Normal Visual Fields Research Articles

A STUDY ON CLINICAL PROFILE AND OUTCOME OF VISUAL PARAMETERS OF OPTIC NEURITIS PATIENTS IN A TERTIARY EYE CARE CENTRE

Introduction: Optic neuritis (ON) is the inflammation of the optic nerve secondary to autoimmune, infectious, or inflammatory conditions. Objective: The objective is to study the clinical profile and changes in visual parameters after the treatment of patients with ON. Methods: This prospective interventional research was done at the ophthalmology department of a tertiary eye care center. 36 cases diagnosed with ON have been analyzed, treated, and followed up for 1 year, for the type of clinical presentation, rate of recurrence, and changes in visual parameters. Results: The prevalence rate was bimodal, more common among age groups between 46 and 55 years at 32% and age group 16–25 at 27%. A higher prevalence rate was seen in females in 63% of cases. The bilateral presentation was observed in 18%. 44% of cases presented as retrobulbar neuritis (RBN) whereas 56% were as papillitis. At 1 year follow up Optic disc edema suggestive of papillitis was seen in 17% of cases, normal disc with RBN in 44% and disc pallor in 32% discs. At the final follow-up after 1 year, 75% of patients could read maximum (10/13) color plates, 64% of cases showed standard contrast sensitivity and 47% showed normal visual field. VA of 6/60 or worse at presentation was seen in 53% cases and <6/12 in (84%) cases which improved to better than 6/12 in 58% cases and better than 6/60 in 67% cases at final follow up at 1 year. The most common visual field abnormality at presentation was generalized field constriction in (34%), central or centrocecal scotoma in (18%), hemianopia or quadrantanopia (12%), and enlarged blind spot in (06%) cases. During the final follow-up at 1 year, 22 cases (61%) showed normal field. Visual Field could not be tested in (30%) at presentation as vision was <3/60, although visual evoked potential was abnormal in all of 36 (100%) cases with mean P 100 latency being 128 ms. Furthermore, 3 (8%) cases demonstrated additional neurological symptoms till the final follow-up and were subsequently identified to be multiple sclerosis (MS). Recurrence rate was 08 (22%) within 1 year follow-up, of which 06 (17%) cases were clinically RBN and 02 (05%) were papillitis. Conclusion: In our study, findings of clinical profile and visual outcomes of ON patients were different from that of Western studies as well as from those done previously in the Indian population, notably lesser prevalence of MS, although other differences were not very significant.

Longitudinal Assessment of Retinal Nerve Fiber Layer and Ganglion Cell Complex Thicknesses in Patients With Large Optic Disc Cups and Normal Intraocular Pressure and Visual Fields.

The thicknesses of the circumpapillary retinal nerve fiber layer (cpRNFL) and ganglion cell complex (GCC) did not change during 5 years in physiological large disc cupping. We evaluated longitudinal changes in the thicknesses of the cpRNFL and GCC in large disc cupping with a normal intraocular pressure (IOP) (<21mmHg) and visual field. This retrospective, consecutive case series study included 269 eyes of 269 patients with large disc cupping and normal IOP. We analyzed patient demographics, IOP, central corneal thickness, vertical cup-to-disc ratios using color fundus photography, the thicknesses of the cpRNFL and GCC using RTVue-100, and mean deviation using visual field examinations. The differences in IOP, vertical cup-to-disc ratios, and mean deviation between the baseline and each follow-up visit were not statistically significant. The baseline average and mean average at 60 months follow-up of the cpRNFL thickness were 106.5±8.5 and 105.1±9.3μm, respectively; differences between the baseline and each follow-up visit were not statistically significant. The baseline average and mean average at 60 months follow-up of the GCC thickness were 82.8±9. and 81.5±9.2μm, respectively; differences between baseline and each follow-up visit were not statistically significant. The thicknesses of the cpRNFL and GCC did not change in well-maintained optic nerve head findings with normal IOP and visual field during a 5-year follow-up period. Optical coherence tomography evaluations of the thicknesses of the cpRNFL and GCC help accurately diagnose physiological optic disc cupping.

Retinal Nerve Fiber Layer Optical Texture Analysis: Detecting Axonal Fiber Bundle Defects in Patients with Ocular Hypertension

