Opinion article: Neurosurgical treatment for neuro-ophthalmologic conditions

A significant role of the neuro-ophthalmologist is to counsel patients on appropriate management and anticipated visual prognosis for conditions affecting the afferent and efferent visual systems, including those requiring neurosurgical treatment. However, the literature regarding anticipated neuro- ophthalmologic prognosis after neurosurgical intervention for cerebral aneurysms, sellar lesions, optic pathway tumors, and elevated intracranial pressure is limited with many key questions unanswered. For example, if a cerebral aneurysm is equally amenable to clipping or endovascular coiling, is there a preferred approach in terms of visual prognosis based on aneurysm location? Is dural venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) superior, equivalent or inferior to shunting in terms of visual recovery and safety profile? Landmark studies on pituitary tumors using pre-operative optical coherence tomography (OCT) imaging of the optic nerve head to predict visual recovery after surgical decompression of the optic chiasm have changed neuro-ophthalmologic practice and enabled patients to be better informed regarding expected visual outcomes. 1,2 In order to optimize an interdisciplinary team approach to patient care, further studies of visual outcomes for neuro- ophthalmologic conditions requiring neurosurgical intervention are needed

Using Muscle

A 30- year-old Saudi female student with no past medical history presented an eight month history of progressive blurred vision primarily at near, anisocoria OS, and periocular discomfort with eye movements. Neuro-Ophthalmologic examination revealed best corrected visual acuity of OD 20/20 and OS 20/30. Color vision was OD 12/12 and OS 12/12. Automated threshold perimetry was normal. The pupils were 4 mm and normally reactive OD and 5 mm and minimally reactive OS. There was no relative afferent pupil defect (RAPD). The pupil was characteristic of absent sympathetic and parasympathetic input as may be seen in cavernous sinus lesions. The eyes were quiet. IOP was normal. Ocular motility examination was normal at initial evaluation but over the next 3 months she developed limited adduction and mild proptosis; other eye movements were normal throughout her 10 month course. Funduscopy was normal. Magnetic resonance imaging (MRI) of the brain and orbit with contrast revealed an enlarged left medial rectus and a linear enhancing structure running from the medial rectus muscle back to the superior orbital fissure and superior lateral wall of the cavernous sinus, believed to be an enlarged, enhancing third nerve. The following laboratory studies were performed and were negative or normal: Angiotensin-converting enzyme, lysozyme, T4, T3, TSH, thyroid stimulating immunoglobulin, thyrotropin binding inhibitory immunoglobulins, thyroid peroxidase antibody, serum protein electropheresis, cysticercosis antibodies, trichinella immunoglobulin G, and IgG4 immunoglobulin. A Quantiferon Gold test was sent three times before receiving a report that it was positive after all the above evaluation and the diagnostic procedure were complete. A diagnostic procedure was don

Using Muscle

A 30- year-old Saudi female student with no past medical history presented an eight month history ofprogressive blurred vision primarily at near, anisocoria OS, and periocular discomfort with eyemovements. Neuro-Ophthalmologic examination revealed best corrected visual acuity of OD 20/20 andOS 20/30. Color vision was OD 12/12 and OS 12/12. Automated threshold perimetry was normal.The pupils were 4 mm and normally reactive OD and 5 mm and minimally reactive OS. There was norelative afferent pupil defect (RAPD). The pupil was characteristic of absent sympathetic andparasympathetic input as may be seen in cavernous sinus lesions. The eyes were quiet. IOP was normal.Ocular motility examination was normal at initial evaluation but over the next 3 months she developedlimited adduction and mild proptosis; other eye movements were normal throughout her 10 monthcourse. Funduscopy was normal. Magnetic resonance imaging (MRI) of the brain and orbit withcontrast revealed an enlarged left medial rectus and a linear enhancing structure running from the medialrectus muscle back to the superior orbital fissure and superior lateral wall of the cavernous sinus,believed to be an enlarged, enhancing third nerve. The following laboratory studies were performed andwere negative or normal: Angiotensin-converting enzyme, lysozyme, T4, T3, TSH, thyroid stimulatingimmunoglobulin, thyrotropin binding inhibitory immunoglobulins, thyroid peroxidase antibody, serumprotein electropheresis, cysticercosis antibodies, trichinella immunoglobulin G, and IgG4immunoglobulin. A Quantiferon Gold test was sent three times before receiving a report that it waspositive after all the above evaluation and the diagnostic procedure were complete. A diagnosticprocedure was don

