Visual Obscurations Research Articles

Risk factors for poor visual outcome in patients with idiopathic intracranial hypertension.

Determine potential risk factors for progressive visual field loss in the Idiopathic Intracranial Hypertension Treatment Trial, a randomized placebo-controlled trial of acetazolamide in patients with idiopathic intracranial hypertension and mild visual loss concurrently receiving a low sodium, weight reduction diet. Logistic regression and classification tree analyses were used to evaluate potential risk factors for protocol-defined treatment failure (>2 dB perimetric mean deviation [PMD] change in patients with baseline PMD -2 to -3.5 dB or >3 dB PMD change with baseline PMD -3.5 to -7 dB). Seven participants (6 on diet plus placebo) met criteria for treatment failure. The odds ratio for patients with grades III to V papilledema vs those with grades I and II was 8.66 (95% confidence interval [CI] 1.65-∞, p = 0.025). A 1-unit decrease in the number of letters correct on the ETDRS (Early Treatment Diabetic Retinopathy Study) chart at baseline was associated with an increase in the odds of treatment failure by a factor of 1.16 (95% CI 1.04-1.30, p = 0.005). Compared with female participants, the odds ratio for male participants was 26.21 (95% CI 1.61-433.00, p = 0.02). The odds of treatment failure were 10.59 times higher (95% CI 1.63-116.83, p = 0.010) for patients with >30 transient visual obscurations per month vs those with ≤30 per month. Male patients, those with high-grade papilledema, and those with decreased visual acuity at baseline were more likely to experience treatment failure. All but one of these patients were treated with diet alone. These patients should be monitored closely and be considered for aggressive treatment of their idiopathic intracranial hypertension.

Idiopathic intracranial hypertension in Omani children

Idiopathic intracranial hypertension (IIH) is a relatively rare disease in children. It is defined as raised intracranial pressure in the absence of clinical, laboratory or radiological evidence of an intracranial space occupying lesion. We aimed to evaluate the clinical and therapeutic features of IIH in a presenting group of Omani pediatric population. We conducted a retrospective chart review of patients below 18 years of age diagnosed with IIH between 1992 and 2006 according to Dandy's Modified Criteria at Sultan Qaboos University Hospital, Oman. Statistical analyses were conducted using McNemar's test. Nineteen patients were included in the study, 11 (58%) were males and 8 (42%) were females, with a ratio of 1.4:1. The median age at presentation was 8.5 years. The average body mass index of the patients was 18.1 with only 2 (11%) children being obese, both males and pubertal. All the patients except 1 (5%) were symptomatic at presentation. The commonest symptom was headache found in 16 (84%) patients. This was followed by visual symptoms in half of them in the form of diplopia (16%) or transient visual obscuration (37%). All patients had bilateral papilledema, 7 (37%) had visual field defects, 4 (21%) had an enlarged blind spot and 3 (17%) had restricted visual field. Secondary causes of intracranial hypertension were not identified but the associated conditions were sickle cell disease, Behcet disease, neurofibromatosis type 1, varicella infection, and brucellosis. Seventeen (89%) patients showed good response to treatment with acetazolamide, steroids or both, with resolution of symptoms and signs ( p< 0.001). Two (11%) had deterioration in their vision despite aggressive medical treatment and were referred for surgical intervention. The epidemiologic features in the studied pediatric population were similar to that of other studies. The prompt recognition, evaluation, and treatment of IIH are needed to alleviate symptoms and to preserve visual function. There was a favorable response to medical treatment in this study cohort.

Tinnitus and Pediatric Pseudotumor Cerebri Syndrome

Pseudotumor cerebri syndrome (PTCS) is defined by increased pressure of cerebrospinal fluid (CSF), with normal CSF contents and without any intracranial disease found on brain imaging. PTCS is a disease with a predilection for childbearing obese women, but it may also occur in children and in man. The most common symptoms include headache, double vision, transient visual obscuration, and pulsatile tinnitus. The reason for which patients with increased CSF pressure experience tinnitus is not clear, and only a few studies have focused on the etiology of this peculiar clinical feature in the context of PTCS presentation. Besides tinnitus, additional otologic manifestations in children with PTCS include aural fullness, low-frequency hearing loss, and vertigo; these symptoms altogether can easily mimic Meniere disease. We hereby present two girls, who presented tinnitus as the first clinical symptom of PTCS, prior to developing headache and visual anomalies, and speculate on a shared pathophysiologic basis for both PTCS and Meniere disease.

