Inflammatory optic neuropathies.

Inflammatory optic neuropathies are common in clinical practice. Monosymptomatic optic neuritis has important implications for the development of multiple sclerosis. In the patient presenting with monosymptomatic optic neuritis, MR imaging provides critical prognostic information concerning the development of MS. The ONTT provided valuable information regarding the natural history and therapy of optic neuritis. Oral prednisone alone is contraindicated in the treatment of optic neuritis because of its association with increased recurrence rate of optic neuritis. Intravenous methylprednisolone remains a viable treatment option to slightly increase the rate of recovery and provide a degree of short-term protection against the subsequent development of MS. Other inflammatory optic neuropathies include sarcoidosis, neuroretinitis, and Devic's disease with each possessing distinct clinical characteristics and treatment approaches.

Sixth nerve palsy as a presenting sign of intracranial plasmacytoma and multiple myeloma.

Multiple myeloma and plasmacytoma are rare causes of mass lesions at the skull base and cavernous sinus. Sixth nerve palsy, in isolation or in combination with other cranial neuropathies, may occur rarely as the initial presenting feature of multiple myeloma. We report the neuro-ophthalmologic, radiologic, and pathologic findings for two patients who developed sixth nerve palsies as an initial manifestation of intracranial plasmacytoma and multiple myeloma. One patient presented with an isolated sixth nerve palsy in the setting of multiple vasculopathic risk factors. Treatable skull base lesions, including plasmacytoma and multiple myeloma, must be considered in patients with sixth nerve palsies, especially among those who demonstrate a progressive course or multiple cranial neuropathies.

Horner's syndrome after posterior spinal fusion in a child: a case report.

STUDY DESIGN: A case report of a complication after posterior spinal fusion. OBJECTIVES: To present the clinical findings of a Horner's syndrome after posterior spinal fusion. SUMMARY OF BACKGROUND DATA: A 14-year-old girl underwent posterior spinal fusion for idiopathic scoliosis. METHODS: Clinical examination and pharmacologic pupillary testing were used to diagnose Horner's syndrome. RESULTS: After surgery, the patient developed a left-sided Horner's syndrome. The Horner's syndrome had resolved 6 months after surgery except for slight ptosis. CONCLUSIONS: This is the first reported case of Horner's syndrome occurring after posterior spinal fusion without the use of epidural analgesia.

Ocular motility review for 1997-1998: part II.

Each year brings new scientific knowledge that builds on itself in a geometric fashion. Ocular motility basic and clinical neurosciences continue to advance with this accelerating pace. The years 1997 and 1998 brought new knowledge to the motility world. This review focuses on the clinical advances within this realm. Part I of this review appeared in the June 2000 (20:2) issue.

Ocular motility review for 1997-1998: part I.

Each year brings new scientific knowledge that builds on itself in a geometric fashion. Ocular motility basic and clinical neurosciences continue to advance with this accelerating pace. The years 1997 through 1998 brought new knowledge to the motility world. This review focuses on the clinical advances within this realm, presented in supranuclear to myopathic organization. Part II of this review will appear in the September 2000 (20:3) issue.

Homonymous visual field defects in patients without corresponding structural lesions on neuroimaging.

Homonymous visual field defects usually occur with structural processes affecting retrochiasmal visual pathways. The responsible lesion is usually evident on magnetic resonance imaging or on other neuroimaging studies. When results of neuroimaging are normal, functional illness is often suspected. The authors report four patients with homonymous visual field defects who presented with no evident corresponding lesion on magnetic resonance or computed tomography imaging. Etiologies for the visual field defects included the Heidenhain variant of Creutzfeldt-Jacob disease, degenerative dementia, subtle occipital ischemia demonstrated only on positron-emission tomography scanning, and nonketotic hyperglycemia. Clinicians should be aware of the alternative etiologies of organic homonymous visual field loss in patients with normal neuroimaging.

Internuclear ophthalmoplegia after coronary artery catheterization and percutaneous transluminal coronary balloon angioplasty.

