Impact of Cardiovascular Disease Risk Factors on Subfoveal Choroidal Thickness by Enhanced-depth Spectral Domain Optical Coherence Tomography.

SIGNIFICANCE: Risk stratification plays a large role in cardiovascular disease (CVD) management. Spectral-domain optical coherence tomography (SD-OCT) allows for noninvasive analysis of the ophthalmic vasculature, with potential for systemic disease surveillance. Subfoveal choroidal thickness (SFCT) may serve as a marker for CVD risk and play a role in risk stratification. PURPOSE: This study aimed to explore the association of major CVD risk factors CVD on SFCT measured from SD-OCT images in a general population of U.S. veterans. METHODS: One hundred fifty veterans were prospectively recruited at the Jamaica Plain VA Hospital (Boston, MA). A total of 143 participants were included in the final analysis. The SFCT was manually measured from Spectralis SD-OCT macular scans, and medical chart review was analyzed for CVD data. The SFCT measurements were correlated with CVD risk factors and CVD clinical makers while controlling for age and refractive error. Mean differences in SFCT between those with and without CVD risk factors were analyzed. RESULTS: In multivariate analysis, diabetes diagnosis was independently associated with thinner subfoveal choroid (P = .001) and hypertension and hyperlipidemia with thicker subfoveal choroid (P = .006 and P = .05). After adjusting for age and refractive error, veterans with diabetes had thinner choroids than those without (P = .02), and veterans with hypertension and hyperlipidemia had thicker choroids than those without, although these differences did not reach statistical significance (P = .07 and P = .1). CONCLUSIONS: Comorbid risk factors for CVD are independently associated with optical coherence tomography-derived measurements of subfoveal choroidal thickness in a vasculopathic population of U.S. veterans, and there are detectable differences in subfoveal choroidal thickness between groups with and without CVD risk factors. Larger studies with adequate controls and longitudinal design are necessary to assess the clinical role of SFCT measurements in CVD risk analysis.

Pseudopartial Third Nerve Palsy as the Presenting Sign of Ocular Myasthenia Gravis.

SIGNIFICANCE: This case emphasizes the high degree of suspicion necessary for a timely diagnosis of myasthenia gravis. PURPOSE: This report discusses a case of ocular myasthenia gravis presenting as a pseudo-third nerve palsy with ptosis. The pathogenesis, treatment, and management of ocular myasthenia gravis are discussed. CASE REPORT: A 68-year-old white man presented to our clinic after noticing a new right eyelid droop for several days and experiencing horizontal double vision for the past 3 weeks. A pupil-sparing partial third nerve palsy was diagnosed, and MRI and laboratory work were ordered to assist with diagnosis. Laboratory results demonstrated highly positive acetylcholinesterase antibodies, confirming a diagnosis of ocular myasthenia gravis. CONCLUSIONS: Myasthenia gravis commonly presents with ocular signs and symptoms. Because ocular myasthenia gravis can mimic other causes of diplopia, heightened awareness and suspicion are necessary to make a timely diagnosis.

Intraoperative hypovolemia as a possible precipitating factor for pituitary apoplexy: a case report.

BACKGROUND: Pituitary apoplexy is acute infarction with or without hemorrhage of the pituitary gland. It is a rare but potentially life-threatening emergency that most commonly occurs in the setting of pituitary adenoma. The mechanisms underlying pituitary apoplexy are not well understood, but are proposed to include factors of both hemodynamic supply and adenoma demand. In the case of patients with known pituitary macroadenomas undergoing major surgery for other indications, there is a theoretically increased risk of apoplexy in the setting of "surgical stress." However, risk stratification of patients with nonfunctioning pituitary adenomas prior to major surgery is challenging because the precipitating factors for pituitary apoplexy are not completely understood. Here we present a case in which intraoperative hypovolemia is a possible mechanistic precipitating factor for pituitary apoplexy. CASE PRESENTATION: A 76-year-old patient with a known hypofunctioning pituitary macroadenoma underwent nephrectomy for renal cell carcinoma, during which there was significant intraoperative blood loss. He became symptomatic with ophthalmoplegia on the second postoperative day, and was diagnosed with pituitary apoplexy. He was managed conservatively with cortisol replacement therapy, and underwent therapeutic anticoagulation 2 months after pituitary apoplexy for deep vein thrombosis. His ophthalmoplegia slowly resolved over months of follow-up. Pituitary apoplexy did not recur with therapeutic anticoagulation. CONCLUSIONS: When considering the risk of surgery in patients with a known pituitary macroadenoma, an operation with possible high-volume intraoperative blood loss may have increased risk of pituitary apoplexy because intraoperative hypovolemia may precipitate ischemia, infarction, and subsequent hemorrhage. This may be particularly relevant in the cases of elective surgery. Additionally, we found that we were able to therapeutically anticoagulate a patient 2 months after pituitary apoplexy for the management of deep vein thrombosis without recurrence of pituitary apoplexy.