Neuro-Ophthalmic Literature Review

Neuro-Ophthalmic Literature Review David Bellows, Noel Chan, John Chen, Hui-Chen Cheng, Michael Vaphiades, and Konrad Weber Findings support the need for immediate evaluation and, if necessary, intervention in patients with central retinal artery occlusion Mir TA, Arham AZ, Fang W, Alqahtani F, Alkhouli M, Gallo J, Hinkle DM. Acute vascular ischemic events in patients with central retinal artery occlusion in the United States: a Nationwide Study 2003–2014.Am JOphthalmol. 2019Apr 1;200:179–86. Central retinal artery occlusion (CRAO) confers a high risk of other ischaemic events. The purpose of this study was to determine the incidence of an acute ischaemic event occurring immediately following CRAO and to identify the risk factors associated with these events. Using the database from the Nationwide Inpatient Sample, the authors reviewed the records of 17,117 patients whowere admitted to a hospital in theUnited States with a diagnosis of CRAO. The primary outcome measure was the incidence of an in-hospital acute ischaemic event. The mean age of patients with CRAO was 68.4 years and 53% of the patients were female. The authors found that the most common risk factors associated with CRAO included hypertension, carotid artery stenosis, atrial fibrillation, and left-sided cardiac valve disease (most commonly aortic stenosis). The incidence of a stroke occurring during hospitalization measured 12.9% and the incidence of myocardial infarction measured 3.7%. The combined risk of stroke, transient ischaemic attack, myocardial infarction or mortality measured 19%. Not surprisingly they found that the risk of stroke was greatest in those patients with co-morbidities including hypertension, carotid artery stenosis, aortic valve disease, smoking, and alcohol abuse. The authors make a convincing argument that high-risk CRAO patients undergo immediate evaluation (with 24 h) and appropriate intervention if risk factors for other acute ischaemic events are identified. David Bellows Likelihood and timing of recurrence after first episode of optic neuritis in Asia Park K-A, Oh SY, Min J-H, Kim BJ. Incidence and timing of recurrence of optic neuritis. Graefe’s Arch Clin Exp Ophthalmol. 2019;257:651–655 This is a retrospective review evaluating the incidence and timing of recurrence after the first episode of optic neuritis in an Asian population. Patients with prior history of multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), systemic vasculitis or other forms of optic neuropathies were excluded while recurrence was defined as new attack occurring after an interval of 30 days. A total of 111 patients were included in the study and all except 2 received intravenousmethylprednisolone for 3–5 days followed by oral prednisolone 1mg/kg daily for 11 days. Two patients did not receive any treatment due to mild disease and one of them was pregnant. Eighteen (16%) patients had positive results forNMOIgG and were started on long-term immunosuppressant after slower tapering of oral steroid. Seven (6%) relapses occurred after intravenous methylprednisolone treatment. The recurrence rate was highest within 1 year after the first episode of optic neuritis. If there was no recurrence until 6 months, 1 year and 2 years after the first episode of optic neuritis, the next 5-year survival probabilitywere 67%, 72%, and 81%, respectively. During the followup, 24 patients (22%) were diagnosed as NMOSD, 13 (12%) developed definite MS, 4 (4%) fulfilled the CONTACT John J. Chen, MD, PhD chen.john@mayo.edu Mayo Clinic, Department of Ophthalmology, 200 First Street, SW, Rochester, MN, USA 55905 NEURO-OPHTHALMOLOGY 2019, VOL. 43, NO. 4, 271–275 https://doi.org/10.1080/01658107.2019.1645496 © 2019 Taylor & Francis criteria for chronic relapsing inflammatory optic neuropathy (CRION). Among the 74 patients with idiopathic optic neuritis, 25 (34%) experienced recurrence. Of the 24 patients with NMO and 13 patients with MS, 17 (71%) and 1 (8%) experienced recurrence. Although the annual incidence decreased over time after the first attack, the cumulative recurrence rate increased continuously for 10 years. Five patients in this study had recurrence at more than 10 years after the first episode. This finding highlights the importance of long-term monitoring and warning patients of the possibility of recurrence even after a single episode of optic neuritis. The estimated cumulative incidence of recurrence in either eye was 26% at 1 year, 33% at 3 years, 37% at 5 years and 50% at 10 years after the first episode of optic neuritis. This figure is higher than the recurrence rate of 35% at 10 years in the ONTT study. Such discrepancy could be attributable to the difference in the method of analysis, racial difference and proportions of patients with NMOSD. Limitations of this study include its retrospective nature, single tertiary centre involvement and lack of anti-myelin oligodendrocyte glycoprotein antibody results. Nevertheless, this study has provided useful observations in terms of the long-term clinical profile in Asian patients presenting with their first episode of optic neuritis. Noel Chan Risk of ischemic stroke after microvascular ocular motor palsy Beato-Coelho J, Varela R, Almendra L, Carvalho M, Duque C, Patrício M, SargentoFreitas J, Freire A, Lemos J. ischaemic stroke incidence in patients with microvascular ocular motor palsy versus patients with lacunar ischeamic stroke. Neurologist 2019;24:50–52. This is a retrospective analysis of a prospective database comparing the incidence of ischaemic stroke in patients with prior microvascular ocular motor palsy (CN III, IV, or VI palsies) versus lacunar ischaemic stroke. The study included 57 patients with microvascular ocular motor palsies (composed of 15 CNIII palsies, 16 CNIV palsies, 26 CNVI palsies) and 53 patients with ischemic lacunar infarcts sharing similar gender distribution and baseline vascular risk factor profiles. After 80 months from the index event, a total of 12 patients developed ischaemic stroke of which 8 (14%) were from ocular motor palsy group and 4 (7%) were patients with prior lacunar infarct. The annual occurrence rate of ischaemic stroke was 2.1% and 0.6% per year for the ocular motor palsy group and lacunar infarct group, respectively. Cox regression analysis did not identify a statistically significant difference between the two groups. This study showed that presumed microvascular ocular motor cranial nerve palsy may be an underrecognized independent risk factor for ischaemic stroke. One other interesting finding in this study was the difference in the use of antiplatelet treatment after the two different index events. At the individualise discretion of the treating physician, antiplatelet treatment was initiated in all patients of the lacunar ischaemic stroke group but only half (56.1%) of the patients in the microvascular ocular motor palsy group. Despite the well-established role of antiplatelet treatment in the prevention of non-cardioembolic ischaemic stroke, this finding might not be too surprising as microvascular ocular motor palsies have been regarded as a selflimiting event. Multivariate analysis in the current study however was not able to demonstrate the relationship between the use of antiplatelet and the risk of subsequent ischaemic stroke in patients with a prior history of ocular motor palsy. Noel Chan Eculizumab is effective for AQP4-IgG-Positive NMOSD Pittock SJ, et al. Eculizumab in aquaporin-4-positive neuromyelitis optica spectrum disorder. New Engl J Med. 2019. The authors conducted a phase 3, multi-centre randomised, double-blind, placebo-controlled trial (PREVENT) to evaluate the efficacy and safety of eculizumab in patients with aquaporin-4 (AQP4)IgG-positive NMOSD. One hundred and fortythree adults with AQP4-IgG-positive NMOSD were randomised in a 2:1 ratio to receive either intravenous eculizumab or placebo. The primary endpoint was the time to first adjudicated relapse. 272 D. BELLOWS ET AL.