Differentiating mild papilledema and buried optic nerve head drusen using spectral domain optical coherence tomography.

PURPOSE: To evaluate the clinical utility of spectral domain optical coherence tomography (SD-OCT) in differentiating mild papilledema from buried optic nerve head drusen (ONHD). DESIGN: Comparative case series. PARTICIPANTS: Sixteen eyes of 9 patients with ultrasound-proven buried ONHD, 12 eyes of 6 patients with less than or equal to Frisén grade 2 papilledema owing to idiopathic intracranial hypertension. Two normal fellow eyes of patients with buried ONHD were included. METHODS: A raster scan of the optic nerve and analysis of the retinal nerve fiber layer (RNFL) thickness was performed on each eye using SD-OCT. Eight eyes underwent enhanced depth imaging SD-OCT. Images were assessed qualitatively and quantitatively to identify differentiating features between buried ONHD and papilledema. Five clinicians trained with a tutorial and masked to the underlying diagnosis independently reviewed the SD-OCT images of each eye to determine the diagnosis. MAIN OUTCOME MEASURES: Differences in RNFL thickness in each quadrant between the 2 groups and diagnostic accuracy of 5 independent clinicians based on the SD-OCT images alone. RESULTS: We found no difference in RNFL thickness between buried ONHD and papilledema in any of the 4 quadrants. Diagnostic accuracy among the readers was low and ranged from 50% to 64%. The kappa coefficient of agreement among the readers was 0.35 (95% confidence interval, 0.19-0.54). CONCLUSIONS: We found that SD-OCT is not clinically reliable in differentiating buried ONHD and mild papilledema.

Untreated bilateral optic nerve sheath meningiomas observed for 27 years.

A 48-year-old woman noted progressive, painless visual loss in her left eye. She was diagnosed with bilateral optic nerve sheath meningiomas (ONSMs), extending across the planum sphenoidale. Radiation was offered, but the patient declined. She has been followed for more than 27 years with stable visual function and neuroimaging findings. Bilateral ONSMs, although usually described as aggressive in nature, may follow a stable clinical course.

Primary dural lymphoma masquerading as a meningioma.

A 39-year-old woman noted progressive blurred vision in the right eye for 1 year. The right eye had visual acuity of 20/25, an afferent pupillary defect, pale optic nerve, and cecocentral scotoma. Magnetic resonance imaging findings were consistent with en plaque meningioma of the planum sphenoidale, which encircled the right optic nerve at the optic canal. The tumor was internally debulked to preserve the optic nerve. Histopathologic and molecular analysis revealed a low-grade B-cell lymphoma. Further evaluation showed no evidence of systemic disease. Primary dural lymphomas are a distinct entity that may mimic meningioma and cause vision loss.

Visual field staging systems in glaucoma and the activities of daily living.

PURPOSE: To compare 8 clinically relevant methods of staging visual field (VF) damage in glaucoma with a performance-based measure of the activities of daily living and self-reported quality of life. DESIGN: Prospective cross-sectional study. METHODS: One hundred ninety-two patients with various types of glaucoma were evaluated at the Wills Eye Institute using standard monocular and binocular VF testing, as well as an objective, performance-based measure of visual function (the Assessment of Disability Related to Vision), and a subjective, standardized measure of quality of life (the 25-item National Eye Institute Visual Function Questionnaire). Binocular VFs were scored according to the Esterman and Integrated VF Systems. Monocular VFs were scored according to the mean defect, pattern standard deviation, Hodapp-Parrish-Anderson method, glaucoma staging system, glaucoma staging system 2, and the field damage likelihood scale. Partial Spearman correlations between VF staging systems, Assessment of Disability Related to Vision scores, and 25-item National Eye Institute Visual Function Questionnaire scores were calculated. RESULTS: Assessment of Disability Related to Vision scores and 25-item National Eye Institute Visual Function Questionnaire scores were associated most closely with the VF score in the better eye and the binocular VF scoring systems. CONCLUSIONS: The amount of binocular VF loss and the status of the better eye most accurately predict functional ability and quality of life in glaucoma.

Bilateral oculomotor synkinesis following Miller Fisher syndrome.

A 64-year-old female presented with ptosis, ophthalmoplegia, ataxia, and weakness. She was diagnosed with Miller Fisher syndrome (MFS) and was treated with plasmapheresis. Six months later, she developed bilateral oculomotor synkinesis, suggesting aberrant regeneration. The pathogenesis of MFS is reviewed in light of this unusual finding.

