Unilateral inferior altitudinal visual field defect related to COVID-19.

Ocular manifestations of COVID-19 are still being studied. Posterior segment involvement in viral entities is either direct viral involvement or a delayed immune response to the antigen. A 22-year-old woman presented with history of perceiving absolute inferior scotoma in the right eye for 4 days and history of fever and sore throat 10 days ago. Fundus examination revealed disc edema and vessel tortuosity. Humphreys Field Analyzer confirmed inferior field defect and Optical Coherence Tomography showed superior, nasal and inferior retinal nerve fiber layer thickening in the right eye. Patient was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription polymerase chain reaction (RT-PCR) testing. Patient received three doses of injection methylprednisolone over 3 days. There was subjective resolution of scotoma reported 3 weeks posttreatment. We bring forward the first reported case of parainfectious optic neuritis associated with COVID-19.

Neuro-Ophthalmic Manifestations of HIV Infection.

Purpose: To review the broad spectrum of clinical neuro-ophthalmic presentations associated with human immunodeficiency virus (HIV) infection. Methods: Critical review of the literature regarding neuro-ophthalmic consequences of HIV infection and its sequelae. Results: Neuro-ophthalmological diseases are common in both asymptomatic HIV-positive patients and those who profound immunosuppression with acquired immune deficiency syndrome (AIDS). Neuro-ophthalmic manifestations of HIV infection can involve the afferent or efferent visual pathway. Common clinical presentations include headache, papilledema, chorioretinitis, optic nerve involvement, meningitis, and cranial nerve palsies. Other neuro-ophthalmic manifestations include involvement of the visual pathway in the brain producing visual field defects such as occur in progressive multifocal encephalopathy. Pupil abnormalities have also been reported. Discussion: Neuro-ophthalmic consequences of HIV are important to recognize as it is critical to identify underlying neoplastic or infectious diseases which could be amenable to treatment.

Cytomegalovirus papillitis in an immunocompetent patient.

A 22-year-old immunocompetent woman who presented with a 3-week history of fever, headache, and visual loss and was found to have subnormal visual acuity and bilateral optic disc swelling. Serum cytomegalovirus (CMV) IgM and IgG and polymerase chain reaction results were positive, indicating an acute CMV infection. No cause of immunocompromise was found. After treatment with intravenous ganciclovir, the papillitis and systemic CMV illness resolved with no residual deficit. This is the first reported case of primary CMV papillitis to be successfully treated with ganciclovir alone.

Juxtapapillary cytomegalovirus retinitis with optic neuritis.

A 49-year-old man with AIDS developed acute monocular visual loss and an ipsilateral swollen optic disc with a large right relative afferent pupillary defect, a nerve fiber bundle visual field defect, and a peripapillary retinal infiltrate. Lumbar puncture disclosed cytomegalovirus (CMV) DNA on polymerase chain reaction (PCR). Treatment with oral valganciclovir produced complete resolution of the visual deficits and the fundus abnormality. This case differs from previously reported cases of CMV optic neuritis in which visual function has been irreversibly lost.

Herpes Simplex Acute Retinal Necrosis Presenting as Unilateral Disc Swelling in Young Immunocompetent Patients.

PURPOSE: To report two cases of young immunocompetent males with herpes simplex acute retinal necrosis (HSV ARN) with initial diagnosis of unilateral disc swelling. METHODS: Retrospective case series. RESULTS: Two young immunocompetent males who were diagnosed to have unilateral disc swelling were treated as presumed optic neuritis and started on systemic steroids. On dilated fundal examination, unilateral retinitis and vasculitis was found after 2-3 days of systemic steroids and the diagnosis of ARN was made. Tetraplex vitreous tap subsequently returned as HSV-2 and HSV for the first and second patient, respectively. Both patients had no significant systemic medical history and tested negative for human immunodeficiency virus (HIV). Despite aggressive treatment, both patients developed profound visual morbidity. CONCLUSIONS: Close monitoring of patients with unilateral disc swelling and dilated fundus evaluation is critical, particularly upon initiation of systemic steroid therapy, even if immunocompetent, as misdiagnoses can result in potentially devastating consequences.

Chikungunya fever presenting with acute optic neuropathy.

