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.

Objective Measurement of Eyelid Force in Ptosis Versus Controls.

Thorough evaluation of the upper eyelid is essential for diagnosis and management planning in blepharoptosis. In a previous study, our group described a novel force gauge for direct assessment of upper lid force in healthy subjects. In this study, the authors apply the same technique for measuring muscle forces in ptotic eyelids.Patients scheduled to undergo surgical repair of aponeurotic blepharoptosis or dermatochalasis, from July 2017 to August 2018, in a tertiary care medical center, were enrolled in this prospective case series. When the eyelid disorder was unilateral, the normal eye was designated as control. The upward force generated by the eyelid was measured directly using a handheld dynamometer noninvasively attached to the upper eyelid. Measurements were conducted with and without fixation of the frontalis muscle, to differentiate between total lid force, levator force, and frontalis contribution.A total of 56 eyes was included in the study: 34 in the ptosis group, 11 in the dermatochalasis group, and 11 as controls. Both the ptosis group and the dermatochalasis group had significantly lower total muscle force and levator force measurements when compared with control (P <0.05). Calculated frontalis force contribution to upgaze did not differ significantly between groups. In the control group, calculated frontalis force contribution to upgaze strongly correlated to marginal reflex distance1 (r = 0.75, P = 0.05)In conclusion, the authors present a simple, inexpensive, new portable force gauge for direct eyelid force measurements in eyelid pathologies. Distinct differences between ptotic and healthy eyelids are demonstrated, suggesting potential applications in patient evaluation and management.

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.

Optic disc drusen demonstrate a hyperechogenic artifact in B mode ultrasound.

We describe a new, specific, hyperechogenic artifact spot in B-mode ultrasound (US) in patients diagnosed with optic nerve drusen (OND). This is a retrospective chart review of 34 consecutive patients with OND using B-scan US. The patients underwent full ophthalmic evaluation and neuro-ophthalmic examination. In all cases, a typical hyperechogenic spot was seen within the acoustic shadows on medium or high gain settings. The length between the US probe and the OND, and the distance between the OND and the artifact were recorded for each patient. In all cases, a typical hyperechogenic spot was seen within the acoustic shadows on medium or high gain settings. Sonograms showed a hyperechogenic focus in all eyes. The average ratio between the cornea-OND distance (25.5mm) and the OND-hyperechogenic spot (32.1mm) distance was 1.26. The size of the hyperechogenic spot was proportional to the size of the deposit on the disc, with the most marked attenuation of the beam seen in the largest lesions. B-scan US is a very sensitive and reliable detector of both superficial and buried OND. The described hyperechogenic artifact spot may be an additional mode to support diagnosis of OND. This finding might be helpful for making a differential diagnosis between OND and papilledema.

Inferior oblique muscle paresis as a sign of myasthenia gravis.

Myasthenia gravis may affect any of the six extra-ocular muscles, masquerading as any type of ocular motor pathology. The frequency of involvement of each muscle is not well established in the medical literature. This study was designed to determine whether a specific muscle or combination of muscles tends to be predominantly affected. This retrospective review included 30 patients with a clinical diagnosis of myasthenia gravis who had extra-ocular muscle involvement with diplopia at presentation. The diagnosis was confirmed by at least one of the following tests: Tensilon test, acetylcholine receptor antibodies, thymoma on chest CT scan, or suggestive electromyography. Frequency of involvement of each muscle in this cohort was inferior oblique 19 (63.3%), lateral rectus nine (30%), superior rectus four (13.3%), inferior rectus six (20%), medial rectus four (13.3%), and superior oblique three (10%). The inferior oblique was involved more often than any other muscle (p<0.01). Eighteen (60%) patients had ptosis, six (20%) of whom had bilateral ptosis. Diagnosing myasthenia gravis can be difficult, because the disease may mimic every pupil-sparing pattern of ocular misalignment. In addition diplopia caused by paresis of the inferior oblique muscle is rarely encountered (other than as a part of oculomotor nerve palsy). Hence, when a patient presents with vertical diplopia resulting from an isolated inferior oblique palsy, myasthenic etiology should be highly suspected.

A simple computer program to quantify red desaturation in patients with optic neuritis.

