Elephantoid eyelid edema associated with continuous positive airway pressure treatment.

A man with rosacea developed bilateral eyelid edema from wearing a continuous positive airway pressure nasal mask daily. The edema was refractory to steroid, diuretics, and lymphatic drainage massage. The effect may be related to cumulative venous congestion and lymphostasis due to the continuous positive airway pressure treatment.

Topical beta-blocker treatment for migraine.

Beta-blockers are a well-known prophylactic treatment for migraine; however, treatment by the ocular route has not been widely considered. This case illustrates the resolution of a visual field defect associated with migraine and improvement of symptoms possibly due to administration of a topical beta-blocker. This novel method of treatment especially when visual field defects are present may have a place in the management of migraine.

Functional vision with bilateral ReZoom and ReSTOR intraocular lenses 6 months after cataract surgery.

PURPOSE: To compare the visual outcomes in patients with bilateral implantation of AcrySof ReSTOR multifocal intraocular lenses (IOLs) (Alcon Laboratories) or ReZoom multifocal IOLs (Advanced Medical Optics) 6 months after cataract surgery. SETTING: Orsett and Southend Hospital, Essex, United Kingdom. METHODS: This study comprised patients who had uneventful bilateral cataract extraction with implantation of ReZoom (n = 50) or ReSTOR (n = 50) multifocal IOLs. Parameters analyzed included binocular uncorrected distance, intermediate, and near acuities; spectacle independence; subjective visual symptoms; and patient satisfaction. All parameters were evaluated 6 months after second-eye surgery. RESULTS: All patients had binocular uncorrected distance visual acuity of 20/32 or better; there was no statistically significant difference between the 2 groups. The mean binocular uncorrected near acuity was 20/26 (J1.22) in the ReSTOR group and 20/34 (J2.34) in the ReZoom group (P<.0001). The mean binocular uncorrected intermediate visual acuity was 20/42 and 20/34, respectively (P = .003). Patients in the ReZoom group reported greater satisfaction with intermediate vision (P = .04). No statistically significant difference was found in satisfaction with near vision. Eighty-six percent of ReSTOR patients and 70% of ReZoom patients did not wear glasses for daily activities; the overall satisfaction was not statistically significantly different between groups. There was no significant difference between groups in photic phenomena. CONCLUSIONS: The ReSTOR IOL provided better near vision and the ReZoom IOL better intermediate vision. Both multifocal IOLs gave excellent distance vision. Photic phenomena were comparable and clinically acceptable. ReSTOR patients had greater spectacle independence for near vision and ReZoom patients for intermediate vision. Overall spectacle independence was not statistically significantly different.

ReSTOR intraocular lens implantation in cataract surgery: quality of vision.

PURPOSE: To compare the visual outcome and subjective visual symptoms in patients who had implantation of the AcrySof ReSTOR multifocal intraocular lens (IOL) (Alcon Laboratories) with those in patients who received the AcrySof SA60AT monofocal IOL (Alcon Laboratories) in cataract surgery. SETTING: Southend Hospital, Essex, United Kingdom. METHODS: Eighty eyes of 40 patients received the ReSTOR multifocal IOL after cataract extraction. They were closely paired in age, sex, and ocular findings with patients who had monofocal IOL implantation during the same period. The distance and near visual acuities were compared, and patient satisfaction with their vision, visual symptoms, and spectacle dependence was assessed using a standardized questionnaire. RESULTS: There was no significant difference in the mean uncorrected and best corrected distance visual acuities between the groups. An uncorrected distance visual acuity of 20/30 or better was achieved in 93.8% eyes in the multifocal group and 82.5% in the monofocal group and of 20/20 or better in 57.5% and 40.0%, respectively (P = .18). Uncorrected near visual acuity was 20/30 or better in 75.0% of eyes in the multifocal group and 3.8% in the monofocal group. Reading glasses were required by 2.5% in the multifocal group and by 92.5% in the monofocal group. Satisfactory uncorrected intermediate distance vision was achieved in 75.0% of eyes in the multifocal group and 87.5% in the monofocal group (P = .089); 85.0% of patients in the multifocal group and 7.5% in the monofocal group never had to wear glasses. Moderate glare was reported by 21.3% in the multifocal group and 7.5% in the monofocal group (P = .008); no patient reported severe glare. In the multifocal group, severe halos and moderate halos occurred in 3.8% [corrected] of eyes and 16.3% [corrected] of eyes, respectively. CONCLUSIONS: The AcrySof ReSTOR IOL provided predictably good uncorrected distance and uncorrected near acuities. Spectacle independence was significantly higher with this multifocal IOL, which outweighed the photic symptoms it caused.

