Ophthalmology

Neuro-ophthalmology Question of the Week: Ptosis and Impaired Elevation Left Eye

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Question:  Where could the lesion causing this defect be located?

1. Brainstem
2. Left cavernous sinus
3. Left orbital fissure
4. Left optic foramen
5. Left orbit

Neuro-ophthalmology Question of the Week: Ocular Bruit

Question: A 57-year-old man who had a traffic accident 1 month previously, presented with left ocular pain, double vision, and left eye proptosis with ptosis and conjunctival hemorrhage.


Which of the following are likely to be present?

1. Dilated fundus veins with no hemorrhages or disc edema
2. Left complete external ophthalmoplegia
3. Left ocular bruit  
4. Dilated left superior ophthalmic vein on MRI/MRA
5. Extravasation into cavernous sinus on MRI/MRA


Neuro-ophthalmology Question of the Week: A Classic Clinical Sign - Racoon Eyes

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Figure 1. Racoon eyes - bilateral periorbital ecchymoses

Question:

Which of the following are correct?

1. Raccoon eyes are most commonly associated with basilar skull fracture.
2. Raccoon eyes are most commonly associated with unilateral or bilateral orbital fractures.
3. Raccoon eyes are seldom seen with basilar skull fracture.
4. Raccoon eyes can be seen in unilateral and bilateral orbital fractures.
5. Beyond trauma the differential diagnosis list for racoon eyes includes: most commonly metastatic neuroblastoma, Kaposi sarcoma, multiple myeloma, and amyloidosis.

Neuro-ophthalmology Question of the Week: Isolated Upbeat Nystagmus

Mystery Case1: A young woman with isolated upbeating nystagmus

A 15-week pregnant 21-year-old woman initially presented with nausea, vomiting, and abdominal pain. The patient admitted to decreased oral intake over the past 4 weeks, including her prescribed prenatal vitamins. She was hypokalemic with elevated transaminases and gallstone pancreatitis was confirmed by imaging. Prior to cholecystectomy, fetal heart tones were lost and intrauterine fetal demise occurred. The patient underwent dilation and evacuation as well as cholecystectomy. She was discharged home but returned within 1 week with persistent nausea and vomiting. She had no neurologic complaints at the time. Basic metabolic panel on admission was unremarkable. On hospital day 2, she developed oscillopsia. Her examination was remarkable for large amplitude upbeating nystagmus (UBN) in primary position. She had gaze-evoked UBN in all other directions. The amplitude of the UBN increased on upgaze and dampened on downgaze. Smooth pursuit was impaired in all directions and saccades were dysmetric (video 1 on the Neurology« Web site at Neurology.org). Extraocular movements were intact with no evidence of ophthalmoplegia. Pupils were equal and reactive, and fundus examination was normal. Reflexes were present and symmetric, and gait was normal. The patient had no deficits on mental status examination. She was oriented to name, date, place, and situation and had no difficulty with complex commands, calculations, or short-term or long-term memory. Language was similarly intact. She demonstrated no ataxia or other focal abnormalities on examination.

Video of patient


Questions for consideration:

What is the differential diagnosis with this history and examination?

What is the next step in management for this patient? What tests would you order?


Neuro-ophthalmology Question of the Week: Posterior Reversible Encephalopathy Syndrome (PRES)

Question:  Which of the following are correct for the posterior reversible encephalopathy syndrome (PRES)?

1. PRES has an excellent prognosis.

2. It is associated with immunosuppressive drugs.

3. It is associated with hypertension.

4. It is associated with preeclampsia/eclampsia.

5. MRI will show edema involving only the white matter of the cerebral posterior regions.

6. Vision may be reduced to hand motion.

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Neuro-ophthalmology Question of the Week: Skew Deviation Test

Question: In a patient with skew deviation what happens when the patient changes position from upright to supine?

1. There is no change in the vertical deviation.
2. The vertical deviation increases.
3. The vertical deviation decreases.

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Neuro-ophthalmology Question of the Week: New findings & the Idiopathic Intracranial Hypertension Treatment Trial

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Question:

Which of the following are correct for the Idiopathic Intracranial Hypertension Treatment Trial?

1. This is the first time there has been proof that acetazolamide use in IIH improves visual outcome.

2. The beneficial effects of acetazolamide and diet are independent. So, although the acetazolamide-plus-diet patients lost twice as much weight as placebo-plus-diet patients, the acetazolamide effect on perimetric mean deviation was independent of the weight loss. The average weight loss in the trial was 6%.

3. The patients with moderate to severe optic nerve swelling recovered substantially less vision than those with mild swelling.

4. Acetazolamide has its greatest effect on visual field function and papilledema in the first month of escalating dosage to the maximum dosage tolerated that did not interfere with activities of daily living.

5. Marked worsening of visual field function was much less common in the acetazolamide-plus-diet group compared to the placebo-plus-diet group (6 patients vs. 1) and risk factors for marked worsening were presence of high grade papilledema and lower visual acuity measures at baseline.

6. Many IIHTT subjects tolerated maximal doses of acetazolamide up to four grams per day.

7. While there were many expected side effects, quality of life measures were significantly better in the acetazolamide-plus-diet group. There was no permanent morbidity (bodily damage) from acetazolamide use. 8. IIH patients on acetazolamide as the only diuretic required potassium supplementation.


Neuro-ophthalmology Question of the Week: Effect of acetazolamide on visual field function in patients with idiopathic intracranial hypertension and mild visual loss

Question:

What magnitude of improvement in visual field function was found in the idiopathic intracranial hypertension treatment trial In patients with mild visual loss using acetazolamide and a low-sodium weight-reduction diet compared with diet alone?
1. Much greater improvement
2. Modestly greater improvement
3. No greater  improvement
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Figure 2.

Neuroimaging features of idiopathic intracranial hypertension

Imaging modalities for diagnosis of idiopathic intracranial hypertension without papilloedema. (A) T1 weighted MRI; sagittal; empty sella turcica (arrow) presents in 70% of patients with idiopathic intracranial hypertension.28 (B) T2 weighted MRI; axial; distension of the optic nerve sheath (arrows) has been reported in 45% of patients with the disorder.28 (C) MRI venography; posterior view; hypoplastic right transverse sinus (arrow). MRI venogram is advised in all new patients with idiopathic intracranial hypertension to rule out venous thrombosis. (D) T2 weighted MRI; axial; flattening of posterior globes (arrows) can be seen in 80% of patients.28


Neuro-ophthalmology Question of the Week: CSF pressure, papilledema grade, and response to acetazolamide in the Idiopathic Intracranial Hypertension Treatment Trial

Question: The effect of acetazolamide on CSF pressure was examined in those with low FrisÚn papilledema grade (FPG) (grades I-III) and those with high FPG (grades IV-V) at baseline and at 6 months.

Which of the following is correct?

1. At 6 months, acetazolamide had a similar effect on CSF pressure in subjects with low FPG  and in subjects with high FPG.

2. At 6 months, acetazolamide had a much better effect on CSF pressure in subjects with low FPG than with high FPG.

3. At 6 months, acetazolamide had a much better effect on CSF pressure in subjects with high FPG than with low FPG.


FrisÚn papilledema grades3

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Neuro-ophthalmology Question of the Week: Risk factors for poor visual outcome in patients with idiopathic intracranial hypertension

Question:

What factors in the Idiopathic Intracranial Hypertension Treatment Trial at baseline were more likely to experience treatment failure?

1. Age
2. Gender
3. Obesity
4. Visual acuity
5. Grade of papilledema

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