PURPOSE: Red desaturation is a subjective, sensitive test for patients with optic nerve disease. There is no quantitative clinical test to measure the severity of color desaturation. The current study introduces a simple PowerPoint presentation for quantification of red desaturation in patients with optic neuritis. METHODS: A Microsoft Office PowerPoint presentation was designed. A red square is shown on each half of the screen. The degree of desaturation on one side is increased in each successive slide. The patient holds a black cardboard divider between his/her eyes, such that each eye can see one-half of the screen. The patient uses the mouse to forward through the slides, thereby gradually increasing the desaturation of the red square presented to the normal eye until it matches the color of the red square seen with the tested eye. Desaturation is graded by the number of slide changes needed until subjective equal color between the eyes is perceived. The test was presented to normal volunteers and to patients with optic neuritis. The difference in saturation levels between the right and the left eyes in patients with optic neuritis vs controls was compared. RESULTS: A total of 83 patients were included. Patients with optic neuritis had significantly increased desaturation compared to controls (6.17 ± 3.3 vs 0.24 ± 2.8 respectively; p < 0.0001). CONCLUSIONS: This test is easy to create and efficiently quantifies the severity of red desaturation.

Measurement of ocular cyclotorsion in superior oblique palsy using a single Maddox rod.

BACKGROUND: To describe a modified technique to measure ocular cyclotorsion using only 1 Maddox rod and compare it with the traditional double Maddox rod test (DMR). METHODS: Ocular cyclotorsion was prospectively measured in 48 consecutive patients with superior oblique palsy. Four measurements were taken; 2 using 2 Maddox rods: (A) a red rod in front of the affected eye and a white rod in front of the fellow eye and (B) red rod in front of the sound eye and red in front of the affected eye. Two additional sets of measurements were taken using 1 red Maddox rod in front of 1 eye only, where horizontal lines in the room served as a reference: (C) the red rod in front of the affected eye and (D) the red rod in front of the sound eye. RESULTS: Mean ocular cyclotorsion in 48 patients was 6.7°, 6.8°, 6.6°, and 6.1° in measures A, B, C, and D, respectively. The agreement between A and C did not differ statistically, whereas the agreement between B and D was statistically different (P < 0.0001). There was high repeatability in both comparisons. CONCLUSIONS: Ocular cyclotorsion may be measured using a single Maddox rod instead of two. It is simpler to conduct than the DMR.

Slit-lamp exophthalmometry, a novel technique.

PURPOSE: Exophthalmometry is clinically important for diagnoses, follow-up, and treatment decision-making. Through the years, several drawbacks and sources of error have been described when using Hertel and other exophthalmometers. METHODS: We describe a simple method of non-touch slit-lamp exophthalmometry. Comparing the results between Hertel and slit-lamp exophthalmometry on 60 patients with proptosis showed no statistically significant differences in the two methods. RESULTS: A total of 60 consecutive patients with proptosis were included. Thirty-six cases (60 %) were women. Their mean age was 55.6 ± 16.4 (median 57.5, range 20-87) years. Only 5 % of the measurements had more than 2 mm difference between the two techniques. There were no significant differences in the measurements between the two methods. Intra-correlation coefficient is 0.96 for right side and 0.956 for lest side. The Bland-Altman plot revealed good agreement. CONCLUSIONS: Slit-lamp exophthalmometry offers a simple, easily available, and reliable non-touch technique that does not require an exophthalmometer.

The correlation between visual acuity and color vision as an indicator of the cause of visual loss.

PURPOSE: To explore the correlation between visual acuity (VA) and color vision and to establish a guide for the diagnosis of the cause of visual loss based on this correlation. DESIGN: Retrospective comparative evaluation of a diagnostic test. METHODS: A total of 259 patients with visual impairment caused by 1 of 4 possible disease categories were included. Patients were divided into 4 groups according to the etiology of visual loss: 1) optic neuropathies, 2) macular diseases, 3) media opacities, and 4) amblyopia. The best-corrected VA was established and a standard Ishihara 15 color plates was tested and correlated to the VA in every group separately. Correlation between the VA and the color vision along the different etiologies was evaluated. Frequency of each combination of color vision and VA in every disease category was established. RESULTS: VA is correlated with color vision in all 4 disease categories. For the same degree of VA loss, patients with optic neuropathy are most likely and patients with amblyopia are the least expected to have a significant color vision loss. Patients with optic neuropathy had considerably worse average color vision (6.7/15) compared to patients in the other 3 disease categories: 11.1/15 (macular diseases), 13.2/15 (media opacities), and 13.4/15 (amblyopia). CONCLUSIONS: Diseases of the optic nerve affect color vision earlier and more profoundly than other diseases. When the cause of visual loss is uncertain, the correlation between the severity of color vision and VA loss can imply the possible etiology of the visual loss.

