A 45-year-old man reported progressively worsening vision, photophobia, and dyschromatopsia in the left eye as well as oblique binocular diplopia. His neuro-ophthalmic examination was significant for ophthalmoplegia and...A 45-year-old man reported progressively worsening vision, photophobia, and dyschromatopsia in the left eye as well as oblique binocular diplopia. His neuro-ophthalmic examination was significant for ophthalmoplegia and optic disc edema in the left eye. MRI of the brain and orbits showed enlargement and contrast enhancement of the left lateral rectus muscle, optic nerve sheath, and cavernous sinus. He was started on corticosteroids with improvement in his symptoms, examination, and imaging. However, on cessation of corticosteroids, he developed worsening symptoms. Biopsy of the left lateral rectus muscle showed reactive lymphoid infiltrates with eosinophilia and no evidence of malignancy. While off corticosteroids, a complete blood count with differential revealed peripheral eosinophilia. He was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) and ultimately started on steroid-sparing therapy with mepolizumab. EGPA may present with primarily ocular or orbital involvement.
BACKGROUND: The visibility of optic disc drusen (ODD) increases with age, yet the anatomical changes related to this finding have not been established. Enhanced-depth imaging optical coherence tomography (EDI-OCT) provid...BACKGROUND: The visibility of optic disc drusen (ODD) increases with age, yet the anatomical changes related to this finding have not been established. Enhanced-depth imaging optical coherence tomography (EDI-OCT) provides a detailed imaging modality to evaluate the anatomical location of ODD within the optic nerve head. The aim of this study was to determine the factors contributing to the age-related increased visibility of ODD using EDI-OCT. METHODS: A retrospective observational study was conducted on patients who were diagnosed with ODD using EDI-OCT of the optic nerve head according to the Optic Disc Drusen Studies Consortium guidelines from November 2017 to December 2023. Data on ophthalmoscopic ODD visibility, OCT-based anatomical location, with superficial ODD being above and deep ODD being below Bruch Membrane Opening, peripapillary retinal nerve fiber layer (RNFL) thickness, and macular ganglion cell layer volume were collected and analyzed. RESULTS: A total of 411 eyes were included for analysis. ODD visibility increased significantly with age, with 6% being visible in the first decade of life and 90% being visible in patients >70 years of age based on fundus photography. The anatomical location of ODD was consistent across all age groups. RNFL thickness exhibited an age-related decline, with a mean thickness of 153 µm in the first decade decreasing to 70 µm in patients >70 years of age. In 17% of cases, ODD were classified as buried on fundus photography despite being superficial on OCT. CONCLUSIONS: Our study revealed that with age, ODD become more visible, while their anatomical location in the optic nerve head remains stable and the peripapillary RNFL thickness decreases. This suggests that RNFL thinning is the primary contributor to the age-related increased ODD visibility.
BACKGROUND: The visual rehabilitation options for patients with homonymous hemianopia (HH) are limited. We developed prototype software for commercially available mixed reality glasses (MRG) to help patients with HH bett...BACKGROUND: The visual rehabilitation options for patients with homonymous hemianopia (HH) are limited. We developed prototype software for commercially available mixed reality glasses (MRG) to help patients with HH better navigate their visual environment. METHODS: Unlike virtual reality, mixed reality allows users to see the actual environment with superimposed holograms. We developed software on the Unity platform for the Microsoft HoloLens 2 MRG to enable real-time picture-in-picture navigation (PIPN). With PIPN, a miniaturized view of the visual environment is transposed into the intact visual field in patients with HH. WebSockets was used for real-time communication between the MRG and remote interface. External calibration controls were developed with the Streamlit web-based interface. In this crossover study, patients with HH were tested on a timed obstacle course with and without the MRG and asked to rate the utility of PIPN on a linear analog scale. RESULTS: We transposed 52 diagonal degrees of the full field as a picture-in-picture into the intact hemifield of patients with HH. Five patients with HH were tested and on average rated the MRG as 19.7% more helpful for ambulation ( P = 0.028). On average, walk times with the MRG were 6 seconds slower than walk times without the MRG, but this was not statistically significant. CONCLUSIONS: We developed working prototype software for PIPN on a commercially available MRG. PIPN is a viable rehabilitation option to improve ambulatory navigation for patients with HH and will continue improving with hardware and software advancements.
