药物与视神经管减压治疗急性球后视神经炎疗效观察

目的探讨药物与视神经管减压手术治疗急性球后视神经炎疗效。方法回顾1988～2005年收治双眼急性球后视神经炎54例108眼,经药物治疗与视神经管减压手术治疗（以下简称减压治疗）并观察其疗效。结果54例108眼经药物治疗16～20d有46例（85．19％）95眼（87．96％）视力恢复到0．5—1．2,但仍有8例（14．81％）13眼（12．04％）视力无光感～2m数指。选择视力最差的无光感～30cm数指的8例8眼施行减压治疗,术后药物继续治疗16～20d,术后8眼视力恢复到0．3～0．7。经3年观察,术侧眼视力0．5～1．0,眼底视乳头色正常;而未手术侧的5眼视力光感-20cm数指,眼底视乳头苍白,血管细小,呈鲜明对比,疗效迥然不同。结论①球后视神经炎经药物治疗,大多数病例视力恢复较好。②经药物治疗2—3周少数病例视力仍无光感一眼前指数,视乳头淡白,经CT或MRI检查排除颅内病变,而球后视神经明显增粗的重症病例,应行减压治疗,可恢复较好视力。     

Optic neuritis with concurrent etanercept and isoniazid therapy

OBJECTIVE: To report a case of optic neuritis associated with concurrent etanercept and isoniazid therapy. CASE SUMMARY: A 55-year-old man diagnosed as having rheumatoid arthritis had received treatment with nonsteroidal antiinflammatory drugs, sulfasalazine, oral methotrexate, leflunomide, and deflazacort. Four months prior to admission, he had a Disease Activity Score of 6.06; treatment with etanercept was considered. Three months prior to admission, because of evidence of latent tuberculosis, isoniazid 300 mg once daily and pyridoxine 50 mg once daily were prescribed. Treatment with subcutaneous etanercept 25 mg twice weekly was started 5 days after isoniazid was initiated. Two weeks prior to admission, the patient developed blurred vision in his left eye. Ten days later, his vision worsened and he was hospitalized. The visual acuity in both eyes was 0.7, and a campimetric examination was compatible with optic neuritis. Magnetic resonance imaging of the brain revealed lesions suggesting demyelinating lesions. The clinical course was consistent with bilateral optic neuritis. Etanercept was stopped, and isoniazid was replaced with rifampin 600 mg once daily. The patient was treated with intravenous methylprednisolone hemisuccinate 1 g/day for 5 days followed by oral prednisolone, resulting in a minor subjective improvement in left eye visual acuity. He then received oral prednisone for 3 weeks, slowly tapering to discontinuation. DISCUSSION: No physiologic factors could have predisposed this patient to develop optic neuritis. He was not diagnosed with a demyelinating disease or underlying systemic condition. The optic neuritis was unlikely to be an early manifestation of multiple sclerosis based on the clinical course and the negative results of the imaging tests. Furthermore, there was a close temporal correlation between the drug exposure and the onset of symptoms. After discontinuation of etanercept and isoniazid therapy, the patient's general condition improved. Use of the Naranjo probability scale indicated a possible relationship between optic neuritis and combined etanercept-isoniazid therapy. CONCLUSIONS: Patients initiated on etanercept and isoniazid should be closely monitored for the development of adverse neurologic signs and effects. If optic neuritis is determined, etanercept and isoniazid should be discontinued immediately.     