Avoiding Complications in Endoscopic Third Ventriculostomy.

Endoscopic neurosurgical techniques hold the potential for reducing morbidity. But they are also associated with limitations such as the initial learning curve, proximal blind spot, visual obscurity, difficulty in controlling bleeding, disorientation, and loss of stereoscopic image. Although some of the surgical techniques in neuroendoscopy and microsurgery are similar, endoscopy requires additional skills. A thorough understanding of endoscopic techniques and their limitations is required to get maximal benefit. Knowledge of possible complications and techniques to avoid such complications can improve results in endoscopic third ventriculostomy (ETV). The surgeon must be able to manage complications and have a second strategy such as a cerebrospinal fluid shunt if ETV fails. It is better to abandon the procedure if there is disorientation or a higher risk of complications such as bleeding or a thick and opaque floor without any clear visualization of anatomy. Attending live workshops, practice on models and simulators, simpler case selection in the initial learning curve, and hands-on cadaveric workshops can reduce complications. Proper case selection, good surgical technique, and better postoperative care are essential for a good outcome in ETV. Although it is difficult to make a preoperative diagnosis of complex hydrocephalus (combination of communicating and obstructive), improving methods to detect the exact type of hydrocephalus before surgery could increase the success rate of ETV and avoid an unnecessary ETV procedure in such cases.

Cataract surgery in infants with microphthalmos.

To report the postoperative outcomes of cataract surgery in microphthalmic eyes of infants. This prospective observational study was carried out on 20 infants with microphthalmos with visually significant cataract. Microphthalmos was defined as axial length of the globe 16.50 mm or less. We excluded eyes with ocular trauma, inflammation, posterior hyperplastic primary vitreous or a tractional retinal detachment, aniridia, or chorioretinal coloboma. All the infants enrolled in this study underwent phacoaspiration with primary posterior capsulotomy, anterior vitrectomy, and peripheral iridectomy. Intraocular lens was not implanted in these children. Post-operative evaluation included refractive errors, irregularity of pupil, posterior synechiae, visual axis obscuration, and intraocular pressure. These children were followed up for a minimum of 12 months. We evaluated 37 eyes of 20 infants, of whom 17 infants had bilateral and three infants had unilateral cataract. The mean age of the children and the mean axial length at the time of surgery were 3.78 ± 2.25 months and 15.76 ± 0.56 mm respectively. The complications observed were irregularity of pupil in seven eyes (18.9 %), glaucoma in five eyes (13.5 %), posterior synechiae in two eyes (5.2 %), visual axis obscuration due to posterior capsule opacification (PCO) in two eyes (5.2 %) and phthisis in one eye (2.7 %). Infants achieved a favorable outcome after phacoaspiration with primary posterior capsulotomy with anterior vitrectomy. However, these children must be followed up to detect and treat postoperative complications such as visual axis obscuration, posterior synechiae, and glaucoma to achieve optimal outcome.

Pseudotumor Cerebri Associated with Leuprolide Acetate for Central Precocious Puberty-Case Report

This article represents the fourth case in literature of an association between pseudotumor cerebri (PTC) and leuprolide acetate, the first with precocious puberty and severe visual loss. A 9-year-old girl with precocious puberty was treated with a once-monthly dose of leuprolide acetate (3.75 mg) for three months. In the 4th month of treatment, it was decided to increase the dosage of leuprolide acetate to 11.25 mg in once-quarterly doses. After 1 month, she complained of holocranial headache, transient visual obscuration followed by progressive visual loss. After 6 months, she persisted with holocranial headache and progressive visual loss associated with ocular deviation. Neuro-opthalmological examination revealed severe visual loss and bilateral papilledema. Cerebrospinal fluid (CSF) analysis showed opening pressure of 45 cm H2O. The most likely diagnosis was PTC associated with leuprolide acetate. Treatment was started immediately with oral acetazolamide and leuprolide was discontinued. Acetazolamide was discontinued for having induced metabolic acidosis. A ventriculoperitoneal shunt was performed to control intracranial pressure as an alternative to acetazolamide treatment. The follow-up of 18 months showed CSF pressure of 14 cm H2O, stabilization of visual acuity and resolution of papilledema. There appears to be a causal relationship between the onset of leuprolide acetate with the development of PTC. Children should have a complete ophthalmic evaluation if they report headache or visual disturbances after administration of leuprolide acetate.

