Neuro-ophthalmic Complications Research Articles

Giant cell arteritis. Part III. New trends in its treatment (role of genetically engineered drugs)

Giant cell arteritis (GCA) is a well-known vasculitis sensitive to glucocorticoid (GC) immuno-suppression. However, during long-term treatment there may be many adverse reactions that remain a serious problem so far. Since GCA encompasses a broad spectrum of clinical subtypes, ranging from severe visual loss and neurological deficits to isolated systemic signs, its treatment must be adjusted specially to each case. The literature contains contradicting recommendations for the therapy for GCA. The paper considers different treatment options for GCA, including that with neuro-ophthalmic and neurological complications, as well as the evidence for their possible adjuvant therapies. Although there is no randomized controlled clinical trial in GCA with ocular and neurological complications, the data available in the literature suggest that these patients are recommended to be admitted for high-dose intravenous methylprednisolone, monitoring, and prevention of GC-induced complications. It is expedient to use aspirin in these cases. The evidence supporting the use of methotrexate, as well as genetically engineered agents (GEAs), infliximab, etanercept) as steroid-sparing agents is discussed. Cases of using individual GEAs (adalimumab, tocilizumab and rituximab) as an alternative to GC monotherapy are described. It is concluded that there is a need for extended clinical trials evaluating the most effective and safe GC-sparing drugs.

Monocular Vision Loss and Headache in a 60-Year-Old Liver Transplant Patient

Monocular Vision Loss and Headache in a 60-Year-Old Liver Transplant Patient

Neuro-Ophthalmology and Pregnancy

Management of the pregnant woman with a neuro-ophthalmic disorder may be challenging. Physiologic changes in pregnancy make vascular conditions more frequent, including retinal artery occlusion, spontaneous orbital hemorrhage, and pituitary apoplexy. Papilledema may signal cerebral venous sinus thrombosis or idiopathic intracranial hypertension. Manifestations of severe preeclampsia and eclampsia include choroidal infarction, serous retinal detachment, and disorders of higher cortical function, such as alexia, simultanagnosia, and cerebral blindness. Cranial neuropathies have also been reported. Transient Horner syndrome, intracranial hypotension with comitant esotropia may occur in the postpartum period. Treatment of the neuro-ophthalmic complications of pregnancy requires an understanding of the risks of medications. Taking optimal care of the mother will usually result in the best care for her baby.

Erblindung nach nichtophthalmologischen Eingriffen

Perioperative visual loss (POVL) after nonocular surgery is a rare but unexpected event and represents a devastating complication. It is most often associated with cardiac, spinal as well as head and neck surgery. The etiology of POVL remains incompletely understood. Any portion of the visual system may be involved, from the cornea to the occipital lobe. The most common site of permanent injury is, however, the optic nerve itself and ischemia is the most often presumed mechanism. Multiple factors have been proposed as risk factors for POVL, including long duration in the prone position, decreased ocular perfusion pressure, excessive blood loss and anemia, hypotension, hypoxia, excessive fluid replacement, elevated venous pressure, head positioning and a patient-specific vascular susceptibility which may be anatomic or physiologic. However, the risk factors for any given patient or procedure may vary. The underlying specific pathogenesis of these neuro-ophthalmic complications remains unknown and physicians should be alert to the potential for loss of vision in the postoperative period. This review updates readers on the incidence, suspected risk factors, diagnosis and treatment of POVL in the setting of nonocular surgery.

Erblindung nach nichtophthalmologischen Eingriffen

Perioperative visual loss (POVL) after nonocular surgery is a rare but unexpected event and represents a devastating complication. It is most often associated with cardiac, spinal as well as head and neck surgery. The etiology of POVL remains incompletely understood. Any portion of the visual system may be involved, from the cornea to the occipital lobe. The most common site of permanent injury is, however, the optic nerve itself and ischemia is the most often presumed mechanism. Multiple factors have been proposed as risk factors for POVL, including long duration in the prone position, decreased ocular perfusion pressure, excessive blood loss and anemia, hypotension, hypoxia, excessive fluid replacement, elevated venous pressure, head positioning and a patient-specific vascular susceptibility which may be anatomic or physiologic. However, the risk factors for any given patient or procedure may vary. The underlying specific pathogenesis of these neuro-ophthalmic complications remains unknown and physicians should be alert to the potential for loss of vision in the postoperative period. This review updates readers on the incidence, suspected risk factors, diagnosis and treatment of POVL in the setting of nonocular surgery.

