating neuro-ophthalmologic complications precipitated by intracortical contrast leakage after angiography from an ischaemic stroke needing a prompt and often invasive treatment.

The place of the botulinum toxin in the management of multiple sclerosis

Neurological complications following cardiac coronary angiography (CAG), such as ischemic stroke and neuro-ophthalmologic syndromes, are uncommon but significant. This report presents a rare case of isolated third cranial nerve palsy that developed after CAG, highlighting the potential risks associated with the procedure. A 51-year-old male with a history of hypertension and ischemic heart disease underwent CAG for non-ST-segment elevation myocardial infarction. Although the procedure and subsequent cardiac imaging results were normal, the patient developed sudden onset binocular diplopia, ptosis, and restricted eye movements in his left eye following CAG, indicative of left third cranial nerve palsy. Initial computed tomography (CT)and computed tomography angiography (CTA) scans were unremarkable, but amagnetic resonance imaging (MRI) revealed multiple recent lacunar infarcts, including one along the path of the left oculomotor nerve, suggesting an embolic cause. Neuro-ophthalmologic complications post-CAG, though rare, require early detection and intervention, emphasizing the need for preventive measures in at-risk patients.