Pediatric Cataract Surgery in Buphthalmos

The pediatric eye offers many inherent surgical difficulties and when associated with a large buphthalmic eyeball, acts as a challenging ground for cataract surgeons. The purpose of our study is to describe the surgical outcome of cataract surgery in 6 children with buphthalmos. Eight eyes of 6 children with congenital glaucoma (buphthalmos) underwent phacoaspiration with or without intraocular lens (IOL) implantation. Demographic data, history of glaucoma surgery, intraocular pressure, biometry, surgical steps, and intraoperative and surgical outcome were noted for all patients from medical records. Postoperative outcome in terms of IOL stability, centration, visual acuity, and intraocular pressure were evaluated. Pediatric cataract surgery was performed in 8 eyes with buphthalmos. Implantation of IOL was possible in 7/8 eyes. Primary posterior capsulorhexis (PPC) was done in 2/8 eyes. The IOL was implanted in the bag in 3 eyes and captured in 4 eyes. Decentration of IOL occurred in 100% of eyes where PPC was performed. Membranectomy for visual axis obscuration was done in 3 eyes. Standard IOLs remain stable and centered with endocapsular implantation or rhexis fixation of IOL after pediatric cataract surgery in buphthalmos. However, PPC should not be attempted in the same sitting, as it leads to decentration.

Visual obscurations in children

Migraine Approximately 10% of all children suffer migraine headaches, with a quarter experiencing a preceding visual aura. Auras can feature visual deficits (negative phenomena) and/or false images (positive phenomena). Negative phenomena are typically described as black spots in front of the eyes or as a partial blurring of vision. The most common positive phenomena are flashes of light (photopsias) and flickering zig-zag patterns (scintillating scotomas). These zig-zag patterns can expand outward to form obscurations likened to a wall around a city (fortification spectra). These phenomena are usually black and white, though they can be coloured. Other positive phenomena include visual illusions such as a feeling that objects have grown larger (macropsia) or smaller (micropsia). The onset of the aura occurs over a period of minutes and can persist for up to an hour before the onset of a migrainous headache (Box 1). The return to normal vision is typically gradual. There is often a family history of migraine. Unlike typical migraine, complicated migraine syndromes feature motor abnormalities and/or changes in consciousness level. However, these are not present at the onset of visual changes.

Sight-threatening pseudotumour cerebri associated with excess vitamin A supplementation

A 17-year-old girl presented with a 2-week history of increasingly severe generalised headache that was worse on waking, with blurring of vision and transient visual obscurations. Her visual acuity was...

Arteritic anterior ischemic optic neuropathy associated with chronic myelomonocytic leukemia (CMML): A case report

Introduction: Ocular involvement in patients with CMML is rarely reported, owing in part to the fact that the severe illness faced by many of these patients limits the feasibility of ocular examinations. Nevertheless, post-mortem examination of the eyes of patients without ophthalmological symptoms and diagnosis of CMML, has revealed ocular infiltration of atypical cells. Case report: A 72-year-old man presented with two days of left-sided blurring of vision and an episode of transient visual obscuration associated to periorbitary pain. A relative afferent pupillary defect was present in the LE. Fundus examination revealed optic disc swelling in LE. The erythrocyte sedimentation rate (ESR) was 120 mm (1 st hour) and C-reactive protein was 7.8. Complementary examinations yielded normal findings. A presumptive diagnosis of arteritic anterior ischemic optic neuropathy (AAION) was made. Treatment with endovenous bolus of methylprednisolone, followed by slow-tapering of oral steroids, was started, without improvement. Temporal artery biopsy confirmed the diagnosis. Conclusions: To our knowledge, this is the second case in peer-reviewed literature reporting the association between AAION and CMML. A possible explanation is the fact that small vessel vasculitis, of unclear pathogenesis so far, complicates approximately 10% of CMML and presents as cutaneous vasculitis and lupus-like syndromes. Therefore, this may be in relation with the vasculitis of the short posterior ciliary arteries which happens in cases of AAION.

