Optic disc edema and visual loss from paracentral acute middle maculopathy mimicking optic neuritis.

Optic neuritis is an important cause of unilateral and acute visual loss in young adults, but other differential diagnoses should be considered, especially when the disease has an atypical presentation. This report presents the case of a young woman with reduced visual acuity in her right eye, associated with optic disc edema and a relative afferent pupillary defect, that was initially misdiagnosed as optic neuritis and subsequently found to have paracentral acute middle maculopathy, possibly secondary to subtle impending central retinal vein occlusion. This case emphasizes the need to remember that retinal vascular diseases can occasionally mimic optic neuritis. Detailed anamnesis and ophthalmic examination can avoid unnecessary interventions.

Macular Star, Optic Disc Swelling, and Lethargy in a Child.

A 13-year-old girl with a 7-day history of painless vision loss and central scotoma in her left eye was referred to the hospital. Dilated fundus examination revealed a bilateral sectorial macular star that was more extended in the left eye and some faint, small, tan-yellow dots were observed at the level of the retinal pigment epithelium in the posterior pole. What would you do next?

Optic Disc Edema and Posterior Globe Flattening Secondary to Ocular Hypotony: Case Report and Discussion Regarding Pathophysiology and Clinical Findings.

ABSTRACT: We describe a case of a young female patient presenting with ocular hypotension (4 mm Hg) secondary to cyclodialysis, and optic disc edema (ODE) after a blunt trauma in the right eye (right eye). MRI showed posterior globe flattening of the right eye, drawing our attention to the pathophysiology behind these findings. The combination of ODE and posterior globe flattening, as observed in the present case of ocular hypotony, is known from other conditions such as intracranial hypertension and space-flight neuro-ocular syndrome, pointing to a common pathophysiological mechanism, possibly resulting from axoplasmic stasis at the level of the lamina cribrosa due to a high translaminar pressure difference.

Desenvolvimento de sistema estruturado com inteligência artificial para apoio no diagnóstico de patologias oftalmológicas mais relevantes / Development of a structured artificial intelligence system to support the diagnosis of the most relevant ophthalmic diseases

Introdução: A inteligência artificial (IA) está revolucionando a área da saúde. Na oftalmologia, esta tecnologia pode possibilitar diagnósticos mais rápidos e precisos, impedindo a progressão das alterações na visão. Médicos e algoritimosalgoritmos podem ser mais eficientes quando trabalham juntos. Desenvolver um software de IA com alta especificidade e sensibilidade para apoio no diagnóstico de algumas patologias oftalmológicas. Métodos: O software de deep learning foi construído através de redes neurais valendo de duas bases computacionais MobileNet e Inception. Para o treinamento do banco de dados foram utilizadas 2.520 imagens de glaucoma, retinopatia diabética, toxoplasmose ocular, papiledema, descolamento de retina e retina normal. Para a validação foi utilizado 428 imagens patológicas e normais para os cálculos de sensibilidade e de especificidade. Todas as imagens foram cedidas da Sociedade Americana de Especialistas da Retina. Resultados: Os resultados de sensibilidade e especificidade foram no MobileNet de 91% (IC 95%, 89-92%) e 98,5% (IC 95%, 98-99%); no Inception, de 91,4% (IC 95%, 89-93,5%) de 98,4% (IC 95%, 98-98,8%), respectivamente. Não houve diferença significativa entre os dois métodos utilizados. Conclusão: O software apresentou resultados promissores na distinção das condições oftalmológicas pesquisadas. (AU)

Introduction: Artificial intelligence (AI) is revolutionizing health care. In ophthalmology, this technology can enable faster and more accurate diagnoses, preventing the progression of vision Physicians and algorithms are most effective when working together. To develop an AI software with high specificity and sensitivity to support the diagnosis of some ophthalmic diseases. Methods: A deep learning software was built through neural networks using two computational bases, MobileNet and Inception. For training the database, 2520 images of glaucoma, diabetic retinopathy, ocular toxoplasmosis, papilledema, retinal detachment, and normal retina were used. For validation, 428 pathological and normal images were used for calculations of sensitivity and specificity. All images were obtained from the American Society of Retina Specialists. Results: The results of sensitivity and specificity were 91% (95% confidence interval [CI], 89-92%) and 98.5% (95% CI, 98-99%) on MobileNet, and 91.4% (95% CI, 89-93.5%) and 98.4% (95% CI, 98-98.8%) on Inception, respectively. There was no significant difference between the two methods. Conclusion: The software showed promising results in distinguishing the main ophthalmic conditions surveyed. (AU)

Acute visual loss and optic disc edema followed by optic atrophy in two cases with deeply buried optic disc drusen: a mimicker of atypical optic neuritis.