BACKGROUND: Intraventricular blockage of cerebrospinal drainage by brain tumors has been proposed as a more powerful mechanism of producing high intracranial pressure (ICP) than tumor size. We tested that hypothesis by i...BACKGROUND: Intraventricular blockage of cerebrospinal drainage by brain tumors has been proposed as a more powerful mechanism of producing high intracranial pressure (ICP) than tumor size. We tested that hypothesis by investigating the MRI signs closely associated with high ICP in brain tumors. METHODS: We conducted a single-institution retrospective chart review of patients with brain tumors between 1990 and 2023. We selected 100 cases from a larger eligible cohort without regard to clinical or imaging features. Based on ophthalmologic examination, 57 patients had papilledema and 43 patients did not. The study neuroradiologist, masked as to the presence of papilledema, noted relevant MRI brain and eye signs. Associations between these MRI signs and papilledema were analyzed statistically. RESULTS: The median age of patients with papilledema was significantly younger than that of patients without papilledema. Among the MRI brain signs, the degree of ventriculomegaly was most highly associated with papilledema, and a temporal horn size of greater than 10 mm predicted a 100% chance of papilledema in patients aged 20 years or younger. Tumor size was not associated with papilledema. Posterior scleral flattening and optic disc protrusion were also highly associated with papilledema but were often difficult to identify because of their subtlety. CONCLUSIONS: The degree of ventriculomegaly, especially of the temporal horn, was the MRI brain sign most associated with papilledema, whereas tumor size was not associated with papilledema. These findings support the idea that intraventricular obstruction of cerebrospinal fluid flow is more likely than tumor size to elevate ICP. Together with posterior scleral flattening and optic disc protrusion, ventriculomegaly can be used to predict with high probability the presence of elevated ICP and as a substitute for finding papilledema on ophthalmologic examination, a service that may not be available in low resource settings.
BACKGROUND: Ocular manifestations of hyperviscosity, particularly associated with the hemodynamic changes in polycythemia, can lead to various ocular vascular events, ranging from transient monocular blindness to potenti...BACKGROUND: Ocular manifestations of hyperviscosity, particularly associated with the hemodynamic changes in polycythemia, can lead to various ocular vascular events, ranging from transient monocular blindness to potentially irreversible vision loss if left untreated. METHODS: This is a multicenter, retrospective case series and review of literature involving 4 patients presenting with neuro-ophthalmic symptoms related to underlying polycythemia. A thorough search for prior reported cases with similar manifestations to ours was conducted through the PubMed database. RESULTS: Four patients, 3 men and 1 woman, ranging in age from 68 to 71 years, were evaluated in the neuroophthalmology clinic. The patients had variable clinical presentations, ranging from transient unilateral or bilateral painless vision loss, nonarteritic anterior ischemic optic neuropathy, and acephalgic migraine with precipitation of visual auras. Polycythemia was secondary to testosterone therapy in 3 cases and primary in 1 case of polycythemia vera. Diagnostic challenges and treatment strategies are discussed in the context of each case. We also describe an additional 14 cases published in prior literature, with the majority presenting with variable symptoms of vision loss associated with polycythemia, and 1 case of amaurosis fugax attributed to a migrainous visual phenomenon. CONCLUSIONS: This case series highlights the role of polycythemia as a precipitating factor for ocular vascular events, necessitating a more careful approach in clinical assessment and management of such patients. Further research is needed to better understand the mechanisms underlying the hemodynamic alterations in polycythemia and their implications for ocular health to optimize therapeutic approaches.