A retrospective chart review was performed for identification of patients with isolated internuclear ophthalmoplegia (INO) postcardiac catheterization from two neuro-ophthalmology units. Of the 110 patients with a diagnosis of INO who were evaluated during the observation period, five patients (4.5%) demonstrated relatively isolated INO occurring in the perioperative period of a cardiac endovascular procedure. These five patients underwent diagnostic catheterization alone (three patients), balloon angioplasty (one patient), or stent placement (one patient). All patients improved, with resolution of diplopia in primary position after a mean period of 82 days. The occurrence of INO in the postcardiac catheterization setting is not uncommon, and it appears to be related to dorsal pontine ischemia. The pontomesencephalic medial longitudinal fasciculus is supplied by small-caliber perforating end-arteries from the basilar trunk, which increases selective vulnerability of this area. Cardiac catheterization may precipitate microemboli involving these vessels, leading to internuclear ophthalmoplegia.

Optic nerve enhancement on magnetic resonance imaging in arteritic ischemic optic neuropathy.

Although optic nerve enhancement may be seen in magnetic resonance imaging of radiation-induced ischemic optic neuropathy, similar enhancement in ischemic optic neuropathy has not been previously reported in the English-language neuroophthalmologic literature. We report three cases of optic nerve enhancement in biopsy-proven arteritic ischemic optic neuropathy. Clinicians should consider giant cell arteritis in the differential diagnosis of an optic neuropathy with optic nerve enhancement on magnetic resonance imaging.

Isolated trochlear nerve palsy in patients with multiple sclerosis.

The authors describe five patients with trochlear nerve palsy and MS to characterize this rare association. In two patients, trochlear nerve palsy was the initial clinical manifestation of MS. In the other three patients, this sign occurred after previous neurologic events. MRI did not identify a lesion of the fourth nerve nucleus or fascicle. Ophthalmoplegia resolved within 2 months in four of the five patients. A reason this association is rare is that the fascicular course of the trochlear nerve is exposed to little myelin.

An ice test for the diagnosis of myasthenia gravis.

OBJECTIVE: To determine whether ice application to a ptotic eyelid can differentiate myasthenic from nonmyasthenic ptosis. DESIGN: Prospective, multicenter, nonrandomized, comparative trial. PARTICIPANTS: Twenty patients with myasthenia gravis (MG) and ptosis were evaluated in the neuro-ophthalmology service. CONTROL SUBJECTS: Twenty patients with nonmyasthenic ptosis evaluated in the same locale. METHODS: Palpebral fissures were measured before and immediately after a 2-minute application of ice to the ptotic eyelid. MAIN OUTCOME MEASURES: The difference in palpebral fissures in millimeters before and after ice application. Two or more millimeters of improvement after ice application was considered a positive ice test result. RESULTS: A positive ice test result was noted in 16 of the 20 (80%) patients with MG and in none of the 20 patients without MG (P < 0.001). Of the 4 patients with MG and complete ptosis, 3 had a negative ice test result. CONCLUSIONS: The ice test is a simple, short, specific, and relatively sensitive test for the diagnosis of myasthenic ptosis. The sensitivity of the ice test in patients with complete ptosis decreases considerably.

Minocycline treatment and pseudotumor cerebri syndrome.

PURPOSE: To demonstrate the association between minocycline treatment and development of the pseudotumor cerebri syndrome. METHODS: A retrospective study was conducted of 12 patients from five neuro-ophthalmic referral centers who developed pseudotumor cerebri syndrome after being treated with standard doses of minocycline for refractory acne vulgaris. The main outcome measures included resolution of headaches, transient visual obscurations, diplopia, papilledema, and visual fields static thresholds after withdrawal of minocycline and treatment for increased intracranial pressure. RESULTS: Nine (75%) of the 12 patients developed symptoms of the pseudotumor cerebri syndrome syndrome within 8 weeks of starting minocycline therapy; six were not obese. Two patients developed symptoms only after a year had elapsed because of commencement of treatment with minocycline. One patient was asymptomatic, and pseudotumor cerebri syndrome was diagnosed by finding papilledema on routine examination 1 year after minocycline was started. None of the patients developed recurrences for at least 1 year after the discontinuation of minocycline and treatment for increased intracranial pressure, but three (25%) of the 12 patients had substantial residual visual field loss. CONCLUSION: Minocycline is a cause or precipitating factor in pseudotumor cerebri syndrome. Although most patients have prominent symptoms and are diagnosed promptly, others are asymptomatic and may have optic disk edema for a long period of time before diagnosis. Withdrawal of minocycline and treatment for increased intracranial pressure lead to resolution of the pseudotumor cerebri syndrome, but visual field loss may persist.