To apply retinal nerve fiber layer (RNFL) optical texture analysis (ROTA) to investigate the prevalence, patterns, and risk factors of RNFL defects in patients with ocular hypertension (OHT) who showed normal optic disc and RNFL configuration in clinical examination, normal RNFL thickness on OCT analysis, and normal visual field (VF) results. Cross-sectional study. Six hundred eyes of 306 patients with OHT. All participants underwent clinical examination of the optic disc and RNFL, OCT RNFL imaging, and 24-2 standard automated perimetry. To detect RNFL defects, ROTA was applied. The risk score for glaucoma development was calculated according to the Ocular Hypertension Treatment Study and European Glaucoma Prevention Study (OHTS-EGPS) risk prediction model. Risk factors associated with RNFL defects were analyzed using multilevel logistic regression analysis. Prevalence of RNFL defects. The average intraocular pressure (IOP) measured from 3 separate visits within 6 months was 24.9 ± 1.8 mmHg for the eye with higher IOP and 23.7 ± 1.7 mmHg for the eye with lower IOP; the respective central corneal thicknesses were 568.7 ± 30.8 μm and 568.8 ± 31.2 μm. Of 306 patients with OHT, 10.8% (33 patients, 37 eyes) demonstrated RNFL defects in ROTA in at least 1 eye. Of the 37 eyes with RNFL defects, the superior arcuate bundle was the most frequently involved (62.2%), followed by the superior papillomacular bundle (27.0%) and the inferior papillomacular bundle (21.6%). Papillofoveal bundle defects were observed in 10.8% of eyes. The smallest RNFL defect spanned 0.0° along Bruch's membrane opening margin, whereas the widest RNFL defect extended over 29.3°. Age (years) (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.03-1.13), VF pattern standard deviation (decibels [dB]) (OR, 1.82; 95% CI, 1.01-3.29), cup volume (mm3) (OR, 1.24; 95% CI, 1.01-1.53), and the OHTS-EPGS risk score (OR, 1.04; 95% CI, 1.01-1.07) were associated with RNFL defects. A considerable proportion of patients with OHT who showed no signs of optic disc and RNFL thickness abnormalities on clinical and OCT examination exhibited RNFL defects on ROTA. Axonal fiber bundle defects on ROTA may represent the earliest discernible sign of glaucoma in the glaucoma continuum. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinical and imaging characteristics of optic nerve tumors as the differencial diagnosis of optic neuritis

Objective: To investigate the clinical and imaging features of optic nerve tumors that require differential diagnosis from optic neuritis. Methods: A retrospective case series study was conducted. Clinical data of patients diagnosed with optic nerve tumors from January 2017 to December 2021 at the Second Affiliated Hospital of Zhejiang University School of Medicine were collected. A total of 29 patients (39 eyes) with clinical and magnetic resonance imaging (MRI) findings similar to optic neuritis or optic neuropathy were included. There were 15 cases of optic nerve sheath meningioma (ONSM) (17 eyes), 4 cases of optic nerve glioma (ONG) (5 eyes), and 10 cases of infiltrative optic nerve lesions (ION) (17 eyes). All patients underwent best-corrected visual acuity (BCVA), anterior and posterior segment examinations, visual field examination, and orbital or cranial MRI examination. Patient data were observed and analyzed, treatment and follow-up information were recorded, and clinical and imaging features were summarized and compared with those of optic neuritis or optic neuropathy. Results: Among the 29 patients with optic nerve tumors, 10 were male and 19 were female, with an average age of (43.3±13.8) years and a range of 11 to 72 years. The follow-up time was 6.8 (2.0, 11.0) months, with a range of 1 to 33 months. Sixteen patients (21 eyes) with optic nerve tumors were initially misdiagnosed as having acute optic neuritis and showed poor response to steroid treatment. Of these, 9 cases (11 eyes) were ONSM, 4 cases (6 eyes) were ION, and 3 cases (4 eyes) were ONG. The diagnostic delay time was 7.1 (1.5, 12.0) months, with a range of 1 to 24 months. The main clinical symptoms of all affected eyes were acute vision loss in 23 eyes, slow vision loss in 5 eyes, transient blackouts in 4 eyes, and no obvious visual symptoms in 7 eyes. The median BCVA of all affected eyes was 0.1, ranging from light perception to 1.0. Fundus examination results showed optic disc edema in 34 eyes and normal optic disc in 5 eyes among the 39 eyes with optic nerve tumors. A total of 27 patients (33 eyes) completed visual field examinations, which revealed an enlarged physiological blind spot in 11 eyes, a concentric or tubular visual field contraction in 8 eyes, a diffuse decrease in light sensitivity in 7 eyes, an arcuate scotoma in 4 eyes, and a normal visual field in 3 eyes. All affected eyes completed orbital or cranial MRI examinations, which showed mild optic nerve thickening in 22 eyes, significant thickening in 6 eyes with distortion, and no significant thickening in 6 eyes. Contrast-enhanced T1-weighted imaging (T1WI) MRI showed optic nerve parenchymal thickening in 5 eyes, all of which were ONG, and 2 of them had optic nerve parenchymal enhancement. Optic nerve sheath thickening and enhancement without optic nerve parenchymal thickening or enhancement were observed in 28 eyes, including 17 eyes of ION and 11 eyes of ONSM. There were 6 eyes with no obvious optic nerve thickening, which were all ONSM, showing mild or significant thickening and enhancement of the optic nerve sheath without optic nerve parenchymal thickening or enhancement. Conclusions: Optic nerve tumors can present with ophthalmic clinical features similar to optic neuritis, such as optic disc edema, and demonstrate MRI findings that resemble those of optic neuritis. Therefore, differentiation between the two is crucial, based on differences in their natural course and response to steroid therapy.

