Correspondence
Junctional visual field loss: a reappraisal of nomenclature
Historically, junctional visual field loss (JVFL) has been associated with a lesion at the junction of the optic nerve and chiasm, and the most common etiologies are neoplasm and aneurysm.1,2 We present 2 cases of JVFL and review the nomenclature on the various types of scotomas associated with lesions at the junction of the optic nerve and chiasm (e.g., junctional scotoma and junctional scotoma of Traquair). Based on our review of the English-language ophthalmic literature, we believe that our cases are unique and serve to demonstrate the need for expansion of the classification of JVFL.Evolution of benign episodic pupillary dilation to Adie's tonic pupil
Benign episodic pupillary dilation (BEPD) may cause significant concern for both patients and clinicians alike. In general, BEPD does not require any work-up or further evaluation beyond simple reassurance. We describe a case of BEPD that evolved into a typical neurologically isolated ipsilateral and idiopathic tonic pupil also known as Adie's tonic pupil. After reviewing the PubMed database in search of similar reported cases, we found that this case is a unique presentation in the English-language ophthalmic literature.Audible blink in carotid-cavernous fistula
A carotid-cavernous fistula (CCF) is an abnormal arteriovenous communication between the carotid artery system and the cavernous sinus. Common ocular manifestations of CCFs include pulsating exophthalmos, conjunctival chemosis, periorbital bruit, diplopia, and ophthalmoplegia.1 We report a patient with atypical CCF who presented with audible blinks and describe the possible pathogenesis of this phenomenon.Follicular lymphoma isolated to the superior oblique muscle
A 76-year-old female presented with bilateral peripheral visual field constriction. She had a past medical history of left common iliac vein stenting secondary to compression from the iliac artery, left lower extremity deep vein thrombosis requiring angioplasty, bilateral lower extremity lipodermatosclerosis, hyperlipidemia, vitamin D deficiency, diverticulitis, and generalized anxiety disorder. Her regular medications included apixaban, clopidogrel, venlafaxine, and montelukast. She denied smoking or alcohol use.Meningococcal B vaccine-associated papillophlebitis and cilioretinal artery occlusion
Vaccine-induced optic neuritis is a known subtype of optic neuritis that has been reported following the administration of various types of vaccines, both viral and bacterial. Ocular symptoms vary significantly and can result in permanent vision loss. There has been only one case of optic neuritis following meningococcal B vaccine (Bexsero; GlaxoSmithKline, London, UK) administration that was reported on the Vaccine Adverse Event Reporting System (2016, VAERS ID 686394), but the details of the event are not thoroughly explained.Delayed-onset abducens nerve palsy following parafalcine meningioma complicated by subdural hematoma
Meningiomas are slow-growing, benign brain tumors accounting for approximately 20% of primary intracranial masses.1 They may remain asymptomatic for long periods of time and can present with headaches, seizures, and other more site-specific symptoms. Although they are highly vascular structures, meningiomas do not typically produce subdural hematoma (SDH).2 Only 38 cases of meningioma associated with acute SDH have been reported in the English literature.1 We report a delayed-onset abducens nerve palsy due to an SDH associated with a parafalcine meningioma.Delayed diagnosis of autosomal dominant optic atrophy until seventh decade of life
Autosomal dominant optic atrophy (ADOA) is the most common hereditary optic neuropathy, manifesting in approximately 1 in 50 000 people, and up to 1 in 10 000 in Denmark, owing to a founder mutation.1 Isolated ADOA typically manifests in the first 2 decades of life as bilateral painless progressive vision loss and is therefore mostly diagnosed in childhood to young adulthood. We present a series of 2 older patients, aged 63 and 64 years, who had delayed ADOA diagnosis as proband patients in their families, emphasizing the point that chronological age should not be the sole determining factor for ordering testing for ADOA in cases of unexplained optic neuropathy.Superior oblique myositis following targeted therapy for papillary thyroid carcinoma
Papillary carcinoma of the thyroid gland (PCTG) constitutes 80%–85% of thyroid cancers globally. Despite early lymphatic invasion, PCTG has a relatively indolent course and rarely metastasizes outside of the neck.1 Metastasis to the brain from PCTG is even more uncommon and usually occurs in the context of widely disseminated disease. While the mainstay of treatment for intracranial metastasis from PCTG includes surgical excision and radiotherapy, recent advances into our understanding of the molecular pathways governing PCTG have facilitated development of novel targeted chemotherapeutics.Murine typhus presenting as pseudotumor cerebri