BACKGROUND: Patients referred to ophthalmology and neuro-ophthalmology clinics often present with complex neurological and visual symptoms, such as headaches, double vision, and vision loss, requiring thorough history, c...BACKGROUND: Patients referred to ophthalmology and neuro-ophthalmology clinics often present with complex neurological and visual symptoms, such as headaches, double vision, and vision loss, requiring thorough history, comprehensive examinations, and neuroimaging to identify the underlying cause. While advances in neuroimaging have improved diagnostic accuracy, they have also introduced challenges with incidental findings and unexpected abnormalities. This study aimed to determine the prevalence, spectrum, and clinical relevance of incidental findings in neuro-ophthalmology patients evaluated at an academic center. METHODS: A retrospective, observational cohort study included 5,000 patients (59% women, 41% men; mean age 53.7 years) who underwent neuroimaging (MRI and CT) for neuro-ophthalmic symptoms at an academic neuro-ophthalmology clinic between July 2008 and June 2024. Details of imaging type, region scanned, and reason for imaging were recorded from electronic medical records. Incidental findings were defined as abnormalities unrelated to the original reason for imaging and categorized into 4 follow-up categories (none, routine, urgent, and emergency). Imaging reports were independently reviewed and categorized by an ophthalmologist and a neuro-ophthalmologist. Descriptive statistics were used to assess the prevalence of incidental findings and their clinical significance. Chi-square tests and analysis of variance were applied to assess associations between imaging modalities, age, and the presence of incidental findings. RESULTS: Incidental findings were present in 31% (n = 1,532) of patients; 20.6% required no follow-up, 9.6% required routine follow-up, 0.34% required urgent follow-up, and 0.1% required emergency follow-up. The most common incidental findings were microangiopathic changes (14.2%), sinus changes (6.96%), and brain atrophy (3.26%). MRI showed a higher prevalence of incidental findings than CT (31.8% vs 25.1%, P < 0.05). There was no difference in incidental findings between 1.5T vs 3T MRI. Age was significantly associated with certain findings, such as microangiopathy and brain atrophy. The most common findings by follow-up category were microangiopathic changes (no follow-up), meningiomas (routine follow-up), suspected neoplasms (urgent), and suspected metastasis (emergency). CONCLUSIONS: Incidental findings are common in neuro-ophthalmology imaging, with the majority requiring no or routine follow-up. However, a small percentage (0.44%) of cases required urgent or emergency attention, underscoring the need for careful evaluation and management protocols. These findings emphasize the importance of developing guidelines to manage incidentalomas in neuro-ophthalmology, particularly for older patients and those undergoing MRI.
J Neuroophthalmol
· 2026 Mar · PMID 40025633
·
Full text
BACKGROUND: Previous studies have determined a signficant correlation between, foveal threshold on automated visual field perimetry and best-corrected visual acuity. To our knowledge, these correlations have not been stu...BACKGROUND: Previous studies have determined a signficant correlation between, foveal threshold on automated visual field perimetry and best-corrected visual acuity. To our knowledge, these correlations have not been studied using the Octopus (Haag-Streit, Köniz, Switzerland) perimeter. METHODS: Patients underwent Octopus automated visual field testing using the glaucoma tendency-oriented perimetry protocol where a foveal threshold value was collected. Visual acuity was determined in the patient's current refractive glasses and/or with pinhole acuity. Visual acuity was converted from Snellen to logarithm of the minimum angle of resolution (logMAR) for statistical analysis. Spearman correlation coefficient was used to determine correlation between visual acuity and foveal threshold value. RESULTS: A total of 332 eyes (243 diseased eyes and 89 healthy eyes) were assessed. A statistically significant negative correlation was found between visual acuity and foveal threshold ( P < 0.001). The estimated foveal threshold was statistically significantly decreased by 1.2 dB per every 0.1 logMAR increase of visual acuity ( P < 0.001). A foveal threshold of 27.47 or higher predicted a visual acuity of 20/40 or better with 90% confidence. CONCLUSIONS: Patient best-corrected logMAR visual acuity has a negative correlation with foveal threshold in automated (Octopus) visual field testing. Our findings suggest that foveal threshold may predict measured visual acuity. We created a website application to predict visual acuity based on foveal threshold, age, and presence or absence of ocular pathology. Foveal threshold may represent a surrogate estimate of acuity for patients who are unable to read the Snellen chart and for patients with functional vision loss.