BACKGROUND: Sudden visual loss and optic disc edema caused by optic neuritis (ON) is usually followed by significant visual recovery. However, little or no recovery occurs when the loss is caused by atypical ON, especially in patients with neuromyelitis optica (NMO). Optic disc drusen (ODD) is a cause of pseudo optic disc edema and may be a predisposing factor for non-arteritic anterior ischemic optic neuropathy (NAION), thereby mimicking atypical ON. In such cases, if globular concretions are seen protruding from the disc substance, ODD may be suspected. The purpose of this paper is to describe two patients with acute visual loss followed by optic disc atrophy initially labeled as atypical ON. Though not suspected on clinical examination, optical coherence tomography (OCT) revealed deeply buried ODD as a predisposing factor for NAION. CASE PRESENTATIONS: Case 1: A 48-year-old woman had bilateral sequential visual loss associated with optic disc edema. Despite treatment, vision did not improve and severe disc pallor ensued. Atypical ON was suspected. Eventually, she was started on immunosuppressant therapy based on a tentative diagnosis of NMO-spectrum disorder. On examination 5 years later, only severe optic disc pallor was observed, but OCT radial B-scans showed ovoid hyporeflective areas in the retrolaminar region of both eyes, compatible with ODD; this led to a diagnosis of NAION and deeply buried ODD. Case 2. A 35-year-old woman with suspicion of ON in the left eye and a history of previous atypical ON in the right eye was referred for neuro-ophthalmic examination which revealed diffuse optic disc pallor and a dense arcuate visual field defect in the right eye. OCT B-scans passing through the disc showed large ovoid areas of reduced reflectivity in the retrolaminar region of the optic disc in the right eye. These findings helped confirm the diagnosis of NAION in one eye, with deeply buried ODD as predisposing factor. CONCLUSIONS: Deeply buried ODD may be associated with NAION causing irreversible visual loss and optic disc pallor, a condition easily mistaken for atypical ON. Awareness of such occurrence is important to avoid unnecessary testing and minimize the risk of mismanagement.

Relationship Between Pattern Electroretinogram, Frequency-Domain OCT, and Automated Perimetry in Chronic Papilledema From Pseudotumor Cerebri Syndrome.

PURPOSE: We evaluated the ability of transient pattern electroretinogram (PERG) parameters to differentiate between eyes with visual field (VF) loss and resolved papilledema from pseudotumor cerebri syndrome (PTC) and controls, to compare PERG and optical coherence tomography (OCT) with regard to discrimination ability, and to assess the correlation between PERG, frequency domain OCT (FD-OCT), and VF measurements. METHODS: The VFs and full-field stimulation PERGs based on 48 and 14-min checks were obtained from patients with PTC (n = 24, 38 eyes) and controls (n = 26, 34 eyes). In addition, FD-OCT peripapillary retinal nerve fiber layer (RNFL) and segmented macular layer measurements were obtained and correlation coefficients were determined. RESULTS: Compared to controls, PERG N95 and P50+N95 amplitude measurements with 48-minute checks were significantly reduced in eyes with resolved papilledema from PTC. Both PERG N95 amplitude and OCT parameters were able to discriminate papilledema eyes from controls with a similar performance. Significant correlations, ranging from 0.25 (P < 0.05) to 0.43 (P < 0.01) were found between PERG amplitude values and OCT-measured macular ganglion cell layer thickness, RNFL thickness, and total retinal thickness. The PERG amplitude also was significantly associated with VF sensitivity loss with correlation coefficients ranging from 0.24 (P < 0.05) and 0.35 (P < 0.01). CONCLUSIONS: The PERG measurements were able to detect neural loss in PTC eyes with resolved papilledema and were reasonably well correlated with OCT measurements and VF parameters. Thus, PERG may be a useful tool in the monitoring of retinal neural loss in eyes with active papilledema from PTC.

Evaluation of retinal nerve fiber layer thickness in a patient with bilateral optic disc drusen

Optic disc drusen (ODD) is the accumulations of calcified hyaline-like material within the substance of the optic nerve head. Optic disc drusen, especially if it is bilateral, may mimic the clinical presentation of papilledema. Usually retinal nerve fiber layer (RNFL) thinning can be present in ODD. In this report we present uncommon RNFL changes in a patient with bilateral ODD. A 17-year-old male was referred by another center with a diagnosis of optic disc edema. The patient’s visual acuity, the slit-lamp examination and the intraocular pressures were normal in both eyes. On fundus examination, there were irregularly elevated discs bilaterally and the optic nerves appear with hazy disk margins. He did not have visual field defects in automated perimetry. Bilateral ODD were identified and confirmed by B-scan ultrasonography and optical coherence tomography (OCT) demonstrated 4 clock hours of RNFL thickening. Optic disc drusen may be misdiagnosed as papilledema. Thus, clinical suspicion of ODD is important in order to diagnose papilledema and prevents unnecessary interventions. Although most of eyes with ODD have normal or thinner RNFL thickness, some of these eyes can have thicker RNFL thickness.

