Neuro-ophthalmic Examination Research Articles

Non-arteritic anterior ischemic optic neuropathy in Black patients

Prior studies have shown that non-arteritic anterior ischemic optic neuropathy (NAION) is uncommon in persons of Black race compared to those of White race, but the reasons behind this discrepancy remain unknown. Our goal was to analyze the systemic and ocular features of Black NAION patients compared to White patients. Retrospective cross-sectional study METHODS: Self-reported race was collected from all NAION patients seen between 2014-2022 from a single US neuro-ophthalmology service. All Black NAION patients and a randomly selected sample of White NAION patients were included. We collected information on hypertension, hyperlipidemia, diabetes mellitus, hypothyroidism, obesity, ischemic heart disease, atrial fibrillation, pacemaker insertion, chronic kidney disease, dialysis, anemia, obstructive sleep apnea, deep vein thrombosis, stroke, use of phosphodiesterase inhibitors, and smoking status. We reviewed color fundus photographs and optic nerve OCT images to assess cup-to-disc ratio and document the presence of optic disc drusen. Counterfactual random forest was used to estimate associations for each characteristic of interest by race controlling for the other exposures. We included 32 Black NAION patients (mean age 57 ± 11 years, 38% men) and 69 of 432 White patients (mean age 57 ± 15 years, 59% men). Time between NAION onset and neuro-ophthalmic examination was significantly longer in Black patients (1.5 to <3 months: OR 4.07, P = 0.03; 6 to <12 months: OR 6.05, P = 0.007). Chronic kidney disease (OR 7.53, P = 0.003) and hemodialysis (OR 13.69, P = 0.02) were significantly more frequent in Black patients. No significant differences in cup-to-disc ratio were present (0.15 to <0.25: OR 2.83, P = 0.09; 0.25 to <0.35: OR 0.56, P = 0.46; ≥0.35: OR 0.66, P = 0.44). Referral delay occurs in Black patients with NAION, likely due to its relative rarity and concern for alternate diagnoses. Black NAION patients were substantially more likely to have chronic kidney disease and be on dialysis than White patients. Despite known racial differences in cup-to-disc ratio, we found no difference between Black and White NAION patients, suggesting that the underlying proposed compartment mechanism is the same between races.

Survey of ocular abnormalities in a population of Turkmen horses.

The aim of this study was to detect and describe ocular abnormalities in a population of Turkmen horses. A total of 55 Turkmen horses (33 mares and 22 stallions) from one herd were evaluated in this study. Demographic data (Age, Sex, Coat color) were recorded. All animals underwent complete ophthalmic examination. The Schirmer tear test -I (STT-I) was performed for all horses prior to other diagnostic tests. Neuro-ophthalmic examinations (menace response, dazzle reflex, pupillary light reflex, maze test, and visual tracking) were carried out in different lighting situations (bright and dim lights). Slit lamp biomicroscopy, direct and indirect ophthalmoscopy, fluorescein staining, and tonometry were performed for each horse. The mean (standard deviation) age of horses was 5.7 (4.6) years (range of 1-17 years). In total, 18 horses (32.7%) had ocular-related lesions. Cataract, iris hyperpigmentation and corneal edema were the most identified conditions in the horses of this study. About one-third of studied horses had at least one ocular abnormality. No ocular abnormalities attributed to the distinct cream/gold coat color were identified, which the Turkmen horse is known for.

Virtual Reality With Eye Tracking for Pediatric Ophthalmology: A Systematic Review.

Virtual reality presents an efficient and engaging approach to ophthalmological diagnosis and treatment in children. This systematic review investigates the current state of eye tracking technology integrated into virtual reality for the spectrum of pediatric ophthalmology. The search encompassed the MEDLINE database via PubMed, without imposing any time restrictions. A total of 20 relevant studies that met our inclusion criteria were incorporated and categorized into the following domains: diagnosis, examination, treatment, and rehabilitation use of virtual reality devices within the realm of pediatric ophthalmology. Strabismus examinations and postoperative monitoring, inherited retinal degeneration examination and visual function testing, therapy of amblyopia, glaucoma visual field testing, cerebral visual impairment rehabilitation, and neuro-ophthalmic disease examination were included in the final analysis. Pediatric ophthalmology offers a promising landscape for the integration of eye tracking technology within virtual reality, with accelerated, quantifiable, and objective examination and diagnosis, and precise, real-time measurements that are crucial in children. Virtual reality is an engaging experience, easily applied in a pediatric setting and facilitating compliance during examination and adherence to therapy. Although our systematic review provides insights into the current state of research, it is anticipated that further exploration is required for the widespread utilization of eye tracking in virtual reality within pediatric ophthalmology. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

