Ischemic Optic Neuropathies Biousse, Valérie; Newman, Nancy J
The New England journal of medicine,
06/2015, Letnik:
372, Številka:
25
Journal Article
Recenzirano
This article reviews the diagnosis, pathophysiological features, and prognosis of ischemic optic neuropathy, a relatively common cause of visual loss in older patients, including visual loss after ...cardiac surgery. It must be distinguished from inflammatory optic neuritis.
Disorders of the optic nerve represent a relatively common cause of visual loss. The optic nerve is a white-matter tract that relays information from the retina to the brain areas of visual processing. Whenever there is damage to an optic nerve, from whatever cause, it is termed an “optic neuropathy.” Unlike inflammatory optic neuritis, which is the most common optic neuropathy in young patients, ischemic optic neuropathy (ION) is the result of vascular insufficiency, not of inflammation. ION refers to all ischemic causes of optic neuropathy. Although IONs are considered to be equivalent to a “stroke of the optic nerve,” . . .
Summary Disorders of the optic nerves (optic neuropathies) are some of the most common causes of visual loss, and can present in isolation or with associated neurological or systemic symptoms and ...signs. Several optic neuropathies—especially inflammatory optic neuropathies—are associated with neurological disorders and thus are often diagnosed and treated by neurologists. The mechanisms underlying optic neuropathies are diverse and typically manifest with decreased visual acuity, altered colour vision, and abnormal visual field in the affected eye. Diagnosis is made on the basis of clinical history and clinical examination, of which several aspects are particularly important, including the mode of onset of visual loss, the presence of pain with eye movements, the visual acuity, and the retention of colour vision. Advances in optic nerve imaging—particularly retinal digital photography, optical coherence tomography, and MRI techniques—have revolutionised the diagnosis and follow-up of patients with an optic neuropathy. Furthermore, improvement and generalisation of some ancillary tests, such as diagnostic antibodies for neuromyelitis optica, allows better phenotyping of the heterogeneous inflammatory optic neuropathies.
Summary New onset of sudden or progressive headache can have various causes, including disorders of intracranial pressure (ICP). Headache is the most common—and often the presenting—symptom of both ...intracranial hypertension and intracranial hypotension syndromes, which can be symptomatic or idiopathic. Despite the widespread availability of diagnostic tests, including ocular ophthalmoscopy, neuroimaging, and measurement of CSF pressure, delays in diagnosis or misdiagnosis of idiopathic intracranial hypertension and spontaneous intracranial hypotension remain common. If left untreated, idiopathic intracranial hypertension and spontaneous intracranial hypotension produce highly disabling headaches, and threaten vision, hearing, and in rare cases, brain function and life. To improve the diagnosis of idiopathic intracranial hypertension and spontaneous intracranial hypotension, changes in the overall diagnostic strategy for headaches will be necessary in most care centres. Improved understanding of CSF physiology and the mechanisms of idiopathic intracranial hypertension and spontaneous intracranial hypotension will guide the development of new treatments.
Acute retinal arterial ischemia, including vascular transient monocular vision loss (TMVL) and branch (BRAO) and central retinal arterial occlusions (CRAO), are ocular and systemic emergencies ...requiring immediate diagnosis and treatment. Guidelines recommend the combination of urgent brain magnetic resonance imaging with diffusion-weighted imaging, vascular imaging, and clinical assessment to identify TMVL, BRAO, and CRAO patients at highest risk for recurrent stroke, facilitating early preventive treatments to reduce the risk of subsequent stroke and cardiovascular events. Because the risk of stroke is maximum within the first few days after the onset of visual loss, prompt diagnosis and triage are mandatory. Eye care professionals must make a rapid and accurate diagnosis and recognize the need for timely expert intervention by immediately referring patients with acute retinal arterial ischemia to specialized stroke centers without attempting to perform any further testing themselves. The development of local networks prompting collaboration among optometrists, ophthalmologists, and stroke neurologists should facilitate such evaluations, whether in a rapid-access transient ischemic attack clinic, in an emergency department-observation unit, or with hospitalization, depending on local resources.