Chikungunya fever is a vector borne virus that typically causes a self-limiting systemic illness with fever, skin rash and joint aches 2 weeks after infection. We present the case of a 69-year-old woman presenting with an acute unilateral optic neuropathy as a delayed complication of Chikungunya virus (CHIKV) infection contracted during a recent trip to the West Indies. She presented to our ophthalmology department with acute painless visual field loss in the right eye and a recent flu-like illness. She was found to have a right relative afferent pupillary defect (RAPD) with unilateral optic disc swelling. Serology confirmed recent CHIKV infection. Treatment with intravenous methylprednisolone was delayed while awaiting MRI scans and serology results. At 5-month follow-up, there was a persistent right RAPD and marked optic atrophy with a corresponding inferior scotoma in the visual field.

Primary varicella infection presenting with headache and elevated intracranial pressure.

Primary varicella infection may be associated with neurologic complications, such as cerebritis and meningoencephalitis. Several cases of varicella infection with elevated intracranial pressure have been reported. We describe a 13-year-old immunocompetent girl who presented with a clinical picture of headaches and elevated intracranial pressure as the only manifestation of primary varicella zoster infection. The working diagnosis at first was pseudotumor cerebri based on complaints of headache of 2 weeks' duration, in addition to vomiting and papilledema, without fever or skin eruption. On lumbar puncture, opening pressure was 420 mmH2O, but mild pleocytosis and mildly elevated protein level ruled out the diagnosis of pseudotumor cerebri. Our patient had no history of previous varicella infection, and she did not receive the varicella zoster vaccine. Serology tests, done on admission and repeated 2 months later, suggested primary varicella infection. The literature on varicella infection associated with pseudotumor cerebri or elevated intracranial pressure is reviewed.

ACUTE POSTERIOR MULTIFOCAL PLACOID PIGMENT EPITHELIOPATHY FOLLOWING INFLUENZA VACCINATION.

PURPOSE: To report a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE), following influenza vaccination. CASE REPORT: An 18-year-old female patient developed a painless significant bilateral decrease of vision, moderate photophobia, metamorphopsia and intermittent headaches two weeks after having a seasonal anti-flu immunization. Clinical evaluation and ancillary testing pointed toward the diagnosis of APMPPE. The case evolved favorable after oral prednisone 0.5 mg/kg/day gradually decreased for over 4 weeks. A total recovery of visual function and no recurrences were noticed at 1, 3 and 5 years follow-up. CONCLUSIONS: Previous case reports already suggested a possible relationship between various immunizations and APMPPE onset. This case is the first one reported in our country. Epidemiological studies are required to link APMPPE occurrence and vaccination.

Adenoviral gene therapy with catalase suppresses experimental optic neuritis.

OBJECTIVE: To determine if adenoviral-mediated transfer of the gene for catalase (CAT), the reactive oxygen species scavenger, suppresses experimental optic neuritis. CLINICAL RELEVANCE: Gene therapy with CAT delivered by an adeno-associated viral vector was previously shown to suppress experimental optic neuritis. Because the transduction of protein expression with recombinant adeno-associated viral vector is relatively slow, taking weeks to reach full levels, we studied the effects of replication-deficient adenovirus containing CAT in suppressing experimental optic neuritis. Transduction with adenovirus occurs within days of inoculation, thus, it may be more applicable for the treatment of patients with acute optic neuritis. MATERIALS AND METHODS: Replication-deficient adenovirus containing CAT was injected above the right optic nerve heads of SJL/J mice that were simultaneously sensitized for experimental allergic encephalomyelitis. For controls, the left eyes were injected with the replication-deficient adenovirus without CAT or no virus. The histological effects of CAT on the lesions of experimental allergic encephalomyelitis were measured by computerized analysis of the myelin sheath area (for demyelination), optic disc area (for optic nerve head swelling), the extent of the cellular infiltrate, extravasated serum albumin labeled with immunogold (for disruption of the blood-brain barrier), and the in vivo hydrogen peroxide reaction product. RESULTS: After 1 month, cell-specific catalase activity, evaluated by the quantitation of catalase immunogold, was increased about 2-fold each in endothelia, oligodendroglia, astrocytes, and axons of the CAT-inoculated right optic nerves compared with the control left optic nerves. The increased cellular levels of catalase reduced demyelination by 30%, optic nerve head swelling by 25%, cellular infiltration by 26%, disruption of the blood-brain barrier by 61%, and in vivo levels of hydrogen peroxide by 81%. CONCLUSIONS: Adenoviral-mediated gene transfer increased catalase levels in all optic nerve cell types, and it persisted for 1 month after inoculation. The increased cellular levels of catalase suppressed demyelination and blood-brain barrier disruption at the foci in the optic nerve where prior magnetic resonance imaging and histopathologic studies have demonstrated the demyelinating inflammation of experimental and human optic neuritis. Together, they suggest that gene therapy with CAT may be helpful in the treatment of patients with optic neuritis.