Optical coherence tomography detects early optic nerve damage before visual field defect in patients with pituitary tumors.

Optical coherence tomography (OCT) is a useful tool for predicting visual recovery after the removal of pituitary tumors. However, the utility of OCT in patients with pituitary tumors and a normal visual field is unclear. We aimed to analyze OCT features in pituitary tumors without visual field defects. Pituitary tumors without visual field defects were selected. A total of 138 eyes from 69 patients, assessed by the Humphrey visual field test and OCT, were enrolled in this study. Using preoperative coronal sections of MR images, patients were divided into chiasmal compression (CC) and non-chiasmal compression (non-CC) groups, and OCT characteristics were examined. The CC and non-CC groups consisted of 40 and 29 patients, respectively. There were no differences in age, sex, tumor type, or degree of visual field testing, but the tumor size was different between the two groups. On OCT, macular thickness ganglion cell complex (mGCC) was significantly thinner in the CC group than that in the non-CC group (112.5 vs 117.4 um, P < 0.05). Based on a database of healthy participants, 24% and 2% of eyes in the CC and non-CC groups had abnormal mGCC thickness (P < 0.01), respectively. In a sub-analysis of the CC group, patients with an abnormal mGCC thickness were older than a normal one (58.2 vs 41.1years, p < 0.01). OCT can detect early optic nerve damage due to optic CC by pituitary tumors, even in normal visual fields. The degree of mGCC thinning may provide an appropriate surgical timing for pituitary tumors that compress the optic chiasm.

Evaluation of Cup Disc Ratio and RNFL Thickness Based on Goldmann Visual Field Test

Introduction and Objective : To assess the relationship between the cup-disc ratio of the optic nerve head and peripapilarry RNFL thickness to the visual field loss in glaucoma patients. Methods : Visual field from Goldmann kinetic perimerty and Ocular Computed Tomography (OCT) records from Yap Eye Hospital, Yogyakarta are used to examine the figure of visual field loss in glaucoma patient. Result: Broad spectrum of glaucoma-related visual field defects were observed from 73 eyes. The most common visual field defects are arcuate defect (23.3%) and followed by general depression. Arcuate defects can already observable in some patients with cup-disk ratio of 0.5 (30%).Arcuate defect occurs in the average RNFL thickness of 69.90 ?m (46.93-118.77). It appears that the pinhole vision appeared on the average RNFL thickness of 44.23 ?m (25.33-63.13), and temporal RNFL thickness remnant occured at 48.64 ?m (46.22-51.06). RNFL thickness with normal visual field was on the thickness of 107.78 ?m (100.27-115.29). Conclusion: Visual field defect that may be observed in glaucoma with Goldmann kinetic perimetry are arcuate defect, and general visual field depression. RNFL thickness may be correlated longitudinally with the worsening of visual field defect.

Spontaneous Near-Resolution of a Rathke’s Cleft Cyst

•Spontaneous near resolution of Rathke’s cleft cyst can occur•Conservative approach is recommended in the absence of mass effect or visual disturbance•The mechanism of spontaneous near resolution of RCC is poorly understood A 70-year-old Caucasian woman with history of chronic sinusitis presented to the Emergency department with 2-week history of headaches. Her physical examination was unremarkable including absence of galactorrhea, abnormal hair growth, or skin changes. Neurologic exam including visual fields were normal. Brain MRI revealed a 1.2 x 1.4x 1.3 cm ovoid, non-enhancing, cyst-like lesion with intrasellar and suprasellar components (Figure 1) with slight elevation and splaying of the optic chiasm and depression of the sella floor. Hormonal testing revealed normal values (Table 1). A conservative approach was chosen given the patient’s age, the lesion size, and lack of visual compromise or hormonal dysfunction.Table 1HormoneResultNormal RangeTSH0.90.280 – 3.980 ng/dlFree T40.600.58-1.64 ng/dlIGF-13741-279 ng/mlGrowth Hormone0.9<7.1 ng/mlProlactin19.272.74-19.64 ng/mLCortisol16.67-9a.m 4.0-22.0 mcg/dl Open table in a new tab At 1 month follow up she denied new symptoms. Repeat hormonal panel revealed a low FT4 0.5, and normal TSH 3.93, which prompted initiation of levothyroxine. The rest of the panel remained normal. A follow-up brain MRI revealed a hypoenhancing lesion within the sella with suprasellar extension measuring 1.1x 1.3 x0.9 cm (figure 2), contacting the optic chiasm without displacement. Ophthalmology evaluation reported normal visual fields. Neurosurgery recommended medical management. A year after initial presentation, TSH and Ft4 were normal on levothyroxine. Brain MRI revealed complete resolution of the previously characterized cystic lesion, with a normal-sized and shaped pituitary gland (figure 3). Patient continued to have intermittent headaches that were attributed to chronic sinusitis. The patient has not returned for a follow up visit, and we have been unable to reassess her pituitary/thyroid axis. What is the diagnosis? Answer: The clinical course and imaging findings are best explained by a rare case of a Rathke’s Cleft Cyst (RCC), with near spontaneous resolution. RCC are remnants of a failed regression of the developmental ectodermal pouch, characterized by unpredictable natural histories that can include spontaneous enlargement or less commonly decrease in size. The latter has been observed in up to 15% in studies evaluating the evolution and volumetry analysis of RCC (1Barkhoudarian G. Palejwala S.K. Ansari S. Eisenberg A.A. Huang X. Griffiths C.F. et al.Rathke’s cleft cysts: a 6-year experience of surgery vs. observation with comparative volumetric analysis.Pituitary [Internet]. 2019; 22 (Available from:): 362-371https://doi.org/10.1007/s11102-019-00962-yCrossref PubMed Scopus (19) Google Scholar). Symptoms may include headaches, pituitary dysfunction, and visual deficits from mass effect (2Altuwaijri N, Cote DJ, Lamba N, Albenayan W, Ren SP, Zaghloul I, et al. Headache Resolution After Rathke Cleft Cyst Resection: A Meta-Analysis. World Neurosurg [Internet]. 2018;111:e764–72. Available from: https://doi.org/10.1016/j.wneu.2017.12.170Google Scholar). There are no standardized management guidelines, however a conservative approach is preferred when there is absence of mass effect or visual disturbance as seen here(3Truong L.U.F. Bazin C. Gomis P. Decoudier B. Delemer B. Litré C.F. Surgery versus conservative care for Rathke’s cleft cyst.Neurochirurgie. 2021; 67: 104-111Crossref PubMed Scopus (4) Google Scholar). The mechanism of spontaneous resolution of RCC is poorly understood. This is a rare case of spontaneous near resolution of RCC in a patient that was followed by conservative therapy with regular clinical and radiologic follow up.