Murine typhus is an acute infection transmitted by rodent or cat fleas carrying gram-negative, obligate intracellular bacteria, Rickettsia typhi. This vector for transmission is most often carried on rodents, but opossums are thought to be a reservoir in suburban settings.1 Associated with overcrowding, pollution, and poor hygiene, murine typhus has been documented worldwide, but the majority of cases in the United States are in Texas and California.2Convergence spasm with horizontal nystagmus in anti-GAD65 antibody syndrome
Anti-glutamic acid decarboxylase (anti-GAD) autoantibody syndrome produces symptoms and signs related to loss of the inhibitory neurotransmitter gamma aminobutyric acid. Patients with GAD antibody may present with hyperexcitability disorders, including stiff-person syndrome, limbic encephalitis, and nystagmus. There has been only one previous report of convergence spasm in a patient with GAD antibody. Here we present a case of convergence spasm and, to our knowledge, the first case in the English-language ophthalmic literature to have concomitant horizontal nystagmus, in a patient with anti-GAD65 antibody syndrome.Dysgeusia and amaurosis fugax: a unique presentation in spontaneous internal carotid artery dissection
Spontaneous internal carotid artery (ICA) dissection is a significant cause of ischemic stroke in young adults1. The presenting symptoms and signs of ICA dissection (ICAD) are variable and can be due to direct local involvement of neural structures (e.g., oculosympathetic plexus causing the ipsilateral Horner syndrome) or indirect distal ischemia to brain or eye (e.g., transient ischemic attack or stroke) from thromboembolic disease 23. Transient monocular visual loss (TMVL) and the Horner syndrome are well-known presentations of ICAD and may occur in up to 50% of cases 4.Infectious keratitis as the presenting sign of giant cell arteritis
Giant cell arteritis (GCA) is a medium-to-large vessel vasculitis that usually presents with headache, loss of vision, jaw claudication, and scalp tenderness. We report a case of biopsy-consistent GCA presenting as an infectious bacterial keratitis. To our knowledge, this is the first such case reported in the English-language ophthalmic literature.Thrombotic thrombocytopenic purpura in chronic myelogenous leukemia
Thrombotic thrombocytopenic purpura (TTP) is a rare disease characterized by the pentad of microangiopathic hemolytic anemia, thrombocytopenia with purpura, acute kidney injury, neurologic abnormality with fluctuating mental status, and fever.1,2 It has an incidence ranging from 3.7 to 11 cases per million and risk factors that include female gender, Afro-Caribbean ancestry, and obesity.2 The prevailing pathophysiologic theory for TTP asserts that patients have a deficiency or defect in A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS13), a protease that cleaves large multimers of von Willebrand factor.Rapid same-day resolution of internuclear ophthalmoplegia in Wernicke encephalopathy following parenteral high dose thiamine
Internuclear ophthalmoplegia (INO) is well known for its association with multiple sclerosis in young patients and ischaemic stroke in older patients. Lesions of the medial longitudinal fasciculus produce the clinical findings of INO. Wernicke encephalopathy (WE) is a metabolic disorder of thiamine deficiency that classically presents with confusion, ataxia, and nystagmus. Diplopia and ophthalmoplegia can also be the presenting or predominant complaint in WE. We report a case of WE presenting with an INO who had same-day resolution of symptoms and signs after high-dose parenteral thiamine.Leber hereditary optic neuropathy: 41-year interval between fellow eye involvement
Leber hereditary optic neuropathy (LHON) is an inherited mitochondrial disorder that typically presents in young men with painless, subacute, bilateral (simultaneous or sequential) central vision loss.1,2 Most cases have nonsimultaneous involvement of the contralateral eye in an interval less than 1 year.2,3 However, there are reports of loss of vision in the fellow eye over 1 year later. To date, the longest interval between affected eyes is 18 years.4 We present a patient with an interval of 41 years.Giant cell arteritis relapse presenting as idiopathic orbital inflammation
Giant cell arteritis (GCA) is a systemic vasculitis that can cause permanent vision loss. Even after treatment, relapses have been reported in 40%–64% of patients, depending on how relapses are defined.1,2 Here, we present a rare case of a GCA relapse mimicking idiopathic orbital inflammation (IOI) on the side contralateral to the initial episode of the disease. Simultaneous, positive biopsies of the orbit and temporal arteries were obtained, offering histological evidence that the orbital inflammation and GCA flare were linked.Reversible anisocoria due to inadvertent ocular exposure to topical anticholinergic treatment for primary axillary hyperhidrosis