Immune-recovery uveitis in patients with cytomegalovirus retinitis taking highly active antiretroviral therapy.

PURPOSE: To investigate the clinical features associated with immune recovery in human immunodeficiency virus (HIV)-infected patients with cytomegalovirus retinitis who are taking highly active antiretroviral therapy. METHODS: Sixteen patients were evaluated prospectively at the National Eye Institute, Bethesda, Maryland. Evaluation included a medical history and a complete ophthalmologic examination. The examination included best-corrected visual acuity score measured by means of logarithmic charts, slit-lamp biomicroscopy, dilated retinal examination, retinal photography, and fluorescein angiography. Immune-recovery uveitis was defined as the ocular inflammation associated with clinical immune recovery in patients taking potent antiretroviral regimens. The ophthalmic characteristics of immune-recovery uveitis were identified, and their effect on visual acuity was statistically analyzed. RESULTS: The mean CD4+ T-lymphocyte count for the 16 patients taking highly active antiretroviral therapy at the time of evaluation was 393 cells/microl (range, 97-1,338 cells/microl). Immune-recovery uveitis was characterized by vitreitis and optic disk and macular edema. Clinically important complications of immune-recovery uveitis included cataract and epiretinal membrane formation. The visual acuity scores were significantly worse in the 23 eyes with cytomegalovirus retinitis (mean, 67.2 letters, 20/50) than in the nine eyes without cytomegalovirus retinitis (mean, 89.8 letters, 20/16) (P <.001). Regression analysis showed that a lower visual acuity score was associated with the presence of moderate to severe macular edema on fluorescein angiography and vitreous haze (P < or =. 001). CONCLUSIONS: Immune-recovery uveitis is an important cause of visual morbidity in HIV-infected patients with cytomegalovirus retinitis in the era of highly active antiretroviral therapy. Although immune recovery associated with highly active antiretroviral therapy has allowed some patients to discontinue specific anticytomegalovirus therapy, the rejuvenated immune response can be associated with sight-threatening inflammation.

[Papillitis due to Epstein-Barr virus infection in an adult patient]. / Papilitis por infección del virus de Epstein-Barr en paciente adulto.

CASE REPORT: A 70-year- old woman who consulted due to poor vision in her right eye for 2 weeks. The examination showed a visual acuity (VA) of 0.6 and 1.0, with normal anterior pole and intraocular pressure and a relative afferent pupillary defect. Some papillitis was observed in the fundus of her right eye. The high levels of acute phase reactants led to an initial diagnosis of arteritic anterior ischemic optic neuropathy (AAION) and treatment with corticosteroids was started. DISCUSSION: According to the age of the patient, the fundus and the high levels of acute phase reactants, the initial diagnosis was AAION. However, the atypical papillitis features, with good AV and non-specific perimetry, together with a suitable medical history, and a profile of viral characteristics, with laboratory confirmation, led to the diagnosis of a primary papillitis infection due to Epstein-Barr virus, a very rare case due to the advanced age of the patient.

Viral-induced intracranial hypertension mimicking pseudotumor cerebri.

BACKGROUND: Pseudotumor cerebri or idiopathic intracranial hypertension is characterized by normal spinal fluid composition and increased intracranial pressure in the absence of a space-occupying lesion. METHODS: This study describes a subgroup of 10 patients with the same typical presenting symptoms (headache, vomiting, and papilledema) but without nuchal rigidity, meningeal signs, or change in mental status. Patients had normal neuroimaging studies and intracranial hypertension but also pleocytosis in the cerebrospinal fluid, suggesting central nervous system infection. From the results it can be hypothesized that those children represent a unique subgroup of viral-induced intracranial hypertension when comparing their risk factors, clinical course, treatment, and outcome with 58 patients who had idiopathic intracranial hypertension. RESULTS: All patients with viral-induced intracranial hypertension presented with papilledema but none had reduced visual acuity or abnormal visual fields, compared with 20.7% of patients who had idiopathic intracranial hypertension. They also responded better to treatment with acetazolamide, needed a shorter duration of treatment (7.7 ± 2.6 months vs 12.2 ± 6.3 months, P = 0.03), and had no recurrences. CONCLUSIONS: The results suggest that children who fulfill the typical presenting signs and symptoms and all diagnostic criteria for pseudotumor cerebri other than the normal cerebrospinal fluid component may represent a unique subgroup of viral-induced intracranial hypertension and should be managed accordingly. The overall prognosis is excellent.