Ultrasonic diagnostic system for interactive interrogation of adult brain through intact skull.

An integrated ultrasonic system has been developed employing static gray scale imaging, digital image processing, and analyses of quantitative ultrasonic backscatter for interactive interrogation of brain through the adult human skull. Operating at 750 kHz, to avoid severe spatial and temporal pulse distortion which accompany ultrasonic transkull transmission at higher frequencies, storage and image processing of successive images taken at selected gain settings in the same image plane allow the reconstruction of a composite cross-section of the brain and skull and enable visualization of internal brain structure. Analyses of digitized backscatter data obtained with the visualization transducer over selectable interrogation paths referenced to the cross-sectional image permit quantitative classification of tissue type independent of qualitative visual image analysis, such that enhanced diagnostic potential is provided. A previous paper described in detail the modifications of the commercial ultrasound diagnostic unit which serves as the core of this system. The present paper presents the rationale for the integrated system design approach, as well as a description of graphics display and tissue classification features which have been incorporated into the instrumentation configuration and are deemed necessary for successful transkull ultrasonic imaging and diagnosis.

Comparison of computed sonographic tomography and pulse-echo imaging in the head.

Computed sonographic transmission tomograms of infant and adult human cadaver heads are presented and compared with sonographic pulse-echo and x-ray tomograms of the same horizontal planes. The sonographic attenuation tomograms were reconstructed from broadband transmission data obtained using the rotate/translate axial scan mode in much the same way as x-ray tomography is performed. The formalin-fixed infant cadaver head was scanned through the anterior fontanelle using pulse-echo and in a horizontal plane (3.3 cm superior to the Frankfort plane) using both pulse-echo (3.5 MHz and 5 MHz) and transmission sonography (5 MHz). The computed sonographic transmission tomogram revealed superior anatomic detail as compared with the pulse-echo images obtained in the horizontal plane and compared favorably with x-ray scans. The quantitative, noninvasive nature of sonographic tomography shows promise for clinical applicability in the infant. In the adult human cadaver, sonographic tomograms at 750 kHz are presented in both the transskull and excised brain conditions. These scans also offer promise for the possible clinical exploration of the method.

Distribution of glycine, GABA, aspartate and glutamate in the rat spinal cord.

Glycine, GABA, aspartate and glutamate are putative neurotransmitters in the mammalian spinal cord. The distribution of these amino acids was determined in the rat spinal cord. Transversely, the highest levels of glycine, aspartate and glutamate were in the intermediate and ventral gray; whereas, the highest levels of GABA were in the dorsal gray. Longitudinally, the highest levels of GABA and aspartate were in the thoracic and lumbar segments; whereas, the highest levels of glycine and glutamate were in the cervical and thoracic segments, respectively. In general, the distribution of these amino acids is similar to that reported for the cat, dog and human.

Transkull focal lesions in cat brain produced by ultrasound.

Focused ultrasound has been used for focal modifications of brain tissue and in preliminary studies of the application of ultrasonic techniques for tissue modification in human stereotaxic neurosurgery; however, the technique has been seriously compromised by the necessity of removal of intervening skull. Such removal was necessary to avoid distortion and extremely large attenuation of the ultrasonic beam which resulted from passage through bone. Recent studies have shown that under proper conditions focal beams of ultrasound can be transmitted with tolerable and attenuation through skull, suggesting the possibility of transkull lesion production in brain. This report describes the acoustical parameters and histological features of focal brain lesions produced in 10 craniectomized cats with intense focal ultrasonic beams which first had passed through a formalin-fixed human skull overlay. The histological appearance of these lesions produced to date is similar to that produced previously without intervening skull.

