BACKGROUND:The purpose of this study was to assess monocular and binocular distance perception, and stereoacuity, in individuals with mild traumatic brain injury (mTBI) who reported the symptom of "poor depth perception";METHODS:Ten patients with mTBI were tested and compared with ten visually-normal asymptomatic individuals in the following areas: perceived distance, stereoacuity at distance (3 meters) and near (40 cm), and a 9-item 5-point rating-scale questionnaire related to distance perception. Distance perception was assessed under monocular and binocular viewing conditions in both clustered and isolated static environments. Magnitude estimation was used to obtain the distance perception response function of physical versus perceived distance using common objects positioned at distances of 0.77 to 12.84 meters.RESULTS:The mean distance perception response function slopes were not significantly different in the two groups for any of the test conditions. Stereoacuity (sec arc) was slightly reduced at both near and distance in the individuals with mTBI (36 ± 24.58 and 84 ± 68.34, respectively) as compared with the normal subjects (20 ± 0 and 51 ± 9.93, respectively). The mTBI group mean symptom score was 3.24 ± 0.26 indicating a moderate problematic level;CONCLUSIONS:Similarity of the mean distance response functions in the mTBI group under monocular and binocular viewing conditions suggested that their misperception of distance was not due to a "binocular vergence" problem. Similarly, the slightly reduced stereoacuity in the mTBI group was not sufficient to explain their symptom of "poor depth perception." Thus, it is speculated that this problem reflects a higher-level cortical perceptual phenomenon related to diffuse brain damage in areas dealing with visuo-spatial mapping.
BACKGROUND:Toxic retinopathy is an uncommon sequella in the treatment of certain autoimmune diseases with hydroxychloroquine (HCQ). We present two cases of HCQ toxic retinopathy, as well as a discussion on how to diagnose and manage early toxicity findings;CASE REPORTS:Two cases are presented of patients who experienced toxic effects of HCQ therapy. The first patient had bull's eye maculopathy confirmed with visual field testing and optical coherence tomography (OCT). The second patient had early signs of toxic maculopathy validated by repeat visual field and OCT testing;CONCLUSIONS:Management of toxic maculopathy includes the cessation of hydroxychloroquine, continued monitoring of the toxic effects and optimizing the remaining vision. The irreversible and potential devastating effect of HCQ toxic maculopathy underscores the importance of early diagnosis and working with the patient's rheumatologist.
Background: Diabetic papillopathy is a benign optic neuropathy with a favorable predictable visual outcome, found in Type 1 and Type 2 patients with diabetes mellitus. The condition manifests with optic disc edema and minimal optic nerve dyfunction. Previous reports have described several similarities between diabetic papillopathy and non-arteritic anterior ischemic optic neuropathy; however, there are clinical differences that make them unique conditions.Case Report: A 62 year old Caucasian male with Type 2 diabetes manifested bilateral optic disc edema without visual dysfunction. The patient was diagnosed with diabetic papillopathy after an extensive systemic evaluation which did not reveal any contributory etiologies. The patient was followed with serial retinal nerve fiber layer scans using optical coherence tomography over the course of one year. The optical coherence tomography measurements demonstrate normalization of retinal nerve fiber layer following optic disc edema resolution.Conclusions: Presented is a case report demonstrated the normalization of retinal nerve fiber layer following bilateral diabetic papillopathy. The use of optical coherence tomography is helpful in both documenting progression and differentiating from similar clinical entities.
Background: Dragged fovea diplopia syndrome is a condition involving intractable binocular diplopia associated with macular pathology often involving epiretinal membrane and macular pucker. The prevalence of this condition is unknown. There is no known cure for this condition but effective treatment for the symptoms is available. Case Reports: Two cases of intractable central binocular diplopia of 2 to 3 years duration that were not correctable with prism are presented. Both patients had a history of epiretinal membrane and had undergone membrane peel with vitrectomy. No extraocular muscle dysfunction or paresis were evident in either patient. Both responded favorably to partial monocular occlusion with semitransparent tape. Conclusion: Dragged fovea diplopia can be extremely frustrating for both patients and doctors. An understanding of this condition will allow practitioners to detect it and treat the symptoms to allow patients to function normally.