Human herpesvirus 6-associated uveitis with optic neuritis diagnosed by multiplex PCR.

PURPOSE: Human herpesvirus 6 (HHV-6), which is usually responsible for exanthem subitum in children, can be reactivated from its latent state. We report a case of unilateral optic disc edema and retinal vasculitis associated with HHV-6 infection. CASE: A healthy 63-year-old man noted a decrease in the vision of his left eye. On examination, his left eye had moderate mutton-fat keratic precipitates, vitreous opacities, significant optic disc edema surrounded by yellowish-white swelling in the inner retina, retinal arteritis, and cotton-wool-like exudates. He was started on corticosteroid therapy and aspirin. After 1 month, the disc edema was reduced, the cotton wool-like exudates had decreased, and his visual acuity had improved to 10/20 OS. Multiplex polymerase chain reaction (PCR) of an aqueous humor sample revealed the presence of genomic DNA of HHV-6 but not of the other HHVs. CONCLUSIONS: The HHVs are known to infect the ocular tissues, but the differential diagnostic signs of HHV-6 are still not well known. We recommend that multiplex PCR of the aqueous humor be performed to search for the genomic DNA of HHV-6 in suspected cases of herpesviral infection.

[Benign but not harmless intracranial hypertension: a case report]. / Hypertension intracrânienne bénigne, mais pas anodine. À propos d'un cas.

Benign intracranial hypertension (BIH) is characterized as an intracranial pressure increase occurring in the absence of brain tumour, sinus thrombosis or hydrocephaly. But contrary to what its designation might suggest, it threatens the visual prognosis. We report the case of a 15-year-old girl with lymphocytic meningitis, developing secondary a BIH. Cerebrospinal fluid pressure was 70cm water, without enlargement of the cerebral ventricles. Along with the progression, bilateral 6th nerve palsy, impairment of visual acuity and bilateral papilledema appeared. No cause was found after a complete assessment. Treatment consisted in oral acetazolamide and 9 depletive spinal taps. Clinical examination, fundus examination and Goldmann visual field normalized after 8 weeks. No relapse occurred after a 1-year follow-up. This case shows that BIH, which is not a well-known disorder, is incorrectly referred to as benign: both prompt diagnosis and proper management are of major importance.

Choroidal and optic nerve infarction in hepatitis C-associated polyarteritis nodosa.

A 39-year-old man presented with headache, weight loss, bilateral subdural hematomas, pansinusitis, and visual loss. The neuro-ophthalmologic examination disclosed deep choroidal lesions and bilateral optic disc edema. Orchiectomy for testicular torsion showed acute vasculitis consistent with polyarteritis nodosa (PAN). Polymerase chain reaction (PCR) testing revealed hepatitis C. This is the first reported case of PAN due to hepatitis C with early findings of choroidal and optic nerve infarction.

[Ocular complications of dengue fever]. / Øjenmanifestationer af denguefeber.

We report a case of a 32-year-old Danish woman with ocular complications of (IgM-verified) dengue fever. After having returned from a trip to Thailand, she became ill with fever and symptoms suggestive of dengue. On the tenth day, when the fever had subsided, she suddenly experienced visual disturbances and was admitted to hospital. Ophthalmologic examination revealed retinal oedema, probably immunologically mediated. Months later, her visual symptoms had still not completely disappeared. Ocular complications of dengue are rarely reported, but in the Third World they are probably common.

Bilateral optic neuropathy and unilateral tonic pupil associated with acute human herpesvirus 6 infection: a case report.

BACKGROUND: Human herpesvirus 6 (HHV-6), a widespread virus and causative agent of exanthema subitum in children, has been associated with a number of neurologic disorders including cranial nerve palsies, seizures, encephalitis, meningitis, and multiple sclerosis. PATIENT: A 31-year-old man presented with bilateral optic neuropathy, disc edema, and unilateral tonic pupil, which were found to be associated with acute HHV-6 infection. The patient had been suffering from juvenile diabetes for 5 years. One week after onset of intravenous antiviral therapy with foscarnet, disc edema subsided, and tonic pupil reaction was no longer detectable. CONCLUSIONS: HHV-6 infection may play a role as a causative agent in patients with optic neuropathy and tonic pupil.