A Consensus Statement on the Terminology for Automated Visual Field Abnormalities.

BACKGROUND: A multitude of terms have been used to describe automated visual field abnormalities. To date, there is no universally accepted system of definitions or guidelines. Variability among clinicians creates the risk of miscommunication and the compromise of patient care. The purposes of this study were to 1) assess the degree of consistency among a group of neuro-ophthalmologists in the description of visual field abnormalities and 2) to create a consensus statement with standardized terminology and definitions. METHODS: In phase one of the study, all neuro-ophthalmologists in Israel were asked to complete a survey in which they described the abnormalities in 10 selected automated visual field tests. In phase 2 of the study, the authors created a national consensus statement on the terminology and definitions for visual field abnormalities using a modified Delphi method. In phase 3, the neuro-ophthalmologists were asked to repeat the initial survey of the 10 visual fields using the consensus statement to formulate their answers. RESULTS: Twenty-six neuro-ophthalmologists participated in the initial survey. On average, there were 7.5 unique descriptions for each of the visual fields (SD 3.17), a description of only the location in 24.6% (SD 0.19), and an undecided response in 6.15% (SD 4.13). Twenty-two neuro-ophthalmologists participated in the creation of a consensus statement which included 24 types of abnormalities with specific definitions. Twenty-three neuro-ophthalmologists repeated the survey using the consensus statement. On average, in the repeated survey, there were 5.9 unique descriptions for each of the visual fields (SD 1.79), a description of only the location in 0.004% (SD 0.01), and an undecided response in 3.07% (SD 2.11%). Relative to the first survey, there was a significant improvement in the use of specific and decisive terminology. CONCLUSIONS: The study confirmed a great degree of variability in the use of terminology to describe automated visual field abnormalities. The creation of a consensus statement was associated with improved use of specific terminology. Future efforts may be warranted to further standardize terminology and definitions.

[Unusual presentation of a carotid-cavernous fistula in Ehlers-Danlos type IV].

Carotid-cavernous fistulae may present clinically in different ways, depending on the diameter and flow of the artery involved. In a direct fistula between the internal carotid artery and the cavernous sinus (high - flow fistula) the clinical presentation is usualLy dramatic and the signs and symptoms are severe. Indirect fistulae, in contrast, result from the connection of branches of the internal carotid, external carotid, or both to the cavernous sinus (low - flow fistula) and often present in a moderate and/or indolent manner. Patients with Ehlers-Danlos type IV suffer from vascular wall fragility resulting in a high frequency of aneurysms, dissections and fistulae. We describe a patient with Ehlers-Danlos vascular type IV who presented with mild signs and symptoms, suggesting the existence of a low-flow fistula. After two weeks, the patient's condition rapidly deteriorated. Endovascular catheterization demonstrated direct carotid cavernous fistula which was successfully treated. This case demonstrates the importance of early consultation with an endo-vascular surgeon in every patient with Ehlers-Danlos suspected of harboring a carotid cavernous fistula.

Comparison of optic nerve head topography findings in eyes with non-arteritic anterior ischemic optic neuropathy and eyes with glaucoma.

BACKGROUND: To compare the peripapillary retinal nerve fiber layer (RNFL) thickness in eyes affected by non-arteritic ischemic optic neuropathy (NAION) or glaucoma as determined by optical coherence tomography (OCT). METHODS: This cross-sectional institutional study included 18 eyes with NAION (at least 6 months since the acute event) and 29 eyes with glaucoma, both having localized visual field (VF) defects confined to one hemifield. Twenty-nine normal subjects served as controls. The fast RNFL thickness protocol (3.4) of the Stratus OCT (Carl Zeiss Meditec, Dublin, CA, USA) was used. The RNFL thickness and inferior maximum/temporal average (Imax/Tavg) and superior maximum/temporal average (Smax/Tavg) data corresponding to the hemifield with and without visual sensitivity loss were compared between NAION and glaucomatous eyes and with corresponding quadrants in normal eyes. The area under the receiver operating characteristic curve (AUC), sensitivities, and specificities were used to determine the OCT parameters that differ most in the two groups. RESULTS: The mean RNFL thickness in the quadrants corresponding to the affected hemifield in the NAION and glaucomatous eyes was not significantly different (P > 0.9), but the values for both were decreased compared to the control eyes (P < 0.0001). The mean RNFL thickness in the quadrant corresponding to the unaffected hemifield was significantly lower in the glaucomatous eyes (73.8 +/- 20.04 micro) than in the NAION eyes (96.6 +/- 23.32 micro, P = 0.023), and in both study groups compared to the controls (117.2 +/- 13.44 micro, P < 0.0001 for glaucomatous vs control eyes, and P < 0.025 for NAION vs control eyes). Smax/Tavg and Imax/Tavg of the quadrant corresponding to the unaffected hemifield had the strongest power to differentiate the two diseases (an AUC of 0.92). CONCLUSIONS: Stratus OCT detected significant quantitative differences in RNFL thickness between glaucomatous and NAION eyes, both conditions with hemifield defects. These differences might hold a clue in understanding the processes involved in optic nerve injury.

