Neuro-Ophthalmic Literature Review

Neuro-Ophthalmic Literature Review David A. Bellows, John J. Chen, Jenny A. Nij Bijvank, Michael S. Vaphiades, and Xiaojun Zhang Functional vision disorders in adults: A paradigm and nomenclature shift for ophthalmology Raviskanthan S, Wendt S, Ugoh PM, Mortensen PW, Moss HE, Lee AG. Functional vision disorders in adults: a paradigm and nomenclature shift for ophthalmology. Surv Ophthalmol. 2022;67(1):8– 18. doi.org/10.1016/j.survophthal.2021.03.002 It is not uncommon for a patient to present with vision loss and no clinical findings. This disorder has gone by many names including non-organic vision loss, functional vision loss, non-physiologic vision loss, psychogenic vision loss, psychosomatic vision loss, etc. In this article the authors review the current terminology and literature pertaining to this disorder and present an approach to its diagnosis and management. The authors propose the use of a unifying term, functional vision disorders (FVD), for this subset of patients with functional neurological symptoms disorders (FND). A thorough examination is a prerequisite to diagnosing FVD since as many as 3% of patient with a FVD are misdiagnosed and as many as 26% to 50% of patients with a functional vision disorder will have a coexistent ophthalmological or neurological disease. The authors review the techniques for diagnosing FVD in patients who present with reduced visual acuity, monocular vision loss, binocular vision loss and visual field loss. Clinicians are often uncomfortable discussing the diagnosis of FVD with their patient since, if handled incorrectly, it can jeopardise the doctor-patient relationship. The authors introduce the SPIKES protocol, first developed by oncologists, as a structured means of delivering unwelcome news to patients in a caring and helpful manner. This review article can serve as a useful resource, especially for physicians in training, for naming, diagnosing, and managing patients with functional vision disorders. David A. Bellows Optic nerve sheath fenestration improves visual function in paediatric patients with severe papilloedema Landau Prat D, Liu GT, Avery RA, Ying G-S, Chen Y, Tomlinson LA, Revere KE, Katowitz JA, Katowitz WR. Recovery of vision after optic nerve sheath fenestration in children and adolescents with elevated intracranial pressure. Am J Ophthalmol, 2021;237:173–182. doi.org/10.1016/j. ajo.2021.11.019 The authors conducted a retrospective study of 14 paediatric patients who underwent optic nerve sheath fenestration for papilloedema at the Children’s Hospital of Philadelphia. Ten (71%) were female and their ages ranged from 8.5 to 17.5. Ten of these patients had a diagnosis of idiopathic intracranial hypertension. Five patients underwent bilateral optic nerve sheath fenestration. Visual acuity improved from 20/138 to 20/68 in the operated eye and from 20/78 to 20/32 in the nonoperated eye. Visual field mean deviation improved from −23.4 dB to −11.5 dB in the operated eye and from −19.8 dB to −6.8 dB in the non-operated eye. Colour vision significantly improved in the operated eyes. In the operated eyes, extra-ocular motility was abnormal in 13 (72.2%) eyes at presentation and improved to three (15.8%) at final visit, while the non-operated eye had abnormal extra-ocular motility in four (44.4%) eyes at presentation and all improved at final visit. Retinal nerve fibre layer thickness improved in the operated eye from 349.1 CONTACT John J. Chen Chen.john@mayo.edu Mayo Clinic Department of Ophthalmology, 200 First Street, SW, Rochester, MN 55905, USA. NEURO-OPHTHALMOLOGY 2022, VOL. 46, NO. 2, 138–145 https://doi.org/10.1080/01658107.2022.2030591 © 2022 Taylor & Francis Group, LLC to 66.2 μm. In 13 out of 14 patients, optic nerve pallor was noted at the final visit. Improvement in some aspects of visual function was seen as early as post-operative day 1, such as visual acuity in the non-operated eye, while other variables reached a significant improvement 1 week or 1 month after surgery. None of the patients suffered any adverse effects from the optic nerve sheath fenestration procedure. The main limitation of the study is its retrospective design and therefore not all patients had optical coherence tomography and visual fields. In addition, the decision to perform optic nerve sheath fenestration was determined by the providers and therefore the timing of surgery and severity of disease varied among the patients. Regardless of these limitations, this study is one of the largest studies on optic nerve sheath fenestration in paediatric patients and demonstrates that optic nerve sheath fenestration is effective in improving visual function in paediatric patients with papillaedema in both the operated and non-operated eyes. John J. Chen Fixational saccades differentiate concussion patients from controls Leonard BT, Kontos AP, Marchetti GF, Zhang M, Eagle SR, Reecher HM, Bensinger ES, Snyder VC, Holland CL, Sheehy CK, Rossi EA. Fixational eye movements following concussion. J Vis. 2021 Dec 1;21(13):11. doi: 10.1167/jov.21.13.11. This study investigated small fixational eye movements in 44 patients with a recent concussion in comparison to 44 controls, using a tracking scanning laser ophthalmoscope (TSLO). Ocular dysfunction is common in concussion patients and predictive of a longer recovery time, but potentially current diagnostic (mostly subjective) tools are not able to capture all deficits sensitively. Fixational saccade amplitude, peak velocity and peak acceleration were significantly larger in concussion patients compared with the controls. This was only found when subjects had to fixate the centre of a (large) raster, in contrast to the edge of the raster. Drift between saccades was not significantly different between concussion patients and controls. These results suggest that TSLO measurement in the acute to subacute period of concussion recovery may provide a quick and accurate assessment of ocular dysfunction, which may be more rapid and objective than current approaches. Task optimisation, as the authors stated, can potentially increase the diagnostic accuracy. Furthermore, the analysis of the TSLO data depended on manual checks of the saccade start and end, therefore further automation of this process is desirable for future implementation. Finally, this study did not investigate the associations with severity of the concussion or the (additional) prognostic value of characteristics of fixational saccades. Overall, measurement of (fixational) saccades is a promising and developing test for oculomotor function in concussion patients and this study provided a detailed approach using TSLO. Jenny A. Nij Bijvank Craniospinal irradiation in the treatment of chemotherapy refractory leptomeningeal metastasis from breast cancer Tesolin D, Vergidis D, Ramchandar K. Craniospinal irradiation in the treatment of chemotherapy refractory leptomeningeal metastasis from breast cancer: A case report. Cancer Rep (Hoboken). 2021 Nov 10: e1556. doi: 10.1002/cnr2.1556. The authors report the case of a 50-year-old woman with a history of metastatic breast cancer who presented with a 2-week history of headaches, nausea, and vomiting and lower extremity weakness. Magnetic resonance imaging of the brain showed a stable or slightly reduced size of a previously treated lesion in the left insular cortex. Given the ongoing symptoms, lumbar puncture with cerebrospinal fluid cytology was performed, which confirmed metastatic carcinoma consistent with a breast primary, establishing a diagnosis of leptomeningeal metastasis. She eventually received chemotherapy and then craniospinal irradiation for chemotherapy-refractory leptomeningeal disease. She died from her disease 2 years and 11 months following her initial presentation but survived well beyond the median survival with good quality of life for the majority of that time. This remarkable survival and performance after treatment suggests NEURO-OPHTHALMOLOGY 139