Interventions for Indirect Traumatic Optic Neuropathy: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head. METHODS: A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis. RESULTS: No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage. CONCLUSIONS: Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.

Ophthalmologic evaluation of severely obese patients undergoing bariatric surgery: A pilot, monocentric, prospective, open-label study.

PURPOSE: The aim of this study was to investigate the pathogenic role of obesity on blinding eye diseases in a population of severely obese patients with no history of eye diseases, and to verify whether weight loss induced by bariatric surgery may have a protective effect. METHODS: This was a pilot, monocentric, prospective, and open label study conducted at the University Hospital of Pisa. Fifty-seven severely obese patients with a mean body mass index value of 44.1 ± 6 kg/m2 were consecutively recruited and received a complete ophthalmological evaluation and optical coherence tomography. Twenty-nine patients who underwent gastric bypass were evaluated also 3 months, and 1 year after surgery. RESULTS: At baseline, blood pressure value were directly and significantly related to intraocular pressure values (p<0.05, R = 0.35). Blood pressure values were also significantly and inversely related to retinal nerve fiber layer thickness, particularly in the temporal sector (RE p<0.05 r-0.30; LE p<0.01, R = -0.43). Moreover, minimum foveal thickness values were significantly and inversely associated with body mass index (RE p<0.02, R = -0.40; LE p<0.02, R = -0.30). A significant reduction of body mass index (p<0.05) and a significant (p<0.05) improvement of blood pressure was observed three months and one year after gastric bypass, which were significantly associated with an increase in retinal nerve fiber layer thickness and minimum foveal thickness values in both eyes (p<0.05). CONCLUSIONS: The results of this study suggest that obese patients may have a greater susceptibility to develop glaucomatous optic nerve head damage and age-related macular degeneration. Moreover, weight reduction and improvement of comorbidities obtained by bariatric surgery may be effective in preventing eye disease development by improving retinal nerve fiber layer and foveal thickness.

Improved immunohistochemical detection of phosphorylated mitogen-activated protein kinases in the injured rat optic nerve head.

The activity of mitogen-activated protein kinases (MAPKs) is largely controlled by addition or removal of phosphate groups, which are carried out by kinase or phosphatase enzymes, respectively. Determining the phosphorylation status of MAPK isoenzymes, therefore, aids elucidation of the physiological and pathological roles of this enzyme. In practical terms, however, end-point procurement of appropriate experimental tissues produces conditions where MAPK phosphorylation status can rapidly alter, thus giving rise to aberrant data. We therefore attempted to instigate a means of stabilising end-point MAPK phosphorylation levels when procuring tissues for analysis. We employed a well-described rat model of ocular hypertension in which MAPK isoenzyme activation occurs in the optic nerve head (ONH), but can vary according to the level of resultant tissue pathology. Animals were appropriately treated and after 3 days were perfused in the presence or absence of a cocktail of phosphatase inhibitors (PIs), immediately prior to tissue fixation, in order to prevent dephosphorylation of phosphorylated MAPKs. Immunohistochemical labelling for phosphorylated MAPKs in untreated ONH sections was unaffected by the presence of PIs in the perfusate. MAPK activation was detected by immunohistochemistry in the treated ONH, but findings varied considerably, particularly in animals with less extensive tissue damage. The presence of PIs in the perfusate, however, significantly reduced this variation and enabled consistent changes to be detected, particularly in the animals with less extensive tissue damage. Thus, the addition of PIs to the perfusate is suggested when studying MAPK activation by immunohistochemistry, especially in the ONH.

Optic nerve avulsion associated with central retinal artery occlusion following rotational globe injury.

Avulsion of the optic nerve head is a rare and severe complication of ocular blunt trauma. Herein, we describe a case of 16-year-old boy, who presented with a rare combination of optic nerve avulsion associated with central retinal artery occlusion, following blunt trauma with a leather ball. This report highlights the potential blinding complication following rotational injury.

Subconjunctival hemorrhage and vision loss after regional ocular anesthesia.

PURPOSE: To report two cases of retinal vascular occlusion and associated subconjunctival hemorrhage in needle optic nerve injury during local bulbar anesthesia. METHODS: Surgical records of these two subjects who presented with acute vision loss after cataract extraction were studied, and systemic workup and ocular imaging were carried out to establish the cause. RESULTS: Computerized tomography showed evidence of optic nerve injury. CONCLUSION: Subconjunctival hemorrhage could be an associated clinical finding in hypodermic needle injury-related retinal vascular occlusion during ocular anesthesia.