Refractive surgery in Israel Defense Forces recruits.

PURPOSE: To determine the prevalence of refractive surgery history in recruits for military service in the Israel Defense Forces (IDF) between 1998 to 2005 and to evaluate the effect of surgery on the recruits' fitness to serve in combat units. SETTING: Surgeon General's HQ, Medical Corps, Israel Defense Forces. METHODS: The computerized medical records of all ametropic Israeli army inductees were reviewed. They included spectacle-wearing, contact lens-wearing, and post refractive-surgery individuals who were examined in the recruitment office before their compulsory military service. The extracted data from the personal files consisted of the assignment to combat units of those who had refractive surgery and those who wore corrective eyewear and the first and last military position of all ametropic recruits who were assigned to combat units. RESULTS: Five hundred ninety-seven inductees (513 men, 84 women) had refractive surgery before their military service during the study period. The prevalence of recruits who had refractive surgery increased from 0.8/1000 ametropes in 1998 to 4.9/1000 ametropes in 2005. Significantly more recruits who had surgery (73.5%) than recruits who wore corrective eyewear were assigned to combat units (P<.001). The dropout rate from combat units of the former was significantly lower than that of the latter (13.1% versus 29.2%) (P<.001). CONCLUSIONS: More corrective eyewear users had refractive surgery before their IDF military service, and relatively more of them applied for combat duty. The high percentage of recruits who had refractive surgery who serve uninterruptedly in combat units indicates that the procedure has no deleterious effect on the recruits' fitness.

Cat-scratch disease: ocular manifestations and treatment outcome.

PURPOSE: To characterize cat-scratch disease (CSD) ocular manifestations and visual outcome and evaluate the effect of systemic antibiotics and corticosteroids on final visual acuity (VA). METHODS: Multicentre retrospective cohort study. Medical records of 86 patients with ocular disease (107 eyes) of 3222 patients identified in a national CSD surveillance study were reviewed. RESULTS: Mean age was 35.1 ± 14.2 years. Median follow-up was 20 weeks (range 1-806 weeks). Of 94/107 (88%) eyes with swollen disc, 60 (64%) had neuroretinitis at presentation, 14 (15%) developed neuroretinitis during follow-up, and 20 (21%) were diagnosed with inflammatory disc oedema. Optic nerve head lesion, uveitis, optic neuropathy and retinal vessel occlusion were found in 43 (40%), 38 (36%), 34 (33%) and 8 (7%) eyes, respectively. Good VA (better than 20/40), moderate vision loss (20/40-20/200) and severe vision loss (worse than 20/200) were found in 26/79 (33%), 35/79 (44%) and 18/79 (23%) eyes at baseline and in 63/79 (80%), 11/79 (14%) and 5/79 (6%) eyes at final follow-up, respectively (p < 0.001). Significant VA improvement (defined as improvement of ≥3 Snellen lines at final follow-up compared to baseline) occurred in 12/24 (50%) eyes treated with antibiotics compared with 14/16 (88%) eyes treated with antibiotics and corticosteroids (p = 0.02). Multivariate logistic regression was suggestive of the same association (odds ratio 7.0; 95% CI 1.3-37.7; p = 0.024). CONCLUSION: Optic nerve head lesion is a common and unique manifestation of ocular CSD. Most patients improved and had final good VA. Combined antibiotics and corticosteroid treatment was associated with a better visual outcome.

Ophthalmic complications of dental anesthesia: three new cases.

Two patients had ipsilateral optic neuropathy and one patient had an ipsilateral abduction deficit and a dilated, poorly reactive pupil immediately after anesthesia of upper alveolar teeth. In one patient with optic neuropathy, the optic disc was not swollen, brain and orbit computed tomography (CT) was negative, and vision recovered completely within 2 weeks. In the other patient with optic neuropathy, the optic disc was swollen, brain and orbit CT were negative, and vision did not recover. In the patient with ductional and pupil deficits, recovery was complete within 24 hours. Since 1960, 39 cases of ophthalmic complications have been reported in the English literature. A majority have followed anesthesia of upper alveolar teeth. In all but three cases, the deficits were temporary. Diffusion, inadvertent needle penetration into the orbit, venous injection, or retrograde arterial injection is postulated as the mechanism by which the anesthetic agent reaches the cavernous sinus or orbit to cause the deficits.