Predictors of Visual Acuity and Usefulness of a Treatment Algorithm in Rhinogenous Optic Neuritis.

Rhinogenous optic neuritis, which causes neuropathy associated with visual dysfunction, greatly reduces patient quality of life and requires suitable early treatment. This study aimed to analyze visual outcome predictors in patients with rhinogenous optic neuritis and to develop and investigate the usefulness of an algorithm to facilitate early treatment. Prospective and retrospective investigations were conducted at the Department of Otorhinolaryngology. The visual outcomes after sinus surgery of 24 of 53 patients suspected of having rhinogenous optic neuritis were analyzed. Furthermore, the usefulness of the treatment algorithm was evaluated in 27 of these 53 patients. Data from 24 patients who underwent surgery were included in a multiple regression analysis to investigate the associations between visual outcomes and concomitant symptoms and the time from symptom onset to surgery. The mean time from the initial examination to a request for otorhinolaryngological examination to assess the usefulness of the treatment algorithm was compared in 27 patients who did not undergo an initial otorhinolaryngological examination. Visual acuity improved in 23 participants who underwent surgery. Multivariate analysis identified the time from onset to surgery and headache as significant predictors of postoperative visual acuity. The mean time from the initial examination to a request for otorhinolaryngological examination was significantly shorter after the algorithm was introduced (1.13 days, 8 patients; P = .008). Early surgical treatment is essential to avoid further postoperative visual acuity decreases in patients with rhinogenous optic neuritis. Patients who experience headache may have poorer postoperative outcomes.

Rhinogenous optic neuritis with full recovery of vision - The role of endoscopic optic nerve decompression and a review of literature.

BACKGROUND: Optic neuritis resulting from paranasal sinusitis is an infrequently described but clinically important and treatable entity. The role of optic nerve decompression has been well established in atraumatic optic neuropathies which are compressive in origin. However, its role in optic neuritis and other infective or inflammatory processes is lacking, and the role for early surgical intervention remains controversial. CASE REPORT: In this case report, we describe a patient who presented with sudden onset of right vision loss secondary to optic neuritis from pansinusitis. He was treated with systemic antibiotics and steroids along with an urgent endoscopic sinus surgery with optic nerve decompression. Full restoration of his vision was recorded within 24 h of surgical decompression. CONCLUSION: Optic neuritis secondary to paranasal sinusitis is a clinically important entity and timely diagnosis and decompression is key to vision restoration.

Optic neuropathy and decorticate-like posture as presenting symptoms of Bickerstaff's brainstem encephalitis: A case report and literature review.

A 72-year-old woman with a 10-day history of bilateral visual impairment after respiratory tract infection showed decorticate-like posture and progressive deterioration of consciousness leading to coma. Ophthalmoplegia was also noted and anti-GQ1b antibodies were positive, consistent with Bickerstaff's brainstem encephalitis. After intravenous immunoglobulin and steroid pulse therapy, her consciousness gradually improved. However, severe visual impairment at the level of hand motion was noticed, which gradually normalized after second steroid pulse therapy. Atypical findings including optic neuropathy and decorticate-like posture can be seen in patients with Bickerstaff's brainstem encephalitis, and early diagnosis is essential for adequate management.

Optic Canal Decompression With Unexpected Changes in Cerebrospinal Fluid of the Optic Canal.

Optic neuritis is a common inflammatory disease of the optic nerve. And the cerebral spinal fluid (CSF) in the subarachnoid space of optic nerve is thought to be homogeneous as in spine. We report a case of optic neuritis, some unexpected opaque fluid observed to flow out from the optic canal during the optic canal decompression surgery when the CSF in spine is normal. One day after the surgery, the visual acuity of the patient improved dramatically to 0.4 from 0.05. This report highlights the possible restrictive pathological changes of the CSF in the optic nerve of acute optic neuritis, which may be the reason of the dysfunction of the optic nerve.

[Clinical research on nasal endoscopic surgery for rhinogenous optic function damage].