Neuro-ophthalmic Tests for Assessment of Vision Before and After Phacoemulsification in Cataractous Dogs

Background: The aim of current study was to assess pre and post-operative vision status through neuro-ophthalmic examination of 24 canine eyes after phacoemulsification with implantation of different acrylic intra ocular lenses. Methods: The study was conducted on 24 canine eyes. Preoperatively, detailed neuro-ophthalmic tests viz. Menace response, Pupillary light reflex (PLR), Obstacle Course and Moving object (cotton ball) were conducted for assessment of vision due to cataract and to exclude other ocular pathologies. Dogs were divided in four groups with 6 eyes in each group and subjected to phacoemulsification procedure for removal of cataractous lens and implanted with square edge or round edge, hydrophilic or hydrophobic intra ocular lenses (IOL). Post operatively, aforementioned neuro-ophthalmic tests were conducted on 3, 7 and 15 days and scores were given and comparatively analysed for vision acuity. Result: Preoperatively, neuro-opthalmic tests indicated poor and absent vision in eyes affected with various stages of cataract. Post operatively, the visual outcome in dogs of all treatment groups were assessed from the scores obtained in various neuro-ophthalmic tests. Neuro-ophthalmic evaluation revealed restoration of vision in 50% dogs in group I, II, IV and in 66.66% dogs of group III on day 15 after phacoemulsification and intraocular lens (IOL) implantation. It was concluded that neuro-ophthalmic tests are useful and mandatory protocols for pre and post-operative vision assessment in dogs with cataract.

Observational cohort study of 100 patients presenting with functional visual loss: clinical characteristics and comparison with other functional neurologic disorders

ObjectiveRecent research has helped to develop a more detailed understanding of many functional neurologic disorders. The aim of this study was to increase our knowledge of functional visual loss and to compare the findings with those of other functional syndromes. DesignProspective and retrospective observational cohort study. MethodsThis study took place at neuro-ophthalmology clinics at 3 major hospitals in London, United Kingdom, over a 12-month period. The study population consisted of 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. All participants had their diagnosis confirmed with a full neuro-ophthalmic examination, neuroimaging, and visual electrophysiology. A full assessment of all participants’ medical history was obtained from their general practitioner, and all participants completed a series of questionnaires assessing relevant associations. ResultsData were obtained on 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. Participants with functional visual loss were typically female (74%) with a mean age at vision loss of 40.0 ± 16 years. Sixty-four percent of participants had bilateral vision loss; the remainder, unilateral loss. Twenty-six percent of the total cohort had organic visual loss with functional overlay. Fifty percent of participants with functional visual loss had a preexisting psychiatric diagnosis, the most common being a depressive disorder. Sixty-two percent of participants had an ocular history, and 87% had a previously diagnosed medical illness, most commonly neurologic (45%). Thirty-five percent of participants self-reported at least 1 additional functional symptom. ConclusionsOur population of functional visual loss subjects shares many similarities with the majority of patients with other functional neurologic disorders. They are generally young and female and have a greater than expected rate of psychiatric, medical, and coexisting ocular conditions. We found increased rates of precipitating stressors, clinical depression, and organic eye problems in subjects with functional visual loss.

Neuro-ophthalmic features of patients with spontaneous cerebrospinal fluid leaks.