As drusas do disco óptico (DDO) são depósitos de material hialino calcificado dentro da substância da cabeça do nervo óptico. Drusas do disco óptico, especialmente se for bilateral, podem apresentar o quadro clínico de edema de papila. Usualmente o espessamento da camada de fibras nervosas da retina (RCFN) podem estar presentes em DDO. Neste relato apresentamos o caso de um homem com 17 anos de idade que foi encaminhado por um outro centro, com o diagnóstico de edema do disco óptico. A acuidade visual do paciente, o exame de lâmpada de fenda e a pressão intraocular foram normais em ambos os olhos. No exame de fundo de olho havia discos elevados de forma irregular bilateralmente e os nervos ópticos com margens de disco nebulosas. Ele não tinha defeitos do campo visual em perimetria computadorizada. Drusas do disco óptico (DDO) bilateral foram identificados e confirmados pela ultrassonografia Bscan e tomografia de coerência óptica (TCO) que demonstraram 4 horas de relógio de RCFN com espessamento. As drusas do disco óptico podem ser diagnosticadas como papiledema. Assim, a suspeita clínica de DDO é importante a fim de evitar intervenções desnecessárias. Embora a maioria dos olhos com DDO têm espessura normal ou thinner RCFN, alguns desses olhos podem ter camada mais grossa na RCFN.

Diagnóstico diferencial de edema de papila óptica / Differential diagnosis of optic disc swelling

Isoladamente, o edema de papila não costuma causar sintomatologia, porém, ao ser encontrado, pode auxiliar no diagnóstico de algumas condições clínicas. Neste capítulo serão descritas as principais causas do seu achado, além da técnica da realização do exame fundoscópico.

Lonely, papilledema doesn't causes symptoms, but, when we find it, it may help us doing diagnosis of some diseases. In this chapter we will find the leading causes of the origin of this disorder and the correct execution of fundoscopic exam.

Ocular toxoplasmosis: clinical characteristics in pediatric patients.

PURPOSE: To describe the clinical features of Ocular Toxoplasmosis in pediatric patients. METHODS: A retrospective, non-comparative series of cases was studied. We reviewed the clinical records of patients 16 year old or younger diagnosed with Ocular Toxoplasmosis. RESULTS: Forty patients (56 eyes) were included. The mean age was 9.5 yrs old. Twenty were female. Unilateral involvement was noticed in 60% of patients. The most common symptoms were strabismus (32.1%) and reduced VA in (23.2%). An inactive retinal scar was observed in most cases (71.4%). Panuveitis was found in 8 eyes (14.2%), and posterior uveitis in 7 eyes of 7 patients (12.5%); one eye presented neuroretinitis. The most frequent location of retinochoroidal lesions was the posterior pole (72.7%). CONCLUSIONS: In children, ocular toxoplasmosis is most commonly diagnosed during the inactive stage. When inflammation is present, it can be severe and frequently associated with other complications such vasculitis and papillitis.

Empleo de la tomografía de coherencia óptica en el diagnóstico del papiledema / The employment of optic coherence tomography in the diagnosis of papilledema

Fundamento: La tomografía de coherencia óptica constituye una de las herramientas más revolucionarias en el diagnóstico oftalmológico de los últimos años. Objetivo: Evaluar la utilidad de la tomografía de coherencia óptica en el diagnóstico del papiledema. Métodos: Estudio prospectivo, observacional y analítico realizado en el período de mayo a octubre del 2007, en el Servicio de Neurooftalmología del Instituto Cubano de Oftalmología Ramón Pando Ferrer. Se analizaron 27 pacientes que presentaban un papiledema típico en primer episodio de menos de 2 meses de evolución. Resultados: Predominó el sexo femenino con una edad media de 27 años. Los valores promedios del grosor de la capa de fibras nerviosas fueron significativos desde el punto de vista estadístico (p=0.000). Este predominó en orden de frecuencia en sectores inferior, superior, nasal y temporal. Conclusiones: La tomografía de coherencia óptica constituye un instrumento de utilidad en el diagnóstico del papiledema(AU)