Decreased macular deep capillary plexus is associated with functional progression of normal tension glaucoma patients with unilateral visual field loss

PurposeTo investigate whether quantitative optical coherence tomography angiography (OCTA) metrics of the superficial/deep macular retina are associated with the development of visual field (VF) loss in the fellow eyes of...

ROLE OF COLOR DOPPLER IMAGING IN PRIMARY OPEN ANGLE GLAUCOMA

PURPOSE- To assess the blood flow velocity by color doppler imaging (CDI) of retrobulbar vessel in eyes with primary open angle glaucoma ( POAG) . A prospective case control study was done on 40 new METHOD- ly diagnosed POAG patients and 40 control patients with no clinical evidence of glaucoma. Color doppler imaging was performed by ultrasound machine using linear high frequency probe. The color doppler window was localized over the retrobulbar area and flow in the ophthalmic artery (OA) and central retinal artery (CRA) identified, Peak systolic velocity (PSV) and End diastolic velocity (EDV) values for both the vessels were obtained. Resistivity index (RI) was calculated as (PSV-EDV)/ PSV. The study sample consisted of 40 RESULT- patients in the POAG group and 40 patients in the control group. All the patients with POAG had raised RI and decreased EDV in both the OA and CRA. Also RI was raised in 45% patients with stable normal visual fields in POAG group. The increase in IOP in POAG group was negatively correlated with PSV and EDV and positively correlated with RI for both the OA and CRA. Despite normal visual fields, retrobulbar hemodynamic alterations CONCLUSIONcontribute to progression of glaucoma in early stage. Early diagnosis of glaucoma can be achieved by using CDIs of ocular blood flow, which enable early intervention to prevent progressive irreversible vision loss.

Melanopsin involvement in the light detectability decrease in the normal visual field induced by light stimulation inside the blind spot

Melanopsin involvement in the light detectability decrease in the normal visual field induced by light stimulation inside the blind spot

ODP292 A Xanthomatous Hypophysitis: Always Think Twice Before Pituitary Resection.

