Síndrome de Parinaud 'plus' en paciente con disgerminoma / Parinaud 'plus' syndrome in a patient with dysgerminoma

CASI CLÍNICO: Varón de 33 años con síndrome de Parinaud, exotropía y atrofia óptica del OI postpapiledema. Tras las pruebas de neuroimagen y biopsia estereotáxica se diagnostica de germinoma pineal. Recibe quimio y radioterapia con respuesta completa del tumor. El síndrome de Parinaud persiste un año después del diagnóstico, y rechaza la corrección del estrabismo. DISCUSIÓN: El síndrome de Parinaud consiste en una parálisis supranuclear de la mirada vertical por daño deltectum mesencefálico. El compromiso de las estructuras adyacentes da lugar al síndrome de Parinaud «plus». Ante un síndrome de Parinaud acompañado de diplopía (síndrome de Parinaud «plus») se debe pensar en la extensión de la lesión a otras áreas adyacentes

CLINICAL CASE: A 33-year-old male diagnosed with Parinaud's syndrome, exotropia and post-papillary oedema optic atrophy in his left eye. A pineal germinoma was diagnosed after performing neuroimaging scans and a stereotactic biopsy. He was treated with chemotherapy and radiotherapy, showing a complete pathological response. The Parinaud's syndrome persists one year after diagnosis and the patient has refused to have strabismus surgery. DISCUSSION: Parinaud's syndrome consists of a supranuclear vertical gaze palsy resulting from damage to the midbrain tectum. The involvement of adjacent structures leads to the «Parinaud-plus» syndrome. When a Parinaud's syndrome is accompanied by diplopia («Parinaud-plus» syndrome), extension of the injury into adjacent areas must be considered

Central Microscotoma: A Rare Presentation of Epiretinal Membranes.

BACKGROUND AND OBJECTIVE: Patients with a symptomatic epiretinal membrane (ERM) typically complain of metamorphopsia and decreased visual acuity. We describe three patients who presented with the single complaint of a central microscotoma due to ERM, an infrequent initial symptom of this entity. PATIENTS AND METHODS: This is a retrospective, interventional, non-comparative case series. Three patients with the chief complaint of a central microscotoma related to ERMs who underwent pars plana vitrectomy by a single surgeon experienced full resolution of the preoperative microscotoma. Best-corrected visual acuity, fundus photography, and optical coherence tomography were obtained at each examination. A comprehensive neuro-ophthalmologic evaluation was performed in all cases, including magnetic resonance imaging of the orbits and brain, automated visual fields, multifocal electroretinography, multifocal visually evoked potentials, and blood tests. RESULTS: Three eyes of three patients who presented with the initial sole complaint of a central microscotoma due to ERM are included in this series. A comprehensive neuro-ophthalmologic evaluation ruled out non-retinal etiologies. After months of observation, a pars plana vitrectomy with ERM and internal limiting membrane peeling was performed in all patients. Postoperatively, the patients experienced a complete resolution of their initial, isolated complaint of a central microscotoma. CONCLUSION: Central microscotoma, as a rare stand-alone presentation of ERM, is described. This symptom resolved after a successful removal of the ERM. A greater awareness among clinicians that ERMs may present in this manner may help avoid excessive and costly medical evaluations.

YAG Laser Membranotomy for Subinternal Limiting Membrane Hemorrhage.

PURPOSE: To report the use of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser internal limiting membranotomy to successfully treat the first reported case of subinternal limiting membrane (sub-ILM) hemorrhage that developed after coil embolization of a cerebral aneurysm. CASE REPORT: A 59-year-old Korean woman visited our clinic complaining of central scotoma in her left eye, which developed shortly after stent-assisted coil embolization of an unruptured internal carotid artery aneurysm. Fundus examination revealed a sub-ILM hemorrhage in her left eye, and after 2 days, a Nd:YAG laser membranotomy was performed with a single 4.5-mJ burst. There was a marked reduction in the sub-ILM hemorrhage 1 day after Nd:YAG laser membranotomy, and after 1 month, her best-corrected visual acuity improved to 20/20, with complete resolution of the sub-ILM hemorrhage. CONCLUSIONS: Sub-ILM hemorrhage can develop after coil embolization of a cerebral aneurysm, and Nd:YAG laser internal limiting membranotomy can be a useful noninvasive treatment alternative to surgical intervention.

[Field of view changes after vitreomacular surgery: a treatment quality criteria].

