scholarly journals The Yield of Neuroimaging in Patients Presenting to the Emergency Department With Isolated Neuro-Ophthalmological Complaints

2021 ◽  
Author(s):  
Tharwat El Zahran ◽  
Dalia El Hadi ◽  
Hala Mostafa ◽  
Hana Mansour ◽  
Ibrahim Hashim ◽  
...  
Keyword(s):  
Emergency Department ◽  
Visual Field ◽  
Physical Exam ◽  
Blurred Vision ◽  
Presenting Symptoms ◽  
Pupil Reactivity ◽  
Life Threatening ◽  
Blurry Vision ◽  
Optic Discs ◽  
Field Defect

Abstract Background: Neuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is currently based on the clinical judgement of the medical team, without defined indications. This study aims to identify presenting symptoms and physical exam findings associated with relative positive findings on neuroimaging studies,Methods: This study was conducted by reviewing the electronic medical records of patients presenting to the Emergency Department (ED) with isolated neuro-ophthalmologic complaints between January 1st, 2013 and September 30th 2019. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses.Results: We reviewed the charts of 211 patients of whom 50.7% were females and had a mean age of 41.2 ±21.4 years. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal findings. Complaining of blurry vision (p=0.038) or visual field changes (p=0.014) at presentation were associated with having positive findings on imaging. Physical exam findings of a visual field defect (p=0.016), abnormal pupil reactivity (p=0.028), afferent pupillary defect (p=0.018), or abnormal optic disc exam (p=0.009) were also associated with positive findings on imaging.Conclusion: Neuroimaging is more likely to yield positive findings in patients presenting to the ED with blurred vision or changes in visual field and in those found to have visual field irregularities, afferent pupillary defects or abnormal optic discs on physical exam. These findings - when combined with the proper clinical setting - should lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making.

scholarly journals Vasculogenic Mimicry Correlates to Presenting Symptoms and Mortality in Uveal Melanoma

2021 ◽  
Author(s):  
Shiva Sabazade ◽  
Viktor Torgny Gill ◽  
Christina Herrspiegel ◽  
Gustav Stålhammar
Keyword(s):  
Visual Field ◽  
Uveal Melanoma ◽  
Poor Prognosis ◽  
Periodic Acid ◽  
Vasculogenic Mimicry ◽  
Clinicopathological Parameters ◽  
Tumor Diameter ◽  
Blurred Vision ◽  
Periodic Acid Schiff ◽  
Presenting Symptoms

Abstract PurposeFluid-conducting extracellular matrix patterns known as vasculogenic mimicry (VM) have been associated with poor prognosis in uveal melanoma and other cancers. We investigate the correlations between VM, presenting symptoms, mortality and the area density of periodic acid-Schiff positive histological patterns (PAS density).MethodsSixty-nine patients that underwent enucleation for uveal melanoma between 2000 and 2007 were included. Clinicopathological parameters, presenting symptoms and outcomes were collected. Histological tumor sections were evaluated for VM and PAS density was quantified with digital image analysis.ResultsThirty-four patients (49 %) presented with blurred vision. 18 (26 %) with a shadow in the visual field, 7 (10 %) with photopsia and/or floaters and 2 (3 %) with metamorphopsia. Nine patients (13 %) had no symptoms at all. Median follow-up was 16.7 years (SD 2.6). A shadow in the visual field, but no other symptom, was positively correlated with the presence of VM (φ 0.70, p<0.001) and greater PAS density (p<0.001). In multivariate regression, retinal detachment (RD), presence of VM and PAS density ≥ median were independent predictors of a shadow, but not tumor distance to the macula, tumor apical thickness, tumor diameter or ciliary body engagement. Presence of VM was associated with significantly shorter cumulative disease-specific survival (Wilcoxon p=0.04), but not PAS density ≥ median, presenting symptoms or RD (p>0.28).ConclusionTumors from uveal melanoma patients that report a visual field shadow are likely to display VM and greater PAS density, likely explaining the previously reported association between this symptom and poor prognosis.

scholarly journals SAT-247 Use of Double Dopamine Agonists in Giant Prolactinomas: A Series of 6 Cases

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Yueh Chien Kuan
Keyword(s):  
Visual Field ◽  
Medical Therapy ◽  
Visual Field Defect ◽  
Tolerability Profile ◽  
Residual Tumour ◽  
Careful Monitoring ◽  
Presenting Symptoms ◽  
Giant Prolactinoma ◽  
Giant Prolactinomas ◽  
Field Defect