Abstract Background A xanthomatous hypophysitis is a rare form of primary hypophysitis common in females. Clinical case: A 47-year-old male was referred for pituitary adenoma resection. The patient presented with low libido and facial and body hair loss for 3 years. He reported increased thirst and nocturia for 2 years. 24-hr fluid intake showed 4,800 ml intake and 6,700 ml output. Physical examination revealed tanner 5 pubic hair with testicle size 12 ml bilaterally. He had a normal visual field. Laboratory testing revealed low morning total testosterone level of 108 ng/dL (241-872), low LH 0.39 mIU/mL (1.14-8.75) and low FSH 1.28 mIU/mL (1.37-13.58). Other pituitary hormones showed normal TSH 0.634 uIU/ml (0.35-4.9) with low free T4 0.64 (0.7-1.48), IGF-1 107 ng/mL (74-196), prolactin 10.92 mcg/mL (3.46-19.4), morning cortisol 8.9 mcg/dL (3.7-19.4). A 1 mcg ACTH stimulation test showed an inappropriate increase in cortisol level of 16.1 mcg/dL with baseline ACTH 28 pg/mL (0-46). Regarding polyuria, biochemical testing showed serum Na 148 mmol/L (136-145), Uosm 307 mOsm/Kg (50-1300), and Sosm 307 mOsm/kg (275-290). After the therapeutic trial with oral DDAVP, urine output significantly decreased. Subsequent tests showed serum Na 144 mmol/L, Uosm of 295 mOsm/kg, and Sosm of 278 mOsm/kg. The final diagnosis was hypopituitarism and central diabetes insipidus. MRI showed an enlarged pituitary gland with 2 decreased enhancing nodules in the post-contrast study of the anterior lobe measuring 4.2 and 6.7 mm in diameter. No stalk thickening was detected. There was no compression on adjacent organs. Since the pituitary lesions could not explain the hypopituitarism and DI. The surgery was postponed, and he underwent an endoscopic transsphenoidal biopsy. The procedure yielded a milky fluid content, and a circumferential dissection of a soft-yellow capsule was done. Pathology examination revealed a chronic hypophysitis with clusters of foamy macrophages. Immunohistochemistry showed positive for CD3, CD20, and CD138. A CD68 was positive in multiple clusters of foamy macrophages, while an IgG4 was negative. The final diagnosis is xanthomatous hypophysitis. The patient was treated with hormonal replacement therapy of levothyroxine, prednisolone, testosterone, and DDAVP. Until now, there are 36 cases in the literature reporting xanthomatous hypophysitis. The prevalences of hormonal deficits are 36.1% adrenal insufficiency, 42.4% central hypothyroidism, 54.6% central DI, 36.4% hypogonadism, 63.6% GH deficiency, and 54.6% hyperprolactinemia. The common MRI characteristic is a cystic mass with a ring or peripheral enhancement. Pituitary stalk thickening is shown in 50% of cases. Conclusion This clinical case demonstrated the rare entity of xanthomatous hypophysitis presenting with secondary AI, hypogonadotropic hypogonadism, central hypothyroidism, and DI. The discrepancy between clinical history and the MRI findings was a clue for pituitary biopsy leading to the final diagnosis and avoidance of unnecessary surgery. Presentation: No date and time listed

ODP318 Idiopathic Granulomatous Hypophysitis : A Rare Cause of Hypopituitarism

Abstract Introduction Pituitary hypophysitis is an inflammatory disorder classified as primary or secondary. The five histologic subtypes of primary hypophysitis are lymphocytic, granulomatous, xanthomatous, IgG4-related, and necrotizing. Idiopathic granulomatous hypophysitis (IGH) has an incidence of 1 in 10 million and accounts for &amp;lt; 1% of cases involving panhypopituitarism, headache, and visual disturbances. We present the case of IGH in a patient initially suspected to have pituitary adenoma. Case Presentation A 54-year-old female with a history of hypertension presented to the emergency department with nausea, vomiting, and acute worsening of a chronic headache of 1-week duration. Her past medical history was significant for a suspected pituitary macroadenoma of 1.7 cm, which was incidentally detected 7 months before the current presentation. She reported a history of 9 lb weight gain in one month, hot flashes, and diplopia, but denied hirsutism, polyuria, polydipsia, and galactorrhea. Prior evaluation revealed normal prolactin, TSH, and visual field testing. Her medication and familial history were unremarkable. Physical exam during the current presentation revealed stable vital signs, left eye exophthalmos, left anisocoria, decreased sensation in the left V1 and V2 trigeminal nerve distribution, and right abducens nerve palsy. Her initial laboratory workup was consistent with panhypopituitarism. Brain Magnetic Resonance Imaging (MRI) revealed an extensive, locally invasive, exuberantly enhancing infiltrative process measuring at least 5.6 cm in maximal transverse diameter involving the pituitary gland with bilateral cavernous sinus and Meckel's caves invasion and extension into bilateral superior orbital fissures. The patient underwent supraorbital craniotomy with subtotal resection of the tumor. Tuberculosis, sarcoidosis, and neoplasm were ruled out by appropriate tests, and the patient was diagnosed to have IGH on histology. Her symptoms improved postoperatively and the patient was discharged on levothyroxine and hydrocortisone. Conclusion Clinically and radiologically, IGH is a rare pathology that can closely mimic a pituitary adenoma. Through this case, we highlight the importance of performing a comprehensive evaluation with a full hormonal workup and imaging, with the exclusion of secondary causes while assessing patients with a sellar mass. Presentation: No date and time listed

ODP324 Internal Carotid aneurysm inside a pituitary macroadenoma: case study and literature review

