Afferent Defect Research Articles

Unilateral Idiopathic Optic Perineuritis in a Normal Fundus

A 22-year-old woman of Malay ethnicity presented with severe blurred vision in the right eye and experienced periocular pain with eye movement. She had a visual field defect over the affected eye, while an examination showed clinically normal optic discs. Relative afferent pupillary defect was also present in the right eye, with reduced optic nerve function. Optic nerve imaging revealed the ‘doughnut sign’ and ‘tram track’ signs, which are characteristics of optic perineuritis. The patient was initiated on a steroid regime that was tapered off over four months. Her visual function recovered gradually during the treatment until reaching a satisfactory final visual outcome. This is a unique case where optic perineuritis occurred in a normal fundus and magnetic resonance imaging (MRI) served as an important diagnostic tool for the condition.
 Optic perineuritis (OPN) is an orbital inflammatory disease that involves the meningeal sheath surrounding the optic nerve.[1] It can be idiopathic or secondary to an underlying systemic autoimmune disorder.[1,2] Visual loss in OPN results from inflammation of the tissue surrounding the optic nerve, resulting in mechanical compression of the nerve and subsequent ischaemia.[1]
 OPN can be diagnosed using an optic nerve sheath biopsy, while magnetic resonance imaging (MRI) diagnoses OPN through perineural enhancement, making it a useful diagnostic tool.[2] Upon diagnosis, OPN should be treated with corticosteroids for a prolonged period to ensure visual recovery.[3]
 We report a unique case of unilateral OPN with severe visual loss in a young Malay woman with a normal fundoscopy who was successfully treated with prolonged corticosteroids.

Ocular Manifestations of Septo-optic Dysplasia

Background: Septo-optic dysplasia (SOD) is a congenital deformity of the brain which can result in neurologic, systemic, and physical malformation.Due to the proximity of these deformities to the optic chiasm and optic nerves, ocular manifestations are common. Case Report: A 28-year-old male with a long-standing history of reduced vision presented for a routine eye examination. Upon examination he was found to have an afferent pupillary defect, bilateral optic nerve pallor with corresponding nerve fiber layer thinning by optical coherence tomography. Humphrey visual field testing revealed a bi-temporal visual field defect. Neurological imaging was obtained with a subsequent diagnosis of Septo-optic dysplasia (SOD). Conclusion: Our patient had bilateral optic nerve hypoplasia and an absent septum pellucidum without endocrine abnormalities. This case reiterates the importance of accurate diagnosis of amblyopia only in the absence of ocular and neurological disease. This review also highlights the importance of imaging in instances of unexplained optic atrophy.

MALT Lymphoma Presenting as Symptomatic Optic Neuritis: A Case Report (P14-13.001)