The study enrolled 177 patients that had been admitted to the Research Institute of Eye Diseases of the Russian Academy of Medical Sciences for diagnostics and treatment - 134 patients with idiopathic macular hole and 43 patients with epiretinal fibrosis. All vitreomacular surgeries were performed between 2005 and 2011. Visual field defects were seen in all groups and were classified as either peripheral or paracentral, or concentric. The groups differed by the rate and the localization of the visual field defects. A direct relation between the severity of iatrogenic retinal damage, the extent of postoperative retinal thinning and the presence/type of visual field defects was established. Causes and risk factors of visual field loss after vitreomacular surgery have been identified and analyzed. Preventive measures for this complication have been proposed. Treatment efficacy varied depending on the causes. Acute peripheral visual field loss--"tunnel phenomenon"--as a result of significant iatrogenic local retinal damage during vitreomacular surgery has been described.

Trabeculectomy in the management of glaucomatocyclitic crisis with visual field defect.

PURPOSE: To investigate the effect of trabeculectomy in the management of glaucomatocyclitic crisis with uncontrolled intraocular pressures (IOPs) and visual field defects. METHODS: Trabeculectomy was performed in 8 patients (2 males and 6 females) who had unilateral glaucomatocyclitic crisis with uncontrolled intraocular pressure (IOP) and visual field defects. After the surgeries the patients were followed up for 30.00 +/- 17.24 (mean +/- SD, the same below) months with best-corrected visual acuity (BCVA) and IOP measurements, keratic precipitates (KP), bleb and anterior chamber exams, and visual field tests. RESULTS: Preoperative IOP of these patients was 50.13 +/- 4.58 mmHg. By the end of follow-up, IOP in all patients was reduced to normal level (14.63 +/- 2.33 mmHg) without any anti-glaucoma medications. Three patients had type I blebs, and 5 patients had type II blebs. Six patients had no recurrent attacks during the entire follow-up period, while recurrent anterior uveitis was observed in the other 2 patients (2 and 3 times, respectively). No visual acuity loss or further visual field loss was found in any of these patients at the end of follow-up. CONCLUSIONS: Trabeculectomy is a safe and effective method for the management of glaucomatocyclitic crisis with uncontrolled IOPs and visual field defects.

Extracción quirúrgica de la neovascularización coroidea peripapilar en pacientes jóvenes / Surgical removal of peripapillary choroidal nevascularization in young patients

Propósito: Analizar el resultado anatómico y visual después de la cirugía subretiniana de la neovascularización coroidea (NVC) peripapilar no asociada a Degeneración Macular Asociada a la Edad (DMAE). Métodos: Se estudiaron retrospectivamente cinco ojos de cinco pacientes con NVC (neovascularización coroidea) tratados mediante cirugía subretiniana. Resultados: La media de edad de los pacientes fue de 32 años (rango de 11 a 49, DE 14,5 años) y la media del seguimiento fue de 31,4 meses (rango de 8 a 48 , DE 20,8 meses). La Mejor agudeza visual corregida antes de la cirugía fue de 0,05 (rango de 0,001 a 0,16, DE 0,07) y de 0,64 (rango de 0,2 a 0,9, DE 0,26) después de la cirugía (p= 0,005; t de Student para datos pareados). No hubo incidencias intraoperatorias ni postoperatorias. Conclusiones: La cirugía de extracción de membranas debe ser considerada entre las opciones terapéuticas para tratar la NVC peripapilar no relacionada con DMAE

Purpose: To analyze anatomical and visual outcomes after subretinal surgery for peripapillary choroidal neovascularization (CNV) not associated with age-related macular degeneration (AMD). Methods: Five eyes from five patients with peripapillary CNV who had been treated by subretinal surgery were retrospectively analyzed. Results: The patients averaged 32 years of age (range, 11 to 49, SD 14.5 years) and mean follow-up was 31.4 months (range, 8 to 48, SD 20.8 months). Best corrected visual acuity was 0.05 (range, 0.001 to 0.16, SD 0.07) before surgery and 0.64 (range, 0.2 to 0.9, SD 0.26) after surgery (p=0.005; Student´s t test for paired data). Neither intraoperative nor postoperative incidences occurred. Conclusions: Surgical removal may be considered one of the therapeutic options to treat peripapillary CNV not related to AMD (Arch Soc Esp Oftalmol 2009; 84: 39-42)

Optic neuritis is nothing to sneeze at.