Ophthalmology update for primary practitioners. Part I. Update on optic neuritis

Optic neuritis is a common cause of acute visual loss. It is typified by sudden onset of visual impairment and pain with eye movements, followed by spontaneous recovery of vision over several months. Pathologically, optic neuritis is an acute demyelinating event affecting the optic nerve. Objective physical findings are typically few, including an afferent pupillary defect or Marcus-Gunn pupil, whereas subjective psychophysical findings abound (ie, diminished central visual acuity, color vision, decreased contrast sensitivity, and visual field abnormalities). These characteristics have made the diagnosis of optic neuritis based solely on clinical grounds disquieting to practitioner and patient alike. In addition, the fact that optic neuritis is often associated with multiple sclerosis as the first clinical manifestation of disease gives further reason for both patient and physician anxiety. The serious nature of visual loss and the consequences of making the diagnosis of optic neuritis has given rise to extensive testing and expensive treatments. This review is intended to explore our current state of knowledge with regard to (1) clinical presentation, (2) ancillary testing, (3) therapeutic intervention, and (4) associated disease, specifically the risk for multiple sclerosis in the patient who presents with an acute optic neuritis. Finally, a suggestion guide for informing the patient and addressing his or her concerns will be presented.     

Normal and abnormal fMRI activation patterns in the visual cortex after recovery from optic neuritis

Recovery to normal or near normal visual acuity after an optic neuritis episode is common, despite frequent persistence of conduction abnormalities, evident in prolonged visual evoked potential (VEP) latencies. Improvement of visual function is commonly attributed to peripheral nerve recovery. However, central reorganization processes may also be involved. To assess this, we compared the patterns of fMRI activation, elicited by stimulation of the affected and the normal eye, along the visual cortical hierarchy. Activation was assessed in 8 subjects, which recovered clinically from an episode of optic neuritis but still had prolonged VEP latencies. In all patients, reduced fMRI activation was seen in V1 during stimulation of the affected eye, compared to the normal eye. The fMRI signal difference decreased in magnitude with progression along the visual hierarchy, and in some regions within the lateral occipital complex even showed the opposite preference (for the affected eye). These results may indicate a built-in robustness of the object-related areas to disruption of the visual input. Alternatively, it could reflect an adaptive functional reorganization of the cortical response to an abnormal input.     

Ophthalmic diagnoses in the ED: optic neuritis

Optic neuritis is the most common cause of decreased vision due to optic nerve dysfunction in patients who are 20 to 40 years of age. Optic neuritis, or inflammation of the optic nerve, is primarily due to idiopathic demyelination. Demyelinative lesions seen in optic neuritis are not unlike those seen in plaque associated with multiple sclerosis. In fact, acute inflammatory demyelination of the optic nerve commonly occurs as an initial manifestation of multiple sclerosis. Key features of optic neuritis include a vision loss occurring over 1 to 10 days, color vision impairment, eye pain with motility, and an afferent pupillary defect. This significant diagnosis can be challenging to an emergency physician as it is relatively infrequently observed.     

经鼻内镜微创手术治疗视功能障碍疾病的探讨

目的探讨鼻科临床相关视功能障碍的病因、诊断、经鼻内镜手术治疗及效果。方法回顾性分析鼻源性球后视神经炎、外伤性视神经病、异物性视神经病及眶肿瘤引起的视功能障碍115例（117眼）的病因、诊断、经鼻内镜治疗经过及效果，术后随访6个月～4年。结果44例球后视神经炎有效率95．5％，外伤性视神经病64例有效率41．5％，异物性视神经病2例中1例视力改善，5例眶肿瘤视力和其他眼症状均获不同程度改善。结论与鼻科临床相关的视功能障碍最常见病因是头部钝性闭合性外伤，其次是鼻窦炎性疾病，鼻窦肿瘤、异物伤和恶性肿瘤转移引起者相对少见；经鼻内镜手术是主要有效的治疗方法。     

A case of acute optic neuritis during pregnancy treated by membrane-based therapeutic plasma exchanges without systemic anticoagulation

