Improvement of optic nerve pial blood supply visualized through indocyanine green videoangiography after resection of a tuberculum sellae meningioma: 2-dimensional operative video

Ischemia of the optic nerve (ON) is an important cause of visual field deficit provoked by tuberculum sellae (TS) meningiomas. Indocyanine green (ICG) videoangiography could provide prognostic information. Moreover, it allows new insight into the pathophysiology of visual disturbance. The authors present the case of a 48-year-old woman with visual field impairment. Magnetic resonance imaging (MRI) depicted a lesion highly suggestive of a TS meningioma. Following microsurgical resection, ICG videoangiography demonstrated improvement of right ON pial blood supply. In this case, there was one lesion causing visual impairment through both direct compression over the left ON and ischemia to the right nerve. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21155

Comparison of Patient Outcomes following Implantation of Trifocal and Extended Depth of Focus Intraocular Lenses: A Systematic Review and Meta-Analysis

Purpose. The purpose is to compare the outcomes of implantation of trifocal intraocular lenses (TIOLs) and extended depth of focus (EDOF) intraocular lenses (IOLs). Methods. A comprehensive search of PubMed, Cochrane Library, EMBASE, and ClinicalTrial.gov was conducted in March 2020 to identify relevant studies. A meta-analysis of the results was performed. Patients implanted with EDOF IOLs or TIOLs in previous studies were included. The primary outcomes of the study were uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), and defocus curve. Results. TIOLs and EDOF IOLs provided comparable binocular UDVA (MD = -0.01, 95% CI: -0.04, 0.03, logMAR). However, EDOF IOLs provided better UIVA (MD: -0.08, 95% CI: -0.14, -0.01, logMAR) and worse UNVA (MD: 0.10, 95% CI: 0.06, 0.14, logMAR) than TIOLs. Fewer patients achieved spectacle independence after implantation of EDOF IOLs (RR: 0.74, 95% CI: 0.63, 0.87) than after implantation of TIOLs, especially for near vision (RR = 0.82, 95% CI: 0.68, 0.99). There was no statistically significant difference in contrast sensitivity (CS) under photopic or mesopic conditions with both IOLs. Patient satisfaction after implantation of both IOLs was high. Conclusion. EDOF IOLs and TIOLs provide comparable distance vision. However, EDOF IOLs provide better intermediate vision and worse near vision than TIOLs. The advantages of EDOF IOLs over TIOLs in terms of CS, aberrations, and visual disturbance are not significant. Patients are satisfied with both types of IOLs.

Tetramine in the Salivary Glands of Marine Carnivorous Snails: Analysis, Distribution and Toxicological Aspects

Focusing on tetramine, tetramethylammonium ion, contained in the salivary glands of marine carnivorous snails, this paper gives an overview of analytical methods, distribution in marine snails, and toxicological aspects. Some Neptunea snails have often caused food poisoning in North Atlantic and Northeast Asia regions, especially in Japan. The toxin of both N. arthritica and N. antiqua was first proven to be tetramine in 1960. Subsequent research on marine snail tetramine has progressed with the development of analytical methods. Of the various methods developed, the LC/ESI-MS method is most recommended for tetramine analysis in terms of sensitivity, specificity, and versatility. Accumulated data show that tetramine is ubiquitously contained at high concentrations (usually several mg/g) in the salivary glands of Neptunea snails. Tetramine is also found in the muscle and viscera of Neptunea snails and even in the salivary gland of marine snails other than Neptunea species, although mostly at low levels (below 0.1 mg/g). Interestingly, the major toxin in the salivary glands of Fusitriton oregonensis and Hemifusus tuba is distinguishable from tetramine. In tetramine poisoning, diverse symptoms attributable to the ganglion-blocking action of tetramine, such as visual disturbance, headache, dizziness, abdominal pain, and nausea, develop within 30 min after ingestion of snails because of rapid absorption of tetramine from the gastrointestinal tract. The symptoms are generally mild and subside in a short time (within 24 at most) because of rapid excretion through the kidney. However, it should be kept in mind that tetramine poisoning can be severe in patients with kidney dysfunction, as shown by two recent case reports. Finally, given the diffusion of tetramine from the salivary gland to the muscle during boiling and thawing of snails, removal of salivary glands from live snails is essential to avoid tetramine poisoning.

