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- Factors associated with confidence in fundoscopy. [Journal Article]
- Clin Teach 2014 Oct; 11(6):431-5.
Fundoscopy is an important component of the neurological examination. Previous studies have shown that students and junior doctors lack confidence in fundoscopy, but to date little is known about possible barriers to the acquisition of confidence in this skill.A questionnaire was designed to quantify prior experience, and to assess confidence in direct ophthalmoscopy. This was distributed among fourth- and final-year medical students.Forty-three per cent of final-year students responding (n = 93) were confident in examining a dilated eye by direct ophthalmoscopy, compared with 88 per cent of fourth-year students (n = 116). Of the 209 students, fewer than 40 per cent felt confident identifying papilloedema, diabetic retinopathy or vascular disease. Students that reported more opportunities to practise were significantly more confident in their ability to examine a dilated (p < 0.001) or undilated (p < 0.01) eye, but were not significantly more confident in recognising pathology. Clinical exposure to abnormal pathology was significantly associated with greater levels of confidence in recognising papilloedema (p = 0.001), diabetic retinopathy (p = 0.015) and vascular disease (p = 0.012). Students that reported receiving no assessment or feedback on their technique were significantly less confident in all aspects of fundoscopy.Final-year medical students lack confidence in their ability to use the direct ophthalmoscope and to recognise pathology. Based on the findings of this study, we have made focused recommendations in order to improve the confidence of graduating doctors in fundoscopy: (1) early formal instruction, with refresher training for final-year students; (2) increasing clinical exposure to abnormal pathology; (3) the provision of assessment and feedback on student technique. Final-year medical students lack confidence in their ability to use the direct opthalmoscope and to recognise pathology.
- Clinical Characterization of Idiopathic Intracranial Hypertension in Children Presenting to the Emergency Department: The Experience of a Large Tertiary Care Pediatric Hospital. [JOURNAL ARTICLE]
- Pediatr Emerg Care 2014 Sep 9.
Idiopathic intracranial hypertension (IIH) is a syndrome characterized by elevated intracranial pressure, without evidence of intracranial mass lesion or venous thrombosis on brain imaging. The syndrome occurs mainly in young, fertile, and overweight women but may present in any age group. The aim of this study was to report the presentation, course, and outcomes of older versus younger children presenting with IIH to the emergency department of our large tertiary care hospital during an 8-year period.Retrospective chart review (January 2000-December 2008) of all patients younger than 17 years with IIH was performed on the basis of modified Dandy Criteria. The patients were analyzed according to age (<11 years and 11-17 years) and weight centile (<90%, 90%-97%, >97%).Ages ranged from 2 to 16.5 years (mean [SD], 9.71 [4.56] years). Thirty males (46.8%) and 33 females (53.2%) were identified: 30 were prepubertal with a male-female ratio of 1:0.56 and 33 were pubertal with a male-female ratio of 1:2 (P < 0.05). There were no significant differences between the 2 age groups in proportions of children in the 3 predefined weight categories The most common presenting symptom was headache (75%), which was significantly less common in the younger age group compared with the older group (P < 0.01). Papilledema was present in 51 patients (82.3%). Mean (SD) cerebrospinal fluid opening pressure was 378 (16) mm H2O. Findings of brain imaging (mostly computed tomographic scan), performed in all patients, were normal in 42 (67.7%); the most common finding in the remainder was swelling of the optic nerves.Our results indicate that IIH should be considered in any child with new-onset headache or visual disturbance, irrespective of age, sex, weight, or the presence of known predisposing factors. When IIH is suspected, neuroimaging should be performed promptly to exclude secondary causes of this condition because IIH in children remains a diagnosis of exclusion. Early diagnosis and prompt treatment for IIH can prevent potential visual loss.
- Choroidal excavation in vogt-koyanagi-harada disease. [Journal Article]
- Case Rep Ophthalmol 2014 May; 5(2):222-5.