Progressive visual loss from giant cell arteritis despite high-dose intravenous methylprednisolone.

BACKGROUND: Giant cell arteritis (GCA) often presents with devastating visual loss in the elderly, yet the ideal treatment is unknown. The disease most often has been treated with oral prednisone, although recently the use of the high-dose intravenous methylprednisolone (IVMP) has been reported to enhance visual recovery. METHODS: The authors reviewed patient charts from two university-based neuroophthalmology services and reviewed all previously reported cases of GCA treated with IVMP. RESULTS: Four patients with GCA exhibited severe, progressive visual loss after at least 48 hours of high-dose IVMP. A fifth patient had further visual loss in one eye and improvement in the other eye after 24 hours of IVMP. In previous reports of IVMP treatment in GCA, four patients lost vision and 14 patients recovered vision. The authors review the details of these reports. CONCLUSIONS: The results of IVMP treatment of patients with visual loss from GCA are similar to the results of treatment with oral corticosteroids, with IVMP treatment being more costly and having a small risk of sudden death. The optimal dosage and route of corticosteroid treatment for GCA with visual loss remain elusive and warrant a treatment trial.

Infective endocarditis--a photo essay.

Infective endocarditis is a microbial affliction of the heart valves or endocardium. Subacute bacterial endocarditis (SBE) may result from infection with low-virulence organisms such as Streptococcus viridans and Staphylococcus epidermidis, or partially treated infection. We report a case of SBE with neuro-ophthalmologic manifestations.

Lumboperitoneal shunt for the treatment of pseudotumor cerebri.

We conducted a retrospective study of 27 patients with pseudotumor cerebri (PTC) treated with at least one lumboperitoneal shunt (LPS) to ascertain the efficacy of this treatment. The average duration of follow-up for this population was 77 months (median, 47 months), with a range of 21 to 278 months. A functioning LPS was successful in alleviating symptoms in all patients studied, and no patient with a functioning shunt complained of shunt-related symptoms, such as low-pressure headache or abdominal pain, within 2 months after the shunt was performed. Twelve patients (44%) required no revisions. The number of revisions among the 15 patients (56%) who required them ranged from 1 (5 patients) to 13 (1 patient). Three of these patients required 35 of the 66 total shunt revisions (53%). There were no major complications from LPS, other than failure of the shunt, even in patients who required multiple shunts. We conclude that placement of a lumboperitoneal shunt is satisfactory treatment for the majority of patients with PTC who require surgical therapy for the disorder, even though some patients ultimately require multiple shunt revisions.

Glioblastoma multiforme masquerading as pseudotumor cerebri. Case report.

A 16-year-old girl developed headaches and bilateral papilledema while taking minocycline for acne. The initial neuro-ophthalmologic evaluation was normal except for enlarged blind spots OU. An MRI scan demonstrated subtle abnormalities. A lumbar puncture was entirely normal except for an increased opening pressure. A tentative diagnosis of pseudotumor cerebri was made and the patient was treated with Diamox. A second MRI was unchanged, and a lumbar puncture performed while the patient was taking Diamox was entirely normal. The patient subsequently lost vision in both eyes, and a third MRI now revealed a supracellar enhancing mass. Biopsy and subtotal resection of the mass showed it to be a glioblastoma multiforme. This case emphasizes pitfalls in the diagnosis of pseudotumor cerebri. Careful follow-up and a high index of suspicion in pseudotumor cerebri syndromes are essential.

Pediatric Miller Fisher syndrome requiring intubation: a case report.

In 1956, C. Miller Fisher described a clinical syndrome of ophthalmoplegia, ataxia, and areflexia. This syndrome, which now bears his name, shares certain features with the Guillain-Barré syndrome (GBS) and generally follows a benign, restricted clinical course, especially in the pediatric population. The authors report a pediatric case of Miller Fisher syndrome (MFS) who subsequently required intubation and mechanical ventilation.