Idiopathic Chiasmal Optic Neuritis in a Pediatric Patient

Purpose: We report a case of idiopathic chiasmal optic neuritis in a pediatric patient.Case summary: A 13-year-old boy with no history of systemic disease was referred to our ophthalmology clinic because of visual disturbance in both eyes of 5 days in duration. The best-corrected visual acuity was 0.08 in the right eye and finger counting at 30 cm in the left eye; mild blurring of the disc margins (both eyes) was evident on fundus examination, as were temporal hemianopsia in the right eye and diffuse field loss in the left eye. Brain magnetic resonance imaging revealed focal nodular enhancement in the optic chiasm. Blood and cerebral fluid analysis yielded no evidence of infection or autoimmune disease. Therefore, we diagnosed isolated idiopathic chiasmal optic neuritis and commenced a systemic steroid. After 5 days, the visual acuity began to improve, and the field defect was almost eliminated (except for a small central scotoma) at 1 month. He has remained stable to the time of writing (4 months after treatment) and his visual acuity has normalized.Conclusions: Isolated idiopathic chiasmal optic neuritis developed in a pediatric patient and the visual function improved after steroid treatment. Although there was no evidence of systemic demyelinating disease, regular observation is scheduled given the possibility of late-onset disease.

A Perplexing Case of Pituitary Apoplexy Masquerading as Meningoencephalitis

Pituitary apoplexy (PA) is extremely rare in children and adolescents. It is a life-threatening condition usually results from sudden hemorrhage or infarction induced swelling in a pituitary adenoma. The clinical manifestations of PA include severe headaches, impaired consciousness, fever, visual disturbance, and variable ocular paresis. Therefore, the presence of meningeal irritation may lead to misdiagnosis as a case of meningoencephalitis or spontaneous subarachnoid hemorrhage, and delay in the proper management of the disease. We report a case of 17-year-old pubertal boy who developed sudden severe headache, vomiting, slurring of speech and abnormal behaviour followed by impaired sensorium with fever. The patient who was initially diagnosed with meningoencephalitis (ME) based on clinical presentation and cerebrospinal fluid (CSF) analysis, which was consistent with bacterial meningitis. MRI of brain was performed, confirming a pituitary macroadenoma with hemorrhage and ischemic changes in both basal ganglia and pons. A complete analysis of the pituitary hormones revealed decreased cortisol and thyroid hormone level and hyperprolactinemia and he was subsequently started on placement corticosteroid and L-thyroxine therapy and cabergoline. After 14/ days of antimicrobial therapy with ceftriaxone and ampicillin, the patient improved and was discharged on hormone replacement therapy and surgical advised. Hereby, we report our case with a review of literatures. Bangladesh J Medicine July 2022; 33(1) : 85-88

Visual disturbance as primary symptom of pituitary apoplexy in pregnancy

Pituitary apoplexy in pregnancy is a potentially fatal condition caused by acute ischaemic infarction or haemorrhage of pre-existing pituitary adenoma or within a physiologically enlarged pituitary gland. It has a wide spectrum of clinical presentations ranging from a mild headache to sudden collapsed. Here, we report a life-threatening case of pituitary apoplexy in a non-functioning pituitary macroadenoma occurring during pregnancy that presented with bilateral blurring of vision. Visual field showed bitemporal superior quadrantanopia. Urgent non-contrast brain MRI revealed an acute expansion of a hemorrhagic pituitary lesion complicated with local compression to the optic chiasm. The patient underwent an uneventful right supraorbital craniotomy and excision of the tumour under general anaesthesia with no foetal loss. The repeated visual field at 2 weeks after surgery showed recovering visual field defect. Hence, early neurosurgical intervention is advisable to prevent mortality and morbidity due to permanent visual field loss.

Surgical treatment of symptomatic pineal cysts without hydrocephalus—meta-analysis of the published literature

Background To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. Methods Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query ‘Pineal Cyst’ AND ‘Surgery’ as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. Results All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4–63) with 77% females. Mean cyst size was 15 mm (5–35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0–228). Presentation: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), ‘psychiatric’ (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0–9). Outcomes: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74–19.02) and resection over fenestration (OR = 12.64; 3.07–52.01). Age predicted worse outcomes (OR = 0.95; 0.91–0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). Conclusions Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Giant cell arteritis complicated by tongue necrosis and bilateral cerebellar ischaemic stroke

Giant cell arteritis (GCA) typically presents with headache, scalp tenderness or visual disturbance. Other symptoms include orofacial pain, constitutional symptoms and ischaemic stroke. An 81-year-old woman with a background of type-2 diabetes and hypertension presented with headache, oral pain and right visual loss. Examination showed hypertension, nodular temporal arteries, reduced visual acuity and suspected oral candida. Inflammatory markers were raised and she was diagnosed with GCA and commenced on corticosteroids. During treatment she developed tongue ulceration, then acute vertigo and incoordination with nystagmus and ataxia. Neuroimaging confirmed bilateral, cerebellar ischaemic strokes and temporal artery biopsy was consistent with GCA. With corticosteroids and secondary prevention of stroke measures she is now functionally independent. Oral pain is an uncommon symptom of GCA and delays in recognition may lead to catastrophic consequences. Clinicians should be aware of uncommon presentations and to optimise additional ischaemic stroke risk-factors.