Increased intracranial pressure is a potential cause of spontaneous cerebrospinal fluid (sCSF) leak. Associated neuro-ophthalmic features have not been well studied, particularly relationships with idiopathic intracranial hypertension (IIH). We hypothesized that neuro-ophthalmic features routinely used in evaluations for IIH can be useful in the investigation of a causal relationship between IIH and sCSF leak. We reviewed the neuro-ophthalmic examination and office-based ophthalmic imaging data of all consecutive patients with sCSF leaks and at least one repair to investigate the clinical and neuro-ophthalmic features of increased intracranial pressure. We conducted a retrospective longitudinal study at a single institution by querying the electronic medical record system for CSF leak Current Procedural Terminology (CPT) codes (G96.00 and G96.01) from June 1, 2019, to July 31, 2022. For patients with a confirmed diagnosis of sCSF leak, demographic information, eye examination results, and ophthalmic imaging details for both eyes were collected. A total of 189 patients with CSF leaks were identified through CPT coding; 159 had iatrogenic or traumatic CSF leaks, and 30 individuals (3 male, 27 female) had confirmed sCSF leaks. The mean age of patients with sCSF leaks was 46 years (range: 29 - 81), with a mean body mass index of 35.2 kg/m2 (range: 18.2 - 54.1). Only 11 of 30 underwent eye examinations (8 before surgical repair and 10 after). The mean pre-repair and post-repair best-corrected visual acuity were 20/30 (range: 20/20 - 20/55) and 20/25 (range: 20/20 - 20/40), respectively (P = 0.188). The mean retinal nerve fiber layer thickness was 99 µm (range: 96 - 104) pre-repair and 97 µm (range: 84 - 103) post-repair (P = 0.195). The mean ganglion cell complex thickness was 84 µm (range: 72 - 94) pre-repair and 82 µm (range: 71 - 94) post-repair (P = 0.500). Humphrey visual field average mean deviation was -5.1 (range: -12.4 - -1.8) pre-repair and -1.0 (range: -10.1 - 2.1) post-repair (P = 0.063). Serial neuro-ophthalmic examinations are recommended for patients with sCSF leaks to screen for signs of current or prior increased intracranial pressure. Larger studies are required to clarify the longitudinal changes in neuro-ophthalmic features, to investigate the incidence of IIH in cases of sCSF leak development or recurrence after surgical repair, and to explore potential causal relationships to guide post-repair management and prevent recurrent leaks. A multicenter consortium is also suggested to develop a standard clinical protocol for comprehensive management of sCSF leaks.

Spastic Paraplegia Type 7-Associated Optic Neuropathy: A Case Series.

Hereditary optic neuropathies comprise a group of clinically and genetically heterogeneous disorders. Optic neuropathy has been previously reported in families with spastic paraplegia type 7 (SPG7) gene mutations. However, the typical time course and clinical presentation of SPG7-associated optic neuropathy is poorly understood. We report a series of 5 patients harboring pathogenic SPG7 mutations who originally presented to a neuro-ophthalmology clinic with symptoms of optic neuropathy. Retrospective case series of 5 patients with pathogenic SPG7 mutations and optic atrophy from 3 neuro-ophthalmology clinics. Demographic, clinical, diagnostic, and treatment data were collected and reported by the clinician authors. Five patients ranging in age from 8 to 48 years were evaluated in the neuro-ophthalmology clinic. Although there were variable clinical presentations for each subject, all noted progressive vision loss, typically bilateral, and several also had previous diagnoses of peripheral neuropathy (e.g., Guillain-Barré Syndrome). Patients underwent neuro-ophthalmic examinations and testing with visual fields and optic coherence tomography of the retinal nerve fiber layer. Genetic testing revealed pathogenic variants in the SPG7 gene. Five patients presented to the neuro-ophthalmology clinic with progressive vision loss and were diagnosed with optic atrophy. Although each patient harbored an SPG7 mutation, this cohort was phenotypically and genotypically heterogeneous. Three patients carried the Ala510Val variant. The patients demonstrated varying degrees of visual acuity and visual field loss, although evaluations were completed during different stages of disease progression. Four patients had a previous diagnosis of peripheral neuropathy. This raises the prospect that a single pathogenic variant of SPG7 may be associated with peripheral neuropathy in addition to optic neuropathy. These results support the consideration of SPG7 testing in patients with high suspicion for genetic optic neuropathy, as manifested by symmetric papillomacular bundle damage without clear etiology on initial workup. Applied judiciously, genetic testing, including for SPG7, may help clarify the cause of unexplained progressive optic neuropathies.

Hyperthyroidism-induced Cerebral Venous Thrombosis Presenting as Chronic Isolated Intracranial Hypertension.

