Neurosyphilis Presenting as Asymptomatic Optic Perineuritis

Introduction. Syphilis is a sexually transmitted disease that is known as “the great imitator” due to its wide variety of clinical presentations, including ocular disorders. There has been an increase in the rate of syphilis in the United States, especially in persons with HIV. We report a case of optic perineuritis in an asymptomatic male secondary to central nervous system (CNS) syphilis. Case Report. A 41-year-old man was found to have bilateral disc edema on a routine exam. Brain MRI was unremarkable, and lumbar puncture revealed a normal opening pressure, with an elevated cerebrospinal fluid white cell count. Orbit MRI showed optic nerve sheath expansion and enhancement, consistent with optic perineuritis. He tested positive for syphilis based on serum RPR and FTA-ABS. Conclusion. Ophthalmologic findings, including disc edema, may be the presenting features of CNS syphilis. Even in asymptomatic persons, perineuritis should be considered early, as diagnosis and treatment are imperative given the progressive nature of the disease

Mobility, Balance and Falls in Persons with Multiple Sclerosis

BACKGROUND: There is a lack of information concerning the relation between objective measures of gait and balance and fall history in persons with MS (PwMS). This investigation assessed the relation between demographic, clinical, mobility and balance metrics and falls history in persons with multiple sclerosis (MS). METHODS: 52 ambulatory persons with MS (PwMS) participated in the investigation. All persons provided demographic information including fall history over the last 12 months. Disease status was assessed with Expanded Disability Status Scale (EDSS). Walking speed, coordination, endurance and postural control were quantified with a multidimensional mobility battery. RESULTS: Over 51% of the participants fell in the previous year with 79% of these people being suffering recurrent falls. Overall, fallers were older, had a greater prevalence of assistive devices use, worse disability, decreased walking endurance, and greater postural sway velocity with eyes closed compared to non-fallers. Additionally, fallers had greater impairment in cerebellar, sensory, pyramidal, and bladder/bowel subscales of the EDSS. CONCLUSIONS: The current observations suggest that PwMS who are older, more disabled, utilize an assistive device, have decreased walking coordination and endurance and have diminished balance have fallen in the previous year. This suggests that individuals who meet these criteria need to be carefully monitored for future falls. Future research is needed to determine a prospective model of falls specific to PwMS. Additionally, the utility of interventions aimed at reducing falls and fall risk in PwMS needs to be established

Longitudinally Extensive Optic Neuritis Distinguishes Neuromyelitis Optica from Multiple Sclerosis

The anterior visual pathway is morphologically and physiologically part of the central nervous system, and its response to injury is similar. Demyelinating and inflammatory processes may affect the AVP and are typically disruptive of the local blood brain barrier, as is frequently noted in optic neuritis. One report showed that enhancement length did not distinguish optic neuritis between neuromyelitis optica (NMO) and multiple sclerosis (MS) when multiple cases were averaged. However, the specificity for longitudinally extensive enhancement of the AVP to differentiate optic neuritis among NMO, MS, and sarcoidosis has not been previously reported. Radiographic analysis can help distinguish abnormal processes affecting the optic nerves and anterior visual pathways (AVP). We hypothesize that length of pathologic AVP contrast enhancement can be a predictor of etiologic diagnosis in optic neuritis

Ocular Neuromyotonia 23 Years after Stereotactic Radiosurgery

Ocular neuromyotonia is a relatively rare clinical entity resulting in spasm of extraocular muscles. The pathophysiology may be related to spontaneous firing of axons, and it has been associated with compressive lesions or previous radiation to the sellar region. Stereotactic radiosurgery is a relatively modern form of radiation therapy, and fewer cases have been described as a consequence.1 We found the longest duration between radiation treatment of any kind and the onset of neuromyotonia previously reported was 18 years

Clinical Course of Patients With Ophthalmoplegia Caused by Radiographically Detectable Brainstem Demyelination Occurring as a Clinically Isolated Demyelinating Syndrome

Demyelinating brainstem lesions often causing ophthalmoplegia may occur as the first manifestation of a clinically isolated demyelinating syndrome (CIS). CIS could be the initial attack of clinically definite multiple sclerosis (CDMS) should a second symptomatic attack occur. We report a series of patients with ophthalmoplegia occurring as CIS and assess potential factors affecting the clinical course and final outcome.A computer search was performed for patients evaluated in a university academic neurology practice to identify those with the diagnosis of diplopia. Selection was then made of patients who met the criteria for CIS, and these individuals formed the basis of this study.Ten of 327 patients presenting with diplopia fulfilled inclusion criteria. Of these, all had ophthalmoplegia in primary position of gaze or symptomatic internuclear ophthalmoplegia, and all recovered irrespective of brain MRI findings, steroid use, presence of oligoclonal bands, or progression to CDMS.The ophthalmoplegia of CIS tends to improve with time, regardless of later progression to CDMS. More analysis is needed to fully understand this unique presentation of demyelination

Medication Reconciliation in a Neuro-Ophthalmology Clinic (.pdf)

The purpose of this study was to quantify and categorize the type of medication errors we may encounter in the patient record, and also to evaluate the relevance of these errors with respect to neuro-ophthalmologic care. We aimed to evaluate the accuracy of the medication list prior to the patient being examined in our clinic. Time-stamping on the electronic medical record allowed us to distinguish medication changes from medication errors (changes which should have been documented at the previous reconciliation).ICmedicalerror

Primary Ocular Adnexal Extranodal Marginal Zone Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma Presenting as Orbital Apex Syndrome

A 75-year-old female with a past medical history significant for prior stroke and atrial fibrillation presented with acute onset of orbital apex syndrome with chemosis and periorbital ecchymosis. Following initial treatment to relieve intraocular pressure, she began spontaneously haemorrhaging retro-orbitally. Preliminary investigation with neuroimaging demonstrated a left orbital mass with extension into the orbital apex. A provisional diagnosis of cavernous haemangioma was made. She was treated with transorbital resection of the orbital mass. Subsequent histopathology revealed a diagnosis of ocular adnexal non-Hodgkin lymphoma of histologic type extranodal marginal zone of mucosa-associated lymphoid tissue (MALT lymphoma). MALT lymphoma should be considered in cases of orbital apex syndrome