<h3>Objective:</h3> To report a case of MALT lymphoma presenting as optic neuritis and highlight its inherent diagnostic challenges. <h3>Background:</h3> Optic neuritis (ON) is the inflammation of the optic nerve associated with multiple sclerosis,. ON with atypical clinical features require thorough evaluation. Primary ocular adnexal lymphomas are the most common orbital tumors, and IgG4-related ocular disease also presents with optic neuropathy and consists of morphologically similar immune infiltrates. Their diagnoses are challenging as corticosteroids can incur non-diagnostic biopsies, complicating further workup. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> 51-year-old healthy African American woman presented with one month of progressive left monocular blurry vision, color desaturation and_pain. Exam showed left visual acuity of 20/60, afferent pupillary defect, and 0/13 Ishihara plates identified in left eye. Remainder of exam was intact. MRI demonstrated left optic nerve sheath enhancement and enlargement. Another enhancing lesion was identified in the right inferior orbit. Despite visual impairment, corticosteroids were deferred prioritizing diagnostic tests. Workup was negative for autoimmunity, systemic neoplasm, and infection. CSF showed a bland profile without malignant cells. Serum and CSF IL2 receptor levels returned normal. Oligoclonal bands and IgG were elevated in serum and CSF; IgG4 levels were high at 156, raising concern for IgG4-related ocular disease. Right intra-orbital mass biopsy demonstrated atypical CD20+ lymphoid infiltrates with rare germinal centers, but &lt;10% plasma cells expressed IgG4. Further molecular analysis was positive for monoclonal IgH gene rearrangement, diagnosing mucosa-associated lymphoid tissue (MALT) lymphoma in the right orbit and probable left optic nerve involvement. She was initiated on bendamustine and rituximab with stabilization of her ocular symptoms. <h3>Conclusions:</h3> Atypical presentations of ON warrant thorough workup. IgG4-related ocular disease and ocular adnexal MALT lymphoma share similarities that require histologic and molecular analysis to differentiate. Early identification of MALT lymphoma is crucial to initiate proper therapies, maintain disease control, and preserve visual acuity. <b>Disclosure:</b> Dr. Jia has nothing to disclose. Ms. Wyckoff has nothing to disclose. Dr. Cohen has nothing to disclose. Dr. Bryar has nothing to disclose. Dr. Lukas has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Merck and Company, Inc.. Dr. Lukas has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Merck and Company, Inc.. Dr. Lukas has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Novocure. Dr. Lukas has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for EBSCO. Dr. Lukas has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Medlink Neurology. Dr. Lukas has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier. The institution of Dr. Lukas has received research support from BMS. The institution of Dr. Lukas has received research support from BrainUp. The institution of Dr. Lukas has received research support from National Cancer Institute. The institution of Dr. Lukas has received research support from National Cancer Institute. The institution of Dr. Lukas has received research support from Ziopharm. Dr. Dixit has nothing to disclose.

Clues on Optical Coherence Tomography Leading to Diagnosis of Primary CNS Lymphoma (P2-9.012)

<h3>Objective:</h3> NA <h3>Background:</h3> Vitreoretinal lymphoma is a rare variant of primary central nervous system lymphoma (PCNSL). Around 20% of the PCNSL patients develop concurrent ocular involvement in the retina, vitreous, or optic nerve head. However, only 50% of these patients report visual symptoms, thus making a detailed ophthalmic examination a necessity. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 65-year-old man with history of hypertension and hyperlipidemia, presented with progressive hypersomnia, confusion, intermittent horizontal binocular diplopia, tremors, and blood pressure fluctuations over a course of 9 months. A magnetic resonance imaging of the brain with and without gadolinium contrast showed multifocal confluent cerebral and cerebellar enhancing and non-enhancing white matter abnormalities. Lumbar puncture revealed borderline pleocytosis (WBC 5) with negative cytology. The patient was referred to neuro-ophthalmology to be evaluated for ocular signs that may help with the diagnosis. At that visit, he was noted to have severe vision loss (visual acuity of 7/200) in the left eye that was not noticed by the patient until the time of examination. There was a left relative afferent pupillary defect. Further exam was notable for vitreous cells and yellow retinal placoid deposits. The optic nerve was normal. Optical coherence tomography (OCT) revealed multiple, hyper-reflective foci in the outer layers of the left macula with patchy discontinuity in the ellipsoid and photoreceptor layers. A vitreous biopsy detected CD20+, MYD88+ large B-cell lymphoma, and patient was initiated on systemic chemotherapy. <h3>Conclusions:</h3> High-resolution OCT has enabled physicians to recognize unique features of different neoplasms such as PCNSL. Our case emphasizes the importance of detailed neuro-ophthalmologic examination and utilization of adjunct tests such as OCT in cases of progressive subacute leukoencephalopathy of unknown etiology. This would also lead to use of less invasive diagnostic methods such as vitreous biopsy instead of brain biopsy, earlier diagnosis, and treatment of patients with PCNSL. <b>Disclosure:</b> Dr. Moheb has nothing to disclose. Dr. Olsen has received personal compensation in the range of $10,000-$49,999 for serving as an officer or member of the Board of Directors for American Academy of Ophthalmology. Dr. Olsen has stock in Non-Medical, unrelated. The institution of Dr. Olsen has received research support from National Eye Institute (NEI). The institution of Dr. Olsen has received research support from Novartis. Dr. Olsen has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Tobin has received research support from Mallinckrodt. Dr. Tobin has received personal compensation in the range of $500-$4,999 for serving as a Speaker with NeurologyLive. John J. Chen has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for UCB. John J. Chen has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Roche. John J. Chen has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Horizon.