Abstract Dopamine agonist monotherapy is first line therapy in giant prolactinomas even when visual field defect is present. The costlier cabergoline is often preferred over bromocriptine due to higher efficacy and tolerability profile. Described herein combined cabergoline and bromocriptine therapy in 6 cases of giant prolactinomas. Retrospective records review of 6 patients with giant prolactinoma (3 males: M1-M3, 3 females: F1-F3) in a single tertiary centre was performed. Mean age at diagnosis: 29 years (range 17-39). Mean duration of follow up: 7 years (range 3-11). Headache and visual field defect were the presenting symptoms in all cases. Basal prolactin concentration: 100000 to 468851 mIU/L (&lt;300 for male, &lt;600 for female). Three patients have hypopituitarism at presentation, one after surgery and one remained eupitary 5 years after diagnosis. One developed late onset hypopituitarism 4 years after normalisation of prolactin levels. Three patients underwent debulking at presentation because of significant mass effects with obstructive hydrocephalus. In all patients cabergoline 1-1.5 mg/wk was started at diagnosis and gradually increased to 0.5 mg daily, aiming for normoprolactinemia. From May 2017 bromocriptine were given to these patients who continued to have hyperprolactinemia despite cabergoline 3.5-4mg/wk. Bromocriptine was commenced 1.25-5mg/day and gradually increased to 10 mg/day on top of cabergoline with careful monitoring of prolactin levels and side effects. Cabergoline was tapered down to 1.5-2mg/wk if prolactin levels remained stable between 2-3x normal while maintaining dose of bromocriptine. In M1, cabergoline was tapered off while maintaining bromocriptine 10mg/day with stable prolactin levels (~1000 mIU/L). In M2, normoprolactinemia was achieved after adding on bromocriptine and is currently on cabergoline 2mg/week and bromocriptine 10mg/day. In M3, whose prolactin were 4x normal value despite cabergoline 3.5mg/week, decreased 50% with bromocriptine 5 mg/day and remained stable when cabergoline reduced to 1.5mg/week. F1 had transphenoidal section twice due to failure of medical therapy. Her prolactin remained markedly elevated 10000-20000 mIU/L despite cabergoline 3.5 mg/week and bromocriptine 10mg/day, with persistent bitemporal hemianopia. F2 developed erythema nodosum after starting bromocriptine which was stopped and continued with cabergoline 1 mg/week. F3 showed partial response with 50% reduction in prolactin to 4485 mIU/L with bromocriptine 10 mg/day and cabergoline 1.5mg/week. In patients who underwent debulking, residual tumour remained unchanged. Two patients - tumour shrank 40% (F2) and 90% (M3) with medical therapy alone. In conclusion, adding on bromocriptine can be considered when high dose cabergoline is required for treatment of giant prolactinoma with careful monitoring. This reduces cabergoline dose which saves cost.

scholarly journals Infliximab-related Optic Neuritis in a Patient with Crohn's Disease: a Case Report and Literature Review

2021 ◽  
Vol 62 (8) ◽  
pp. 1160-1166
Author(s):  
Su Hwan Park ◽  
Min Seung Kang ◽  
Sang Yoon Kim ◽  
Ji-Eun Lee ◽  
Su Jin Kim
Keyword(s):  
Visual Acuity ◽  
Crohn’S Disease ◽  
Visual Field ◽  
Crohn's Disease ◽  
Optic Neuritis ◽  
Visual Field Defect ◽  
High Dose ◽  
Infliximab Treatment ◽  
Blurred Vision ◽  
Field Defect

Purpose: We report a case of optic neuritis related to infliximab treatment in a patient with Crohn’s disease, along with a review of the relevant literature.Case summary: A 22-year-male patient complained of blurred vision in the left eye for 2-3 weeks. His best-corrected visual acuity was 8/20 in the left eye. Relative afferent pupillary defect was detected in the left eye and the pupils were of equal size. There was no pain on ocular movement. The results of slit-lamp and fundus examinations were normal. A visual field test revealed a central to inferior visual field defect in the left eye. Orbit magnetic resonance imaging revealed perineural enhancement of the left optic nerve. He had a 5-year history of Crohn’s disease and had been treated with intravenous infliximab (600 mg every 2 weeks). A diagnosis of retrobulbar optic neuritis associated with infliximab was made. He was infused with high-dose methylprednisolone, which was changed to per oral administration. His visual acuity and visual field defect improved after 3 months.Conclusions: Tumor necrosis factor-α inhibitors, such as infliximab, may cause optic neuritis. Therefore, history-taking is important for differential diagnosis and appropriate treatment.

scholarly journals Vasculogenic mimicry correlates to presenting symptoms and mortality in uveal melanoma