To report a case of choroidal excavation accompanied by Vogt-Koyanagi-Harada disease (VKH).A 54-year-old Japanese woman who was complaining of bilateral blurring of vision associated with headache underwent optical coherence tomography (OCT), fluorescein angiography, and indocyanine green angiography as well as a routine ophthalmological examination.Fundoscopy showed papilloedema and serous retinal detachment in both eyes. Fluorescein angiography detected bilateral multifocal leakage with pooling of dye in the subretinal space. Indocyanine green angiography showed patches of hyperfluorescence and hypofluorescent spots bilaterally. A diagnosis of VKH was reached soon afterwards. OCT of the left eye revealed the presence of a unilateral choroidal excavation under the fovea and subretinal fibrin over the site of the excavation. Treatment successfully resolved VKH symptoms with gradual resolution of subretinal fibrin and fluid; however, the choroidal excavation remained.This case is the first report of choroidal excavation associated with VKH. Our results suggest that choroidal excavation can be induced by choroidal inflammation caused by VKH.
- Idiopathic intracranial hypertension and oxaliplatin: a causal association? [JOURNAL ARTICLE]
- Cutan Ocul Toxicol 2014 Sep 8.:1-5.
Abstract We report a case of a 54-year-old woman presented at the emergency service with complaints of transitory visual obscurations for four days, and headache, nausea and occasional vomiting in the last two months. She had been diagnosed of colorectal cancer one year ago and she was on treatment with oxaliplatin on a FOLFOX schedule. On ophthalmic examination, the vision was of 20/20 in both eyes and bilateral disc swelling was noted. The neurologic examination was normal. Magnetic resonance revealed no changes. A diagnostic lumbar puncture demonstrated an elevated opening pressure of 290 mm H2O with normal compounds. Due to the suspicion of ocular toxicity, oxaliplatin treatment was stopped. Treatment with oral acetazolamide was started and maintained for one month. In three weeks ocular and systemic symptoms totally disappeared and disc swelling gradually improved in the following months. Ocular toxicity has been reported as an infrequent adverse effect of oxaliplatin, but intracranial idiopathic pressure has not yet been described. Findings in this case suggest that oxaliplatin could be the cause for these symptoms. As the use of oxaliplatin is increasing as first-line treatment in colorectal cancer, we have to be alert to its potential toxicity.
- The role of orbital ultrasonography in distinguishing papilledema from pseudopapilledema. [JOURNAL ARTICLE]
- Eye (Lond) 2014 Sep 5.
PurposeTo determine the sensitivity and specificity of orbital ultrasonography in distinguishing papilledema from pseudopapilledema in adult patients.MethodsThe records of all adult patients referred to the neuro-ophthalmology service who underwent orbital ultrasonography for the evaluation of suspected papilledema were reviewed. The details of history, ophthalmologic examination, and results of ancillary testing including orbital ultrasonography, MRI, and lumbar puncture were recorded. Results of orbital ultrasonography were correlated with the final diagnosis of papilledema or pseudopapilledema on the basis of the clinical impression of the neuro-ophthalmologist. Ultrasound was considered positive when the optic nerve sheath diameter was ≥3.3 mm along with a positive 30° test.ResultsThe sensitivity of orbital ultrasonography for detection of papilledema was 90% (CI: 80.2-99.3%) and the specificity in detecting pseudopapilledema was 79% (CI: 67.7-90.7%).ConclusionsOrbital ultrasonography is a rapid and noninvasive test that is highly sensitive, but less specific in differentiating papilledema from pseudopapilledema in adult patients, and can be useful in guiding further management of patients in whom the diagnosis is initially uncertain.Eye advance online publication, 5 September 2014; doi:10.1038/eye.2014.210.
- [Clinical and therapeutic differences in neuro-ophthalmological involvement secondary to syphilis]. [English Abstract, Journal Article]
- Rev Neurol 2014 Sep 16; 59(6):264-8.