A 38-year-old woman with untreated Graves' disease was admitted to our hospital because of headache and diplopia for 3 months. A neuro-ophthalmic examination showed bilateral papilledema and abducens nerve paralysis. The cerebrospinal fluid pressure was extremely high. Brain magnetic resonance imaging showed cerebral venous thrombosis in the superior sagittal and right transverse and sigmoid sinuses. Laboratory investigations revealed elevated factor VIII and von Willebrand factor levels. The patient recovered after propylthiouracil and anticoagulation therapy. We herein report a rare case of cerebral venous thrombosis with hyperthyroidism presenting as chronic isolated intracranial hypertension. Hyperthyroidism can induce a hypercoagulable state and lead to venous thromboembolism.

Eight-and-a-half syndrome – A rare presentation of pontine infarction

Eight-and-a-half syndrome is clinically characterized by conjugate gaze palsy and internuclear ophthalmoplegia along with lower motor neuron type facial nerve palsy. Usually, it occurs because of infarction or demyelinating disease at paramedian tegmentum of lower pons. It emphasizes the importance of checking ocular movements. A 55-year-old male patient presented with sudden onset of double vision, headache, and vomiting and found to have horizontal gaze palsy, internuclear ophthalmoplegia, and facial palsy of the left side. High blood pressure was noted. Clinically, eight and a half syndrome was identified. MRI brain showed infarct at pons. The patient was stabilized systemically. A detailed clinical neuro-ophthalmic examination, along with a clear understanding of the neuro-anatomical pathways, gives clinicians a good diagnostic opportunity to localize precisely lesions in the brainstem. The disease should be evaluated for etiology.

MRI Signal Intensity Varies Along the Course of the Normal Optic Nerve.

MRI can help distinguish various causes of optic neuropathy including optic neuritis. Importantly, neuromyelitis optica spectrum disorder (NMOSD) has a propensity to cause enhancement of the prechiasmatic optic nerves. To determine whether the prechiasmatic optic nerve (PC-ON) demonstrates a different intensity from the midorbital optic nerve (MO-ON) on MRI among patients without optic neuropathy. Data were retrospectively obtained from 75 patients who underwent brain MRI for an ocular motor nerve palsy between January 2005 and April 2021. Inclusion criteria were patients aged 18 years or older with visual acuities of at least 20/25 and no evidence of optic neuropathy on neuro-ophthalmic examination. A total of 67 right eyes and 68 left eyes were assessed. A neuroradiologist performed quantitative intensity measurements of the MO-ON and PC-ON on precontrast and postcontrast T1 axial images. Normal-appearing temporalis muscle intensity was also measured and used as a reference to calculate an intensity ratio to calibrate across images. The mean PC-ON intensity ratio was significantly higher than the MO-ON intensity ratio on both precontrast (19.6%, P < 0.01) and postcontrast images (14.2%, P < 0.01). Age, gender, and laterality did not independently affect measurements. The prechiasmatic optic nerve shows brighter intensity ratios on both precontrast and postcontrast T1 images than the midorbital optic nerve among normal optic nerves. Clinicians should recognize this subtle signal discrepancy when assessing patients with presumed optic neuropathy.

Neurochondrin Autoimmunity With Slow Saccades: A Case Report

Objective N/A. Background Neurochondrin is a cytoplasmic neuronal antigen that can be targeted by specific antibodies, resulting in an antigen-specific T-cell response and autoimmune cerebellar and brain stem degeneration.1 Previously reported cases of neurochondrin antibody positivity have been predominantly associated with rapidly-progressive rhombencephalitis, but various other neurological symptoms and signs may be present.1,2 Design/Methods N/A. Results 34-year-old woman presented with 2 years of constant numbness in her toes, gradually worsening to involve the entire lower and upper extremities. She also reported dysarthria, imbalance, and leg spasticity. Neurological examination showed a slow, wide-based gait, brisk reflexes bilaterally, and bilateral extensor plantar responses. MRI brain was normal and CSF analysis showed 7 oligoclonal bands. The patient was diagnosed with probable multiple sclerosis and steroids were initiated but resulted in no improvement of symptoms. Plasmapheresis was also ineffective. 3 months later, MRI showed subtly increased T2 signal of the central cord mainly involving the gray matter at the level of C5 and C6. CSF analysis showed 15 oligoclonal bands and an elevated IgG index of 1.39. VDRL was nonreactive. HTLV, ANCA, AQP4, CSF VZ PCR, HSV PCR, and HHV6 PCR were all negative. EMG showed mild length-dependent axonal sensory motor peripheral neuropathy. On neuro-ophthalmic examination, the patient showed slowed saccades with some preservation of optokinetic nystagmus (OKN) fast phases. Repeat MR showed abnormal T2 hyperintensity in the anterior horns of the gray matter from C1-2 to T1. Serum testing at that time showed a positive neurochondrin antibody. She was then started on cyclophosphamide and mycophenolate mofetil. 6 months after initiation of cyclophosphamide, dysarthria and upper limb mobility improved, and she had no further neurological deterioration at that time. Conclusions Neurochondrin IgG-related autoimmunity is rare and can result in a wide variety of neurological signs and symptoms. Ocular dysmotility, including slowed saccades, may be present.