Pediatric Ocular Manifestations of HIV/AIDS in Makurdi Benue State, A Hyperendemic State in Nigeria

Benue State, Nigeria, currently has the highest seroprevalence nationwide. Data available from developed countries and the few available ones from the developing countries have all indicated that the pattern and prevalence of HIV-related ocular morbidity in the paediatric population is quite different from those that occur in the adult population.This study is aimed at ascertaining the pattern of ocular affectations of HIV-infected paediatric age group. A retrospective study of all the children aged 1-16 years, diagnosed cases of HIV/AIDS who presented to the eye unit or were seen by Invitation for Consultation in other units of the Federal Medical Centre in Makurdi between June 2002 to May 2006. A register was open in the Eye Department of Federal Medical Centre between June 2002 to May 2007. Extracted from this register were the bio-data of the patients, Ocular presentation, corrected Visual acuity and Ocular diagnosis of all Seropositive HIV/AIDS children reviewed. Of all the358 seropositive children, only 121 ( 33.8% ) had ocular affectations. . There were 206 (57.5%) males 152 (42.5%) females. The most common anterior segment lesions were conjunctival microangiopathy, non-purulent conjunctivitis, recurrent chalazion and external hordeolum. The most prevalent posterior segment ocular lesions were peri-vasculitis, toxoplasmal retinochoroiditis retinal haemorhages, and macular edema. In conclusion, posterior segment and neuro-ophthalmic complications of the HIV/AIDS were the major causes of ocular morbidity and visual impairment. Ocular assessment is of paramount importance for early detection and management of vision threatening complication of HIV/AIDS in children.Key words: HIV, AIDS, Paediatric, Hyper-endemic State, Benue State.

A review of Complications in 577 cases of Endoscopic Endonasal Surgeries done in KVG Medical College

BackgroundObjectives The complications of endoscopic endonasal surgeries are rare but can occur as grave orbital complications. Complications range from minor bleeding to major orbital complications like orbitaland periorbital hemorrhage medial rectus muscle damage and rarely optic nerve damage. DesignRetrospective study of 577 patients who underwent endoscopic endonasal surgeries for various sinus amp other endonasal diseases. SettingDepartment of ENT Head amp Neck Surgery KVG Medical College Sullia. Materials amp Methods Complications seen during endoscopic surgeries done in 577 patients were evaluated during the study period of 48 months between January 2006 and December 2010. Results 23 3.98 cases of orbital complications 16 2.77 cases of post operative bleeding and16 2.77 cases of nasal synechia were seen in our study. No neuro-ophthalmic complications were seen in our study. Conclusion Orbital complications are the commonest major complications seen in endoscopic endonasal surgeries apart from other minor common complications. Early diagnosis amp accurate treatment avoids further complications.

Delays in recognition and management of giant cell arteritis: results from a retrospective audit

Prompt institution of corticosteroids (CS) can prevent devastating neuro-ophthalmic complications (NOC) in patients with giant cell arteritis (GCA). Guidelines on managing GCA place emphasis on early recognition of symptoms and prompt treatment of the disease where there is a high index of clinical suspicion. The aims of this study are to review the clinical findings in patients with GCA, evaluate the baseline practice in diagnosis and treatment and to identify delays in treating patients with NOC. The study utilised retrospective case notes review of patients diagnosed with GCA between 2003 and 2008. Sixty-five patients were identified (47 females, 18 males, mean age, 75years). A significant minority presented with constitutional, polymyalgic and ischaemic symptoms. Mean time from symptom onset to diagnosis of GCA was 35days. CS were not delayed in those diagnosed with GCA. Recognition of ischaemic symptoms was slow. Visual loss at presentation occurred in 16 patients (24.6%). Ten patients (15.4%) presented with NOC in the absence of headache, seven (70%) of whom developed permanent visual impairment. Five (7.7%) patients had cerebrovascular complications. There are major delays in the recognition and treatment of GCA. There is a high incidence of irreversible ischaemic complications which may partly result from diagnostic and treatment delay.

Current understanding and management of giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are linked conditions that occur in the elderly. GCA is a vasculitis of large- and medium-sized vessels causing critical ischemia. It is a medical emergency owing to the high incidence of neuro-ophthalmic complications. PMR is an inflammatory disease characterized by abrupt-onset pain and stiffness of the shoulder and pelvic girdle muscles. Both conditions are associated with a systemic inflammatory response and constitutional symptoms. The pathogeneses are unclear. The initiating step may be the recognition of an infectious agent by activated dendritic cells. The key cell type involved is CD4+ T cells and the key cytokines are IFN-γ (implicated in granuloma formation) and IL-6 (key to the systemic response). The pathogenesis of PMR may be similar to that of GCA, however, PMR exhibits less clinical vascular involvement. The mainstay of therapy is corticosteroids, and disease-modifying therapy is indicated in relapsing disease. This article reviews recent guidelines on early recognition, investigations and management of these diseases, as well as advances in imaging.