Intracranial idiopathic hypertension: 1-year follow-up study.

Standard guidelines for ongoing management, as well as definitive data about the long-term course of idiopathic intracranial hypertension (IIH) are not available. The aim of this study was to compare several clinical and instrumental variables as assessed at the time of diagnosis and then after 1 year in a sample of IIH patients. A total of 21 patients were studied. Our results confirmed that headache and TVO are the most frequent symptoms in IIH patients, and that overweight is a very common feature. A trend towards a favorable outcome in patients followed for 1 year and treated by usual medical therapy was found: intracranial pressure was lower at follow-up; improvement of headache and transient visual obscurations, as well as of papilledema, was reported in most patients. On the other hand, neuroradiological findings (such as empty sella, perioptic subarachnoid space distension, narrowing of the transverse sinuses) were substantially stable at follow. These findings may be relevant for future research as far as understanding the role of different clinical and instrumental findings as diagnostic items as well as predictors of outcome in IIH.

Foster Kennedy Syndrome

Foster Kennedy Syndrome

Bilateral jugular paragangliomas

A 28-year-old woman presented with a 2-year history of pulsatile tinnitus with recent onset of headaches and bilateral transient visual obscurations. Examination revealed bilateral optic disc edema. MRI showed enhancing lesions surrounding the internal jugular veins and magnetic resonance venography showed bilateral internal jugular vein occlusions with extensive collaterals (figure 1). Both lesions were resected. The pathology was that of a paraganglioma (figure 2).

Outcomes of congenital cataract surgery: Intraoperative intracameral triamcinolone injection versus postoperative oral prednisolone

To compare the outcomes of congenital cataract surgery using intraoperative intracameral triamcinolone versus postoperative oral prednisolone to modulate ocular inflammation. Department of Congenital Cataract, Altino Ventura Foundation, Recife, Brazil. Randomized clinical trial. Children younger than 2 years were randomly divided into 2 groups. The study group received an intraoperative intracameral injection of 1.2 mg/0.03 mL of triamcinolone acetonide. The control group (29 eyes) received 1 mg/kg per day of prednisolone syrup for 15 days postoperatively, which was then tapered over the following 2 weeks. Intraocular pressure (IOP), central corneal thickness (CCT), cell deposits on the intraocular lens (IOL), posterior synechiae, visual axis obscuration, additional surgical procedures, and IOL centration were assessed 12 months postoperatively. The mean patient age at surgery was 10.45 months±6.22 (SD) in the study group (31 eyes) and 10.0±6.15 months in the control group (29 eyes) (P=.779). In both groups, the mean IOP and CCT did not change significantly postoperatively (study group P=.922 and P=.149, respectively; control group P=.483 and P=.416, respectively). The groups had similar incidences of cell deposits (P=.517) and posterior synechiae (P=.247). No eye developed visual axis obscuration or had additional surgical procedures. All eyes had a clinically centered IOL. One year postoperatively, the outcomes were similar with intraoperative intracameral triamcinolone injection and postoperative oral prednisolone for modulating inflammation after congenital cataract surgery. No author has a financial or proprietary interest in any material or method mentioned.

Variation in the time length for the occurrence of Posterior Capsular Opacification following PMMA versus AcrySof Intraocular lens implants