Intravitreal triamcinolone acetonide preceding photodynamic therapy for exudative age-related macular degeneration.

BACKGROUND AND OBJECTIVE: To evaluate the efficacy of intravitreal triamcinolone acetonide 1 week before photodynamic therapy (PDT) with verteporfin in the treatment of exudative age-related macular degeneration (AMD). PATIENTS AND METHODS: Retrospective chart review of 70 eyes of 66 consecutive patients who were treated with intravitreal triamcinolone acetonide followed by standard PDT 1 week later. Group 1 consisted of 42 eyes that received one or more previous treatments with PDT alone and responded poorly. Group 2 consisted of 28 eyes that had never received PDT. RESULTS: No statistically significant change in mean visual acuity was seen during the follow-up period for either group. At 12 months, 90% of group 1 eyes and 80% of group 2 eyes lost less than 2 lines of Snellen visual acuity. A mean of 1.24 additional PDT sessions were required in group 1 eyes and 1.04 additional sessions in group 2 eyes during the follow-up period. CONCLUSION: In eyes with exudative AMD, intravitreal triamcinolone acetonide preceding PDT with verteporfin results in stabilization of visual acuity and a decreased need for re-treatments with PDT. This regimen may be superior to PDT monotherapy.

The temporal sequence of combined intravitreal triamcinolone acetonide and photodynamic therapy for exudative age-related macular degeneration.

BACKGROUND AND OBJECTIVE: To compare visual acuity results in patients with exudative age-related macular degeneration treated with two different temporal sequences of combination intravitreal triamcinolone acetonide and photodynamic therapy with verteporfin. PATIENTS AND METHODS: A retrospective, comparative, interventional case series was used. Thirty-one eyes received intravitreal triamcinolone acetonide 1 week prior to photodynamic therapy, and 30 eyes received intravitreal triamcinolone acetonide followed by photodynamic therapy the same day. RESULTS: There was no significant difference in visual acuity between the groups at baseline (P = .084), 6 to 12 weeks of follow-up (P = .085), or 1 year of follow-up (P= .093). When visual acuity outcomes were adjusted for baseline visual acuity, spot size, lesion type, age, and gender, there was no significant difference in visual acuity at 6 to 12 weeks (P = .44) or 1 year (P= .28). CONCLUSIONS: There appears to be no significant difference in visual outcomes in eyes with exudative age-related macular degeneration treated with intravitreal triamcinolone acetonide 1 week prior to photodynamic therapy or those treated with intravitreal triamcinolone acetonide on the same day as photodynamic therapy.

Current visual and anatomic outcomes of pneumatic retinopexy.

PURPOSE: To assess current visual and anatomic outcomes of pneumatic retinopexy (PR) for the repair of rhegmatogenous retinal detachment (RD). METHODS: Retrospective chart review of 150 patients who underwent PR for RD between January 2000 and February 2005. Patients with a history of scleral buckling, Lincoff balloon, or proliferative diabetic retinopathy in the same eye were excluded. RESULTS: Successful reattachment was achieved in 76.7% with a single procedure and 98.7% after additional procedures. A total of 17.3% underwent a subsequent procedure for a new or persistent tear. The success rate remained consistent in pseudophakic and aphakic eyes, and eyes with traumatic detachments, macular detachment, multiple breaks, poor preoperative visual acuity (VA) (<20/50), superior and inferior lattice degeneration, >or=6 clock hours of detachment, and prior pars plana vitrectomy. A total of 2.7% of eyes underwent a second additional procedure for RD. A total of 32% of males versus 15.3% of females underwent an additional procedure for RD (P = 0.07). Final VA >or=20/50 was achieved in 80.8% of macula-on and 73.6% of macula-off RDs. Of eyes that underwent an additional procedure, final VA >or=20/50 was achieved in 63.2% of macula-on and 43.8% of macula-off RDs, and those with macula-on RD lost a mean of 1.79 (+/-4.9) lines of Snellen VA, while those with macula-off RD gained a mean of 5.6 (+/-4.6) lines (P = 0.00006). CONCLUSIONS: : PR had a high anatomic success rate in eyes with a wide variety of complicated RDs. Male sex may be a risk factor for failed PR. Careful monitoring and treatment of postoperative tears is important in preventing redetachment.