Diagnostic value of imaging in horner syndrome in adults.

BACKGROUND: The yield of imaging in Horner syndrome has been explored only in children. This study evaluates the yield of imaging in adults. METHODS: This was a retrospective cohort study of 52 patients with Horner syndrome examined in 2 neuro-ophthalmology hospital clinics. Patients were divided into 3 groups according to the ability to determine the etiology at the time of the first neuro-ophthalmology consultation: group I, etiology of Horner syndrome known at the initial neuro-ophthalmologic examination; group II, etiology of Horner syndrome not known at the initial neuro-ophthalmologic examination, but sufficient information obtained to allow targeted imaging; and group III, etiology of Horner syndrome not known at the initial neuro-ophthalmologic examination, and sufficient information not obtained to allow targeted imaging. The yield of investigation and the frequency of the different etiologies were evaluated. RESULTS: In 32 (62%) patients, the etiology was already known at the initial neuro-ophthalmologic examination (group I). The most prevalent etiology was surgical trauma. In 11 (21%) patients, a targeted imaging workup was possible, revealing an etiology in 7 patients (group II). Carotid dissection and cavernous sinus mass were the most common etiologies. In 9 (17%) patients, a nontargeted imaging evaluation was necessary, revealing an etiology in only 1 patient, who had a previously undetected thyroid malignancy (group III). CONCLUSIONS: The etiology of Horner syndrome is usually known at the time of initial presentation to a neuro-ophthalmologist. When the etiology is not known and clinical information permits a targeted imaging evaluation, an etiology can usually be determined, most commonly a cervical carotid artery dissection or a cavernous sinus mass. When the etiology is not known and clinical information is insufficient to allow a targeted imaging evaluation, an etiology is rarely discovered. Even so, nontargeted imaging is warranted because life-threatening lesions, such as thyroid malignancies, may rarely be detected.

A benign syndrome of transient loss of accommodation in young patients.

OBJECTIVE: To describe a benign condition of transient, isolated accommodation paralysis in young patients as a specific entity. DESIGN: Case series of children and young adults with transient loss of accommodation who were referred to the neuro-ophthalmology clinic at the Meir Medical Center from 1997 to 2006. Five young patients who complained of an inability to read had full neuro-ophthalmological examinations. Those who were found to have isolated accommodation paralysis without any other related ocular or systemic findings were prescribed reading glasses and followed up. RESULTS: All 5 patients had isolated loss of accommodation. No one had other ocular, neurological, or systemic abnormalities that could be associated with accommodation paralysis; they all did well with near correction. Accommodation returned to normal within 3 to 14 months in all 5 patients. CONCLUSION: An isolated transient loss of accommodation unrelated to any other ocular or systemic manifestations may occur in children and young adults and may be considered a specific idiopathic entity.

A new method for eyelid elevation in glaucoma patients with ptosis during automated perimetry testing.

PURPOSE: Ptosis is a well-recognized confounding factor when interpreting superior visual field defects. As the current technique for eyelid elevation during automated perimetry is cumbersome and inconsistent, we developed a new technique. To evaluate its efficacy and feasibility, we studied a group of glaucoma patients with ptosis and superior visual field defects that had been attributed to nerve fiber layer defects. PATIENTS AND METHODS: A 24-2 SITA-fast visual field was performed without eyelid elevation. Then, it was repeated either with elevation (group A, 14 eyes, 7 patients) or without (group B, 9 eyes, 5 patients). Elevation was achieved by the following method: a 4-0 silk suture (needle removed) was wrapped around a micropore strip, attached to the upper eyelid margin. Suture edges were pulled and attached to the forehead creating a slinglike elevation. Mean thresholds of upper and lower hemifields were calculated. Mean deviation and pattern standard deviation were recorded for each visual field. Results of the first and second tests were compared. RESULTS: Eyelid elevation resulted in significant improvement in mean thresholds for upper hemifield in group A: values increased by 28% in OD and 22% in OS. Lower hemifield values did not change. Significant improvement also was observed in mean deviation and pattern standard deviation. In group B, there were no significant differences between the 2 sets of tests. CONCLUSIONS: This new method of eyelid elevation significantly improves visual field testing by reducing the confounding effect of ptosis on interpretation of visual field defects in glaucoma patients.

[Optic disc drusen and acute vision loss].