Background: Optic nerve sheath meningiomas (ONSMs) are the second most common optic nerve tumor. ONSMs typically affect middle-aged women. The most common presenting symptom is a painless progressive loss of vision. ONSMs are not typically associated with mortality or neurological morbidity. Case Report: A 44-year-old white female presented with right-sided periorbital headaches and transient visual obscurations in her right eye only for the past 6 months. Ocular examination revealed that all visual and ocular parameters were normal in each eye with the exception of optic nerve edema in her right eye (O.D.) only, with a corresponding enlarged blind spot on visual field. All serological and spinal fluid tests were normal. Imaging revealed enhancement of the optic nerve sheath without involvement of the optic nerve parenchyma. The patient was diagnosed with a presumed primary optic nerve sheath meningioma. Conclusion: The preferred management of ONSMs is assiduous clinical observation with prompt initiation of treatment upon documented visual deterioration. Stercotactic fractionated radiation therapy is the modality most likely to achieve long-term preservation of visual function. This approach has shown good visual outcomes with reduced risk of side effects to the surrounding radiosensitive ocular and neural tissues.
Background: Topiramate is an anticonvulsant drug prescribed for seizure and migraine prevention. Recently, it has begun to be prescribed as a weight management option for obese patients due to its well-documented side effect of appetite suppression. Various ocular effects with topiramate have been reported; however, to the best of our knowledge, this is the first case documenting toxic optic neuropathy resulting from nutritional deficiency in topiramate use.Case Summary: A 50-year-old woman presented with bilateral, painless, progressive decreased vision of four months duration. Medical history was significant for epilepsy, treated with topiramate, and recent 40 lb weight loss. Best-corrected visual acuities were 20/200 right eye and 20/400 left eye. Fundus examination revealed temporal pallor of the optic nerve heads in both eyes, and visual field testing revealed early cecocentral field defect in both eyes. Blood work demonstrated reduced vitamin B complex levels. Following treatment with vitamin injection and daily oral vitamin B-12, folate, and thiamine, the optic nerve pallor remained unchanged and vision improved to 20/120 in the right eye and 20/160 in the left eye.Conclusion: Patients taking topiramate and presenting with vision loss warrant investigation for low vitamin B-12, folate, and thiamine levels, in addition to advanced imaging. Early medical intervention to restore appropriate nutrition levels is imperative to save vision.
This article reviews the advantages of performing driving research in a high-fidelity driving simulator where the driver can be challenged in ways that could lead to property damage and personal injury if done on a test track or public roadway. Several vision related studies performed at the University of Iowa National Advanced Driving Simulator are review in this article to demonstrate the capabilities of these devices.
Background: Intertrigo is an inflammatory condition of the skin caused by friction between opposing skin surfaces. This leads to small breaks in the skin which allow a secondary infection, in this case a fungal infection, to occur. Intertrigo is most commonly found in patients who are obese, diabetic, or often exposed to heat and humidity. This case is unique as fungal intertrigo seldom affects the skin folds of the upper eyelid. Management options include topical and oral antifungal medications, absorptive powders, and lifestyle changes. Case report: A 53-year-old man presented to the eye clinic with chronic symptoms of discharge and pain emanating from his left upper eyelid. The diagnosis of fungal intertrigo was made based on the clinical appearance of the lesion, and was treated with antifungal medications. Conclusion: Fungal intertrigo is a skin infection that can clinically mimic other dermatologic conditions, making the diagnosis difficult. Greater awareness and understanding of this skin condition can lead to earlier diagnosis and appropriate treatment.