Teaching Video NeuroImages: Marcus-Gunn pupil in tuberous sclerosis

A 22-year-old woman with tuberous sclerosis (TS) and an incomplete resection of a left-sided astrocytoma presented with a 4-year history of visual deterioration. Neurologic examination revealed a left relative afferent pupillary defect (RAPD) (video) with a pale left optic disc. Visual acuity was 20/100 bilaterally and a left-sided superior visual field loss was seen. Optical coherence tomography showed a left retinal hamartoma (figure 1). Contrast-enhanced brain MRI showed bilateral cortical and subcortical tubers (figure 2). Marcus-Gunn pupil or RAPD is a nonspecific feature denoting optic neuropathy.1 TS ophthalmopathy includes retinal and iris hamartomas, choroid colobomas, and hypopigmented lesions on iris and ciliary body.2

A rare simultaneous presentation of combined occlusion and optic neuritis in a lupus erythematosus patient with anti-phospholipid antibody syndrome.

A known case of Systemic Lupus Erythematosus (SLE) developed sudden loss of vision (no light perception) with relative afferent pupillary defect in her right eye (RE) and fundus examination revealed cherry red spot over tomato splash background with tortuous and dilated veins suggestive of combined central retinal arterial and vein occlusion. Left eye (LE) had 6/6 vision but posterior segment revealed a hyperemic disc. Fundus fluorescein angiography (FFA) revealed delayed arm to retina time and increased arterial to vein transit time in RE. LE showed pooling of dye around optic disc suggestive of SLE related Optic neuritis. Patient was re-evaluated and she tested positive for Lupus anticoagulant. Patient was diagnosed to have anti-phospholipid antibody syndrome (APS) occurring secondary to SLE. She was started on intra venous steroids, anti-coagulants and disease progression in left eye was controlled. We report a rare simultaneous presentation of complete combined occlusion of central retinal artery and vein (CCRAVO) in RE and Optic neuritis in LE which has not been reported in literature so far. Ocular involvement may precede other systemic symptoms in SLE, so ophthalmologist should know about this rare simultaneous presentation. Ocular activity can correlate with systemic disease activity and starting early effective treatment can prevent other systemic lesion and can be life saving.

A Case Study of Infantile Nystagmus Syndrome (Congenital)

Infantile nystagmus (IN), formerly known as congenital nystagmus, is an involuntary to-and-fro movement of the eyes that persists throughout life. IN is one of three types of early-onset nystagmus that first appear in infancy, alongside fusion maldevelopment nystagmus syndrome and spasmus nutans syndrome. Patients with acquired nystagmus may also be seen by optometrists. The features of IN overlap largely with those of fusion maldevelopment nystagmus syndrome, spasmus nutans syndrome, and acquired nystagmus, yet the management for each subtype is different. We report a case of bilateral congenital sensory nystagmus with bilateral megalocornea with left-sided relative afferent pupil defect with left eye global enlargement in ap axis with reduced caliber in left optic artery with pseudo polycorea with reduced visual acuity in the bilateral eye with buphthalmos with haab striae.