Abstract BACKGROUND: Coexisting pituitary adenoma (PA) and intracranial aneurysms (IA) is relatively frequent. However, the finding of an aneurysm inside a PA is extremely rare. We report a patient with pituitary macroadenoma with an embedded internal carotid artery (ICA) aneurysm, who presented with anterior hypopituitarism. CLINICAL CASE: 73 y. o. black female presented after a fall secondary to orthostastic hypotension. In the ER her BP was 78/50 mmHg, HR 76/min sinus rhythm. She reported fatigue, presyncope, and 20 lbs weight loss in the preceding 3 months. CT head without contrast showed a sellar mass. Pituitary MRI confirmed a 20×24×29 mm sellar mass consistent with a macroadenoma extending laterally to both cavernous sinuses with bilateral encasement of ICAs, superiorly elevating optic chiasm, and mild extension to the left Meckel's cave. The study also incidentally showed a &amp;gt; 5 mm ICA aneurysm embedded within the macroadenoma. Diagnostic cerebral angiogram demonstrates a medially directed left superior hypophyseal ICA aneurysm measuring 5.4×4. 0 mm with a 3.5 mm neck. The patient denied headaches, peripheral vision loss, or polyuria. On examination her weight was 154 lbs, height 5'6", normal visual field testing, and no neurologic deficits. Endocrine testing was consistent with anterior hypopituitarism: ACTH 17 pg/mL (10-48), Cortisol 4.7 mcg/dL (6-18.4), TSH 1.4 mIU/L (0.4- 4. 0), FT4 0.7 (0.7-1.9 ng/dL), IGF1 7 ng/mL (55-162), Prolactin 38.3 ng/mL (4.8- 23.3), and FSH 6.6 IU/mL (20-138). Clinical improvement followed hydrocortisone and levothyroxine replacement. Patient was discharged home with a plan for outpatient endocrine follow up and subsequent endovascular intervention. Unfortunately, she presented a few weeks later with pulmonary embolism, for which she was treated with Eliquis. Given high risk of bleeding, the plan for endovascular embolization was postponed. Patient was educated about sick day rules and is set for routine endocrine visit and periodic MRI surveillance of the macroadenoma. DISCUSSION: intracranial aneurysms appear to occur more frequently in association with PAs than among the general patient population. In 2 cohort of patients with PA, 5.4-7.3% had coexisting IAs, the majority of which are outside the pituitary region. However, the presence of an aneurysm embedded within a PA, as in our case, is very rare, and most are discovered by accident. In such cases, although spontaneous aneurysm rupture or pituitary apoplexy is extremely rare, misdiagnosis of the embedded aneurysm can potentially result in catastrophic outcomes if it is not appropriately recognized and addressed prior to pituitary surgery. Cerebral angiography with embolization or coiling of the aneurysm prior to hypophysectomy can decrease the risk of perioperative rupture or bleeding. In our case, given the risk of bleeding while on anticoagulation therapy, the plan for endovascular intervention was postponed. Presentation: No date and time listed

A Case of Idiopathic Intracranial Hypertension with Papilledema Secondary to Recombinant Human Growth Hormone Treatment

Purpose: To report a child with idiopathic intracranial hypertension secondary to recombinant human growth hormone treatment.Case summary: An 11-year-old girl presented with blurred vision in both eyes starting 6 weeks earlier. She did not have any underlying disease and her body mass index was normal. She had started recombinant human growth hormone injections for idiopathic short stature 3 months earlier. The best corrected visual acuity was 20/25 in both eyes. Fundoscopy revealed bilateral disc edema with peripapillary hemorrhage and increased tortuosity of the retinal vessels. Bilateral enlargement of the blind spot was found on automated visual field examination. Magnetic resonance imaging and venography of the brain showed no evidence of structural or vascular lesions related to increased intracranial pressure. A lumbar puncture showed an elevated opening pressure of 26 cmH2O with normal cerebrospinal fluid constituents. She was diagnosed with growth hormone-related idiopathic intracranial hypertension and it was recommended that the growth hormone injection be discontinued and oral acetazolamide started. After 4 weeks of treatment, the optic disc edema and visual field defect improved. At the 2-year follow-up, she had a normal visual field with a normal optic nerve in both eyes.Conclusions: Ophthalmologists should be aware of the clinical features and treatment of idiopathic intracranial hypertension secondary to recombinant human growth hormone treatment, which is a very rare, vision-threatening complication. Complete neuro-ophthalmological examinations should be performed immediately in children complaining of visual disturbances or headache during treatment with recombinant human growth hormone.

Microvasculature Dropout and Development of Normal Tension Glaucoma in Glaucoma Suspects: The Normal Tension Glaucoma Suspect Cohort Study

To investigate the contribution of vessel parameters to identify normal tension glaucoma (NTG) suspects at risk of NTG development. Multicenter prospective cohort study. A total of 307 eyes of 307 NTG suspects having intraocular pressure within the normal range; a suspicious optic disc, but without definite localized retinal nerve fiber layer (RNFL) defects; and a normal visual field (VF). To measure laminar vessel density (VD), the VD was measured in the intradisc region from images of the deep vascular layers of optical coherence tomography angiography (OCT-A). Conversion to NTG was defined either by a new localized RNFL defect in the superotemporal or inferotemporal region, or the presence of a glaucomatous VF defect on 2 consecutive tests according to the pattern deviation plots. Conversion to NTG. In total, 73 (23.8%) of the 307 NTG suspects converted to NTG during the follow-up period of 59.84 ± 12.44 months. Detection rate of microvasculature dropout (MvD) was significantly higher in NTG suspects who progressed to NTG (50.7%) than in those who did not (6.4%; P < .001). The macular deep VD (P=.006) and laminar deep VD (P=.004) were significantly lower in NTG suspects who progressed to NTG. The presence of MvD (P < .001) and lower laminar deep VD (P=.006) were significantly associated with NTG conversion. NTG suspects with baseline MvD or a lower laminar deep VD on OCT-A had a higher risk of conversion.