Ocular Complications among Cases of Head Injury Seen in a Neurosurgical Hospital in Southeastern Nigeria

Background: Head injuries with ocular involvement are of great importance due to the visual morbidity and mortality which may result.Objective: To determine the pattern of ocular complications among cases of head injury seen in Memphys Hospital for Neurosurgery, Enugu, in south-eastern Nigeria.Patients and Methods: In a prospective study, consecutive patients with head injury seen in Memphys Hospital for Neurosurgery, Enugu, from June 2007 to May 2008 were analysed for age, sex, cause of head injury, presence or absence of ocular complication and type of ocular complication.Results: A total of 26 patients were analysed – 21 men and 5 women (M: F = 4:1), with an age range from 21-64 years. Road traffic accident was the leading cause of head injury, accounting for 88.3% of all the cases. All the patients presented within 72 hours of injury. Fifteen (57.7%) of the 26 patients had ocular complications in one or both eyes. The complications were more neuro-ophthalmic (76.2%) than ophthalmic (23.8%).Damage to the ocular cranial nerve was the most frequently occurring injury, accounting for 61.9% of all complications, followed by soft tissue injury, which was seen in 5 (23.8%) cases.Conclusion: Neuro-ophthalmic complications involving the ocular cranial nerves were the most commonly occurring complication among the cases of head injury seen in Memphys Hospital for Neurosurgery, Enugu.Key words: Ocular complications, head injury, Nigeria.

Perioperative visual loss in ocular and nonocular surgery.

Incidence estimates for perioperative vision loss (POVL) after nonocular surgery range from 0.013% for all surgeries up to 0.2% following spine surgery. The most common neuro-ophthalmologic causes of POVL are the ischemic optic neuropathies (ION), either anterior (AION) or posterior (PION). We identified 111 case reports of AION following nonocular surgery in the literature, with most occurring after cardiac surgery, and 165 case reports of PION following nonocular surgery, with most occurring after spine surgery or radical neck dissection. There were an additional 526 cases of ION that did not specify if the diagnosis was AION or PION. We also identified 933 case reports of central retinal artery occlusion (CRAO), 33 cases of pituitary apoplexy, and 245 cases of cortical blindness following nonocular surgery. The incidence of POVL following ocular surgery appears to be much lower than that seen following nonocular surgery. We identified five cases in the literature of direct optic nerve trauma, 47 cases of AION, and five cases of PION following ocular surgery. The specific pathogenesis and risk factors underlying these neuro-ophthalmic complications remain unknown, and physicians should be alert to the potential for loss of vision in the postoperative period.

Thunderclap headache caused by a pituitary non-functioning tumour presenting as spontaneous pituitary apoplexy

Hemorrhagic or ischemic pituitary apoplexy is a rare neuro-endocrine emergency, potentially leading to coma. Neuro-ophthalmic symptoms or complications are amongst the most prevalent clinical features at onset, especially in previously asymptomatic patients. Usually, permanent pituitary insufficiency of various degrees follows, implying long-term hormone substitutive therapy. Rarely, the association of pituitary apoplexy with diabetes insipidus has been noticed. We report the case of a young, apparently healthy 32-year-old man presenting with thunderclap headache, fever, optic chiasm compression, central diabetes insipidus and central thyro-gonadic insufficiency. Magnetic resonance imaging and neurosurgery revealed a clinically non-functioning macro-adenoma developing pituitary hemorrhage. One year after the apoplectic episode, complete recovery of diabetes insipidus and pituitary function was confirmed.

HIV/AIDS in the Developing World

This article reviews information available from developing countries including those in Africa Asia Eastern Europe Latin American and the Caribbean regarding the current state of the HIV/AIDS epidemic. It also discusses the common ocular manifestations associated with HIV/AIDS including: HIV microvasculopathy cytomegalovirus (CMV) retinitis ocular toxoplasmosis non-CMV herpetic retinitis neuro-ophthalmic complications herpes zoster ophthalmicus and ocular neoplasia.

Thunderclap headache caused by a pituitary non-functioning tumour presenting as spontaneous pituitary apoplexy

Hemorrhagic or ischemic pituitary apoplexy is a rare neuro-endocrine emergency, potentially leading to coma. Neuro-ophthalmic symptoms or complications are amongst the most prevalent clinical features at onset, especially in previously asymptomatic patients. Usually, permanent pituitary insufficiency of various degrees follows, implying long-term hormone substitutive therapy. Rarely, the association of pituitary apoplexy with diabetes insipidus has been noticed. We report the case of a young, apparently healthy 32-yearold man presenting with thunderclap headache, fever, optic chiasm compression, central diabetes insipidus and central thyro-gonadic insufficiency. Magnetic resonance imaging and neurosurgery revealed a clinically non-functioning macro-adenoma developing pituitary hemorrhage. One year after the apoplectic episode, complete recovery of diabetes insipidus and pituitary function was confirmed.

