Clinical Reasoning: Wilbrand's Knee, Scotoma of Traquair, and Normal Tension Glaucoma.

An otherwise healthy 63-year-old woman was given a diagnosis of normal tension glaucoma (NTG) in the right eye (OD) 2 months before presentation. Standard computerized perimetry showed a unilateral right hemianoptic temporal field defect. On examination visual acuity was preserved, intraocular pressure was normal, there was a right relative afferent pupillary defect (RAPD) with an asymmetric cupping of the disc, but no pallor. Brain magnetic resonance imaging (MRI) showed a meningioma compressing the right optic nerve at its junction with the chiasm. Compressive disorders on the anterior chiasm, albeit rarely, may cause cupping of the disc and unilateral temporal visual field defect (junctional scotoma of Traquair) with normal visual acuity that should be considered in the differential diagnosis of NTG.

Optical Coherence Tomography Angiography in Chiasmitis.

A 29-year-old girl presented complaining of acute bilateral visual loss associated with mild headache and retrobulbar pain. She was diagnosed with chiasmal optic neuritis caused by multiple sclerosis. Her visual acuity and visual field defect promptly improved after steroid therapy. However optical coherence tomography angiography showed a progressive reduction of superficial capillary plexus density of the retina and optic nerve consistent with the progressive impairment of the retinal ganglionar cell layer. Contrary to chiasmal compression, in chiasmal optic neuritis, the superficial capillary plexus density reduction is diffuse and does not reflect the peculiar anatomy of the chiasm.

A Case of Spontaneous Bilateral Direct Carotid-Cavernous Fistula.

A 92-year-old female with poorly controlled systemic hypertension presented with bilateral eye redness, lid fullness, conjunctival chemosis, ophthalmoplegia, and ptosis for two days. A neuro-ophthalmic evaluation revealed bilateral proptosis, severe conjunctival chemosis and congestion, and an almost complete bilateral ophthalmoplegia with a complete right superior eyelid ptosis. Computed tomography (CT) scans demonstrated bilateral dilation of the superior ophthalmic veins, and a CT angiography (CTA) showed a direct high-flow carotid-cavernous fistula (CCF) with secondary extraocular muscle enlargement. Clinicians should be aware that a typical direct high-flow CCF, although usually occurs after trauma and unilaterally, can present spontaneously without trauma and bilaterally.

Intraocular Tuberculosis: A Challenging Case Mimicking Wet Age-Related Macular Degeneration.

An otherwise healthy 72-year-old Chinese patient diagnosed with exudative age-related macular degeneration and decreased vision in left eye was fully investigated. The retrospective analysis of past multimodal imaging revealed bilateral severe choroidal neovascularization and choroiditis associated with a positive tuberculin skin testing and interferon-gamma release assay (QuantiFERON-TB Gold - Cellestis®, Chadstone, VIC, Australia) suggestive of latent ocular tuberculosis. The variable presentation and tests' results interpretation represent the greatest limitations in understanding and treating intraocular TB (IOTB). This may present without any other systemic symptoms, the intraocular tissues are of limited access to biopsies and other tests, including imaging and immunological tests, are of relative value. This case highlights how variable may be the presentation of IOTB, which can be easily misdiagnosed leading to a delayed treatment and worse prognosis.

Suprasellar meningioma presenting with glaucomatous type cupping.

PURPOSE: To describe a case of a suprasellar meningioma compressing the chiasm from below and producing a unilateral fascicular (nasal) visual field defect that mimicked glaucomatous cupping. CASE REPORT: A 78-year-old man presented with painless, progressive, unilateral arcuate visual field defect. He was diagnosed with "normal tension glaucoma" based on an asymmetric cup to disc ratio. Despite treatment with anti-glaucoma drops, the visual field defect progressed. Neurophthalmic evaluation was consistent with a compressive optic neuropathy OD. Brain MRI showed a suprasellar meningioma compressing on the junction of the optic nerve and chiasm from below. CONCLUSION: Although junctional visual field loss (e.g. junctional scotoma and junctional scotoma of Traquair) are well-known presentations of compressive lesions at the optic chiasm, we describe a monocular, ipsilateral compressive superior nasal defect and asymmetric cupping as the presenting sign of a junctional compressive lesion mimicking glaucomatous cupping.

Conjunctival findings in hyperbaric and low-tension glaucoma: an in vivo confocal microscopy study.

PURPOSE: To analyse the epithelial features of the bulbar conjunctiva in hyperbaric and low-tension glaucoma (LTG) using in vivo confocal microscopy (IVCM). METHODS: Thirty-six eyes of 36 patients [18 affected by primary open-angle glaucoma (POAG) and 18 with LTG] were studied; control group was constituted by 28 eyes of 28 healthy subjects. All eyes were examined using digital confocal laser-scanning microscopy (HRT II Rostock Cornea Module). The main IVCM outcome measurements were mean density (MMD: cysts/mm(2)) and mean total area (MMA: µm(2)) of the epithelial microcysts. RESULTS: The mean intraocular pressure level (mmHg ± SD) was 15.1 ± 1.7, 16.3 ± 3.1 and 12.6 ± 1.8 in healthy, POAG and LTG eyes, respectively. Conjunctival microcysts were found in all patients and subjects: for healthy subjects, MMD = 10.9 ± 11.1 cysts/mm(2) and MMA = 1501.9 ± 1191.1 µm(2); for patients infected with POAG, MMD = 36.8 ± 28.6 cysts/mm(2) and MMA = 7904.8 ± 7050.5 µm(2); and for patients infected with LTG MMD = 45.6 ± 29.0 cysts/mm(2) and MMA =7946.9 ± 5227.5 µm(2). MMD and MMA were not significantly different between patients infected with POAG and those with LTG, whereas they were significantly greater in patients (fourfold and fivefold, respectively) than healthy subjects. CONCLUSIONS: The present study demonstrated that conjunctival microcysts represent an in vivo feature in all eyes with medically controlled POAG and LTG. Therefore, conjunctiva deserves careful analysis, because its accurate microscopic definition could help clarify the pathophysiology of aqueous outflow in glaucoma.