2021 ◽  
Author(s):  
Shiva Sabazade ◽  
Viktor Gill ◽  
Christina Herrspiegel ◽  
Gustav Stålhammar
Keyword(s):  
Visual Field ◽  
Uveal Melanoma ◽  
Poor Prognosis ◽  
Periodic Acid ◽  
Vasculogenic Mimicry ◽  
Clinicopathological Parameters ◽  
Tumor Diameter ◽  
Blurred Vision ◽  
Periodic Acid Schiff ◽  
Presenting Symptoms

Abstract Purpose Fluid-conducting extracellular matrix patterns known as vasculogenic mimicry (VM) have been associated with poor prognosis in uveal melanoma and other cancers. We investigate the correlations between VM, presenting symptoms, mortality, and the area density of periodic acid-Schiff positive histological patterns (PAS density). Methods Sixty-nine patients that underwent enucleation for uveal melanoma between 2000 and 2007 were included. Clinicopathological parameters presenting symptoms and outcomes were collected. Histological tumor sections were evaluated for VM and PAS density was quantified with digital image analysis. Results Thirty-four patients (49%) presented with blurred vision. 18 (26%) with a shadow in the visual field, 7 (10%) with photopsia and/or floaters, and 2 (3%) with metamorphopsia. Nine patients (13%) had no symptoms at all. Median follow-up was 16.7 years (SD 2.6). A shadow in the visual field, but no other symptom, was positively correlated with the presence of VM (φ 0.70, p < 0.001) and greater PAS density (p < 0.001). In multivariate regression, retinal detachment (RD), presence of VM, and PAS density ≥ median were independent predictors of a shadow, but not tumor distance to the macula, tumor apical thickness, tumor diameter, or ciliary body engagement. The presence of VM was associated with significantly shorter cumulative disease-specific survival (Wilcoxon p = 0.04), but not PAS density ≥ median, presenting symptoms or RD (p > 0.28). Conclusion Tumors from uveal melanoma patients that report a visual field shadow are likely to display VM and greater PAS density, likely explaining the previously reported association between this symptom and poor prognosis.

scholarly journals Temporal crescent syndrome caused by a lateral ventricular glioependymal cyst: case report

2020 ◽  
Vol 26 (3) ◽  
pp. 232-236
Author(s):  
Izumi Yamaguchi ◽  
Kyong-Hon Pooh ◽  
Mai Azumi ◽  
Yasushi Takagi
Keyword(s):  
Visual Field ◽  
Visual Field Defect ◽  
Striate Cortex ◽  
The Body ◽  
Blurred Vision ◽  
Anterior Portion ◽  
Glioependymal Cyst ◽  
The Right ◽  
Field Defect

Temporal crescent syndrome is a monocular visual field defect involving the temporal crescent of one eye caused by a retrochiasmal lesion. The most anterior portion of the striate cortex is the only area where the retrochiasmal lesion produces a monocular visual field defect. The authors present the case of a 9-year-old boy who presented with mild headache. MRI revealed a cyst with cerebrospinal fluid signal intensity, occupying the body and trigone of the right lateral ventricle. Conservative treatment with regular clinical and radiological follow-up was chosen because neurological examination findings were normal. Three years later, the patient experienced blurred vision with a temporal crescent defect in the left eye. Endoscopic cyst fenestration was performed, and the pathological findings indicated a glioependymal cyst. After surgery, the monocular temporal crescent disorder was resolved. MRI indicated shrinkage of the cyst and improvement in the narrowing of the anterior calcarine sulcus. These findings suggested that the temporal crescent syndrome was caused by a lateral ventricular glioependymal cyst. This is the first known report of temporal crescent syndrome caused by a lateral ventricular glioependymal cyst. In patients with monocular temporal crescent disorder without intraocular disease, a retrochiasmal lesion in the most anterior portion of the striate cortex should be considered.

scholarly journals Bowel Obstruction due to Migration of an Intragastric Balloon Necessitating Surgical Removal before Completion of the Recommended 6 Months

2012 ◽  
Vol 2012 ◽  
pp. 1-3 ◽  
Author(s):  
Seyed Morteza Mousavi Naeini ◽  
Mahdi Sheikh
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Bowel Obstruction ◽  
Intragastric Balloon ◽  
Surgical Removal ◽  
Gastric Balloon ◽  
Presenting Symptoms ◽  
Prevalence Of Obesity ◽  
Life Threatening ◽  
Original Procedure