Age- and frequency-dependent changes in dynamic contrast perception in visual snow syndrome

Objective Patients with visual snow syndrome (VSS) suffer from a debilitating continuous (“TV noise-like”) visual disturbance. They report problems with vision at night and palinopsia despite normal visual acuity. The underlying pathophysiology of VSS is largely unknown. Currently, it is a clinical diagnosis based on the patient’s history, an objective test is not available. Here, we tested the hypothesis that patients with VSS have an increased threshold for detecting visual contrasts at particular temporal frequencies by measuring dynamic contrast detection-thresholds. Methods Twenty patients with VSS were compared to age-, gender-, migraine- and aura-matched controls in this case-control study. Subjects were shown bars randomly tilted to the left or right, flickering at six different frequencies (15 Hz, 20 Hz, 25 Hz, 30 Hz, 35 Hz, 40 Hz). The contrast threshold (CT) for detection of left or right tilt was measured in a two-alternative adaptive forced-choice procedure (QUEST). The threshold was defined as the Michelson contrast necessary to achieve the correct response in 75% of the cases. Results The CT increased for higher flicker frequencies (ANOVA: main effect frequency: F (5,180) = 942; p < 0.001), with an additional significant frequency*diagnosis interaction (ANOVA: F (5,180) = 5.00; p < 0.001). This interaction effect was due to an increased CT at a flicker frequency of 15 Hz in the VSS cohort (VSS: MC = 1.17%; controls: MC = 0.77%). At the other frequencies, group comparisons revealed no differences. Furthermore, in the VSS cohort we observed an increase of CT with higher age (r = 0.69; p < 0.001), which was not seen in controls (r = 0.30; p = 0.20). Conclusions This study demonstrates a lower visual contrast sensitivity exclusively at 15 Hz in VSS patients and demonstrates frequency-dependent differences in dynamic contrast vision. The peak sensitivities of both parvo- and magnocellular visual pathways are close to a frequency of about 10 Hz. Therefore, this frequency seems to be of crucial importance in everyday life. Thus, it seems plausible that the impairment of contrast sensitivity at 15 Hz might be an important pathophysiological correlate of VSS. Furthermore, the overall age-related decrease in contrast sensitivity only in VSS patients underscores the vulnerability of dynamic contrast detection in VSS patients. Dynamic CT detection seems to be a promising neurophysiological test that may contribute to the diagnosis of VSS.

Findings by an International Collaboration on SJS/TEN With Severe Ocular Complications

Stevens-Johnson Syndrome (SJS) is an acute inflammatory vesiculobullous reaction of the skin and mucosa, e.g., the ocular surface, oral cavity, and genitals. In patients with extensive skin detachment and a poor prognosis, the condition is called toxic epidermal necrolysis (TEN). Not all, but some patients with SJS/TEN manifest severe ocular lesions. Approximately 50% of SJS/TEN patients diagnosed by dermatologists and in burn units suffer from severe ocular complications (SOC) such as severe conjunctivitis with pseudomembrane and ocular surface epithelial defects in the acute stage. In the chronic stage, this results in sequelae such as severe dry eye and visual disturbance. Before 2005, our group of Japanese scientists started focusing on ophthalmic SJS/TEN with SOC. We found that cold medicines were the main causative drugs of SJS/TEN with SOC and that in Japanese patients, HLA-A*02:06 and HLA-B*44:03 were significantly associated with cold medicine-related SJS/TEN with SOC (CM-SJS/TEN with SOC). We expanded our studies and joined scientists from Korea, Brazil, India, Taiwan, Thailand, and the United Kingdom in an international collaboration to detect the genetic predisposition for SJS/TEN with SOC. This collaboration suggested that in Japanese patients, cold medicines, including NSAIDs, were the main causative drugs, and that HLA-A*02:06 was implicated in Japanese and Korean patients and HLA-B*44:03 in Japanese-, Indian-, and European ancestry Brazilian patients. Our joint findings reveal that there are ethnic differences in the HLA types associated with SJS/TEN with SOC.