Acute zonal occult outer retinopathy misdiagnosed as giant cell arteritis: a challenging case

Background: Acute zonal occult outer retinopathy (AZOOR) is a rare autoimmune retinopathy that is challenging to diagnose and treat. It usually presents with subtle fundus changes and severe visual symptoms. Herein, we report a challenging case of AZOOR, emphasizing that multimodal imaging could be valuable in diagnosis and monitoring of treatment response.&#x0D; Case Presentation: A 53-year-old woman presented to the emergency department with a one-week history of subacute, severe, painless vision loss without photopsia in her right eye. Her best-corrected distance visual acuity was 20/800 in the right eye and 20/20 in the left eye. Slit-lamp examination findings were unremarkable, and intraocular pressure was normal in both eyes. Initially, fundus examination findings appeared normal; however, serum levels of inflammatory markers were elevated. Brain and orbital magnetic resonance imaging results were unremarkable. A relative afferent pupillary defect was present in subsequent follow-up examinations at the hospital. The patient initially received a diagnosis of posterior ischemic optic neuropathy secondary to occult giant cell arteritis, underwent steroid treatment, and was evaluated by rheumatology and neurology consultants. Both consultants concurred with the presumed diagnosis. Subsequent multimodal imaging in the ophthalmology clinic revealed a trizonal pattern of fundus autofluorescence. Corresponding to these areas, we noted a loss of the ellipsoid zone on optical coherence tomography, depression on multifocal electroretinogram, and scotoma on visual field testing. Accordingly, the diagnosis of AZOOR was made. The patient was referred back to the rheumatologist for initiation of steroid-sparing treatment, and methotrexate was administered. Five months after the initial presentation, the patient showed significant visual field improvement in both eyes.&#x0D; Conclusions: Eye care practitioners should consider AZOOR in the differential diagnosis of patients with subacute painless severe unilateral vision loss and unremarkable findings on fundus examination. Multimodal imaging could be valuable in diagnosis and monitoring of treatment response, as observed in the current case. Further studies with larger sample sizes are needed to confirm the value of multimodal imaging and the available management options for AZOOR.

Central Retinal Vein Occlusion after COVID-19 Infection.

Central retinal vein occlusions are not well-known complications of SARS-CoV-2 infection. We describe a case of central retinal vein occlusion secondary to COVID-19, and a review of the literature was performed. A 47-year-old woman with no underlying ocular or medical condition presented to the hospital complaining about sudden onset of multiple scotomas in her left eye. A COVID-19 infection was confirmed 2 days previously by a PCR test that was performed 2 days after the onset of symptoms. Medical history revealed no risk factors and no oral contraception. Her best-corrected visual acuity was 1.0 in the right eye and 0.04 in the left eye. Clinical exam showed a left relative afferent pupillary defect and a nasally localized papilledema on fundoscopy of the left eye. Multiple dot and blot hemorrhages were also present. Optical coherence tomography revealed cystoid macular edema and paracentral acute middle maculopathy. The results of the fluoresceine angiography were consistent with central retinal vein occlusion. Laboratory workup later revealed an elevated fibrinogen level, corresponding to the COVID-19-induced hypercoagulable state. No other prothrombotic conditions were found. The patient immediately received an intravitreal injection of Lucentis (ranibizumab) after diagnosis. Complete resolution of the retinal hemorrhages and papilledema was observed 1.5 months after treatment and the final visual acuity was 1.25 in the left eye. Coagulation abnormalities are frequently observed in infectious diseases such as COVID-19 infection and the resulting prothrombotic state can sometimes lead to retinal vascular complications, including central retinal vein occlusion, irrespective of the presence of other classical risk factors. The consideration of this information could help clinicians establish a prompt diagnosis and therefore appropriate treatment, which could hopefully lead to complete healing of retinal lesions.