OBJECTIVE: To explore the surgical treatment of rhinogenous optic function damage (ROFD) through transnasal endoscopic approach. METHODS: Twenty-three patients (25 eyes) with ROFD were retrospectively reviewed. All patients were operated on through transnasal endoscopic approach, and 9 patients underwent endoscopic optic nerve decompression. RESULTS: Four patients had bilateral pansinusitis, 6 patients had unilateral posterior ethmoidal sinusitis and sphenoiditis. One patient had frontal and ethmoidal sinusitis. Five patients had fungal sinusitis occurred in the sphenoid sinus and unilateral posterior ethmoid sinus. Two patients had unilateral pyocyst and cyst of the sphenoid and ethmoid sinus. The preoperative visual acuity preoperative were as follows: 2 patients (2 eyes) no light perception (NLP), 6 patients (7 eyes) hand movement (HM), 7 patients (7 eyes) fingers counting (FC) less than 20 cm and 8 patients (9 eyes) were vision impaired in different degree. One patient (1 eye) was ophthalmoptosis, direct and indirect light reflex vanished. Three patients (3 eyes) diplopia, 2 patients (2 eyes) abduction paralysis, 3 patients (3 eyes) defect of visual field. One patient ptosis of upper lid. The visual acuity postoperative: 2 eyes failed, 10 eyes cured;13 eyes improved from HM or FC to FC (30-60 cm). CONCLUSIONS: The endoscopic sinus surgery combined with appropriate medical therapy are effective to ROFD. Patients who suffered from severe visual damage and either unresponsive or intolerant to medical treatment should be administrated endoscopic sinus surgery including endoscopic optic nerve decompression.

Diagnostic pitfall: optic neuritis mimicking optic nerve glioma.

We report a case of optic neuritis with enlargement of the optic nerve on MRI. This neuroradiological finding is most commonly seen in tumours of the optic nerve and led together with an inconclusive intraoperative frozen section to an incorrect tentative diagnosis of optic nerve glioma which fatally resulted in the resection of the optic nerve.

[Intraocular pressure after treatment for thyroid-associated ophthalmopathy]. / Presión intraocular post-tratamiento de la oftalmopatía tiroidea.

OBJECTIVE: To evaluate the change in the intraocular pressure (IOP) in subjects with thyroid-associated orbitopathy (TAO) treated with orbital decompression, extraocular muscle surgery or methylprednisolone pulse therapy. METHODS: The charts of 31 subjects with TAO who visited in our department between 1998 and 2004 were analyzed. Subject age, gender, diagnosis and treatment for glaucoma, use of systemic steroids, procedure performed and pre-operative and post-operative IOP in the primary position and in upgaze, were all evaluated. RESULTS: Of the 20 eyes that underwent orbital decompression, the mean pre-operative IOP was 17.35 (3.86 SD) mmHg and 22.45 (6.36 SD) mmHg in upgaze. The post-operative IOP was 14.24 (3.43 SD) mmHg and 18.20 (4.74 SD) mmHg in upgaze. The mean pre-operative IOP in the 10 eyes who had strabismus surgery was 18.9 (3.07 SD) mmHg and 22.4 (6.14 SD) mmHg in upgaze. The post-operative IOP was 16.6 (3.50 SD) mmHg and 18.6 (3.33 SD) mmHg in upgaze. In the 12 patients treated with methylprednisolone pulse therapy, the mean pre-treatment IOP was 21.33 (6.42 SD) mmHg and 24.45 (8.15 SD) mmHg in upgaze. After the treatment the mean IOP was 17.33 (4.38 SD) mmHg and 20.08 (4.86 SD) mmHg in upgaze. In subjects with a pre-operative IOP>or=21 mmHg or in treatment for glaucoma we observed a greater reduction in IOP (p<0.005). CONCLUSIONS: We have observed a significant reduction in IOP in the three groups of patients after treatment for TAO, however no significant difference was found between the methods used.

Optic nerve sheath fenestration for a reversible optic neuropathy in radiation oncology.