We report a 25-year-old man with small bowel obstruction due to migration of a saline-filled intragastric balloon before the completion of the recommended 6 months of treatment who presented to the emergency department with abdominal pain. The patient had received a gastric balloon insertion 5 months prior. Within 24 hours of the original procedure, he noticed urine staining. The results of an endoscopy conducted the next day were normal. After ruling out other possible complications using endoscopy and confirming the diagnosis by computed tomography (CT) scan and conservative treatment for 48 hours the patient underwent surgery and the balloon was extracted. Due to the growing prevalence of obesity and the modalities used for treating it, physicians should be familiar with the side effects of each option and their presenting symptoms as well as the differential diagnosis they should not miss. Physicians must also improve their knowledge of how to approach these patients to avoid life-threatening complications caused by these modalities.

scholarly journals Binasal hemianopia in two sisters

2020 ◽  
Vol 13 (1) ◽  
pp. e232486 ◽  
Author(s):  
Sam Scotcher ◽  
George Morphis ◽  
Peter Good
Keyword(s):  
Head Injury ◽  
Visual Field ◽  
Visual Field Defect ◽  
Minor Head Injury ◽  
Teenage Girl ◽  
Blurred Vision ◽  
A Minor ◽  
Field Defect

Binasal hemianopia is a rare visual field defect. A teenage girl presented with blurred vision and persistent headaches following a minor head injury. The ocular examination was normal except for a binasal hemianopia, and subsequent neuroimaging was also unremarkable. Her older sister was found to have the same visual field defect, also with normal neuroimaging. This represents the first reported case of binasal hemianopia found in siblings. Given that no neurological or ocular cause was identified in either sister, this supports the theory of an unknown congenital aetiology.

scholarly journals An Active Duty Sailor With Worsening Headaches and Blurry Vision

2019 ◽  
Vol 184 (7-8) ◽  
pp. e365-e367
Author(s):  
Chad A Thompson ◽  
Eric Barnes
Keyword(s):  
Final Diagnosis ◽  
Active Duty ◽  
Physical Exam ◽  
Intracranial Tumors ◽  
Medical Department ◽  
Critical History ◽  
Academic Center ◽  
Life Threatening ◽  
Blurry Vision ◽  
Direct Ophthalmoscopy

Abstract Headaches are a typical presentation to a military medical department or emergency room. Having a broad differential diagnosis and utilizing a thorough physical exam can assist providers in honing down the list of pathology and in identifying potentially life-threatening causes of cephalgia such as intracranial tumors. In this case, a 27-year-old man presented with progressive headaches along with vision changes for the preceding 2–3 months. On initial physical exam, he was found to have bilateral papilledema using a panoptic ophthalmoscope, confirmed after sending the patient to optometry. Neurology evaluated him and found a pineoblastoma on MRI. He underwent eventual neurosurgical debulking and radiation. The highlight of this case is the critical history components along with physical exam techniques that can assist providers in the identification of life-threatening causes of a headache. Direct ophthalmoscopy was vital in this case to encourage referral for further management. In selected studies, emergency medicine providers performed ophthalmoscopy in 14% of patients, with roughly 10% of those patients having erroneous findings. Another study showed that 13% of all cases presenting to a large academic center had fundoscopic findings that were important to the final diagnosis.

Visual Field Examination in Glaucoma Patients : Humphrey Visual Field Analysis vs Amsler Grid

2017 ◽  
Vol 43 (2) ◽  
pp. 124
Author(s):  
Ivana Tanoko ◽  
Fifin L Rahmi
Keyword(s):  
Visual Field ◽  
Visual Field Defect ◽  
Glaucoma Patient ◽  
Field Analysis ◽  
Glaucomatous Optic Neuropathy ◽  
Visual Field Examination ◽  
Cross Sectional ◽  
Rnfl Thickness ◽  
Amsler Grid ◽  
Field Defect

Introduction and Objective: Glaucoma is the leading cause of global irreversible blindness, signed by glaucomatous optic neuropathy related to visual field defect. The purpose of the study is comparing visual field defect examination using HVFA to Amsler Grid in glaucoma patient at dr. Kariadi Hospital. Methods: This is a cross-sectional study. Amsler Grid were performed to the patients who have reliable HVFA at last 6 months and presented as descriptive analytic results. Result: There were 40 eyes involved in this study from 27 patients (15 men, 12 women), 26-68 years old and visual acuity 1/60-6/6. Seventeen eyes showed visual field defect in HVFA and Amsler Grid had average MD - 24.97 dB, CDR 0.89 and RNFL thickness 51.74. We found that 11 eyes didn’t showed in both of examination had average MD -8.06, CDR 0.63 and RNFL thickness 103.23 and those parameters are significantly different to the 17 eyes before (p<0.05). Data from 12 eyes that showed visual field defect only one of examination (9 only in HVFA and 3 in Amsler Grid) didn’t show difference statistically each other. Conclusion: HFVA and Amsler Grid seemed to be comparable in detecting visual field defect in advanced glaucoma.

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