Brain Tumor Induced Narrow Angle Glaucoma

Hemangioblastomas (HBLs) are tumors of indeterminate clinicopathologic or immunohistochemical features that may be sporadic or associated with von Hippel-Lindau (VHL) disease. Suprasellar HBLs without VHL are extremely rare, with and only 5 cases have been reported to date. The most common presenting symptoms are visual disturbance, headache, and endocrine disturbances. This is the first case where a suprasellar HBL presents with narrow angle glaucoma due to intratumoral AV shunting. The narrow angle glaucoma reversed after tumor resection

Pallid Disc Edema and Choroidal Perfusion Delay in Post-Hemodialysis Non-Arteritic Ischemic Optic Neuropathy

Non-arteritic anterior ischemic optic neuropathy (NAION) is a rare but recognized ophthalmic complication in patients with end-stage renal disease (ESRD) on chronic hemodialysis characterized by unilateral or bilateral acute visual loss. Anemia, concomitant vaculopathic risk factors (i.e. diabetes, atherosclerosis), autonomic dysfunction and the hypotensive effect of hemodialysis are among the predisposing factors to the development of ischemic optic neuropathy (ION) in this patient population. Although pallid disc edema, cotton wool spots, and a choroidal perfusion delay have been classically associated with giant cell arteritis (GCA). We reported two cases of NAION in patients with ESRD on chronic hemodialysis who demonstrated pallid disc edema in conjunction with choroidal and retinal ischemia. To our knowledge, this is the first such report in the English language ophthalmic literature

Neuro-Ophthalmic Complications of Chemotherapy

This lecture covers the effect of antineoplastic chemotherapy, which can cause damage to the optic nerve and the ocular motor nerves.[1] Front. Ophthalmol., 18 November 2022 Sec. Neuro-Ophthalmology Disorders Volume 2 - 2022 | https://doi.org/10.3389/fopht.2022.1044904 [2] Bhatti MT, Salama AKS. Neuro-ophthalmic side effects of molecularly targeted cancer drugs. Eye (Lond). 2018 Feb;32(2):287-301. doi: 10.1038/eye.2017.222. Epub 2017 Oct 20. PMID: 29052609; PMCID: PMC5811730. [3] Omoti AE, Omoti CE. Ocular toxicity of systemic anticancer chemotherapy. Pharm Pract (Granada). 2006 Apr;4(2):55-9. PMID: 25247000; PMCID: PMC4166144

Lateral Rectus Muscle Enlargement in Multiple Myeloma

Multiple myeloma (MM) is a systemic disease that is part of a spectrum of disorders ranging from monoclonal gammopathy of unknown significance (MGUS) to plasma cell leukemia, characterized by a proliferation of malignant plasma cells and production of monoclonal proteins. Extra-skeletal involvement in MM is rare and orbital involvement are extremely rare. The most common clinical presentation includes mass effect with subacute , painful or painless swelling involving the eye and periocular tissue, proptosis, diplopia, and decreased vision.We report a 73 year-old man with a recent diagnosis of MM who developed rapidly progressive painful right eye proptosis, diplopia and vision loss

Invasive Thymoma Presenting with Ocular Myasthenia Gravis

Invasive thymoma is an uncommon neoplasm with an aggressive course that has been noted with increasing frequency in recent years. Forty percent of invasive thymomas are associated with paraneoplastic syndromes including myasthenia gravis. We report two patients with ocular MG with biopsy confirmed invasive thymoma. Prompt computed tomography (CT) of the chest should be performed in all patients with MG including ocular MG. To our knowledge this is the largest series in the English language ophthalmic literature of invasive thymoma with ocular MG

Leukemic Optic Neuropathy

Patient with acute lymphoblastic leukemia presented with left eye vision loss