IntroductionIn acute optic neuritis, high dose steroid therapy as first - line treatment is contraindicated in early pregnancy, therapeutic plasma exchanges (TPE) represent an alternative. We report a case of a pregnant woman with progressive, acute optic neuritis subjected to membrane-based therapeutic plasma exchange with extracorporal citrate-based anticoagulation.Case presentationA 35 year-old second-time pregnant woman (4th week of gravidity) of Caucasian ethnicity complained of visual impairment of the right eye. She was hospitalized for suspected optic neuritis. In the eye exam central and peripheral scotoma of the right side were found. T2 weighted Magnetic-Resonance Imaging revealed an isolated, prechiasmal lesion of the right optic nerve, and the patient had a delayed p100 latency of visually evoked potentials of the right eye. Cerebrospinal-fluid investigation was unrevealing. The diagnosis of right sided optic neuritis was established. Due to early pregnancy, steroids were contraindicated. Visual disturbances further deteriorated by day 2 in hospital. For therapy, 5 sessions of membrane-based therapeutic plasma exchange with albumin solution were performed. An extracorporal anticoagulation using citrate with calcium substitution was applied. After the second session, there was a subjective improvement of symptoms. At discharge on day 14, visual acuity was no longer impaired, sensitivity to bright light remained. In eye exam at 3.5 months after discharge, the patient ha d a complete recovery. Follow-up gynecological exams were unrevealing.ConclusionThis case of unilateral acute optic neuritis supports the view that membrane-based therpautic plasma exchange without systemic anticoagulation represents a safe intervention in pregnancy.     

Optic nerve atrophy and retinal nerve fibre layer thinning following optic neuritis: evidence that axonal loss is a substrate of MRI-detected atrophy

Magnetic resonance imaging (MRI) measures of brain atrophy are often considered to be a marker of axonal loss in multiple sclerosis (MS) but evidence is limited. Optic neuritis is a common manifestation of MS and results in optic nerve atrophy. Retinal nerve fibre layer (RNFL) imaging is a non-invasive way of detecting axonal loss following optic neuritis. We hypothesise that if the optic nerve atrophy that develops following optic neuritis is contributed to by axonal loss, it will correlate with thinning of the RNFL. Twenty-five patients were studied at least 1 year after a single unilateral attack of optic neuritis without recurrence, with a selection bias towards incomplete recovery. They had MR quantification of optic nerve cross-sectional area and optic nerve lesion length, as well as optical coherence tomography (OCT) measurement of mean RNFL thickness and macular volume, quantitative visual testing, and visual evoked potentials (VEPs). Fifteen controls were also studied. Significant optic nerve atrophy (mean decrease 30% versus controls), RNFL thinning (mean decrease 33% versus controls), and macular volume loss occurred in patients' affected eyes when compared with patients' unaffected eyes and healthy controls. The optic nerve atrophy was correlated with the RNFL thinning, macular volume loss, visual acuity, visual field mean deviation, and whole field VEP amplitude but not latency. These findings suggest that axonal loss contributes to optic nerve atrophy following a single attack of optic neuritis. By inference, axonal loss due to other post-inflammatory brain lesions is likely to contribute to the global MRI measure of brain atrophy in multiple sclerosis.     

激素联合脑苷肌肽及脱水药物治疗外伤性视神经损伤的临床分析

目的:回顾性分析外伤性视神经病变（traumatic optic neuropathg,TON患者应用激素联合脑苷肌肽及脱水药物治疗的效果。方法:选取本院2014年2月到2021年9月期间285例TON患者,按照治疗方法不同分为联合组、常规组,分别为143例、142例。对比各组患者基线资料、治疗前后的视力恢复情况、不良反应,单因素分析两组预后良好以及视力改善的指标差异。结果:联合组患者的视力恢复有效率明显高于常规组,差异有统计学意义（ P<0.05）;治疗后联合组患者的眼压以及视野平均缺损度均明显低于常规组,数据差异均具有统计学意义（ P<0.05）;单因素亚组分析结果显示年龄≤40岁、伤后残留光感、就诊时间≤24 h以及VEP未熄灭的TON患者联合应用激素与脑苷肌肽以及脱水药物治疗的视力改善效果与常规组的数据差异均具有统计学意义（ P<0.05）;单因素亚组分析结果显示有视神经管骨折、不伴有视神经肿胀迂曲的TON患者应用联合激素、脑苷肌肽以及脱水治疗的预后结局良好,与常规组的数据差异均有统计学意义（ P<0.05）。 结论:脑苷肌肽与脱水治疗基础上联合激素甲泼尼龙琥珀酸钠治疗可以改善TON患者视力,减轻视神经损伤,并且不会增加不良反应发生风险,安全性较高,需重点关注年龄超过40岁、就诊时间超过24 h以及VEP熄灭、视神经肿胀等预后不良以及疗效差的高危患者,值得临床推广。     