Melanocitoma de la cabeza del nervio óptico en un adulto joven / Melanocytoma of the optic nerve head in a young adult

Se describe el caso clínico de un paciente de 34 años edad que en abril de 2012 asistió a la consulta de retina del Hospital General Docente "Dr. Juan Bruno Zayas" de Santiago de Cuba por presentar, desde hacía 3 meses aproximadamente, disminución progresiva de la visión en el ojo izquierdo. Los resultados de los exámenes oftalmológicos y complementarios efectuados confirmaron el diagnóstico de melanocitoma de la cabeza del nervio óptico

The case report of a 34 years patient that attended the retina service of "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital in Santiago de Cuba in April, 2012 is described. He had for 3 months approximately, progressive vision decrease in the left eye. The results of the ophthalmologic and complementary tests confirmed the diagnosis of melanocytoma of the optic nerve head

SD-OCT para distinguir papiledema de seudopapiledema / SD-OCT to distinguish papilledema from pseudopapilledema

CASOS CLÍNICOS: Se describen los casos de 2 pacientes con cefalea y edema de papila bilateral. La paciente 1 tenía un papiledema (P) con presión intracraneal de 32 cmH2O. La paciente 2 tenía migraña con seudopapiledema (PP) (drusas del nervio óptico). La SD-OCT fue utilizada para estudiar la morfología del disco óptico, el espacio hiporeflectivo subretiniano (EHS) y el ángulo alfa (Aα). DISCUSIÓN: La SD-OCT de papila óptica puede ser útil para diferenciar su morfología en P y PP. El EHS y el Aα fueron mayores en el paciente con P que en el paciente con PP

CASES REPORT: Two patients presented with headache and bilateral papillary edema. Patient 1 was found to have a papilledema (P) with intracranial pressure of 32 cmH2O. Patient 2 was found to have a migraine with a pseudopapilledema (PP) (optic nerve head drusen). SD-OCT was used to image the optic disc, subretinal hyporeflective space (SHS), and alpha-angle (Aα). DISCUSIÓN: Optic disc SD-OCT may be useful for differentiating disc morphology in P and PP. The area of the SHS and the Aα were higher in the P patient than in the patient with PP

Altered Expression Levels of MMP1, MMP9, MMP12, TIMP1, and IL-1ß as a Risk Factor for the Elevated IOP and Optic Nerve Head Damage in the Primary Open-Angle Glaucoma Patients.

The aim of presented work was to analyze the impact of particular polymorphic changes in the promoter regions of the -1607 1G/2G MMP1, -1562 C/T MMP9, -82 A/G MMP12, -511 C/T IL-1ß, and 372 T/C TIMP1 genes on their expression level in POAG patients. Blood and aqueous humor samples acquired from 50 patients with POAG and 50 control subjects were used for QPCR and protein levels analysis by ELISA. In vivo promoter activity assays were carried on HTM cells using dual luciferase assay. All studied subjects underwent ophthalmic examination, including BCVA, intraocular pressure, slit-lamp examination, gonioscopy, HRT, and OCT scans. Patients with POAG are characterized by an increased mRNA expression of MMP1, MMP9, MMP12, and IL-1ß genes as compared to the control group (P < 0.001). Aqueous humor acquired from patients with POAG displayed increased protein expression of MMP1, MMP9, MMP12, and IL-1ß compared to the control group (P < 0.001). Allele -1607 1G of MMP1 gene possesses only 42,91% of the -1607 2G allele transcriptional activity and allele -1562 C of MMP9 gene possesses only 21,86% of the -1562 T allele. Increased expression levels of metalloproteinases can be considered as a risk factor for the development of POAG.

Comparative findings in childhood-onset versus adult-onset optic disc pit maculopathy.

PURPOSE: To compare the clinical characteristics of eyes with childhood-onset to those with adult-onset optic disc pit maculopathy. METHODS: Twenty-seven eyes of 25 patients with optic disc pit maculopathy were reviewed. The clinical characteristics, clinical history including a history of blunt trauma, ophthalmoscopic evaluations and intraoperative findings in the childhood-onset (age <15 years, four eyes of four patients) cases were compared with those in the adult-onset (≥15 years, 23 eyes of 21 patients) cases of optic disc pit maculopathy. The strength of the vitreous adhesions was graded by what was required to create a posterior vitreous detachment (PVD); grade 1 = with vitreous cutter, grade 2 = by microhook or forceps and grade 3 = by forceps with removal of remnants of Cloquet's canal. RESULTS: The incidence of visual impairments following blunt trauma was significantly higher in childhood-onset (three of four eyes) than that of adult-onset (0 of 23 eyes, p = 0.0014). Vitreous surgery with creation of a PVD was performed in the four childhood-onset eyes and 18 adult-onset eyes after an absence of a spontaneous resolution. The grade of the vitreous adhesions was significantly higher in childhood-onset than in adult-onset eyes (p = 0.0096). CONCLUSIONS: An ocular trauma may provide an opportunity to detect optic disc pits. However, childhood-onset optic disc pit maculopathy was noted most commonly following blunt ocular trauma in eyes with a strong vitreous adhesion to the optic disc margin.