Purpose: Describe results from a large-scale market research study by a major contact lens manufacturer (Vistakon), related to the segmentation of the vision care market according to respondent's judgments of value for examination services and the purchase of eyeglasses and contact lenses. Methods: This market segmentation study enrolled a sample of 7,500 adult vision care consumers who had been examined and subsequently obtained vision correction with glasses or contact lenses at 1 of 7 specified outlets affiliated with a corporate brand, or an independent eye care provider or private practitioner (one not affiliated with any corporate brand) within the previous 18 months. The sample was balanced for demographic characteristics such as age, gender, metropolitan size, region, education, ethnicity and household income. Additional requirements for representation relative to the vision care market share were also included. A larger sample was selected and screened to get 7,500 who met the exam and vision correction purchase criteria. The study consisted of 624 questions in a 60-minute internet interview. It included questions designed to identify the factors that influenced their last purchase and those that will influence their decisions regarding the next purchase of examination services, glasses, and/or contact lenses. It also included questions designed to discover the consumers' shopping philosophies and their perceptions of the available value propositions responsible for the market segmentation observed. Results: Five shopping philosophies emerged in the vision care market based on consumers' approach to purchasing vision care goods and services. Consumers grouped the corporate affiliated outlets into 3 channels according to their perception of the value proposition representing each provider. The channels did not represent only the operational model of the providers. Independent Eye care Providers (IEP's) were pre-defined as 1 channel based on their operational similarities; consumers also described them as 1 provider channel based on a perceived value proposition of expert, highly credentialed, and providing the most advanced care. Besides these results related to market segmentation, additional findings related to the purchase of exams, contact lenses, and spectacles are reported.
Purpose: A few reports have indicated corneal hysteresis (CH) is influenced by different anti-glaucoma medications. This retrospective study was created to determine if CH is affected by the use of 2 commonly prescribed compounds to lower the intraocular pressure (TOP). Overview and Methodology: The objective was attained by reviewing patient records of selected veteran patients at a busy outpatient clinic. Patients were divided into 3 groups: (a) primary open angle glaucoma/ocular hypertension (POAG/OHTN) patients taking only prostaglandin analogs (PAs); (b) POAG/OHTN patients using only beta blockers (BBs), and a (c) control group of non POAG/OHTN patients. Ocular Response Analyzer (ORA) measurements were taken before and after initial treatment to determine relationship between intraocular pressure and CH values respectively. Results: All patients using PAs showed lower TOP values and an increase in CH values thirty days after treatment as measured by the Ocular Response Analyzer. The ratio was calculated to be a 5 mm Hg IOP decrease to every I mm Hg of CH increase in this population. The other 2 groups showed reduced IOP in the beta-blocker group with a slight elevation of CH. In contrast no IOP or CH change was seen in the control group. Conclusion: Treatment of these patients with topical PAs lower the IOP while concurrently increasing the CH values. This was also noted in the BB group to a lesser extent, and absent in the control group.
Purpose: Various tools have been developed and validated to accurately diagnose the severity of ocular surface disease (OSD) and convergence insufficiency (CI). They are primarily based on the symptoms associated with each of the two conditions. We investigated whether the treatment of CI would affect the symptoms experienced with OSD. Methods: Twenty six prcsbyopic patients with CI, who participated in a study to determine the efficacy of base- in prism in the treatment of this condition, were asked to quantify symptoms associated with OSD on a scale of 0 to 4 before entering the study The selected symptoms were burning and tearing, aching and pain, and dry and sandy feeling. The patients were again asked to quantify the severity of their symptoms after the use of a placebo pair of glasses and a treatment pair with base-in prism. Results: The total OSD symptom scores were 6.42 +/- 2.64 (baseline), 5.38 +/- 3.19 (placebo) and 2.69 +/- 2.29 (treatment). A one way repeated-measures ANOVA found the OSD symptoms in the treatment group to be significantly different from the baseline and placebo groups (p=.001). Conclusion: While CI and OSD are distinct clinical entities, there appears to be an overlap of symptoms associated with the two conditions.
Purpose: To develop and validate a model of reversible central and peripheral visual field loss in healthy subjects using contact lenses. Methods: A prospective, single center, unmasked study. Custom contact lenses which fully corrected any ametropia were ordered for 15 subjects with normal ocular health. The right eye wore 3 different contact lenses with painted central opacities of 4mm, 6mm, and 8mm, respectively. The left eye wore 3 different contact lenses with clear centers of 1mm, 2mm, and 4mm, with the remainder of the lens pacified. Visual acuity, contrast sensitivity, and Humphrey automated perimetry were performed for each contact lens condition and compared to baseline values. Results: Our model of reversible visual field loss using contact lenses produced profound effects for central occlusion sizes of 8mm and moderate effects with central occlusion sizes of 6mm. Contact lenses that produced peripheral occlusion effects showed statistically significant decreases in our outcomes variables for the 1 and 2mm pupil sizes. Both the 4mm central and peripheral occlusion contact lenses, while statistically significant for some outcomes measures, did not seem to produce sufficiently large visual field defects to mimic clinically noticeable impairments. Conclusions: It is possible to use contact lenses with painted opacities to produce reversible central and peripheral visual field defects in healthy subjects.