Sellar masses: diagnosis and treatment.

Sellar mases can cause a variety of neuro-ophthalmic manifestations, including compressive optic neuropathy, chiasmal syndrome, and ophthalmoplegia due to cranial nerve palsy. Diagnosis involves a thorough history, neuro-ophthalmic examination, and ancillary tests and investigations. Visual field testing is critical in diagnosing and localizing the lesion and determining the extent of visual field loss. Appropriate neuro-imaging is essential in characterizing and localizing the lesion. Neuro-ophthalmologic assessment include meticulous clinical examination and ancillary tests including,visual field testing, which is useful in localizing the lesion, and optical coherence tomography, which is helpful in assessing the degree of axonal and neuronal loss and predicting the visual outcome. Treatment requires a multidisciplinary approach by different specialties, including radiologists, neuro-ophthalmologists, and neurosurgeons. The two primary treatment modalities for these tumors are surgery and radiation therapy. We review the main types of sellar lesions, their neuro-ophthalmologic evaluation, and treatment options.

Tele-Neuro-Ophthalmology Utilization, Availability, and Attitudes: Update 1 Year Into the COVID-19 Public Health Emergency.

Telehealth was rapidly adopted early in the COVID-19 pandemic as a way to provide medical care while reducing risk of SARS-CoV2 transmission. Since then, telehealth utilization has evolved differentially according to subspecialty. This study assessed changes in neuro-ophthalmology during the first year of the COVID-19 pandemic. Telehealth utilization and opinions pre-COVID-19, early pandemic (spring 2020), and 1 year later (spring 2021) were surveyed among practicing neuro-ophthalmologists in and outside the United States using an online platform. Demographics, self-reported utilization, perceived benefits, barriers, and examination suitability were collected over a 2-week period in May 2021. A total of 135 practicing neuro-ophthalmologists (81.5% United States, 47.4% females, median age 45-54 years) completed the survey. The proportion of participants using video visits remained elevated during COVID + 1 year (50.8%) compared with pre-COVID (6%, P < 0.0005, McNemar), although decreased compared with early COVID (67%, P < 0.0005). Video visits were the most commonly used methodology. The proportion of participants using remote testing (42.2% vs 46.2%), virtual second opinions (14.5% vs 11.9%, P = 0.45), and eConsults (13.5% vs 16.2%, P = 0.38) remained similar between early and COVID + 1 year ( P = 0.25). The majority selected increased access to care, better continuity of care, and enhanced patient appointment efficiency as benefits, whereas reimbursement, liability, disruption of in-person clinic flow, limitations of video examinations, and patient technology use were barriers. Many participants deemed many neuro-ophthalmic examination elements unsuitable when collected during a live video session, although participants believed some examination components could be evaluated adequately through a review of ancillary testing or outside records. One year into the COVID-19 pandemic, neuro-ophthalmologists maintained telemedicine utilization at rates higher than prepandemic levels. Tele-neuro-ophthalmology remains a valuable tool in augmenting patient care.

Idiopathic Intracranial Hypertension is Associated with a Higher Burden of Visible Cerebral Perivascular Spaces: The Glymphatic Connection.