Archetypal analysis of visual fields in optic neuritis reveals functional biomarkers associated with outcome and treatment response

Background and objectivesArchetypal analysis (AA), a form of unsupervised machine learning, can identify quantifiable visual field (VF) patterns seen in optic neuritis (ON), known as archetypes (ATs). We hypothesized that AT weight changes over time would reflect the course of recovery and the effects of therapy in ON. We explored whether baseline AT weights would be associated with VF status at the clinical trial outcome and if ATs would indicate residual VF defects in eyes with mean deviation (MD) ≥ -2.00 at six months. MethodsWe used a published 16-AT model derived from 3892 Optic Neuritis Treatment Trial VFs (456 eyes) for all analyses. We measured AT weight changes over the six-month study period and used asymptotic regression to analyze the rate of change. We compared AT weights at six months between treatment groups. We evaluated associations between baseline AT weight thresholds and VF outcome or treatment effect. We calculated residual AT weights in eyes with MD ≥ -2.00 dB at six months. ResultsOver six months, AT1 (a normal VF pattern) demonstrated the greatest median weight change, increasing from 0.00% (IQR 0.00–0.00%) at baseline to 60.0% (IQR 38.3–70.8%) at six months (p < 0.001). At outcome, the intravenous methylprednisolone (IVMP) group had the highest median AT1 weight (IVMP: 63.3%, IQR 51.3–72.8%; placebo: 56.2%, IQR 35.1–71.6%; prednisone 58.3%, IQR 35.1–71.6%; p = 0.019). Eyes with AT1 weight ≥ 19% at baseline had superior median MD values (-0.91 vs. -2.07 dB, p < 0.001) and AT1 weights (70.8% vs. 57.8% p < 0.001) at six months. Only eyes with AT1 weight < 19% at baseline showed a treatment benefit for IVMP, with a higher six-month median AT1 weight compared to placebo (p = 0.015) and prednisone (p = 0.016), and a higher median MD compared to placebo (p = 0.027). At six months, 182 (80.2%) VFs with MD ≥ -2.00 had at least one abnormal AT. DiscussionChanges in quantifiable, archetypal patterns of VF loss reflect recovery in ON. Machine learning analysis of the VFs in optic neuritis reveals associations with response to therapy and VF outcome, and uncovers residual deficits, not readily seen with standard evaluations.

Differences in visual field loss pattern when transitioning from SITA standard to SITA faster

Swedish Interactive Threshold Algorithm (SITA) Faster is the most recent and fastest testing algorithm for the evaluation of Humphrey visual fields (VF). However, existing evidence suggests that there are some differences in global measures of VF loss in eyes transitioning from SITA Standard to the newer SITA Faster. These differences may be relevant, especially in glaucoma, where VF changes over time influence clinical decisions around treatment. Furthermore, characterization of differences in localizable VF loss patterns between algorithms, rather than global summary measures, can be important for clinician interpretation when transitioning testing strategies. In this study, we determined the effect of transitioning from SITA Standard to SITA Faster on VF loss patterns in glaucomatous eyes undergoing longitudinal VF testing in a real-world clinical setting. Archetypal analysis was used to derive composition weights of 16 clinically relevant VF patterns (i.e., archetypes (AT)) from patient VFs. We found switching from SITA Standard to SITA Faster was associated with less preservation of VF loss (i.e., abnormal AT 2–4, 6–9, 11, 13, 14) relative to successive SITA Standard exams (P value < 0.01) and was associated with relatively greater preservation of AT 1, the normal VF (P value < 0.01). Eyes that transition from SITA Standard to SITA Faster in a real-world clinical setting have an increased likelihood of preserving patterns reflecting a normal VF and lower tendency to preserve patterns reflecting abnormal VF as compared to consecutive SITA Standard exams in the same eye.