Optic disc drusen (ODD) are calcified nodules within the optic nerve head. These are products of degenerated retinal ganglion cells axoplasmic transport, also known as hyaline or colloid bodies. They are mainly encountered as an incidental benign finding, or as a benign cause of swollen discs (in the differential diagnosis of papilledema). The majority of the patients are asymptomatic, and a slowly progressive sub-clinical visual field loss is found in about 80% of the patients. However, acute painless symptomatic visual field loss, occasionally massive, is rare. This is a case history of 4 patients who developed acute painless visual field loss which was attributed to optic disc drusen. The clinical features and proposed ischemic pathophysiology of acute vision loss and ODD are discussed.

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.

Plotting visual fields using contralateral fixation: a novel honeycomb device.

A device that maintains steady fixation while plotting the visual field of an eye with a large central defect is presented. The device is composed of multiple adjacent pinhole tubes mounted on an eye shield and placed in front of the seeing fellow eye. The device constricts the visual field of the fixating nontested eye to preserve only the central 3 degrees, thus not interfering with the visual field of the tested eye. We tested 3 healthy volunteers with simulated visual field defects and more than 100 patients with unilateral loss of central vision. The use of this device allowed us to plot visual field defects with clear-cut borders while no meaningful results could be obtained without it. We found this device to be efficient, simple to use, and suitable for all varieties of perimetry.

Visual outcome in eyes with asymptomatic optic disc edema.

BACKGROUND: Asymptomatic optic disc edema may last for months before conversion to anterior ischemic optic neuropathy (AION). Alternatively, the optic disc edema may resolve with preservation of normal vision. The conversion rate of asymptomatic optic disc edema to AION has not been prospectively studied. We prospectively followed patients with asymptomatic disc edema to determine this conversion rate. METHODS: The cohort was followed from 1991 to 2000 at a single ophthalmology clinic in Israel. There were 23 patients aged 47-74 years with asymptomatic disc edema and no signs of optic nerve dysfunction in whom the disc edema had been incidentally discovered on routine fundus examination performed for diabetes, hypertension, or follow-up after AION in the fellow eye. RESULTS: In 9 (36%) eyes, optic disc edema progressed to overt AION with a mean latency of 16.8 weeks (range 2-80 weeks). In 16 (64%) eyes, optic disc edema resolved without loss of vision with a mean latency of 15.5 weeks (range 4-44 weeks). The conversion rate to AION was 40% in patients who had had AION in the fellow eye, 31% in patients with diabetes, 43% in patients with diabetic retinopathy, and 0% in four amiodarone-treated patients. CONCLUSION: Asymptomatic disc edema generally resolves with no visual loss, but one third of patients progress to full-blown AION. Diabetes mellitus is common in patients with asymptomatic optic disc edema. Perhaps patients diagnosed as having diabetic papillopathy actually have an impending AION that does not progress to overt disease.

[Bilateral acute angle closure glaucoma following topiramate treatment].

We describe a case of bilateral acute angle closure glaucoma associated with oral topiramate therapy. A 64 year old woman developed bilateral acute angle closure glaucoma two weeks after beginning topiramate therapy for peripheral diabetic neuropathy. A topical and systemic anti-glaucomatous treatment were given and laser peripheral iridotomies were performed and, the intraocular pressure were stabilized. However, the anterior chambers remained very shallow and peripheral ciliochoroidal detachment was observed and confirmed echographically. Assuming that the mechanism of acute bilateral simultaneous angle closure glaucoma differs from the common pupillary block, and is related to external cause, the topiramate therapy was discontinued, and the patient was treated with cycloplegic agent and steroids. A gradual deepening of the anterior chamber and resolution of the choroidal edema were accompanied by improvement of visual acuity and corneal clarity. The presumed mechanism of drug related acute bilateral angle closure glaucoma is choroidal effusion and detachment associated with forward budging of the iris-lens diaphragm. This, in turn, causes a shallow anterior chamber and blockage of the ocular draining system.

Adie's tonic pupil-induced angle-closure glaucoma.

A 52-year-old woman was diagnosed as having Adie's tonic pupil in her right eye. She reported few episodes of blurring of vision in her right eye in the recent few months. On one of the routine follow-up visits, right intraocular pressure (IOP) was 70 mm Hg and on gonioscopy the angle was closed 360 degrees. Medical treatment resulted in IOP reduction and laser iridotomy was then performed. This is, to our knowledge, the first description of intermittent angle-closure glaucoma attacks induced by a tonic pupil. The possibility of angle-closure glaucoma should be considered in patients with a tonic pupil, especially with symptoms of blurred vision or ocular pain.