Síndrome do ápice orbitário causada por herpes zóster oftálmico: relato de caso e revisão da literatura

O Herpes Zoster Oftalmico (HZO) decorre da infeccao pelo virus da varicela-zosterque permanece latente no gânglio de Gasser ate que seja reativado e comprometa adivisao oftalmica do nervo trigemeo. HZO frequentemente causa manifestacoesoftalmologicas como lesoes vesiculares palpebrais, ceratoconjuntivite, esclerite, uveite,paralisia oculomotora, miosite orbitaria e neurite optica. Raramente o acometimentodo apice da orbita pode ser a manifestacao inicial desta grave afeccao. Este trabalhorelata um caso de sindrome do apice orbitario associado a meningite, causado por HZOe que foi tratado com corticosteroide e aciclovir sistemicos.

Neuro–ophthalmic complications in pregnancy

Neuro–ophthalmic conditions associated with pregnancy challenge the ophthalmologist to make the correct diagnosis and recommend appropriate treatment. Pregnancy is a dynamic vascular state, making it likely that vascular disorders can occur. There are also conditions that occur more frequently in this age group (e.g., idiopathic intracranial hypertension), and the ophthalmologist will be instrumental in the evaluation of the condition. Other pregnancy-specific conditions, such as preeclampsia and eclampsia, present with neuro–ophthalmic findings. Diagnosis is crucial before appropriate treatment can be initiated. Treatment must consider the effect on both the woman and the fetus. This article explores the diagnosis and treatment of neuro–ophthalmic conditions in pregnancy.

Current Advancements in the Management of Giant Cell Arteritis

Giant cell arteritis (GCA) is a vasculitis of large and medium-sized vessels that predominantly affects the elderly. GCA should be recognized as a medical emergency owing to its associated critical ischemia, which frequently causes neuro-ophthalmic complications. The pathogenesis of GCA is unclear, but it is speculated that the disease process is triggered by an infectious agent or an autoantigen (through molecular mimicry) being sensed by Toll-like receptors on immature dendritic cells in the tunica adventitia of arteries. Dendritic cells then present antigen to CD4+ T cells leading to T-cell proliferation and cytokine release, activation of macrophages and formation of granulomata-containing giant cells, with injury to the arterial wall by matrix metalloproteinases, reactive oxygen and nitrogen intermediates. Reparative processes then cause revascularization and intimal hyperplasia. This results in vascular occlusion and consequent tissue ischemia. Features predictive of visual loss in GCA include jaw claudication, diplopia and temporal artery abnormalities on physical examination. Modern imaging with duplex ultrasonography and fluorodeoxyglucose positron emission tomography shows promise for early diagnosis and detection of major artery involvement in GCA. However, temporal artery biopsy remains the gold-standard investigation. Early recognition and urgent institution of high-dose corticosteroids is the mainstay of treatment. Studies have found mixed experiences of using conventional disease-modifying drugs and biological therapies. Furthermore, evaluation of their steroid-sparing potential is required with well-constructed, randomized, controlled trials.

Neuro-ophthalmic complications of acute paranasal sinusitis a surgical emergency

Neuro-ophthalmic complications of acute infective sinusitis are a therapeutic emergency. It can lead to blindness or even death. We report a series of four cases of paranasal sinusitis who presented with unilateral sudden loss of vision. There were four patients in age group of 24 years to 65 years with mean age of 43.3 years. The four cases were of acute bacterial sinusitis. Staphylococcus aureus was isolated in three patients with bacterial sinusitis. All patients required an emergency sinus surgery to prevent permanent visual loss. doi : 10.5214/ans.0972.7531.2009.160309 Competing interests: None. Source of Funding: None Received Date: 20 June 2009 Revised Date: 06 July 2009 Accepted Date: 29 July 2009

Neuro-ophthalmic complications of acute paranasal sinusitis a surgical emergency

Neuro-ophthalmic complications of acute paranasal sinusitis a surgical emergency

Treatment and outcomes of large vessel arteritis

Giant cell arteritis (GCA) and Takayasu's arteritis (TA) are characterised by systemic inflammation and critical ischaemia. GCA is a medical emergency. Neuro-ophthalmic complications occur early, with permanent vision loss in up to a fifth of patients, resulting mainly from failure of prompt recognition and treatment. Diagnosis of large vessel vasculitis is often delayed due to poor recognition of early, often non-specific symptoms. Laboratory inflammatory markers are often discordant with disease activity. Modern imaging techniques show promise in diagnosis and disease monitoring, improving our understanding of major artery involvement in large vessel vasculitis. However, in practice, their role is still unclear. The mainstay of therapy remains corticosteroids. Experience using conventional disease-modifying drugs is mixed, and biological therapies require further evaluation for their steroid-sparing potential.