Aim: To evaluate the significance of the biomaterial composition of the implanted Intra Ocular Lenses, in the occurrence of Posterior Capsular Opacification following a cataract surgery. Methods: A total of 75 patients who underwent IOL implant surgery were studied. The patients were classified based on the biomaterial of the IOL implanted in the eye following a cataract surgery. Group A consisted of eyes implanted with Polymethyl Methacrylate IOLs and Group B consisted of eyes implanted with AcrySof IOLs. The patients were later treated with YAG laser to clear the Posterior Capsular Opacification at the Ujjain laser center, Ujjain, Madhyapradesh. Results: The incidence of Posterior Capsular Opacification was found to develop earlier in the eyes implanted with PMMA IOLs as compared to Posterior Capsular Opacification occurrence in eyes implanted with AcrySof IOLs. Conclusion: The incidence of Posterior Capsular Opacification was found to be delayed by the use of AcrySof IOLs when compared to the use of PMMA IOLs. Index terms:Intraocular lenses, Polymethyl Methacrylate, AcrySof, Posterior Capsular Opacification, Lens epithelial cells, Capsulotomy, Biocompatibility I. Introduction The occurrence of Posterior Capsular Opacification is a prominent complication observed postoperatively in patients implanted with IOLs following a cataract surgery. The surgery involves removal of the anterior capsular bag, leaving the posterior capsular bag and the anterior capsular edge. Thereafter the lens nucleus and cortex is removed via phacoemulsification, small incision cataract surgery or any other standardized method. The surgery leaves the capsular bag with traces of Lens Epithelial Cells and fibers. The leftover Lens epithelial cells proliferate, undergo abnormal differentiation and migrate from the equator to the center, causing visual axis obscuration and dimness in vision. The factors that play a role in Posterior Capsular Opacification include biomaterial of the IOL, the edge of the IOL and the surgical skills of the surgeon. This study presents a comparison in the significance of the biomaterial of the IOLs and the shape of the IOLs, in the time length variation for the occurrence of Posterior Capsular Opacification following a cataract surgery. All the surgeries that have been used for this study were performed by the same surgeon thus eliminating any errors that can be caused by differences in surgical skills. Posterior Capsular Opacification can be treated by posterior capsule scrapping, which is a surgical method or by Nd: YAG laser capsulotomy, which is a non-surgical method. Under various studies, AcrySof IOLs have been found to have very low incidence of Posterior Capsular Opacification when compared to Posterior Capsular Opacification incidence in PMMA IOLs. This reduced incidence of Posterior Capsular Opacification in AcrySof IOLs is due to lower migration of lens epithelial cells (LECs) on the posterior capsule and their subsequent regression (1). AcrySof lenses have presented no signs of regeneration of Posterior Capsular Opacification after the capsulotomy via Nd:YAG laser. The following paper represents a comparative study of the occurrence of Posterior Capsular Opacification following PMMA vs AcrySof IOL implantation.

Idiopathic intracranial hypertension: diagnosis and management

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, may occur at any age but is primarily a disease of obese women between the ages of 15 and 40. Diagnosis is made based on modified Dandy criteria, which include normal neuroimaging studies, elevated intracranial pressure (ICP) on lumbar puncture, signs and symptoms of elevated ICP, and a non-focal neurologic examination aside from sixth nerve paresis. Presenting symptoms include headache, pulsatile tinnitus, transient visual obscurations, diplopia, and visual field constriction. Diagnosis may be delayed because headache from other causes such as migraine is much more common, and patients may be treated for this condition without improvement before the actual diagnosis is recognized. Ophthalmologic signs may include papilledema and esotropia (from the sixth nerve palsy) as well as visual field and even visual acuity loss; the latter two signs are very ominous, as they indicate severe and potentially permanent visual damage. Medical and surgical options vary depending on the severity of the disease and are used to control headache as well as to prevent vision loss. Because most IIH is associated with obesity, weight loss is an essential element of any treatment regimen, as retrospective as well as prospective studies have shown disease resolution with as little as 6% weight reduction. Secondary causes of high ICP are being recognized in a greater number of IIH patients, and the term idiopathic likely applies to fewer patients than in the past. The underlying pathogenesis of the disorder remains elusive.