[Posterior approach for foreign body removal from optic nerve head. Case report].

A technique of foreign body removal from optic nerve head performing an external approach and optic nerve transection is described. After 3 months of follow-up cosmetic result is satisfactory and there are no surgery related complications.

Complicaciones tras queratoplastia endotelial: tres años de experiencia / Complications after endothelial keratoplasty: three years of experience

ObjetivoExaminar las complicaciones tras queratoplastia endotelial automatizada con disección de la membrana de Descemet (DSAEK).MétodosRevisión retrospectiva de 75 cirugías de DSAEK en 67 pacientes con distrofia endotelial de Fuchs o queratopatía bullosa realizadas en el Instituto de Oftalmología La Arruzafa desde marzo de 2007 hasta marzo de 2010. En 30 casos se asoció facoemulsificación e implante de LIO. Todas las complicaciones intraoperatorias y postoperatorias fueron registradas, además de la densidad celular endotelial.ResultadosLa dislocación del disco fue la complicación más frecuente: 17 casos (22,5%); 16 se resolvieron con la reintroducción de aire en cámara anterior. La tasa de desprendimiento del injerto fue del 50% en los 8 ojos sin soporte capsular. En 5 casos se produjo un fracaso primario del injerto y en 2 (2,6%) el injerto ha fracasado a medio plazo; solo tenemos un caso de rechazo endotelial (1,3%). Cinco ojos (6,5%) desarrollaron un bloqueo pupilar postquirúrgico que se resolvió tras la extracción del aire. Un ojo (1,3%) con rotura capsular posterior durante la cirugía desarrolló al año un desprendimiento de retina. La pérdida celular media fue del 42,75%.ConclusionesDSAEK ha demostrado ser un tratamiento efectivo para la disfunción endotelial; sin embargo no está exenta de complicaciones. La dislocación del disco es la complicación más frecuente siendo resuelta tras la reintroducción de aire en la mayoría de los casos. Existe una curva de aprendizaje y el traumatismo intraoperatorio es un factor relacionado con la pérdida endotelial(AU)

ObjectiveTo study the complications after Descemet's stripping automated endothelial keratoplasty (DSAEK).MethodsRetrospective study of 75 eyes in 67 patients with Fuchs’ endothelial dystrophy or bullous keratopathy operated on in the Instituto de Oftalmología La Arruzafa from March, 2007 until March, 2010. Phacoemulsification and IOL implantation was involved in 30 cases. All surgical and post-surgical complications, as well as the endothelial cell density were recorded.ResultsGraft detachment was the most common complication: 17 cases (22.5%); 16 of them resolved with reintroduction of air in the anterior chamber. The rate of detachment in cases without capsular support (8 eyes) increased up to 50%. Five cases had primary graft failure and, in 2 cases, a medium term failure was observed. Only one case of endothelial rejection was observed (1.3%). Five eyes (6.5%) developed a pupillary block, but of them were solved with the aspiration of the air. In one eye (1.3%), a posterior capsule rupture was observed during the phacoemulsification. This case ended with a retinal detachment. The endothelial cell loss was 42.75%.ConclusionsDSAEK is an effective surgical technique to resolve the corneal oedema due to endothelial failure; however, complications are not uncommon. Graft detachment is the most common complication, but is usually resolved with re-bubbling. There is an evident learning curve and the surgical trauma to the endothelium is the most important factor that influences the endothelial cell loss(AU)

The optic nerve head is the site of axonal transport disruption, axonal cytoskeleton damage and putative axonal regeneration failure in a rat model of glaucoma.