Solitary intracranial Rosai-Dorfman disease: case report and literature review

Rosai-Dorfman disease is a well-established autoimmune histioproliferative disorder, and solitary central nervous system involvement is rare. A 35-year-old man presented with headache and transient blurred vision of 4 months' duration and weakness of the left extremities for 1 month. He had left temporal hemianopsia, a right nasal visual field defect of the upper medial quadrant and decreased muscle strength of the left extremities. Magnetic resonance imaging (MRI) showed a contrastenhancing tentorium-based lesion in the right trigone, intruding into the right lateral ventricle. The lesion was totally resected. Rosai-Dorfman disease was confirmed pathologically by an inflammatory infiltrate in the absence of an infectious agent, emperipolesis and positive S100 staining. From a review of the literature on Rosai-Dorfman disease in the central nervous system it is concluded that follow-up MRI should be performed in order to detect possible recurrence and that this rare entity should be considered in the differential diagnosis of intracranial lesions.     

Bilateral simultaneous optic nerve dysfunction after periorbital trauma: recovery of vision in association with with chiropractic spinal manipulation therapy

OBJECTIVE: To discuss the recovery of optic nerve function after chiropractic spinal manipulation in a patient with loss of vision as a result of facial fracture from a fall. CLINICAL FEATURES: In a fall down a stairwell, a 53-year-old woman with migraines fractured her right zygomatic arch, which was later treated surgically. Approximately 3 weeks after the accident, vision in her contralateral eye became reduced to light perception. Electrophysiologic studies revealed that the function of both optic nerves was diminished, the right significantly more than the left. Single photon emission tomography showed pancerebral ischemic foci. INTERVENTION AND OUTCOME: Chiropractic spinal manipulation was used to aid recovery of vision to normal over a course of 20 treatment sessions. At times, significant improvement in vision occurred immediately after spinal manipulation. Progressive recovery of vision was monitored by serial visual field tests and by electrophysiologic studies. Unfortunately, the patient refused a further single photon emission tomographic study when visual recovery was complete. CONCLUSION: This case report adds to previous accounts of progressive and expeditious recovery of optic nerve function in association with spinal manipulation therapy.     

B型超声在球后视神经炎诊断中的作用

目的探讨B型超声在球后视神经炎诊断中的应用价值。方法应用美国Alcon Digital超声系统,对30例（48只眼）临床诊断球后视神经炎病人行B型超声检查。观察视盘及视神经横断面的形态,对视神经直径进行生物测量。结果B型超声检查发现视神经异常44只眼,其中视神经直径增大38只眼,伴视盘水肿22只眼,伴视神经鞘膜积液18只眼;视神经直径变小6只眼。超声检查阳性率达91．7％。结论B型超声对球后视神经炎的诊断具有重要的临床应用价值。     

Granulomatous arteritis.

Granulomatous, or temporal, arteritis is a disease of older people and should be considered when any patient over 55 years old has complaints consistent with a multi-system disease and/or visual loss, especially if combined with a history of diplopia, amaurosis fugax, loss of vision, or with the findings of ischemic optic neuritis or central retinal artery occlusion. Treatment should be instituted immediately with high doses of corticosteroids. The sine qua non for the diagnosis is a positive temporal artery biopsy when ocular involvement is a feature of the disease. Treatment includes administration of systemic and retrobulbar steroids. The ESR is used as a guide in determining the level of maintenance steroid dosage.     

Acute sphenoid sinusitis induced blindness: a case report

Background

Acute, isolated sphenoid sinusitis is a rare but potentially devastating clinical entity. Missing this diagnosis can lead to permanent vision loss due to injury of the optic nerve. Patients may present with preseptal inflammation, lid edema, chemosis, or ophthalmoplegia.