Trauma-Related Acute Macular Neuroretinopathy. A Case Report

To introduce a case report and review the literature on trauma-related acute macular neuroretinopathy as an unusual etiology of acute macular neuroretinopathy. A 24-year-old man presented with unilateral paracentral scotoma following non-ocular trauma in a car accident. The relative afferent pupillary defect was negative and the best corrected visual acuities of both eyes were 10/10 (by the Snellen chart scale). Retinoscopy revealed a reduced foveal reflex, along with a small pre-retinal hemorrhage over the mid-pathway of the supranasal arteriole. OCT images showed an obvious ellipsoid zone (EZ) layer disruption in the macula of the left eye. The infrared fundus photograph of the same eye revealed a distinct hyporeflective area involving the macula. On fundus angiography, no macular vascular lesion was detected. The scotoma persisted after 3 months follow-up. Non-ocular trauma including head or chest trauma without direct ocular injury accounts for most cases of trauma-related acute macular neuroretinopathy. It is important to distinguish this entity, given that there are also unremarkable findings in the retinal examination of these patients. Indeed, proper clinical suspicion leads to further suitable investigations and impedes other extraordinary images, which are the basic rules in the management of traumatic patients suffering multiple injuries and incurring medical expenses.

Incidence of ophthalmologic pathology and associated risk factors in orbital fractures at a level I trauma centre

ObjectifEstimer l'incidence des affections ophtalmologiques détectées lors de l'examen initial de patients en proie à une fracture orbitaire qui se sont présentés dans un centre de traumatologie de niveau I, d'une part, et les facteurs de risque connexes les plus significatifs, d'autre part. MéthodesOn a recensé, pendant une période de 2 ans, 278 fractures orbitaires chez 244 patients examinés dans un centre de traumatologie de niveau I. Le paramètre principal était l'incidence d'affections ophtalmologiques urgentes devant être traitées sans délai. Ont été enregistrés les caractéristiques démographiques des patients, leurs antécédents ainsi que les résultats de l'imagerie radiographique et de l'examen physique lors de l'examen initial et des visites de suivi. Les rapports de cotes (RC) ont été calculés avec un intervalle de confiance à 95 %. RésultatsLors de l'examen initial et des visites de suivi, 9,7 % des orbites présentaient une affection ophtalmologique. Celle-ci était urgente (syndrome orbitaire aigu et rupture du globe oculaire, notamment) chez seulement 3 patients (1,1 %); 22 patients (7,9 %) présentaient une affection semi-urgente et 4 patients (1,4 %), une affection sans caractère d'urgence. Les RC de la baisse subjective de la vision (RC = 3,5; p = 0,021), des blessures résultant de voies de fait (RC = 2,4; p = 0,036), d'un accident de travail (RC= 7,7; p = 0,004), du déficit pupillaire afférent (RC = 19,2; p = 0,017), de l'anisocorie (RC = 7,8; p = 0,001), de la limitation des mouvements extraoculaires symétriques (RC = 5,2; p = 0,003) et de la fixité pupillaire (RC = 16,9; p < 0,001) témoignent d'un lien statistiquement significatif avec la présence d'une affection ophtalmologique. En revanche, le sexe du patient, l’œil touché, l'intoxication, la prise d'anticoagulants et d'antiplaquettaires ainsi que les antécédents de chirurgie oculaire n’étaient pas associés à la présence d'une maladie ophtalmologique. ConclusionsLa plupart des fractures orbitaires ne s'accompagnent pas d'une affection ophtalmologique. La baisse subjective de la vision, les antécédents de voies de fait ou d'accident de travail et les anomalies pupillaires notées lors de l'examen étaient les principaux facteurs de risque d'affection ophtalmologique. Nos résultats mettent en lumière les éléments clés qui, relevés lors de l'examen initial, doivent inciter les premiers intervenants à consulter d'urgence un ophtalmologiste.