According to these guidelines, patients with abnormal diffusion-weighted MRI are diagnosed as having an acute stroke (and admitted to the hospital and managed accordingly) regardless of their initial ...clinical presentation, whereas those with normal MRI results usually are evaluated within 24 hours in a dedicated TIA clinic, an emergency department observation unit, or a stroke center.2-7 This is not routinely performed currently in the United States, where a large majority of patients with acute retinal arterial ischemia are never sent to the emergency department or a stroke neurologist for immediate evaluation.8 Additionally, most health professionals and the public consider retinal TIAs benign with a low risk of subsequent stroke.9 This is incorrect, and such belief only delays the evaluation of patients with visual loss as the main symptom of retinal or cerebral ischemia.
Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke that causes severe visual loss and is a harbinger of further cerebrovascular and cardiovascular events. There is a paucity ...of scientific information on the appropriate management of CRAO, with most strategies based on observational literature and expert opinion. In this scientific statement, we critically appraise the literature on CRAO and provide a framework within which to consider acute treatment and secondary prevention.
We performed a literature review of randomized controlled clinical trials, prospective and retrospective cohort studies, case-control studies, case reports, clinical guidelines, review articles, basic science articles, and editorials concerning the management of CRAO. We assembled a panel comprising experts in the fields of vascular neurology, neuro-ophthalmology, vitreo-retinal surgery, immunology, endovascular neurosurgery, and cardiology, and document sections were divided among the writing group members. Each member received an assignment to perform a literature review, synthesize the data, and offer considerations for practice. Multiple drafts were circulated among the group until consensus was achieved.
Acute CRAO is a medical emergency. Systems of care should evolve to prioritize early recognition and triage of CRAO to emergency medical attention. There is considerable variability in management patterns among practitioners, institutions, and subspecialty groups. The current literature suggests that treatment with intravenous tissue plasminogen activator may be effective. Patients should undergo urgent screening and treatment of vascular risk factors. There is a need for high-quality, randomized clinical trials in this field.
Idiopathic intracranial hypertension is a disease of unknown aetiology, typically affecting young obese women, producing a syndrome of increased intracranial pressure without identifiable cause. ...Despite a large number of hypotheses and publications over the past decade, the aetiology is still unknown. Vitamin A metabolism, adipose tissue as an actively secreting endocrine tissue and cerebral venous abnormalities are areas of active study regarding the pathophysiology of idiopathic intracranial hypertension. There continues to be no evidence based consensus or formal guidelines regarding management and treatment of the disease. Treatment studies show that the diagnostic lumbar puncture is a valuable intervention beyond its diagnostic importance, and that weight management is critical. However, many questions remain regarding the efficacy of acetazolamide, CSF shunting procedures and cerebral transverse venous sinus stenting.
Retinal vascular occlusions Scott, Ingrid U; Campochiaro, Peter A; Newman, Nancy J ...
The Lancet,
12/2020, Letnik:
396, Številka:
10266
Journal Article
Recenzirano
Odprti dostop
Acute retinal vascular occlusions are common causes of visual impairment. Although both retinal artery occlusions and retinal vein occlusions are associated with increased age and cardiovascular risk ...factors, their pathophysiology, systemic implications, and management differ substantially. Acute management of retinal artery occlusions involves a multidisciplinary approach including neurologists with stroke expertise, whereas treatment of retinal vein occlusions is provided by ophthalmologists. Optimisation of systemic risk factors by patients’ primary care providers is an important component of the management of these two disorders.
Once considered a rare and often difficult diagnosis in the era predating routine MRI, idiopathic intracranial hypertension has become an everyday concern in ophthalmology and neurology clinics ...where, especially in the latter, essentially every young overweight woman with headaches is initially presumed to have IIH. Has the diagnosis of IIH become too easy, and are we over-diagnosing IIH in this period of an accelerating obesity crisis? Or are we actually missing cases of IIH because they do not fit the classic clinical profile? We think it is both: at the same time IIH is being diagnosed in excess in obese women without papilledema, often resulting in unnecessary procedures, inappropriate treatment and even iatrogenic complications, the spectrum of this disorder is expanding to include a broad array of clinical presentations that involve multiple specialists beyond just the ophthalmologist and neurologist.
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