Objective

We report a case of acute sphenoid sinusitis in a 10-year-old child who presented to the Emergency Department with essentially painless vision loss.

Case Report

Previously healthy, the patient reported progressive decrease in vision in her right eye for the 5 days prior. Other than blurred vision in the right eye, she complained of a mild frontal headache and right eye irritation the past week, which had abated. On examination, she was reading a book with her head tilted to one side. She had no photophobia, or facial or eyelid swelling. Her pupils were 5 mm bilaterally, but the right was non-reactive to light. She was unable to see two fingers 6 inches in front of her face (right eye), whereas her visual acuity on the left was 20/25. She had bilateral elevated intraocular pressures and a Marcus Gunn pupil on the right. Ophthalmology was consulted and the diagnosis of acute sphenoid sinusitis causing compression and vascular compromise to the optic nerve was diagnosed ultimately by magnetic resonance imaging. The patient was transferred to the nearest pediatric specialty hospital, where an emergent endoscopic sphenoidotomy was performed. The patient’s vision subsequently returned.

Conclusion

Sphenoid sinusitis should be considered in patients presenting with acute vision loss. Awareness, early diagnosis, and intervention help prevent permanent complications.     

More than meets the eye: Point-of-care ultrasound diagnosis of acute optic neuritis in the emergency department

Optic neuritis (ON) is an inflammatory condition that causes demyelination and thickening of the optic nerve leading to acute/subacute vision loss. It is frequently associated with other conditions like multiple sclerosis, but is often misdiagnosed, which can lead to a suboptimal prognosis.Ultrasound is rarely utilized to help make this diagnosis, even though it can easily detect a thickened retrobulbar optic nerve sheath diameter.We describe four cases in which ultrasonographic measurement of the optic nerve sheath diameter aided in the diagnosis of ON.     

Bilateral simultaneous optic nerve dysfunction after pariorbital trauma: Recovery of vision in association with chiropractic spinal manipulation therapy

Objective: To discuss the recovery of optic nerve function after chiropractic spinal manipulation in a patient with loss of vision as a result of facial fracture from a fall. Clinical Features: In a fall down a stairwell, a 53-year-old woman with migraines fractured her right zygomatic arch, which was later treated surgically. Approximately 3 weeks after the accident, vision in her contralateral eye became reduced to light perception. Electrophysiologic studies revealed that the function of both optic nerves was diminished, the right significantly more than the left. Single photon emission tomography showed pancerebral ischemic foci. Intervention and Outcome: Chiropractic spinal manipulation was used to aid recovery of vision to normal over a course of 20 treatment sessions. At times, significant improvement in vision occurred immediately after spinal manipulation. Progressive recovery of vision was monitored by serial visual field tests and by electrophysiologic studies. Unfortunately, the patient refused a further single photon emission tomographic study when visual recovery was complete. Conclusion: This case report adds to previous accounts of progressive and expeditious recovery of optic nerve function in association with spinal manipulation therapy. (J Manipulative Phsyiol Ther 1999;22:615–21)     

Unilateral syphilitic optic neuritis without meningitis or uveitis

A 69‐year‐old man with left eye pain and visual impairment was diagnosed with syphilitic optic neuritis, who was successfully treated by penicillin. Although it is difficult to decide syphilis as the direct cause of optic neuritis, it is essential to diagnose syphilis in every patient with optic neuritis.     

Two common neuro-ophthalmic problems. Optic neuritis and transient visual disturbances

Optic neuritis and transient visual disturbances are common and challenging neuro-ophthalmic problems. Optic neuritis may occur during the course of several neurologic and systemic disorders and is characterized by reversible central visual loss. In many patients, signs and symptoms of multiple sclerosis occur after an episode of optic neuritis. Although several risk factors for development of multiple sclerosis have been identified, the relationship between optic neuritis and multiple sclerosis is still controversial. Transient visual disturbances may take the form of visual loss or visual hallucinations. In many cases, the cause of transient visual loss is never found. Hallucinations of ocular origin, however, are easily diagnosed by a thorough eye examination.     