Magnetic resonance imaging of petrous carotid aneurysms.

Aneurysms arising from the petrous segment of the internal carotid artery are rare and the majority of reports are based on evaluations with x-ray catheter angiography (XRA) and computed tomography (CT). Due to the paucity of magnetic resonance imaging (MRI) information, the author describes 2 patients with petrous carotid aneurysms evaluated with MRI and magnetic resonance angiography (MRA). Compared to XRA and CT, MRI and MRA are less invasive and provide more information regarding the aneurysm, including the size, shape, and site; the absence or presence and extent of hemorrhage, thrombus, and bony erosion; patency of the vessel; neck; and the extent of perianeurysmal compromise of vessels, cranial nerves, and parenchyma.

Phase-contrast magnetic resonance angiography for the determination of cerebrovascular reserve.

Cerebrovascular reserve (CVR) is the potential for cerebral arteriolar dilatation to occur, in response to decreased cerebral perfusion pressure, in order to maintain constant cerebral blood flow. Diminution or absence of CVR is considered a risk factor for stroke. Current methods for determining CVR include single-photon emission computed tomography, positron emission tomography and transcranial Doppler (TCD) ultrasonography. However, significant advantages could derive from the utilization of magnetic resonance angiography (MRA) based on the concurrent acquisition of hemodynamic information (CVR and collateral flow) with phase-contrast (PC) techniques and vascular morphology with three-dimensional, time-of-flight methods. With a 1.5-T scanner and acetazolamide (AZM), an arteriolar dilator, CVR was determined in 7 normal subjects. Mean flow velocity in the middle cerebral arteries was determined by PC MRA before and after AZM administration. For comparative purposes, mean flow velocities in the same middle cerebral arteries were determined by TCD before and after AZM administration. The mean flow velocities were as follows (mean +/- standard deviation, n = 7): 40 +/- 8 (PC MRA) versus 61 +/- 10 cm/sec (TCD) before AZM treatment and 58 +/- 11 (PC MRA) versus 85 +/- 15 cm/sec (TCD) after AZM administration. The increase in mean flow velocity (before vs after AZM), that is, the CVR, was 45 +/- 11% as shown by PC MRA and 39 +/- 14% as shown by TCD. Although significant differences were present between the mean flow velocities measured before and those after AZM administration, as determined by PC MRA and TCD, the CVR was not significantly different (45 vs 39%, respectively). These preliminary results suggest that PC MRA may be a method for determining CVR.

Cervical (C2) herpes zoster infection followed by pontine infarction.

This article reports a man who had herpes varicella zoster cervicalis with delayed stroke in the posterior circulation. Empiric treatment was acyclovir, methylprednisolone, and aspirin. Pontine infarction involving migration of the virus via cervicovascular innervation from C2 dorsal root ganglia to the vertebrobasilar circulation with attendant angiitis/angiopathy and thrombosis is proposed.

The size of subcortical ischemic infarction in patients with and without diabetes mellitus.

Diabetes mellitus is associated with a higher frequency and poorer outcome of ischemic stroke. Determinants of the poorer prognosis of stroke in patients with diabetes are not well defined. We investigated whether size of cerebral infarction differs in patients with and without diabetes mellitus. We compared ischemic lesions in 41 consecutive stroke patients with subcortical infarction-22 with and 19 without diabetes mellitus. The location and size of the ischemic infarct were derived from magnetic resonance images obtained on day 3 or 4 post stroke onset. Cross-sectional infarct area was determined by direct measurement from film. The age of patients was similar in both groups. Patients with diabetes had higher prevalence of arterial hypertension, and previous stroke, and higher admission triglyceride and glucose levels compared to patients without diabetes. We found no significant difference in the size of ischemic lesions in patients with and without diabetes mellitus (1.87 vs. 1.72 cm2, respectively). We conclude that among patients with subcortical ischemic stroke the size of infarction is not different between patients with and without diabetes mellitus.