Anisocoria is a common clinical challenge and can be due to benign (e.g., pharmacologic anisocoria, iris damage, tonic pupil) or potentially dangerous (e.g., aneurysm, syphilis, tumour) etiologies. Although pharmacologic dilation and anisocoria from topical, dermatologic, nebulized, and systemic mydriatics is well-known, pharmacologically induced mydriasis from topical treatments for primary axillary hyperhidrosis is less well-described. Two relatively new anticholinergic topical agents, sofpironium bromide (currently in phase 3 clinical trials [Argyle Study]) and glycopyrronium (Qbrexza), are now available.Abducens nerve palsy and ipsilateral Horner syndrome as the presenting finding of carotid cavernous fistula
An 84-year-old female with history of hypertension and hyperlipidemia presented with nontraumatic left eyelid edema, erythema, and ptosis followed by acute painless binocular horizontal diplopia. Best corrected visual acuity was 20/20 OD and 20/30 OS. The OD pupil measured 4 mm in the dark and 2 mm in the light, and the OS pupil measured 3 mm in the dark and 2 mm in the light. No relative afferent pupillary defect was detected. There was a 50 prism diopter esotropia in primary gaze and an abduction deficit of –4 OS (Fig.Presumed ischemic optic neuropathy
Nonarteritic anterior ischemic optic neuropathy (NAION) is a relatively common cause of acute, painless vision loss in patients typically older than 50 years. Presentation is often associated with predisposing vasculopathic risk factors, but has also been reported as a complication of pregnancy. We describe a young, healthy female with disc drusen who suffered bilateral NAION due to postpartum blood loss. To our knowledge this is the first such case to be reported in the English-language ophthalmic literature.Chronic myelomonocytic leukemia-related vasculitis mimicking giant cell arteritis
Giant cell arteritis (GCA) is a medium-to-large vessel vasculitis, commonly seen in the elderly, that can produce visual loss.1 Although the diagnosis of GCA is typically made via a temporal artery biopsy (TAB), other vasculitides have been diagnosed by TAB in patients with symptoms and signs initially suggestive of GCA. Chronic myelomonocytic leukemia (CMML) is a myeloid neoplasm characterized by persistent monocytosis, macrocytic or normocytic anemia, and thrombocytopenia.2 We report an unusual case of CMML-associated vasculitis mimicking GCA.Primary central nervous system lymphoma of the optic chiasm
Primary CNS lymphoma (PCNSL) is a rare form of extranodal, high-grade, non-Hodgkin lymphoma (NHL), accounting for approximately 3% of newly diagnosed brain tumors and 2 to 3% of all NHL.1 PCNSL can also arise from posttransplant lymphoproliferative disorder (PTLD), a disorder in patients with secondary immunodeficiency after a solid organ or hematopoietic stem cell transplant.2 PCNSL is characterized by rapid growth usually confined to the CNS and can originate in the brain, leptomeninges, spinal cord, or eyes.Optic neuropathy in extramedullary, blast crisis of chronic myeloid leukemia
Chronic myeloid leukemia (CML) represents 10%–20% of all leukemias. Vision loss in patients with CML is usually related directly to the disease (CML) or less likely to potential side effects of the treatment of CML (e.g., radiotherapy or chemotherapy). Extramedullary CNS or meningeal blast crisis in CML is an uncommon but well-known complication of CML. Visual loss in CML typically occurs with abnormal serum white blood cell (WBC) count, peripheral blood smear, bone marrow biopsy, cerebrospinal fluid (CSF) analysis, or neuroimaging.Elevated lipoprotein(a) levels as the cause of cryptogenic stroke in a young Ashkenazi Jewish female
Lipoprotein(a) is a cholesterol carrier molecule, structurally similar to low-density lipoprotein (LDL), but with distinct properties predisposing it to associations with increased risk of stroke, myocardial infarction (MI), and aortic stenosis.1–4 However, lipoprotein(a) levels are not routinely checked, although there is a known pattern of genetic inheritance.5 We present a case of a young patient with purported cryptogenic stroke and a family history of cardiovascular disease, which was attributed to elevated lipoprotein(a) levels.Triple-hit lymphoma of the cavernous sinus
Diffuse large B-cell lymphoma (DLBCL) is the most common non–Hodgkin-type lymphoma in adults, and the myriad of clinical presentations is well known to neuro-ophthalmologists.1 Traditionally, DLBCL was treated with standard chemotherapy, including R-CHOP (i.e., rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Newer cytogenetic, fluorescent in situ hybridization (FISH), and next-generation sequencing (NGS) techniques, however, have shown the presence of genomic abnormalities that have significant treatment and prognostic implications.Idiopathic intracranial hypertension in a transgender female
A 39-year-old morbidly obese African-American male-to-female transgender patient presented with acute-on-chronic vision loss in the right eye. She reported a 1-year history of a dim temporal field OD initially at night, which progressed acutely to include daytime as well. The patient was seen by an optometrist, who found bilateral optic disc edema and referred the patient to an outside hospital. A computerized tomography (CT) of the head was normal.