Unsupervised Machine Learning Shows Change in Visual Field Loss in the Idiopathic Intracranial Hypertension Treatment Trial

We previously reported that archetypal analysis (AA), a type of unsupervised machine learning, identified and quantified patterns of visual field (VF) loss in idiopathic intracranial hypertension (IIH), referred to as archetypes (ATs). We assessed whether AT weight changes over time are consistent with changes in conventional global indices, whether visual outcome or treatment effects are associated with select AT, and whether AA reveals residual VF defects in eyes deemed normal after treatment. Analysis of data collected from a randomized controlled trial. Two thousand eight hundred sixty-two VFs obtained from 165 participants during the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT). We applied a 14-AT model derived from IIHTT VFs. We examined changes in individual AT weights over time for all study eyes and evaluated differences between treatment groups. We created an AT change score to assess overall VF change from baseline. We tested threshold baseline AT weights for association with VF outcome and treatment effect at 6 months. We determined the abnormal ATs with meaningful weight at outcome for VFs with a mean deviation (MD) of -2.00 dB or more. Individual AT weighting coefficients and MD. Archetype 1 (a normal VF pattern) showed the greatest weight change for all study eyes, increasing from 11.9% (interquartile range [IQR], 0.44%-24.1%) at baseline to 31.2% (IQR, 16.0%-45.5%) at outcome (P<0.001). Archetype 1 weight change (r= 0.795; P < 0.001) and a global score of AT change (r= 0.988; P < 0.001) correlated strongly with MD change. Study eyes with baseline AT2 (a mild diffuse VF loss pattern) weight of 44% or more (≥ 1 standard deviation more than the mean) showed higher AT2 weights at outcome than those with AT2 weight of < 44% at baseline (P < 0.001). Only the latter group showed a significant acetazolamide treatment effect. Archetypal analysis revealed residual VF loss patterns, most frequently representing mild diffuse loss and an enlarged blind spot in 64 of 66 study eyes with MD of -2.00 dB or more at outcome. Archetypal analysis provides a quantitative approach to monitoring VF changes in IIH. Baseline AT features may be associated with treatment response and VF outcome. Archetypal analysis uncovers residual VF defects not otherwise revealed by MD.

Understanding the role of microperimetry in glaucoma.

The present narrative review attempts to provide an overview on the use of microperimetry or fundus-driven perimetry in glaucoma, considering the clinical use, the different strategies and limits compared to standard automated perimetry. An electronic database (PubMed and Medline) search was performed of articles of any type published in the English language between 1998 and 2020 with a combination of the following terms: microperimetry, glaucoma, primary open-angle chronic glaucoma, visual field, Humphrey visual field, fundus automated perimetry. All the original articles, case reports, and short series analyzed were included in the present review, offering an excursus on the strengths and limitations characterizing the use of microperimetry in glaucomatous patients. The characteristics of a recently introduced fundus-driven perimetry Compass (CMP; Centervue, Padua, Italy) were also included. Although there remain several contradictions regarding routine use of microperimetry and the restricted research on this topic limits our ability to draw firm conclusions, microperimetry may be preferable in cases of localized retinal nerve fiber layer defects in patients with primary open-angle glaucoma and normal visual field. However, standard automated perimetry remains the gold standard for monitoring glaucoma, especially in patients with diffuse retinal nerve fiber layer impairment and visual field defects. The newly introduced Compass device can potentially provide a more accurate structural-functional evaluation than standard automated perimetry and can therefore produce superior testing reliability.

GlauCUTU: Time Until Perceived Virtual Reality Perimetry With Humphrey Field Analyzer Prediction-Based Artificial Intelligence

The increasing prevalence of glaucomatous optic neuropathy, which can result in permanent blindness (visual impairment), accentuates the importance of screening and early diagnosis for prevention of blindness. GlauCUTU, a novel time until perceived (TUP) visual field (VF) testing, utilizes a portable virtual reality (VR) headset with visual stimulus that progressively increases in intensity to detect VF defects. GlauCUTU was evaluated on participants with normal visual fields and those with early, moderate, and severe glaucoma. Responses were collected in terms of time until response (TUR). TUR was used to calculate TUP and reported in terms of GlauCUTU sensitivity. False positives were detected with pretest and latency analysis using reaction time (RT). In addition, a novel automated transformation was developed to convert GlauCUTU sensitivity into HFA sensitivity using machine learning (ML) and deep learning (DL) algorithms. Visual field index (VFI) was generated from HFA sensitivity to determine severity of glaucoma. The VFI results were evaluated using post-hoc analysis from two-way analysis of variance (ANOVA). Results demonstrate no significant difference (p=0.073) between Humphrey visual field analyzer (HFA) and GlauCUTU with machine learning transformation (GlauCUTU-ML) in all glaucoma stages. However, there was a significant difference between HFA and GlauCUTU with deep learning transformation (GlauCUTU-DL) in severe glaucoma (p<0.050). GlauCUTU-ML generates the lowest root mean square error (RMSE) of 4.92. Meanwhile, GlauCUTU-DL yields the highest Pearson’s <inline-formula xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"> <tex-math notation="LaTeX">$r$ </tex-math></inline-formula> correlation coefficient with HFA of 0.74, but produces the highest RMSE of 6.31. Comparison between three expert ophthalmologists’ grading of glaucomatous eyes on GlauCUTU-ML and HFA aligns with the majority voting with an average agreement of 0.83, which is highly reliable. All in all, the portable and inexpensive GlauCUTU perimetry system introduces the use of TUP for VF evaluation with results comparable to HFA. GlauCUTU proves to be a promising method to increase accessibility to glaucoma screening, particularly in low-resource setting countries.