A Case of Bilateral Optic Neuropathy Following COVID-19 Infection

Purpose: To report a case of bilateral optic neuropathy after COVID-19 infection.Case summary: Thirty-four-year-old woman presented with bilateral ocular pain, visual disturbance, and decreased visual acuity after contracting COVID-19 infection 16 days ago. At the initial visit, best-corrected visual acuity was 0.8 in the right eye, and 0.7 in the left eye. Left eye had relative afferent papillary defect and visual field tests revealed enlarged blind spot in both eyes. Fundus exam showed bilateral optic disc swelling and peripapillary retinal hemorrhage along with vitreous hemorrhage in the left eye. Fluorescein angiography revealed bilateral leakage of dye from the optic disc with area of hypofluorescence corresponding to retinal hemorrhage around the optic disc in both eyes. Brain magnetic resonance imaging (MRI) showed ill-defined left optic nerve enhancement. A diagnosis of bilateral optic neuropathy was made, and the patient was treated with high dose IV steroid 1 g per day for 3 days and oral steroid tapering for 2 weeks. Disc swelling and retinal hemorrhage were improved 1 month after treatment along with enhanced visual acuity to 1.0.Conclusions: Bilateral optic neuropathy following COVID-19 infection showed improvement after steroid treatment.

Successful Management of a Spontaneous Retrobulbar Hematoma After Heart Transplantation. A Case Report

We present a case of a 65-year-old patient who underwent heart transplantation. After the surgery, left proptosis, conjunctival chemosis, and ipsilateral palpebral ecchymosis were found while he was still intubated. A retrobulbar hematoma was suspected, confirmed by a computed tomography scan. Initially, expectant management was considered, but with the appearance of an afferent pupillary defect, the patient underwent orbital decompression and posterior collection drainage, which prevented visual impairment. Spontaneous retrobulbar hematoma after heart transplantation is a rare condition that risks vision. We intend to discuss the importance of postoperative ophthalmologic examination after heart transplantation in intubated patients for early diagnosis and rapid treatment. Spontaneous retrobulbar hematoma (SRH) after heart transplantation is an exceptional condition that risks vision. Bleeding in the retrobulbar space provokes an anterior ocular displacement, extending the vessels and the optic nerve, which can generate ischemic neuropathy and, finally, a loss of vision [1]. A retrobulbar hematoma is usually associated with trauma or eye surgery. Though, in non-traumatic cases, the underlying cause is not evident. An adequate ophthalmologic examination is usually not performed in complex surgeries like heart transplantation. However, this simple measure can prevent permanent vision loss. Non-traumatic risk factors should also be considered, which include vascular malformations, bleeding disorders, use of anticoagulants, and increased central venous pressure usually triggered by a Valsalva maneuver [2]. The clinical presentation of SRH consists of ocular pain, decreased visual acuity, conjunctival chemosis, proptosis, abnormal extraocular movements, and elevated intraocular pressure (IOP). Its diagnosis is often clinical; however, it can be confirmed with computed tomography or magnetic resonance imaging. Treatment aims to reduce IOP with surgical decompression or pharmacologic measures [2]. In the reviewed literature, less than 5 spontaneous ocular hemorrhages related to cardiac surgery have been reported [3-6], of which only one is related to heart transplantation [3]. A clinical challenge of an SRH after heart transplantation is presented below. Surgical management was performed with a favorable result.

Elevated Intraocular Pressure in Periorbital Sweet's Syndrome.

A 66-year-old immunocompromised man presented with cellulitis around the left eye that was initially concerning for necrotizing fasciitis. Exam findings were remarkable for exquisite periocular tenderness with rigid, immobile eyelids resulting from severe erythema, edema, and induration. Given the concern for orbital compartment syndrome and a necrotizing infection, the patient was taken urgently to the operating room for debridement of the eyelid skin as well as an urgent lateral canthotomy and cantholysis. His eye exam revealed 360° of hemorrhagic chemosis, no relative afferent pupillary defect, and an ipsilateral elevated intraocular pressure of 35 mm Hg. No visual acuity measurement could be obtained secondary to the patient's altered mental status. His intraocular pressure normalized after treatment with antihypertensive drops and further extension of the canthotomy. Histopathological analysis showed extensive neutrophilic infiltrate of the dermis which was compatible with a diagnosis of Sweet's syndrome.