Background: Pigment dispersion syndrome (PDS) refers to a bilateral pathological deposition of pigment onto the intraocular tissues of the anterior segment. The pigment is liberated from the iris by the mechanical rubbing of the posterior iris surface againstthe lens zonules. The released pigment follows the flow of aqueous and ultimately accumulates in the trabecular meshwork (TM). Pigmentary glaucoma (PG) is a potential sequela. Although PDS and PG predominantly occur in young, myopic white males, these conditions do affect the black population. However, the clinical presentation of PDS in blacks is variable and may confound the diagnosis.Case Reports: Two patients with PDS are discussed. The first was a 28-year-old white male who indicated that he manifested blurred vision and brow ache whenever he underwent long, vigorous runs. Examination revealed a dense, vertical band of endothelial pigment on both corneae, iris transillumination defects in both eyes, and dense, 360 degree pigment on the TM of both eyes. At the time of presentation, the IOPs were not elevated, and there was no evidence of glaucoma. However, IOPs were found to be elevated when measured after the patient had engaged in a long run. Since the patient indicated that he would continue to engage in long runs and would persist in vigorous exercise, he was considered to be at risk for the development of PG. Various options were presented, and the patient finally opted for peripheral iridotomies. The patient has remained symptom-free for several years.The second patient was a 65 year-old black male who presented for a second opinion regarding a diagnosis of normal tension glaucoma. He manifested some of the stigmata of PDS. However, gonioscopy revealed greater pigment in the superior angle than the inferior angle, a sign that pigment deposition had occurred many years earlier. The pigment dispersion process was deemed to be inactive. The IOPs measured 14 mmHg OU. The optic nerves revealed large, vertically elongated cups. The visual fields revealed glaucomatous defects. Inactive PG was diagnosed, and no treatment was instituted. The patient has been followed for several years with no increase in IOPs and no progression of optic nerve head cupping or visual field defects.Conclusions: Diagnosing PDS and preventing consequent PDG in a young white patient involves careful, intuitive diagnostic testing and a step-wise approach to control IOP. Older black patients with subtle stigmata of PDS and burned-out PG may present with findings that masquerade as normal tension glaucoma and can be diagnostic challenges.
Background: Meningiomas are the most frequently reported intracranial tumor. Skull-base meningiomas may enlarge and have the potential to affect structures of the visual system through a compressive and space-occupying mechanism. This case describes an atypical course of a meningioma determined to be histologically benign but structurally invasive.Case Report: A 45-year-old African American female veteran presented with complaints of decreased vision in her left eye for I month duration. Neurological imaging revealed a large, World Health Organization Grade 1 skull base meningioma which displaced the optic nerve of the right eye and compressed the optic nerve in the left eye. The tumor had also progressed over the optic chiasm. Timely surgical intervention resulted in improved visual function in both eyes.Conclusion: Clinicians need to be aware of the potential of intracranial tumors causing a compressive optic atrophy even if visual acuity is initially close to normal. The optic nerves should be carefully studied and compared. Brain imaging should be completed when even subtle optic atrophy is present without other explanation. Detection of these lesions is imperative to ensure the best potential visual outcome, or even save a life, as even a benign tumor can produce lasting visual scquelae and life-threatening complications.