To the authors' knowledge, there is a paucity of published accounts of management of radiation-induced optic neuropathy (RION) by optic nerve sheath fenestration (ONSF) in the conventional medical literature. With higher doses of radiation being given by using conformal techniques, more radiation-induced optic neuritis and neuropathy will be identified. We report here the successful use of ONSF to restore vision to three consecutive patients with pending anterior RION, and the importance of early identification and intervention in these potentially reversible cases.

[Subfrontal approach in sellar and suprasellar lesions]. / Acesso sub-frontal a lesões selares e para-selares.

A variety of mass lesions are placed in and around of the sella turcica. Although their common location these lesions have distinguishing features and different approaches can be selected. There are conventional transcranial and sophisticated skull base approaches. We report our experience with a subfrontal route to the sellar region. Between February 1997 and March 1998, 19 tumors placed around the sella have been treated surgically by this method. Eleven of them were pituitary tumors, 3 were craniopharyngeomas, 2 were meningiomas, and 1 was germinoma. Total removal was achieved in 17 cases. There was not operative mortality. Postoperative complications included twelve cases of unilateral anosmia and four cases of transitory diabetes insipidus. Progressive stroke occurred in one patient. These results stress the importance of the subfrontal approach to reach such lesions in sellar region.

Acesso sub-frontal a lesões selares e para-selares / Subfrontal approach in sellar and suprasellar injuries

Os processos expansivos situados ao nível da região selar constituem um variável número de patologias que, apesar da localização semelhante, têm características clínicas, radiológicas, patológicas e origens diferentes. Assim sendo, diferentes tipos de abordagens são utilizados no tratamento cirúrgico destas lesões. Dentre os acessos transcranianos convencionais e os mais sofisticados acessos à base do crânio, o acesso sub-frontal proporciona visão direta das estruturas neurovasculares da região. Este estudo descreve 19 tumores operados por esta via, no período compreendido de fevereiro de 1997 a março de 1998. Onze destas lesões eram adenomas pituitários, 3 eram craniofaringiomas, 2 eram meningiomas, 1 germinoma e 1 lesão inflamatória do nervo óptico. A remoção total dos tumores foi conseguida em 17 casos. Não houve mortalidade operatória e as complicações mais comuns foram: anosmia unilateral, que ocorreu em 12 casos; diabetes insipidus transitório, que acometeu 4 pacientes; e déficit isquêmico progressivo, que ocorreu em 1 paciente. Estes resultados demonstram que a via sub-frontal é uma opção segura para a cirurgia dos tumores desta região.

[Optic neuritis--from diagnosis to optic nerve transplantation].

Optic neuritis is a clinical syndrome resulting from inflammation, demyelination, or infection of the optic nerve. Its diagnosis and treatment are complicated. In 1884, Nettleship first reported 28 cases of optic neuritis whose clinical symptoms have been accepted up to the present without any change. On the other hand, the development of diagnostic procedures and steroid therapy have also altered the clinical features of optic neuritis. Among several developed diagnostic procedures, the visually evoked cortical potential (VECP) has become a good tool to prove the impairment of the optic nerve. In 1971, we reported a decrease of threshold intensity required to evoke VECPs in optic neuritis patients whose visual acuity was relatively well preserved. In the same year, Halliday et al. reported that pattern VECP (PVECP) was delayed in 93% of patients with multiple sclerosis (MS) without optic neuritis. Stimulated by this report, a great number of studies appeared to show the usefulness of PVECP in the diagnosis of MS. However, few of these studies gave descriptions of ophthalmic findings. PVECP later become known to be closely related with ophthalmic conditions. In the ophthalmological field, we reported the influence of pupillary size, accommodation power, refractive powers, eccentricity of stimulated retinal area, retinal luminance, contrast, wavelengths, spatial and temporal frequencies, stimulus field etc. On the basis of our results, we developed a television display system in 1975 and applied it clinically. In the present study, we reviewed the medical records of a total of 272 cases of optic neuritis who presented in our clinic between 1978 and 1999. In the diagnostic, therapeutic point of view in relation with the data of other countries, the study was important regarding the racial differences and recent conceptions of optic neuritis. The results showed that there were no racial difference in optic neuritis as had been thought. The development from optic neuritis to multiple sclerosis was not less than in Caucasian patients. Regarding steroid therapy, we found that the most effective method was sub-Tenon injection. For cases which recur and progress to optic atrophy, optic nerve transplantation will be needed. Therefore, we have been studying the reconstruction of the optic nerve in Wister rats. We experimentally damaged the ganglion cells by causing ischemic retina with ligation of the ophthalmic artery and cutting the optic nerve just behind the eyeball. To prevent the apoptosis of ganglion cells, we injected various neurotrophic factors such as BDNF, GDNF, and HSP 27 into the vitreous. For effective injection of DNA, electropolation was applied and the best condition for avoiding apoptosis was chosen. Further, in Mx-c-fos transgenic mice, we found that regeneration of ganglion cells was inhibited. Based on the rescue study of the ganglion cells, optic nerve transplantation was performed using an artificial graft in which cultured Schwann cells from the ischiatic nerve, BDNF, CNTF, insulin, and forscolin were compound and bridged to the superior colliculus. The results showed a regeneration rate of the optic nerve axon of 15%. This rate was much higher than in other reports. Keratoplasty and intraocular lens implantation had a relatively long history of research before achieving clinical success. We believe that optic nerve transplantation will one day be successful in clinical treatment in the same way.