Posterior Ischemic Optic Neuropathy Associated With Migraine

Anterior ischemic optic neuropathy is a well-recognized clinical syndrome that has been described in patients after an episode of migraine with visual aura (classic migraine) and, less commonly, after an episode of visual aura without headache (acephalgic migraine). Little emphasis, however, has been placed on migraine associated retrobulbar or posterior ischemic optic neuropathy. We report two cases of visual loss presumed to be due to posterior ischemic optic neuropathy that occurred In the setting of otherwise typical migraine episodes. We review the English language literature on Ischemic optic neuropathy associated with migraine. Although most cases of ischemic optic neuropathy associated with migraine are of the anterior variety, posterior ischemic optic neuropathy should be considered in the differential diagnosis of any patient with acute loss of vision and evidence for a retrobulbar optic neuropathy, during or after an attack of migraine headache or following an otherwise typical episode of visual aure without headache (acephalgic migraine).     

Effects of dorzolamide 2% added to timolol maleate 0.5% on intraocular pressure, retrobulbar blood flow, and the progression of visual field damage in patients with primary open-angle glaucoma: a single-center, 4-year, open-label study

OBJECTIVE: This study assessed the long-term effects of dorzolamide 2% BID added to timolol maleate 0.5% BID on intraocular pressure (IOP), retrobulbar blood flow, and the progression of visual field damage in patients with primary open-angle glaucoma. METHODS: This was a prospective, 4-year, open-label intervention study. All consecutive patients with a clinical diagnosis of open-angle glaucoma in both eyes (mean defect greater than -6 dB) who presented for a regular check-up between January and July 2001 at the Instituto Galego de Oftalmoloxía were screened for study eligibility. All participants had been treated with timolol 0.5% BID in both eyes for at least 6 months before the screening visit. Dorzolamide 2% BID was added to timolol 0.5% BID in the eye with the larger visual field defect (study eye), whereas timolol 0.5% BID was continued in the eye with the smaller visual field defect (control eye). Variables evaluated at baseline and every 6 months for 48 months included retrobulbar hemodynamic parameters (using color Doppler imaging), progression of visual field damage, and IOP. Progression of visual field damage was defined according to modified Anderson criteria. Visual field progression-free survival rates for the study and control eyes were plotted using Kaplan-Meier analysis and were compared using a log-rank test. RESULTS: Forty-five patients met the inclusion criteria, of whom 5 were lost to follow-up. Thus, 80 eyes of 40 patients were included in the analysis. Patients' mean (SD) age was 68.0 (7.1) years; all patients were white and 21 (52.5%) were male. Mean baseline IOP was 19.18 (1.34) and 18.23 (1.64) mm Hg in the study and control eyes, respectively (P=0.006). The combination of dorzolamide and timolol was associated with significant increases from baseline in enddiastolic velocity in the ophthalmic and short posterior ciliary arteries (P<0.001) and significant decreases in the resistivity index in both arteries (P<0.001). Twenty-three of the 80 eyes (28.8%) had progression of visual field damage (7 study eyes and 16 control eyes). On Kaplan-Meier survival analysis, the risk of progression was significantly lower in the eye treated with dorzolamide and timolol compared with the eye treated with timolol alone (hazard ratio=0.41; 95% CI, 0.17 to 0.94; P=0.035). Mean changes in IOP from baseline to month 48 were -1.10 mm Hg in the dorzolamide and timolol group (95% CI, -1.73 to -0.51; P<0.001) and 1.27 mm Hg in the control group (95% CI, -2.74 to 1.72; P=NS). CONCLUSIONS: In this 4-year, open-label study in patients with primary open-angle glaucoma, dorzolamide 2% BID added to timolol 0.5% BID was associated with a significant reduction in IOP and significant increases in retrobulbar hemodynamic parameters in both the ophthalmic and short posterior ciliary arteries. Dorzolamide added to timolol may be effective in preventing progression of glaucomatous visual field damage.