Ultrasound and the blood-brain barrier.

High intensity focused ultrasound was employed to modify the permeability of the normal feline and canine blood-brain barrier (BBB) to a circulating vital dye--Evans blue (EB). The threshold doses (W sec/cm2) for focally increasing the permeability of the BBB in white matter (WM) and gray matter (GM) were as follows: internal capsule (WM)--340 to 680; thalamus (GM)--approximately 1326; and caudate nucleus (GM)--2284 to 2952. In the presence of supralesioning doses of ultrasound, the cross sectional area occupied by the EB was consistently greater than that of the attendant nonhemorrhagic lesion--thus suggesting that BBB changes may be inducible at sublesioning doses. These findings, in conjunction with those of others, suggest that high intensity focused ultrasound may have a role in the treatment of brain tumors based on cell destruction by two mechanisms: (a) direct, by the ultrasound and (b) indirect, by an antineoplastic agent which is delivered via an ultrasonically modified BBB.

Does choroidal melanoma regression correlate with chromosome 3 loss after ruthenium brachytherapy?

AIM: To determine the reduction of choroidal melanoma thickness 6 months after ruthenium 106-brachytherapy according to chromosome 3 status, which correlates strongly with metastatic death. METHODS: Transscleral fine needle aspiration biopsy was performed prior to the insertion of a radioactive plaque if the tumour was deemed sufficiently thick and anterior for such a procedure. Transretinal biopsy with a 25-gauge vitreous cutter was performed for thin and posterior tumour within a month of plaque removal. The chromosome 3 status was determined by fluorescence in situ hybridisation from 2002 until 2006, and by either multiplex ligation-dependent probe amplification and/or microsatellite analysis after this period until the end of the study. The choroidal melanoma dimensions were obtained from outpatient visits. RESULTS: 149 eyes from 149 patients were included. The mean age was 60.8 years. 84 eyes (56.4%) had disomy 3 and 65 eyes (43.6%) monosomy 3. The median pretreatment tumour thickness was 3.0 mm in disomy 3 and 4.1 mm in monosomy 3 tumours (p=0.018). The follow-up duration medians were 6.3 months for disomy 3 and 6.4 months for monosomy 3 tumours (p=0.68). The rates of thickness reduction were 6.7% and 7.0% per month, respectively (p=0.59). Thickness reduction exceeding 50% occurred in 32 (38.1%) disomy 3 and 24 (36.9%) monosomy 3 tumours. CONCLUSIONS: The rate of choroidal melanoma regression after ruthenium-106 brachytherapy does not appear to correlate with chromosome 3 loss, suggesting that tumour thickness reduction 6 months after treatment is unlikely to predict survival.

A case of misconstrue proptosis.

This case illustrates an overlooked metastatic lung carcinoma to the orbit. The rapid onset of symptoms and oedema mimicked a cellulitis. The patient was initially treated with a broad-spectrum topical and intravenous antibiotic therapy. The white blood cell count (WBC) and C reactive protein (CRP) were normal. Compressive optic neuropathy and serous retinal detachment ensued. The initial chest x-ray revealed lung shadows; however, this was not reviewed. Eventually, CT of the chest was organised and showed a lung mass. The management of such a case remains a challenge for the uninitiated, and high index of suspicion is required to ensure early appropriate management. Despite complete resolution of the swelling with sequential chemotherapy (cisplatin and etoposide) and radiotherapy, the visual prognosis remained grim.

Delay time between onset of ischemic stroke and hospital arrival.