Background: Diabetic retinopathy (DR) development/progression is influenced by risk factors. The authors sought to characterize a vulnerable population of Type 2 Diabetes Mellitus (DM2) patients with and without DR using these factors.Methods: The Vision of Hope Health Alliance (VOHHA) program provided eye care to low-income uninsured adults. VOHHA patients with a history of DM2 were included in this analysis. Data collected included demographic information (including information on DM), history of DM, DR and hypertension, DR status, and blood pressure (BP). Classification of BP was based on Joint National Commission of Prevention, Detection, Evaluation and Treatment of High Blood Pressure VII (JNC recommendations.Results: Of 3,966 VOHHA patients, DM2 was self-reported by 33.4%. Of those who reported DM2, DR was diagnosed in 22.7% while a previous history of DR was reported by 2.9%. An association was found between DR and gender as well as years since diagnosis of DM2 and DR. The last eye exam was reported > 15 months prior by 68.4% of those with DM2. The majority reported 'unsure' of glycosylated hemoglobin (HbAlc). There was an association between those who reported hypertension (HTN)/ HTN not reported but BP exceeded JNC VII guidelines ('HTN/JNCHTN') and DR. There was also an association between DR and elevated BP level based on JNC VII guidelines in 'HTN/JNCHTN.'Conclusion: A large number of VOHHA DM2 patients have factors which put them at risk for development/ progression of DR. Associations between identified risk factors and DR found agree with other studies and illustrate the necessity of providing eye care /education to vulnerable populations.
Background: This paper explores issues that affect both the supply and demand of optometrists and ophthalmologists. Supply of eye care providers must be determined and related to demographic, economic, and epidemiological factors that may increase the demand for eye care services. Enrollment trends at the colleges of optometry and the anticipated increases in the national supply is discussed. New schools have recently opened, and their impact on the required supply of eye care providers needs to be assessed. Methods: The SUNY State College of Optometry initiated the New York Workforce Study to guide its enrollment strategy and to ensure the future workforce needs of New York State are met. A thorough analysis of the supply of eye care providers, optometrists and ophthalmologists, was undertaken. Results: The New York State-based optometry school has contributed to an overall increase of optometric practitioners in the state over the past 40 years, although the net increase in providers has now slowed to approximately 1% per year. During this same period, the number of ophthalmologists has not kept pace with practitioner attrition nor population growth. Conclusions: Despite the contributions of the state-based school to the supply of optometrists within New York State, the net increase in optometry providers is now barely keeping up with the attrition rate of optometrists leaving practice. The supply of ophthalmologists in New York State has decreased over the past decade and a more substantial decrease in their numbers is projected by 2030.
Background: Myopic foveoschisis is an additional complication of pathologic myopia and has recently been more precisely described with the advent of optical coherence tomography (OCT). Although the pathogenesis of this condition remains undefined, vitreoretinal traction appears to play a primary role in its development.Visual function may be compromised if complications develop.Case Report: A 22-year-old highly myopic male presented for comprehensive eye examination with no ocular or visual complaints. Best corrected visual acuities were 20/15 OD and 20/20 OS. On fundus examination, retinal elevation was found temporal to the macula in the left eye. Further examination, via Cirrus OCT((C) Carl Zeiss Meditec, Germany), revealed focal vitreoretinal traction with an underlying paramacular schisis.The patient has been followed for a number of years without progression.Conclusion: Myopic retinoschisis is a poorly understood entity that can lead to significant visual morbidity. The natural evolution and surgical outcome of this condition needs to be further studied to optimally manage patients. We present a variant of myopic retinoschisis in an asymptomatic male.
Background With new technology and techniques to improve the diagnosis of ocular melanomas, earlier and more specified treatments may be chosen to decrease the incidence of metastases. Therefore, we reviewed multiple diagnostic tools and treatment modalities for the identification and treatment of choroidal melanoma. Case Report An 80-year-old Caucasian male presented with temporal vision loss and photopsias OS at a regularly scheduled follow-up exam for ocular hypertension. After the dilated fundus exam and a B scan ultrasonography, the patient was diagnosed with a large choroidal melanoma. A consultation with an ocular oncologist confirmed the diagnosis. Enucleation was performed as the primary treatment for the tumor, and additional testing was completed to rule out metastasis specifically to the liver and/or lungs. Conclusion Newer diagnostic and treatment modalities can complement existing methods, leading to earlier detection and initiation of treatment, which may permanently and completely eliminate the tumor. Since many patients are asymptomatic, optometrists play an important role in the detection and referral of choroidal melanomas through dilated fundus examinations.