The neurodegenerative disease glaucoma is characterised by the progressive death of retinal ganglion cells (RGCs) and structural damage to the optic nerve (ON). New insights have been gained into the pathogenesis of glaucoma through the use of rodent models; however, a coherent picture of the early pathology remains elusive. Here, we use a validated, experimentally induced rat glaucoma model to address fundamental issues relating to the spatio-temporal pattern of RGC injury. The earliest indication of RGC damage was accumulation of proteins, transported by orthograde fast axonal transport within axons in the optic nerve head (ONH), which occurred as soon as 8 h after induction of glaucoma and was maximal by 24 h. Axonal cytoskeletal abnormalities were first observed in the ONH at 24 h. In contrast to the ONH, no axonal cytoskeletal damage was detected in the entire myelinated ON and tract until 3 days, with progressively greater damage at later time points. Likewise, down-regulation of RGC-specific mRNAs, which are sensitive indicators of RGC viability, occurred subsequent to axonal changes at the ONH and later than in retinas subjected to NMDA-induced somatic excitotoxicity. After 1 week, surviving, but injured, RGCs had initiated a regenerative-like response, as delineated by Gap43 immunolabelling, in a response similar to that seen after ON crush. The data presented here provide robust support for the hypothesis that the ONH is the pivotal site of RGC injury following moderate elevation of IOP, with the resulting anterograde degeneration of axons and retrograde injury and death of somas.

Sistemas de análisis digital de imágenes en el glaucoma / Systems of imaging digital systems in case of glaucoma

A la luz del desarrollo tecnológico actual incorporado a la Oftalmología, no se concibe el seguimiento riguroso del Glaucoma sin el uso de los sistemas de análisis digital de imágenes de la papila y de la capa de fibras neurorretinianas. Se realiza una revisión bibliográfica sobre los aportes de la Polarimetría Láser de Barrido (GDx VCC, Carl Zeiss Meditec, Dublin, CA), la Tomografia Confocal Láser (Heidelberg Retina Tomograph HRT, Heidelberg Engineering Inc.) y la Meditec, Alemania) en el diagnóstico y seguimiento del Glaucoma. Se considera que las mensuraciones objetivas brindadas deben ser incorporadas de forma eficiente e intuitiva para sacarles el máximo de provecho en beneficio de los pacientes(AU)

Now a day we can´t consider the strict follow up in Glaucoma without the use of the digital analysis of image system of the optic nerve head and the retinal nerve fiber layer. This is a review about some contributions of Scanning Laser Polarimetry (GDx VCC, Carl Zeiss Meditec, Dublin, CA), Confocal Scanning Laser (Heidelberg Retina Tomograph HRT, Heidelberg Engineering Inc.) and Optical Coherence Tomography (Stratus OCT, Carl Zeiss Meditec, Alemania) in the diagnosis and follow up of Glaucoma. It´s considered that objective measurement giving by them must be incorporate in the rigorous analysis of each glaucomatous patient(AU)

Sistemas de análisis digital de imágenes en el glaucoma / Systems of imaging digital systems in case of glaucoma

A la luz del desarrollo tecnológico actual incorporado a la Oftalmología, no se concibe el seguimiento riguroso del Glaucoma sin el uso de los sistemas de análisis digital de imágenes de la papila y de la capa de fibras neurorretinianas. Se realiza una revisión bibliográfica sobre los aportes de la Polarimetría Láser de Barrido (GDx VCC, Carl Zeiss Meditec, Dublin, CA), la Tomografia Confocal Láser (Heidelberg Retina Tomograph HRT, Heidelberg Engineering Inc.) y la Meditec, Alemania) en el diagnóstico y seguimiento del Glaucoma. Se considera que las mensuraciones objetivas brindadas deben ser incorporadas de forma eficiente e intuitiva para sacarles el máximo de provecho en beneficio de los pacientes.

Now a day we can´t consider the strict follow up in Glaucoma without the use of the digital analysis of image system of the optic nerve head and the retinal nerve fiber layer. This is a review about some contributions of Scanning Laser Polarimetry (GDx VCC, Carl Zeiss Meditec, Dublin, CA), Confocal Scanning Laser (Heidelberg Retina Tomograph HRT, Heidelberg Engineering Inc.) and Optical Coherence Tomography (Stratus OCT, Carl Zeiss Meditec, Alemania) in the diagnosis and follow up of Glaucoma. It´s considered that objective measurement giving by them must be incorporate in the rigorous analysis of each glaucomatous patient.

[Traumatic optic neuropathy]. / Traumatische Optikusneuropathie.

Traumatic optic neuropathy is a severe complication of a head or face trauma. Diagnosis is established by analyzing pupillary responses to light. Fundus examination and orbital CT scan help to localize the site of the lesion and may show a fracture involving the optic canal. Surgical decompression or megadose steroids are therapeutic options. No therapeutic approach has proven with sufficient evidence to be effective. Spontaneous improvement is definitely possible. Based on experiences in single cases direct compression of the optic nerve by bone fragments or optic nerve sheath haemorrhage are as a rule treated surgically. In all other cases usually high dose steroids are given without proven effectiveness.