Incidence and Risk Factors for Poor Postoperative Visual Outcome After Excision of Orbital Cavernous Venous Malformations.

To determine the incidence and risk factors for poor postoperative visual outcome (PPVO) after removal of orbital cavernous venous malformations (OCVMs). Retrospective case-note and imaging review for patients undergoing excision of OCVMs, with estimation of odds-ratios (ORs) and relative risks (RRs) for visual loss in relation to the position of the mass, surgical approach, and patient factors. The 290 patients (179 female; 62%) presented at a mean age of 46.4 years: 243/287 (85%) OCVMs were intraconal, with 213/243 (88%) located freely in the posterior two-thirds of the orbit, and 30/243 (12%) wedged tightly in the apex. PPVO was observed in 6.9% (20/290) patients, solely after removal of intraconal lesions, Univariate analysis showed increased risk with preoperative relative afferent pupillary defect (RAPD) (14/107 [13%]; RR 2.9; P = 0.011), apical lesions (9/30 [30%]; RR 5.8; P < 0.001), situated below optic nerve (15/115 [13%]; RR 3.3; P = 0.007), fibrous masses (14/78 [18%]; RR 6.7; P = 0.005), or intraoperative diastolic blood pressure below 50mmHg (10/64 [16%]; RR 2.8; P = 0.007). Multivariate analysis found apical extension (OR 4.9; P = 0.036) and fibrous lesions (OR 10.0; P = 0.035) as strongest predictors for PPVO. The incidence of complete visual loss (no light perception) was 4.1% (12/290); half of these patients had preoperative acuity of counting fingers or worse, 8 (67%) had RAPD, 7 (58%) wedged apical lesions, and 8 (67%) were below the optic nerve. PPVO after excision of OCVMs can occur in up to 5% of "free" retrobulbar intraconal lesions and in approximately one-third of apical lesions.

Detection of relative afferent pupillary defect and its correlation with structural and functional asymmetry in patients with glaucoma using Hitomiru, a novel hand-held pupillometer

Detection of relative afferent pupillary defect and its correlation with structural and functional asymmetry in patients with glaucoma using Hitomiru, a novel hand-held pupillometer

Detection of relative afferent pupillary defect and its correlation with structural and functional asymmetry in patients with glaucoma using Hitomiru, a novel hand-held pupillometer

Detection of relative afferent pupillary defect and its correlation with structural and functional asymmetry in patients with glaucoma using Hitomiru, a novel hand-held pupillometer

Detection of relative afferent pupillary defect and its correlation with structural and functional asymmetry in patients with glaucoma using Hitomiru, a novel hand-held pupillometer

Detection of relative afferent pupillary defect and its correlation with structural and functional asymmetry in patients with glaucoma using Hitomiru, a novel hand-held pupillometer

Prognosticators for Visual Outcome in Indirect Traumatic Optic Neuropathy: A Prospective Cohort Study.