Research suggests a connection between idiopathic intracranial hypertension and the cerebral glymphatic system. We hypothesized that visible dilated perivascular spaces, possible glymphatic pathways, would be more prevalent in patients with idiopathic intracranial hypertension. This prevalence could provide a biomarker and add evidence to the glymphatic connection in the pathogenesis of idiopathic intracranial hypertension. We evaluated 36 adult (older than 21 years of age) patients with idiopathic intracranial hypertension and 19 controls, 21-69 years of age, who underwent a standardized MR imaging protocol that included high-resolution precontrast T2- and T1-weighted images. All patients had complete neuro-ophthalmic examinations for papilledema. The number of visible perivascular spaces was evaluated using a comprehensive 4-point qualitative rating scale, which graded the number of visible perivascular spaces in the centrum semiovale and basal ganglia; a 2-point scale was used for the midbrain. Readers were blinded to patient diagnoses. Continuous variables were compared using a Student t test. The mean number of visible perivascular spaces overall was greater in the idiopathic intracranial hypertension group than in controls (4.5 [SD, 1.9] versus 2.9 [SD, 1.9], respectively; P = .004). This finding was significant for centrum semiovale idiopathic intracranial hypertension (2.3 [SD, 1.4] versus controls, 1.3 [SD, 1.1], P = .003) and basal ganglia idiopathic intracranial hypertension (1.7 [SD, 0.6] versus controls, 1.2 [SD, 0.7], P = .009). There was no significant difference in midbrain idiopathic intracranial hypertension (0.5 [SD, 0.5] versus controls, 0.4 [SD, 0.5], P = .47). Idiopathic intracranial hypertension is associated with an increased number of visible intracranial perivascular spaces. This finding provides insight into the pathophysiology of idiopathic intracranial hypertension, suggesting a possible relationship between idiopathic intracranial hypertension and glymphatic dysfunction and providing another useful biomarker for the disease.

Segmented retinal analysis in pituitary adenoma with chiasmal compression: A prospective comparative study.

Purpose:The aim of this study was to determine the alteration in ganglion cell complex and its relationship with retinal nerve fiber layer (RNFL) thickness as measured by spectral-domain optical coherence tomography (OCT) in pituitary adenoma cases and also its correlation with visual field (VF).Methods:This is a prospective comparative study wherein detailed neuro-ophthalmic examination including perimetry, RNFL and ganglion cell layer inner plexiform layer (GCL-IPL) thickness were measured preoperatively in the cases of pituitary adenoma with chiasmal compression with visual symptoms and field changes who were planned for neuro-surgical intervention. These parameters were repeated 1 year after the surgery. GCL-IPL, RNFL parameters were compared with controls and were correlated with VF mean deviation (MD). The diagnostic power of GCL-IPL was tested using the receiver operating characteristic (ROC) curve. Healthy age and sex-matched controls without any ocular and systemic abnormality were taken for comparison.Results:Twenty-four patients qualified the inclusion criteria. A significant thinning of GCL-IPL (P = 0.002) and RNFL (P = 0.039) was noticed in the pituitary adenoma group. GCL-IPL (r = 0.780 P < 0.001) and RNFL (r = 0.669, P < 0.001) were significantly correlated with the MD. The ROC curve values of GCL-IPL were 0.859 (95% confidence interval 0.744% to 0.973) and of RNFL were 0.731 (95% confidence interval 0.585–0.877). The diagnostic ability of GCL-IPL was more as compared to the RNFL analysis, although it was statistically insignificant (P = 0.122).Conclusion:GCL-IPL measurements on the OCT are a sensitive tool to detect early anterior visual pathway changes in chiasmal compression for pituitary adenoma patients.

Telemedicine in neuro-ophthalmology.

The COVID-19 public health emergency accelerated the adoption of telemedicine in neuro-ophthalmology. This review surveys the current telemedicine landscape and discusses associated limitations and opportunities. Logistic considerations and regulatory changes related to the COVID-19 pandemic have spurred a proliferation of tele-neuro-ophthalmic practice. One significant benefit of telemedicine is increased access to the limited number of neuro-ophthalmologists in the country. Certain elements of the neuro-ophthalmic examination can be ascertained during a video visit or through the use of mobile applications. However, data quality can be limited and more direct evaluation of the fundus currently requires the implementation of imaging techniques, such as fundus photography and/or optical coherence tomography. For cases that require it, a 'hybrid' model can be adopted in which patients physically present to designated locations for testing and subsequently participate in televisit with the physician to discuss the assessment and plan. Telemedicine provides an alternate pathway for patients to access the limited resource of neuro-ophthalmic care, and it will likely persist beyond the current COVID-19 pandemic. It has some limitations currently but continued progress in technologic, legal, and reimbursement strategies will hopefully facilitate further adoption.