Continuous 24-Hour Intraocular Pressure Pattern Monitoring in Medically Treated Normal Tension Glaucoma

The typical presenting ocular signs of idiopathic intracranial hypertension (IIH) include bilateral papilledema, enlarged blind spots, and abducens nerve palsy. Unilateral papilledema with choroid folds is an atypical presenting sign of IIH. The authors report the case of a 55-year-old Chinese gentleman, of medium-built, presenting with right eye transient visual obscuration associated with tinnitus for 2 weeks. Physical examination revealed ipsilateral choroidal folds and disc swelling. Computerized tomography of the brain and orbit with contrast revealed no intracranial space occupying lesions. Lumber puncture revealed an elevated opening cerebrospinal fluid pressure (30 cmH₂O) with normal biochemistry. Subsequent contrast Magnetic Resonance Imaging of the brain and orbit with venogram revealed features of empty sella, compatible with the diagnosis of IIH. He was subsequently treated with oral acetazolamide for 6 months and the symptoms resolved. Unilateral papilloedema with choroidal folds is an uncommon presentation of IIH, a lumbar puncture with opening pressure measurement and proper neuro-imaging should be considered when there is suspicion of IIH

Reply—Spontaneous Cerebrospinal Fluid Otorrhea and Rhinorrhea in Idiopathic Intracranial Hypertension Patients

Background:Spontaneous cerebrospinal fluid (CSF) leakage may occur in patients with normal or increased intracranial pressure (ICP). We describe herein spontaneous CSF leakage as a result of chronic increased ICP in 4 patients with idiopathic intracranial hypertension (IIH). Although rhinorrhea prev

Intermediate term follow-up after a single-piece-acrylic intraocular lens implantation in the ciliary sulcus- a cross-sectional study

BackgroundImplantation of a single-piece-acrylic intraocular lens (SPA-IOL) in the ciliary sulcus during phacoemulsification complicated with posterior capsule tear (PCT) may be associated with severe complications. The purpose of this study was to report the efficacy and safety of sulcus implantation of a SPA-IOL, designed for both in-the-bag and sulcus positioning.MethodsA prospective cross-sectional study including 12 patients, who underwent phacoemulsification with PCT and sulcus implantation of SPA-IOL designed for both in-the-bag and sulcus positioning (Seelens AF, Hanita, Israel) between January 2009 and March 2012 (follow-up 12–37 months). Preoperatively corrected distance visual acuity (CDVA), subjective refraction and intraocular pressure (IOP) were recorded. Postoperative evaluation included anamnesis for IOL edge symptoms and transient visual obscurations (TVO) along with CDVA, subjective refraction IOP, anterior segment biomicroscopy, gonioscopy, assessment of IOL centration, fundus biomicroscopy and spectral-domain optical coherence tomography of the macula.ResultsPreoperatively, mean CDVA was 0.84 ± 0.60 LogMAR (Counting Finger-20/33) improving to 0.18 ± 0.13 LogMAR (20/40-20/20) at last examination (p = 0.004), as all the patients gained better CDVA. Mean preoperative spherical equivalent was −0.2 ± 2.5 Diopter (D) (−4.0D to +5.4D) reaching −1.9 ± 0.9 (−4.0D to −0.6D) at last examination (p = 0.12). Mean preoperative refractive astigmatism magnitude was 1.0 ± 0.6D (0.3D to 2.3D) changing to 1.1 ± 1.0D (0.0D to 3.0D) at last examination (p = 0.88). Mean preoperative IOP was 14.7 ± 3.2 mmHg (11–23 mmHg) without medications reaching 15.9 ± 3.3 mmHg (10–21 mmHg) at last follow up (p = 0.21). Postoperatively one patient required two medications for IOP control in his study and contralateral eyes. None of the patients had symptoms of IOL edge or TVO. There were no intraocular hemorrhages, inflammatory reactions, or pigment dispersion and the IOLs were well centered in all cases. Central foveal thickness was 280 ± 33 μm (193–310 μm).ConclusionsAppropriately designed SPA-IOL may be implanted in the ciliary sulcus during phacoemulsification with PCT rather than switching to another backup IOL demanding wound enlargement.

English

Idiopathic intracranial hypertension, also known as pseudotumour cerebri, is a disorder of elevated intracranial pressure of unknown etiology. Patients present with daily headache, pulse-synchronous tinnitus transient visual obscurations, papilledema with its associated visual loss, and diplopia from sixth nerve paresis. Many disease associations have been alleged, but few besides obesity, hypervitaminosis A and related compounds, steroids withdrawal and female gender have been proven (1). Here we are going to present a case report of anaesthetic management of cesarean section who was operated for pseudotumour cerebri by lumbar peritoneal shunt by giving general anaesthesia.