Some current experimental protocols for acute ischemic stroke require the initiation of treatment within hours of the onset of stroke symptoms. We prospectively evaluated 30 patients with acute ischemic stroke based on clinical and computed tomography findings. The time between the onset of stroke symptoms and arrival in the emergency room and subsequently on the stroke service was determined. Within 3, 6,12, and 24 h of the onset of stroke symptoms, 16 (53%), 19 (63%), 22 (73%), and 25 (83%) patients had arrived at the emergency room and 0 (0%), 4 (13%), 14 (47%), and 22 (73%) of them on the stroke service, respectively. From the onset of stroke symptoms, the mean arrival time to the emergency room was 24 h (range, 30 min to 144 h) and to the stroke service was 61 h (range, 4-150 h). The mean time between arrival in the emergency room and stroke service was 8.6 h (range, 0-47 h). Even though 53% and 63% of our patients arrived at the emergency room within 3 and 6 h of the onset of stroke symptoms, only 0% and 13% of them arrived on the stroke service within the same time period for the initiation of treatment, respectively. Thus, in order for more patients to qualify for current experimental protocols, they must arrive on the stroke service more quickly or treatment must be initiated in the emergency room.

Recurrent pure sensory transient ischemic attacks: In vivo demonstration of associated thalamic infarction.

We present a case study and literature review to clarify the pathoanatomic substrate of recurrent pure sensory transient ischemic attacks (TIAs). A 60-year-old woman had had over 50 transient episodes of left hemibody hypoesthesia over the previous 15 years. Interictal neurologic examination was normal. Magnetic resonance imaging (MRI) showed a small infarct in the ventroposterolateral (VPL) nucleus of the right thalamus. Symptoms resolved with warfarin therapy. Ischemia-related pure sensory symptoms present as one of two clinical syndromes: (a) sudden onset of persistent unilateral face, arm, and/or leg hypoesthesia/paresthesias, preceded by no or few TIAs, or (b) frequent espisodes of transient unilateral hypoesthesia/paresthesias not progressing to permanent deficit. The first is widely recognized; recent computed tomography/MRI series have reported 105 cases associated with thalamic, brainstem, or thalamocortical projection sensory pathway infarction. Although equally common, the syndrome of recurrent transient hemihypoesthesia is under-recognized and has a less well-described pathologic substrate. One previous case with postmortem documentation of a VPL thalamic infarction has been reported. We believe this is the first reported case of recurrent transient hemihypoesthesia associated with VPL thalamic infarction imaged in vivo.

Alterations of amino acid transmitter systems in spinal cords of chronic paraplegic dogs.

The high-affinity uptake of [3H]serotonin, [3H]glutamate, and [3H]gamma-aminobutyric acid [( 3H]GABA) and the Na+-independent binding of [3H]glutamate and [3H]GABA were studied using spinal cord preparations obtained from normal mongrel dogs and from dogs made paraplegic by midthoracic spinal cord crush. Lumbosacral regions of the spinal cord were removed either before (1 week) or after (3 to 8 weeks) onset of spasticity. A myelin-free synaptosomal fraction was obtained by centrifugation and used for studying high-affinity uptake and for preparing synaptic plasma membranes for Na+-independent binding experiments. For the paraplegic groups, the uptake of 30 nM [3H]serotonin was 66 and 18% of control values after 1 and 3 weeks, respectively. Eadie-Hofstee analysis of [3H]serotonin uptake showed a 90% reduction in Vmax for the paraplegic group relative to control values, thereby indicating the expected loss of descending serotonergic pathways. The high-affinity uptakes of 1 microM [3H]glutamate and [3H]GABA were the same in both the control and nonspastic paraplegic groups after 1 week. However, after 3 weeks, the uptakes of [3H]glutamate and [3H]GABA were 60-70% higher for the spastic group than for the control animals. For both amino acids, Eadie-Hofstee plots revealed no difference in Km and higher Vmax for the spastic group relative to control values. After 1 and 3 weeks, the Na+-independent binding of 5 nM [3H]glutamate was 40-85% higher and the binding of 10 nM [3H]GABA was 40-60% lower for the paraplegic groups relative to the values for the control animals.(ABSTRACT TRUNCATED AT 250 WORDS)

A simple device to couple linear array transducers to neonate heads for ultrasonic scanning of the brain.

A plastisol coupler has been designed that improves acoustical coupling for linear array ultrasound transducers. This device improves both ease in scanning and image quality in real-time scanning of the infant brain.