The optic coherence tomography constitute one of the most revolucionary tool in the ophtalmic diagnosis in the latest years, and is very useful in the papilledema studies. Objectives: Evaluate the optic coherence tomography useful in papilledema diagnosis. Methods: Prospective, observacional and analytic study made since may to october 2007 in the neuroophtalmology deparment, Ophtalmology Cuban Institute Ramón Pando ferrer. Were studied 27 patients that presented a typical papilledema in the first episode at least with 2 months of duration. Results: The female sex was predominant with 27 of medium age. The medium thickness values of nervous fiber layer were stadistic important betwen the sectors (p=0.000). The nervous fiber layer thickness was predominant in order to frequency in lower, upper, nasal and temporal sectors. Conclusions: The optic coherence tomography constitute an useful instrument to papilledema diagnosis(AU)

Papiledema: un enfoque actualizado / Papilledema: an updated approach

El término papiledema se refiere al edema de papila que se produce después de una hipertensión intracraneal. Dentro de sus causas más comunes se citan: las lesiones intracraneales, la hipertensión intracraneal idiopática, hidrocefalia, trombosis de los senos venosos y meningitis. El aumento de la presión intracraneal se relaciona con los hallazgos encontrados en el fondo deojo, los cuales se clasifican en diferentes estadios: incipiente, establecido, crónico y atrófico, endependencia de su gravedad o avance. Es imprescindible realizar pruebas imaginológicas antes de realizar la punción lumbar; así como el cuidado integral del enfermo. En el presente trabajo se propone un acercamiento al diagnóstico y tratamiento de dichaentidad nosológica(AU)

The term papilledema refers to the edema that appears in the optic papilla after intracranial hypertension. Some of its most frequent causes are intracranial lesions, hydrocephaly, thrombosis venous sinus and meningitis. The increase of intracranial tension is related with the results of the eye´s fundus examination, which are classified differently: incipient, established, chronic, and atrophic, depending on its severity or development. It is indispensable to carry out imaging tests beforeperforming lumbar puncture. This article is an approach to the diagnosis and treatment of this gnoseological entity(AU)

Idiopathic intracranial hypertension with and without papilloedema in a consecutive series of patients with chronic migraine.

Chronic migraine (CM) has been associated with idiopathic intracranial hypertension without papilloedema (IIHWOP), a significant percentage of these cases occurring in obese patients with intractable headache. A prospective study from February 2005 to June 2006 was made of 62 CM patients who fulfilled International Headache Society diagnostic criteria and had cerebral magnetic resonance venography (MRV) and lumbar puncture (LP) done. Two patients were excluded, six (10%) with elevated cerebrospinal fluid (CSF) open pressure (OP), five with body mass index (BMI) > 25. None of the patients had papilloedema or abnormal MRV. BMI and CSF OP were significantly correlated (r = 0.476, P < 0.001, Pearson's correlation test). Obesity (defined as BMI > 30) was a predictor of increase in intracranial pressure (defined as OP > 200 mmH(2)O) (f = 17.26, 95% confidence interval 6.0, 8.6; P < 0.001). From our study we strongly recommend that not only intractable CM patients with high BMI, but also first diagnosed patients with BMI > 30 should be systematically evaluated by a LP to rule out IIHWOP.

Optic nerve changes in ocular toxoplasmosis.

PURPOSE: To determine the prevalence and features of the different types of involvement of the optic nerve in ocular toxoplasmosis. METHODS: Retrospective cross-sectional study. All patients with active ocular toxoplasmosis, consulting in the Uveitis Section of the Ophthalmology Department were selected. The involvement of the optic nerve was classified in the following categories: juxtapapillary retinochoroiditis, pure papillitis, neuroretinitis, distant lesion, and mixed lesion. RESULTS: The prevalence of involvement of the optic nerve found was 5.3%. The optic nerve involvement with the presence of a concurrent active distant lesion, occurred in 22 eyes (43.1%). A juxtapapillary lesion was found in 18 eyes (35.3%). Eight eyes (15.7%) presented lesions characterised as mixed. Isolated papillitis occurred in 3 eyes (5.9%). Forty-seven lesions (95.9%) were unilateral and two (4.1%) were bilateral. Twenty-eight eyes (54.9%) had pre-existing lesions and 23 (45%) were primary lesions. Visual acuity improved in 35 eyes (71.4%) and remained unchanged in 14 eyes (28.5%). CONCLUSION: The involvement of the optic nerve most frequently found in ocular toxoplasmosis was optic nerve oedema with a concurrent distant active lesion. The second type of lesion most often found was juxtapapillary retinochoroiditis. Involvement was monocular in most cases and the visual prognosis was favourable.