Optic disc laceration with combined retinal artery and vein occlusion following penetrating injury.

Ocular trauma is a major cause of unilateral blindness and male adults in the working age group have been found to have higher rates of ocular injury. A case of a work-related penetrating ocular trauma with an intraocular foreign body causing an optic disc laceration and consequently a combined retinal arterial and venous occlusion is presented. The patient did not recover useful vision despite early surgical intervention. This case highlights an unusual sequelae following penetrating ocular trauma as well as the importance of safety eyewear for individuals in high-risk occupations.

Thermal injury induces heat shock protein in the optic nerve head in vivo.

PURPOSE: To investigate the induction of heat shock protein (Hsp)70 in the optic nerve head by localized laser application in transpupillary thermotherapy (TTT). METHODS: TTT was performed on the right eye of Norwegian brown rats with an 810-nm diode laser installed on a slit lamp biomicroscope. The laser was aimed at the center of the optic nerve head with a 50-microm spot size. Various exposures (range, 60-200 mW) were used with an exposure duration of 60 seconds, and the various exposure durations (range, 1-5 minutes) were used with a power of 100 mW. Twenty hours after laser irradiation, immunohistochemical staining and Western blot analyses were performed. For morphologic analysis of the optic nerve head, confocal scanning laser ophthalmoscopy and scanning electron microscopy were performed. RESULTS: In the control eyes, Hsp70 was detected minimally in the optic nerve tissues by immunohistochemistry. After TTT, Hsp70 in the optic nerve tissue was induced more than in the control eyes. By Western blot, Hsp70 expression was found to increase progressively after TTT as the power was increased, but it also decreased slightly at powers >140 mW. The optimal setting of TTT without tissue damage was determined to be 100 mW for 60 seconds. CONCLUSIONS: Transpupillary laser irradiation of the optic nerve head induces Hsp70 expression. This result can be applied to the neuroprotective experiments in glaucoma by enhancement of a natural cytoprotective stress response.

Escleritis posterior: a propósito de un caso / Posterior scleritis: a purpose of a case

Se valora paciente femenino de 30 años de edad, quien presenta en ojo derecho dolor ocular profundo y disminución de la agudeza visual de un mes de evolución presentando pliegues retinales en 360º en área macular y edema del disco, se le realiza ecografía y se sugiere el diagnóstico de escleritis posterior; por lo que se indica prednisolona tópica al 1% e ibuprofeno vía oral, con mejoría del cuadro clínico. La escleritis posterior es una patología infrecuente, que se presenta en mujeres de edad media, con una variedad de presentación clínica que puede ser enmascarada por múltiples patologías del segmento posterior y puede estar asociada a enfermedades sistémicas, como Artritis Reumatoidea y enfermedad de Wegener, sobre todo en mayores de 60 años. La ecografía es el estudio más útil para su detección y seguimiento, y el tratamiento está basado en analgésicos no esteroideos, corticoesteroides sistémicos e inmunosupresores en casos de poca respuesta. Se ha evidenciado una recurrencia de hasta un 40%. En el caso presentado la escleritis posterior parece ser del tipo idiopática.

Ocular complications of boxing.

OBJECTIVES: To investigate the prevalence of ocular injuries in a large population of boxers over a period of 16 years, in particular, the most severe lesions that may be vision threatening. METHODS: Clinical records of the medical archive of the Italian Boxing Federation were analysed. A total of 1032 boxers were examined from February 1982 to October 1998. A complete ophthalmological history was available for 956, who formed the study population (a total of 10 697 examinations). The following data were collected: age when started boxing; duration of competitive boxing career (from the date of the first bout); weight category; a thorough ocular history. The following investigations were carried out: measurement of visual acuity and visual fields, anterior segment inspection, applanation tonometry, gonioscopy, and examination of ocular fundus. Eighty age matched healthy subjects, who had never boxed, formed the control group. RESULTS: Of the 956 boxers examined, 428 were amateur (44.8%) and 528 professional (55.2%). The median age at first examination was 23.1 (4.3) years (range 15-36). The prevalence of conjunctival, corneal, lenticular, vitreal, ocular papilla, and retinal alterations in the study population was 40.9% compared with 3.1% in the control group (p< or =0.0001). The prevalence of serious ocular findings (angle, lens, macula, and peripheral retina alterations) was 5.6% in boxers and 3.1% in controls (NS). CONCLUSIONS: Boxing does not result in a higher prevalence of severe ocular lesions than in the general population. However, the prevalence of milder lesions (in particular with regard to the conjunctiva and cornea) is noteworthy, justifying the need for adequate ophthalmological surveillance.