Introduction Traumatic optic neuropathy (TON), with indirect TON as its more prevalent form, is a dreadful cause of severe visual dysfunctions. The condition is known to have a contentious treatment plan and poor visual sequelae; hence, the assessment of prognostic signs becomes valuable. Prospective studies evaluating important predictors of visual recovery after traumatic optic nerve injury can particularly be helpful in a longitudinal observation. The possible roles of clinical variables need to be assessed. Absent visual evoked potential (VEP) records as a crucial finding associated with TON has reportedly valuable prognostic significance. This also needs to be explored. Hence, the study sought to determine the role of prognosticators in the visual outcome of the patients, with a focus on evaluating the role of VEPs in the severity and prognosis of indirect TON. Methods A prospective observational study involving 40 patients with indirect TON was conducted. Ocular, neuro-ophthalmological, radiological, and neurophysiological variables, including flash VEP, were investigated at their initial visit and followed up until the end of six months. Final visual acuity was the primary outcome variable studied. Paired t-test was used to perform the comparison between the flash VEP variables for normal and affected eyes at the initial visit. Pearson correlation coefficient was computed for obtaining the association of initial visual acuity and flash VEP variables with the outcome variable. Relative risk was calculated and analysed for the prognosticators in univariate analysis. Statistical significance was defined as p < 0.05. Results Statistically significant variations in mean P100 latency, N75-P100, and P100-N145 amplitudes compared between normal and affected eyes in the patients at the initial visit were obtained (p < 0.0001; paired t-test). Pearson correlation coefficient for initial visual acuity and flash VEP variable as independent variables and final visual acuity as the dependent variable were statistically significant (p < 0.05). The relative risks for prognosticators with a statistically significant range of confidence intervals were poor initial visual acuity, greater relative afferent pupillary defect (RAPD) grades, deranged flash VEP variables (absent VEP, reduction in amplitude ratio (>50%), and increased interocular latency differences), loss of consciousness during injury, age greater than 40 years, and lack of improvement after 48 hours of steroid treatment. Conclusion The identified negative prognosticators may be helpful in deciding the kind of therapeutic approach and predicting the visual outcome in patients with indirect TON.

Surgical decisions in the setting of zonulopathy.

An 85-year-old man with a history of type 2 diabetes, pseudoexfoliation (PXF) in both eyes, and tamsulosin use was referred for the evaluation of a dense cataract in the right eye and a subluxated intraocular lens (IOL) in the left eye. Unfortunately, his surgery in the left eye was complicated by diffuse zonulopathy. The referring surgeon placed a 3-piece IOL in the sulcus. However, the passively fixated 3-piece IOL moved inferiorly causing monocular diplopia for over a year. Because the patient was pleased with the IOL immediately postoperatively, a refixation procedure was performed in the form of sulcus placement with iris suture fixation in the left eye. Fortunately, the iris-fixated IOL in the left eye has remained well centered and stable without cystoid macular edema (CME) or chronic inflammation for over 8 months. The patient is on no ocular medications and has no family history of glaucoma. He now needs cataract surgery in the right eye and is extremely apprehensive because of his difficult course in the left eye. The corrected distance visual acuity is 20/70 in the right eye and 20/25 in the left eye. Intraocular pressures (IOPs) measure 20 mm Hg in the right eye and 14 mm Hg in the left eye by Goldmann tonometry. Pachymetry is 536 µm in the right eye and 543 µm in the left eye. Pupils are round with minimal reactivity and without a relative afferent pupillary defect. Extraocular motility is normal in both eyes, and confrontation visual fields is full in both eyes. Gonioscopy reveals an angle open to the pigmented trabecular meshwork (PTM) in the right eye and the ciliary body in the left eye with 1+ PTM and without peripheral anterior synechia in both eyes. The retinal nerve fiber layer and macular optical coherence tomography are normal in both eyes. On slitlamp examination, pertinent findings include pseudoexfoliative changes at the pupillary margin with poor dilation of 3.5 mm in both eyes; the anterior chamber (AC) is shallow but adequate in the right eye and deep and quiet with rare pigmented cells in the left eye. There is a 5+ nuclear sclerotic cataract with pseudoexfoliative changes on the anterior capsule and no obvious phacodonesis in the right eye and a 3-piece posterior chamber IOL in the sulcus fixated to the iris with 10-0 polypropylene sutures at 6 and 12 o'clock without pseudophacodonesis in the left eye. Dilated fundus examination reveals a cup-to-disc ratio of 0.4 with healthy neuroretinal rims in both eyes, posterior vitreous detachments in both eyes, and no evidence of diabetic retinopathy in both eyes. All other findings are unremarkable. How would you counsel this patient regarding his risk factors for surgery in the right eye? What surgical maneuvers would you use to remove the cataract safely? How would you stabilize the IOL if the capsule bag becomes compromised due to zonulopathy?