Monocular Diplopia in Idiopathic Intracranial Hypertension: A Case Report and Literature Review.

Diplopia is the double vision of a single object, and can be binocular or monocular. Binocular diplopia is caused by the misalignment of the visual axes, with images falling on the fovea of the fixating eye and on the extra-foveal retina of the non-fixating eye, as a consequence of both neurological (i.e., oculomotor nerve palsies, ocular myopathies, neuromuscular junction disorders) and ophthalmic disorders (i.e., decompensation of a pre-existing strabismus). In contrast, monocular diplopia is generally explained by intraocular pathology (i.e., refractive errors, ocular media abnormalities, dry eyes), causing the image of a single object to fall, at the same time, on the fovea and on the extra-foveal retina of the same eye. We report the case of a 22-year-old woman presenting with acute-onset monocular diplopia. The diagnosis of idiopathic intracranial hypertension (IIH) was based on the presence of papilloedema and elevated cerebrospinal fluid (CSF) pressure. Monocular diplopia resolved after CSF subtraction. We describe a case of monocular diplopia as a presenting symptom of IIH, and discuss diagnostic issues of this possibly underestimated symptom in neurology clinical practice. Careful ophthalmic and neuro-ophthalmic examination can identify clinical features of diplopia, and drive diagnosis and treatment. Monocular diplopia is mostly an ophthalmological condition but can occur in a number of neurological diseases.Idiopathic intracranial hypertension can present with monocular diplopia.Differential diagnoses of diplopia in neurology and ophthalmology settings need to account for headache disorders.

Case 292.

History A 24-year-old right-handed woman presented to a neuro-ophthalmology clinic in Massachusetts in the summer with acute binocular diplopia when looking down and to the left, which started about 1 month earlier. Her medical history was notable for Raynaud syndrome, recurrent streptococcal pharyngitis, and an allergy to amoxicillin. Three days prior to developing diplopia, she presented to an outside emergency department due to fever, chills, and back pain. She received ciprofloxacin for presumed urinary tract infection based on urinalysis, which demonstrated few bacteria and was negative for leukocyte esterase, nitrites, and white blood cells. She then presented again to an outside emergency department for diplopia evaluation. Initial MRI and MR angiography of the brain at that time did not demonstrate any relevant findings, and the patient was referred to our department for neuro-ophthalmic evaluation, where she was seen 4 weeks later. Neuro-ophthalmic examination revealed 20/20 visual acuity in both eyes, and a right hypertropia in left gaze, downgaze and right head tilt, with right eye excyclotorsion. There were no ocular signs of myasthenia gravis or thyroid eye disease, nor did the patient report ocular or systemic symptoms. She denied recent travel. High-spatial-resolution MRI of the brain and orbit were performed (Figs 1, 2).

Binasal visual field defects caused by temporal posterior subcapsular cataracts

A 55-year-old female presented with binasal visual field defects and normal neuro-ophthalmic examination. Slit-lamp examination demonstrated posterior subcapsular cataracts that were located temporally in the visual axis. Due to the location of the nodal point in the eye, her visual field defect was contralateral to the opacity. Her visual field defects resolved after cataract surgery.

Pediatric ophthalmology, strabismus and neuro-ophthalmology practice in the COVID-19 era: All India Ophthalmological Society guidelines.

The COVID-19 Pandemic has prompted substantial changes in the way ophthalmology is practiced globally. General guidelines on safe ophthalmic practice have been issued by various bodies across the globe including the All India Ophthalmological Society. While these are suitable to ophthalmology overall, they are not entirely suitable to a subspecialty practice, particularly pediatric ophthalmology, strabismus and neuro-ophthalmology, which entails dealing with children, surgery under general anesthesia and managing possible life threatening situations. A group of sub-specialists and anesthetists met virtually and arrived at a consensus with regard to practice and general anesthesia protocols pertaining to these subspecialties of ophthalmology. The recommendations made by the expert group are specific yet can be universally followed to ensure the best and safest outcome for the practitioner and patient alike. The recommendations pertain to listing conditions which need emergency or urgent care in the fields of pediatric ophthalmology and neuro-ophthalmology, precautions and technique of pediatric and neuro-ophthalmic eye examination and a protocol for delivering a safe general anesthesia for a pediatriceye surgery.