A 36-year-old man developed acute visual loss, mimicking an optic neuritis in the left eye. Cranial magnetic resonance imaging revealed a sphenoid sinus mucocele with extension into the anterior clinoid process abutting the left optic nerve. Endoscopic marsupialization of the mucocele led to marked improvement of vision. Sphenoid sinus mucocele is discussed, as is the differential diagnosis of optic neuritis.

Resolution of macular scotoma after radial optic neurotomy in central retinal vein occlusion.

Radial optic neurotomy was performed on a hypertensive 65-year-old man with decreased vision in the right eye secondary to ischemic central retinal vein occlusion. Three months later, his visual acuity improved to 20/50. There was improvement in disc and macular edema, and reduction in retinal hemorrhages clinically and angiographically. Liquid crystal display microperimetry revealed improvement in fixation stability and macular sensitivity. Radial optic neurotomy appears to be an effective treatment alternative for selected patients with ischemic central retinal vein occlusion, and results in rapid improvement in visual acuity, central fixation, and macular scotoma as measured by a liquid crystal display microperimeter. Liquid crystal display microperimetry is a good and reliable alternative to the scanning laser ophthalmoscope for macular perimetry.

Macular changes after peeling of the internal limiting membrane in macular hole surgery.

PURPOSE: To report the incidence of macular changes following pars plana vitrectomy with peeling of the internal limiting membrane (ILM) for idiopathic macular hole. DESIGN: Prospective consecutive series. METHODS: In a prospective study 105 eyes of 105 patients underwent vitrectomy for idiopathic macular holes. Surgery consisted of a standard three-port vitrectomy, induction of a posterior hyaloid detachment, removal of epiretinal membranes including the ILM, fluid-air exchange and intraocular gas tamponade (15% hexafluoroethane (C2F6) gas mixture) followed by head-down positioning for at least five days. No adjuvants were used during surgery. In addition to the clinical examination, static microperimetry using a Rodenstock scanning laser ophthalmoscope (SLO-105) was performed pre- and 6 or 12 weeks postoperatively. The stimulus size was 0.2 degrees (Goldmann II), intensities employed were 0 and 12 dB. For all tests, 20-degree fields were used. RESULTS: Anatomic closure of macular holes was achieved in 92 (87.6%) of 105 patients by one operation. Eight patients underwent a successful second procedure. The closure rate after two operations was 95.2%. Best corrected visual acuity increased from a median of 0.2 (range 0.05 to 0.5) preoperatively to a median of 0.5 (range 0.05 to 1.0) postoperatively. Anatomical macular changes were found in 8 (7.6%) patients: There were two cases of macular edema following secondary cataract extraction and six cases of retinal pigment epithelium changes. Formation of postoperative epiretinal membranes or late reopenings were not noted. Small, mostly asymptomatic paracentral scotomata were seen in 59 (56.2%) of 105 patients. CONCLUSION: Anatomical changes of the macula following vitrectomy with removal of the ILM are infrequent. However, paracentral scotomata observed in our series might be caused by a trauma to the nerve fibers during ILM peeling. To achieve reliable results a standardized procedure for microperimetry should be developed.

Visual fields after removal of subretinal hemorrhages and neovascular membranes in age-related macular degeneration.

BACKGROUND: Surgical removal of subretinal hemorrhaging and membranes in eyes with age-related macular degeneration is feasible from a technical point of view, but no advantage over the spontaneous course of the disease has been proven. Visual acuity usually does not improve much. A realistic aim of surgical intervention may be diminution of the central scotoma size, which has not been studied. METHOD: In a prospective study visual fields were measured preoperatively and 6 weeks and 6 months postoperatively in eyes operated on for subretinal hemorrhages and membranes in exudative age-related macular degeneration. The OCTOPUS 1-2-3 program glx, which tests the visual field of 60 degrees diameter at 59 points, was used. Changes in the total size of areas with sensitivity loss of 10-20 dB (= relative scotoma) and > 20 dB (= absolute scotoma) were interpreted as surgical effect. Patients with postoperative retinal detachment or neovascular recurrence were excluded. 30 eyes of 29 patients were enrolled (mean age 75.3 years, 11 male, 18 female) and divided into 3 groups: 14 eyes with massive subretinal hemorrhage of diameters > 30 degrees; 12 eyes with hemorrhages of 10 degrees-30 degrees; 4 eyes with mere neovascular membranes < 10 degrees. RESULTS: (1) The visible area of damage is diminished by surgery (P < 0.01). The reduction for lesions > 30 degrees is 80%; for lesions between 10 degrees and 30 degrees the improvement is 43%. For lesions < 10 degrees there is no significant change. (2) The absolute scotoma size diminishes in all three groups (P = 0.05). The reductions are 63%, 57% and 21%, respectively. (3) Areas of absolute scotoma do not regain full function but are converted to relative scotoma depth, at best. Therefore, in the > 30 degrees group an overall increase (P < 0.01) of the relative scotoma size is observed. (4) The mean sensitivity in the 60 degrees field enhances by 1.6 dB (average over 30 eyes, P = 0.04). (5) Mean preoperative visual acuities were 0.03, 0.12 and 0.17, respectively, with no significant change after surgery. The power of testing is sufficient (0.93) to reject an increase of acuity from 0.12 to 0.2 in group 2. CONCLUSIONS: For hemorrhagic subretinal lesions of diameter > 10 degrees a relevant reduction of central scotoma size is achieved by surgery. The final benefit for the patients depends on the frequency of surgical complications and neovascular recurrence.

