| PURPOSE: To describe the pathologic findings in an unusual case of giant cell arteritis that presented initially with visual loss and rapidly culminated in myocardial infarction. CASE REPORT: After the death of the patient, a complete autopsy was performed, including bilateral enucleation. All specimens, including a temporal artery biopsy completed before the patients death, were processed for routine paraffin histology and initially stained with hematoxylin and eosin. Elastic stains were subsequently used on specimens of temporal and coronary artery. The patient presented with loss of vision in the right eye. The clinical diagnosis was anterior ischemic optic neuropathy, secondary to temporal arteritis. The temporal artery biopsy was positive. Despite high-dose corticosteroid administration, the patient progressed to neurologic impairment, and subsequently to a fatal myocardial infarction. DISCUSSION: Previous reports of temporal arteritis with coronary involvement are summarized. myocardial infarction may be a more common early complication of temporal arteritis than appreciated previously. This important complication can occur despite administration of high-dose corticosteroid therapy. ( info) |
2/153. Lessons to be learned: a case study approach--a case of temporal arteritis. A 71-year-old male presented with a history of sudden partial visual loss in the right eye with an inferior visual field defect over the past 3-4 days. He had no history of headache or of facial pain. Clinical examination confirmed that vision on the right side was reduced to 6/18 and on the left to 6/12. The right eye showed a relative afferent pupillary defect. There was no other abnormality of the anterior segment of either eye. The right retina showed a pale swollen optic disc and a provisional diagnosis of anterior ischaemic optic neuropathy (AION) was made. An urgent erythrocyte sedimentation rate (ESR) was ordered and the patient was asked to return to the eye clinic in one month. However, 16 days later--when it was first recognised that his ESR was elevated to 75 mm in the first hour--the patient was recalled immediately in order to commence systemic steroid treatment; but regrettably, by this time, his right eye had become totally blind. In this case, although the attending doctor made a correct clinical diagnosis on presentation, he failed to act upon the result of the blood test. ( info) |
3/153. Bilateral posterior ischemic optic neuropathy after spinal surgery. PURPOSE: To report the association between bilateral posterior ischemic optic neuropathy and spinal surgery. METHOD: Case report. RESULTS: After prone-position spinal surgery of 8 hours' duration, a 68-year-old woman was completely blind in both eyes. Moderate periorbital edema and temporal conjunctival chemosis were present bilaterally. Ophthalmic examination disclosed normal-appearing optic nerve heads, except for bilateral nasal fullness related to bilateral optic nerve drusen, and no retinal edema. Immediate cerebral arteriography, magnetic resonance imaging, and electroretinography were normal. Visual-evoked response was not detectable, and 7 weeks later, severe bilateral optic nerve head pallor developed. CONCLUSIONS: Severe selective hypoperfusion of the retrobulbar optic nerves may occur after spinal surgery. Pressure to the periorbital region may be a contributing factor. ( info) |
4/153. Acute unilateral visual loss due to a single intranasal methamphetamine abuse. An otherwise healthy 35 year old male with insulin-dependent diabetes mellitus (IDDM) presented himself three days after a single intranasal methamphetamine abusus. Directly upon awakening the day after the recreational use of this drug, he discovered an acute and severe visual loss of his right eye. This unilateral loss of vision was permanent and eventually lead to a pale and atrophic optic nerve head. The characteristics of this visual loss, together with the aspect of the optic nerve head was very similar to the classical non-arteritic ischemic optic neuropathy (NAION). We suggest a direct ischemic episode to the short posterior ciliary arteries due to this single intranasal abuse of methamphetamine as the underlying pathogenesis of this acute and permanent visual loss. ( info) |
5/153. Hypotensive ischemic optic neuropathy and peritoneal dialysis. PURPOSE: To report anterior ischemic optic neuropathy associated with systemic hypotension in a patient undergoing continuous ambulatory peritoneal dialysis. methods: Case report. A 58-year-old man undergoing continuous ambulatory peritoneal dialysis developed painless blurred vision in both eyes and bilateral optic disk swelling with an altitudinal field defect in the left eye. Twenty-four-hour ambulatory blood pressure monitoring was requested in addition to other routine investigations. RESULTS: Routine blood pressure measurement in the clinic was 130/86 mm Hg, but ambulatory blood pressure monitoring demonstrated pronounced early morning hypotension with individual readings as low as 91/41 mm Hg. CONCLUSIONS: renal dialysis can render patients hypotensive, and this may be associated with anterior ischemic optic neuropathy. The overnight drop in blood pressure may not be appreciated with routine blood pressure measurement. Therefore, 24-hour ambulatory blood pressure monitoring should be considered when investigating patients with suspected anterior ischemic optic neuropathy who are undergoing renal replacement. ( info) |
| The primary objective of this review of the literature is to identify the probable causes of blindness after bilateral radical neck dissections. This case report and literature review also discusses possible preventive measures that may avert this catastrophic outcome. Cases of blindness after bilateral radical neck dissection were identified by an electronic literature search, as well as cross-checking all references of the above-identified papers. Eleven previous cases of blindness after bilateral neck dissection were identified. The most common cause was posterior ischemic optic neuropathy (PION), which was permanent. We present the only case in the literature in which blindness occurred after radical neck dissections separated by a span of 9 years. The cause of blindness in our patient was posterior ischemic optic neuropathy. Contributing factors included anemia, hypotension, and disruption of collateral venous return from the neck. ( info) |
7/153. Acute vision loss in children with autosomal recessive polycystic kidney disease. patients with autosomal recessive polycystic kidney disease (ARPKD) often present with renal insufficiency and hypertension. We present two children with ARPKD and end-stage renal disease who developed anterior ischemic optic neuropathy and vision loss. Anterior ischemic optic neuropathy occurs rarely in children and has never been reported in children with ARPKD or end-stage renal disease. Both of our patients were chronically hypotensive and anemic, which are known risk factors for ischemic optic neuropathy. ( info) |
8/153. 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. ( info) |
9/153. The diagnostic challenge of occult large vessel ischemia of the retina and choroid. Vascular occlusions of the retina and choroid can cause severe visual loss. These occlusions can occur as a result of systemic disease or after surgery. In most cases, the retinal appearance provides evidence of ischemia as the cause of visual loss. On occasion, however, clinical examination shows no objective signs of vascular occlusion, and this can lead the clinician to suspect optic nerve pathology as the cause of visual loss. This paper outlines some of the diagnostic criteria, clinical findings, and ancillary studies that can be used to differentiate between occult occlusion of the retina or choroid and optic nerve disease. ( info) |
10/153. Delayed anterior ischemic optic neuropathy after neck dissection. There are only 2 published cases of anterior ischemic optic neuropathy (AION) occurring after neck dissection, to our knowledge. We report a case of bilateral AION following neck dissection, discuss the differential diagnoses, and compare the features of this case with those of previously described cases. There were none of the previously described risk factors for the development of AION after head and neck surgery (eg, hypotension, facial edema, or sudden massive hemorrhage) in this case, but there was prolonged diffuse postoperative bleeding. Also, the symptoms did not arise before the fifth postoperative day as they did in the other cases. Prolonged, mild postoperative bleeding is a risk factor for AION. Visual loss during the entire first postoperative week has to be regarded as a complication of surgery, requires the exclusion of several differential diagnoses, and must not be confounded with the patient's confusion or symptoms of withdrawal. ( info) |