Disc-damage Likelihood Scale (DDLS) as a Clinical Indicator of the Presence of a Relative Afferent Pupillary Defect (RAPD).

PURPOSE: To evaluate clinical parameters and their relationship to the presence of a relative afferent pupillary defect (RAPD). MATERIALS AND METHODS: Retrospective chart review of 672 consecutive patients who presented to the Glaucoma Service at Wills Eye Hospital from January 1 through May 29, 2012. Swinging flashlight method (SFM) was used to test for RAPDs. Records of visual acuity, intraocular pressure (IOP), disc-damage likelihood scale (DDLS), cup/disc (C/D) ratio, visual field mean deviation (MD), optical coherence tomography (OCT), and Heidelberg retinal tomography (HRT) asymmetries were examined. We measured the prevalence of RAPDs as clinical asymmetries increase, calculated cut-off points for clinical asymmetries that optimized sensitivity and specificity in detecting RAPDs, and determined values of clinical asymmetries above which a RAPD always exists. RESULTS: Upon exclusion, we studied 409 patients, 175 (42.8%) with RAPDs and 234 (57.2%) without. Age, visual acuity, IOP, DDLS, C/D ratio, MD, retina nerve fiber layer thickness by OCT, HRT C/D, and HRT rim area asymmetries all correlated with RAPD status (OCT and HRT parameters did not include enough patients for multivariable analysis or cut-off determination). Multivariable analysis indicated that IOP, DDLS, and MD asymmetries were significantly correlated with RAPD status (P-value<0.05). Although the optimal cut-off values for the variables retained in the final multivariable model had low sensitivity and moderate specificity, DDLS had the highest specificity of 0.86. CONCLUSIONS: IOP, DDLS, and MD asymmetries had the best correlation with RAPD status, and increased asymmetries in these parameters were associated with higher likelihood of RAPDs. DDLS score had the highest specificity in predicting a RAPD, and DDLS asymmetry scores ≥6 identified all cases of RAPDs.

Ventriculoperitoneal shunt as a treatment of visual loss in idiopathic intracranial hypertension.

BACKGROUND: The aims of this study were to evaluate visual function outcomes in idiopathic intracranial hypertension (IIH) patients who underwent ventriculoperitoneal (VP) shunt for visual loss and to determine a VP shunt survival curve over time. METHODS: A retrospective medical record review was performed of all new IIH patients first evaluated at our institution who underwent VP shunt placement over a 7-year period (2004-2010). There were 2 primary outcome measures: the first being visual acuity (VA) and the second being shunt survival. Patients who received VP shunt for visual loss were included in the visual outcome analysis, and all patients who received VP shunt for any reason were included in the shunt survival analysis. RESULTS: Of the 338 new patients with IIH, 19 patients (6%) met the inclusion criteria and 17 underwent VP shunt for visual loss and 2 for headaches. Average follow-up was 21.2 months (range, 5-1,342 days). Of the 17 patients who had VP shunt for visual loss, 5 patients had optic nerve sheath fenestration (ONSF) surgery before VP shunt, and 1 patient had bilateral ONSF surgery after VP shunt. Median VA before shunt was 20/200 in the worse eye (range, 20/20 to NLP) and 20/40 in the better eye (20/20 to HM). Median VA after shunt was 20/60 in the worse eye (20/20 to lumboperitoneal) and 20/30 in the better eye (20/20 to 20/800). The improvement in VA was statistically significant in both worse eyes (P = 0.002, Wilcoxon signed-rank test) and better eyes (P = 0.028). The mean automated visual field (AVF) mean deviation (MD) of available AVFs before shunt was 223.36 dB (range, 233.38 to 27.01 dB) for the worse eye (n = 11) and 219.66 dB (230.11 to 25.91 dB) for the better eye (n = 11). Mean AVF MD deviation of available AVFs after shunt was 220.68 dB (232.13 to 23.97 dB) for the worse eye (n = 11) and 216.35 dB (232.13 to 21.00 dB) for the better eye (n = 11): this improvement was not significant (P = 0.27, P = 0.26, respectively). Independent masked record reviews by 3 neuro-ophthalmologists showed that 9 (53%) patients improved, 5 (29%) unchanged, 1 (6%) worsened, and 2 (12%) were indeterminate. Kaplan-Meier analysis showed a persistent steady decrease of functioning VP shunts over the entire period of 36 months with 80%, 65%, and 48% of VP shunts functioning without replacement, removal, or revision at 12, 24, and 36 months, respectively. CONCLUSION: VP shunts improve or stabilize most IIH patients presenting with severe progressive visual loss or those with visual loss refractive to medical treatment and ONSF. Survival analysis shows persistent decrease of functioning shunts over time.