INTRODUCTION.There are many forms of neuro-ophthalmological involvement secondary to syphilis, and not all of them are well known. Our aim is to determine the clinical and therapeutic differences in these patients. CASE REPORTS. Our sample included eight patients diagnosed with an ocular and neuro-ophthalmological disorder due to syphilis over the years 2012 and 2013. Five of them presented uveitis, pan-eveitis being the most frequent, with three cases. Two cases presented papilloedema and another displayed retrobulbar optic neuropathy. A total of 62.5% were diagnosed with neurosyphilis, the presence of which was related with compromise of the optic nerve (p = 0.035). None of them gave positive for VDRL in cerebrospinal fluid and they were diagnosed by the presence of FTA antibodies together with high protein levels in cerebrospinal fluid, lymphocytic pleocytosis or intrathecal synthesis of antibodies. In the absence of uveitis, diagnosis was delayed by a mean time of 2.6 months (p = 0.047). All the patients, except one who required a vitrectomy, progressed favourably with intravenous antibiotic therapy.
CONCLUSIONS.In cases of neuro-ophthalmological compromise, whether inflammatory or non-inflammatory, the physician must bear syphilis in mind as a potential causation in order to avoid delays in the diagnosis, since early well-tailored treatment can prevent permanent loss of sight.
- The ophthalmic natural history of paediatric craniopharyngioma: a long-term review. [JOURNAL ARTICLE]
- J Neurooncol 2014 Aug 31.
We present our experience over the long-term of monitoring of visual function in children with craniopharyngioma. Our study involves an analysis of all paediatric patients with craniopharyngioma younger than 16 at the time of diagnosis and represents a series of predominantly sub-totally resected tumours. Visual data, of multiple modality, of the paediatric patients was collected. Twenty patients were surveyed. Poor prognostic indicators of the visual outcome and rate of recurrence were assessed. Severe visual loss and papilledema at the time of diagnosis were more common in children under the age of 6. In our study visual signs, tumour calcification and optic disc atrophy at presentation are predictors of poor visual outcome with the first two applying only in children younger than 6. In contrast with previous reports, preoperative visual field (VF) defects and type of surgery were not documented as prognostic indicators of poor postoperative visual acuity (VA) and VF. Contrary to previous reports calcification at diagnosis, type of surgery and preoperative VF defects were not found to be associated with tumour recurrence. Local recurrence is common. Younger age at presentation is associated with a tendency to recur. Magnetic resonance imaging (MRI) remains the recommended means of follow-up in patients with craniopharyngioma.
- Neurosyphilis in a man with human immunodeficiency virus. [Journal Article]
- J Clin Aesthet Dermatol 2014 Aug; 7(8):35-40.
The authors describe a 33-year-old man with human immunodeficiency virus who developed erythematous macules on the palms and soles with subsequent headaches, papilledema, and iritis. They review the salient characteristics of neurosyphilis with a focus on human immunodeficiency virus-positive individuals. The incidence of syphilis has increased since the year 2000 in African Americans, Hispanics, and men who have sex with men. Treponema pallidum is the causative agent of this disease-a fastidious, slowly growing, microaerophilic spirochete. Sexual contact is the most common mode of transmission. The rapid plasma reagin, Venereal Disease Research Laboratory assay, and fluorescent treponemal antibody absorption assay are commonly used to diagnose syphilis. The mainstay treatment is penicillin. Special considerations exist in the natural history and management of syphilis in the setting of human immunodeficiency virus.
- Steroid-induced recurrent myocardial ischemia. [JOURNAL ARTICLE]
- Rev Port Cardiol 2014 Aug 22.
We report the case of a female patient under oral prednisolone therapy due to a diagnosis of idiopathic intracranial hypertension with papilledema. Unfortunately, short-term treatment with prednisolone caused an unusual complication in the patient, i.e., recurrent myocardial ischemia. Possible mechanisms leading to this complication were evaluated in the light of current knowledge.