[Report of 4 cases for treating optic nerve inflammation through total ethmoidectomy under nasal endoscope].

OBJECTIVE: The curative effect of treating optic nerve inflammation through total ethmoidectomy under nasal endoscope is evaluated. METHOD: The operations through total ethmoidectomy under nasal endoscope for 4 patients who had optic nerve inflammation has been done. RESULT: Two patients have apparent effect while the other two patients are effective, and the symptoms such as snuffle, eye distension and headache are well remitted. CONCLUSION: Towards the sufferer who had both optic nerve inflammation and intercurrent nasosinusitis, when conservative treatment was invalid or the patient was relapsed after surgery, it is necessary to do the operation in season and its effective rate is satisfactory. Total ethmoidectomy under nasal endoscope is safety and reliable.

Diffuse bilateral subacute neuroretinitis: first patient with documented nematodes in both eyes.

OBJECTIVE: To describe the first patient with documented evidence of diffuse unilateral subacute neuroretinitis (DUSN) in both eyes. METHODS: A 10-year-old healthy Brazilian girl was first seen with signs of late-stage DUSN in both eyes. A careful search for a nematode was performed in each eye. RESULTS: A motile 550- to 660-microm nematode was found in the inferotemporal retina of the left eye. A similar-sized motile nematode was found in the superotemporal retina of the right eye. Both nematodes were treated with argon green laser applications with bilateral improvement of visual function. CONCLUSION: Although most patients with DUSN do not develop the disease in the fellow eye, this case demonstrates that DUSN can occasionally affect both eyes.

Diffuse unilateral subacute neuroretinitis in Europe.

BACKGROUND: Diffuse unilateral subacute neuroretinitis is thought to be caused by a solitary helminth migrating within the subretinal space. Laser photocoagulation of the located worm is the preferred mode of therapy. METHODS: We describe the clinical and electrophysiological features of a case of a 15-year-old Caucasian male with a longstanding diffuse unilateral subacute neuroretinitis (DUSN), in whom two worms were seen in the fundus examination. Focal photocoagulation of the worms was applied as treatment. RESULTS: No signs of inflammation could be seen after treatment. Three months later, the patient was doing well. Follow-up examination 4 years later revealed an unchanged fundus appearance in the affected eye, with no evidence of progression of the syndrome. CONCLUSIONS: If a worm is identified in DUSN, focal laser treatment of the located area is the treatment of choice, regardless of whether fundus changes suggest late stages of the disease. However, the eye of the patient should be thoroughly examined to rule out the presence of more than one worm that might cause the failure of therapy.

Isolated mucocele in an Onodi cell.