Nd:YAG laser posterior hyaloidotomy for the treatment of a premacular vitreous floater.

A 63-year old man, with a large central vitreous floater, underwent a Nd:YAG laser posterior hyaloidotomy. Although the vitreous floater disappeared from the central optical axis, visual acuity did not improve. Microperimetry performed with the SLO revealed an absolute scotoma, which corresponded well in shape and dimension with the original vitreous floater. This finding suggests that a fragment of the neurosensory retina became detached together with the internal limiting membrane in the process of the vitreous collapse.

[Fundus oriented microperimetry with the scanning laser ophthalmoscope in age-induced macular degeneration]. / Fundus-orientierte Mikroperimetrie mit dem Scanning-Laser-Ophthalmoskop bei der altersbedingten Makuladegeneration.

The indication of laser therapy of subretinal neovascularization is based on the visual acuity and the localization and extension of subretinal membranes. However, laser therapy based on these guide-lines, repeatedly leads to disappointing results as functional effects of neovascularizations on the central visual field and fixation are not considered. With fundus-controlled scanning laser microperimetry we examined light sensitivity and fixation in areas of subretinal neovascularization of 33 patients suffering from beginning (n = 8), advanced (n = 17) or hemorrhagic (n = 8) neovascularization in age-related macular degeneration. 14 out of 17 patients with signs of advanced and all patients with hemorrhagic neovascularization had absolute scotoma in the affected area. In each of the patients suffering from beginning neovascularization we found relative scotomas and preserved central fixation, even in subfoveal membrane localization. The role of scanning laser microperimetry in the indication of laser therapy in age-related macular degeneration is discussed.

Resolution of an absolute scotoma and improvement of relative scotomata after successful macular hole surgery.

Visual loss in eyes with full-thickness macular holes is thought to be caused by the absence of retinal function in the area of the neurosensory defect as well as reduction in retinal function in the surrounding area of neurosensory retinal detachment. To improve characterization of the visual function of eyes after successful macular hole surgery, we studied six eyes preoperatively and postoperatively with macular microperimetry using the scanning laser ophthalmoscope. Best-corrected visual acuity was improved postoperatively in all eyes. Microperimetry performed preoperatively demonstrated an absolute scotoma that corresponded to the neurosensory defect in all eyes, with surrounding concentric isopters of relative scotomata. No detectable absolute scotoma was found in any eye postoperatively. All eyes showed partial or complete resolution of the surrounding relative scotomata. Improvements in visual acuity after successful macular hole surgery may be related to disappearance of a detectable absolute scotoma as well as improvement in the surrounding retinal function.

Asymmetric papilledema and visual loss in pseudotumour cerebri.

We report the case of a 26 year old obese woman who presented with intermittent headaches and blurred vision in her left eye (OS) and on clinical examination had an enlarged visual field blind spot OS with OS disc edema. After an extensive neurologic work up including two nondiagnostic lumbar punctures, a clinical diagnosis of OS anterior ischemic optic neuropathy was made. Gradual progression of visual field loss OS prompted reassessment of the diagnosis and intracranial pressure was confirmed to be markedly elevated by usage of a subarachnoid monitoring bolt, thus establishing the diagnosis of pseudotumour cerebri. An optic nerve sheath fenestration was performed OS with subsequent reversal of the progressive visual field loss.