A rare case of retrobulbar optic neuropathy caused by an isolated mucocele in an Onodi cell is presented. A 63-year-old man suffering from left recurrent optic neuropathy had shown improved visual acuity with steroid treatment at the age of 48 and 56 years. Impaired visual acuity and blurred vision in the left eye appeared again, and a marked inferior decrease in the left visual field was noted. Although axial computed tomography (CT) showed no abnormal findings, magnetic resonance imaging (MRI) revealed a small squamous-shaped lesion (17 x 17 x 7.3 mm) in the left posterior ethmoidal air cell (Onodi cell) hanging over the left optic nerve. Endoscopic sinus surgery was performed. The optic canal was extruding into the Onodi cell cavity, and the superior bony wall of the canal was eroded by the mucocele. The isolated mucocele in the Onodi cell seemed to be compressing the optic nerve downward an causing retrobulbar optic neuropathy. An Onodi cell lesion, even if it was isolated and small, would cause optic neuropathy. MRI and coronal CT scanning should be performed for the diagnosis and preoperative planning in a case of retrobulbar optic neuropathy.

Combined paresis and restriction of the extraocular muscles after orbital fracture: a study of 16 patients.

Sixteen patients with combined paresis and restriction of extraocular muscle(s) orbital fracture repair were studied before and after in order to determine the clinical features and management of such patients. All 16 patients showed limited ductions of the involved eye in the field of action of the entrapped, paretic muscle and of the antagonist muscle after orbital fracture. Single extraocular muscles (13 patients) and two extraocular muscles (three patients) were demonstrated adjacent to the fracture site on orbital computed tomography (CT). In three patients prior to orbital surgery, a deviation in primary position was present. After fracture repair with release of the entrapped muscle in all patients, evidence of paresis of the muscle was demonstrated by underaction in its field of action and overaction in the field of its antagonist. There was a resultant manifest tropia or phoria in the primary position. In seven patients, the paresis gradually improved with no tropia and little diplopia in the functional fields of gaze. Three patients had minimal deviations and required no further treatment. Six patients with significant deviations required prisms (three patients) or strabismus surgery (three patients). The latter three patients had two muscles involved. Results of this study demonstrate that the ophthalmologist must appropriately diagnose patients with paresis and restriction of an extraocular muscle and counsel them that "new" diplopia may occur after orbital fracture repair and that this diplopia may require additional therapy.

[Microsurgical endonasal decompression in traumatic and neoplastic optic nerve compression]. / Mikrochirurgische endonasale Dekompression bei traumatischer und neoplastischer Optikuskompression.

UNLABELLED: The therapy of traumatic optic neuropathy remains controversial. Some authors recommend observation and others, the use of megadose corticosteroids or surgical decompression of the optic nerve. Improvements in visual acuity from no light perception (NLP) preoperatively to close to normal visual acuities have been reported after transethmoidal decompression and systemic steroids. The transnasal microscopic approach offers safe and effective access to the optic canal. MATERIALS AND METHODS: Retrospectively 15 patients (13 men/2 women) ranging in age from 17 to 67 years, who were surgically decompressed in the Ear-Nose-Throat Department between 1989 and 1994, were analyzed. Thirteen patients had experienced sudden visual loss after trauma; in 2 patients a tumor was diagnosed. After an initial ophthalmologic examination and CT scans, the patients underwent transnasal decompression of the optic canal for at least 180 degrees. In the postoperative period, visual acuity, pupillary reaction, visual field and optic nerve morphology were monitored. RESULTS: The overall visual results were poor. In 8 patients with no light perception (NLP) preoperatively, no improvement in visual acuity was found. Minor improvements were seen with an initial vision of 20/200 or less. Dramatic improvements were found in both patients with rapidly progressive neoplastic optic nerve compression. No intra- or postoperative complications were seen. CONCLUSION: In our study we were unable to reproduce the good visual results of some series. If there is NLP preoperatively, surgical intervention does not seem to be promising. However, in patients with incurable tumors transnasal decompression of the optic canal offers a minimally invasive palliative measure to preserve and restore vision.