RESUMO
OBJECTIVES: To determine quantitative and qualitative hemodynamic alterations within the ophthalmic, central retinal, and short posterior ciliary arteries in patients with giant cell arteritis (GCA) proved by biopsy specimen. DESIGN, PATIENTS, AND SETTING: A consecutive case series of patients with GCA referred to an urban eye hospital who were evaluated with color Doppler imaging that was used to analyze orbital blood flow velocities and vascular resistance in 22 consecutive patients with GCA compared with age and sex-matched controls. RESULTS: Patients with GCA all demonstrated significantly reduced central retinal and short posterior ciliary arterial mean flow velocities as well as significantly increased vascular resistance compared with matched controls. Ophthalmic artery mean flow velocity demonstrated marked variation depending on the anatomic location studied. Other color Doppler imaging characteristics of GCA included the following: ophthalmic artery aliasing (high velocity and turbulent flow at presumed focal vasculitic stenoses), reversal of flow within the ophthalmic artery, reduced and truncated time-velocity waveforms of the central retinal and short posterior ciliary arteries, and absolute deficits of flow within the central retinal and short posterior ciliary arteries. Aliasing of flow velocity within the ophthalmic artery (two patients) was associated with clinical progression of GCA. CONCLUSIONS: These data support the concept that quantitative and qualitative alterations in blood flow or pathophysiologic mechanisms of visual loss in GCA. This technique may be useful in the diagnosis and management of GCA since some of the color Doppler waveforms observed in GCA have not been seen in non-arteritic optic neuropathy. Treatment with corticosteroids often appears to stop the progression of these hemodynamic abnormalities but generally does not improve preexisting vascular abnormalities.
Assuntos
Corpo Ciliar/irrigação sanguínea , Arterite de Células Gigantes/fisiopatologia , Artéria Oftálmica/fisiopatologia , Artéria Retiniana/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Velocidade do Fluxo Sanguíneo/fisiologia , Feminino , Arterite de Células Gigantes/tratamento farmacológico , Humanos , Fluxometria por Laser-Doppler , Masculino , Metilprednisolona/uso terapêutico , Pessoa de Meia-Idade , Fluxo Sanguíneo Regional/fisiologiaRESUMO
OBJECTIVE: To describe three patients with giant cell arteritis (GCA) who suffered profound, irreversible visual loss due to delayed initiation or discontinuation of corticosteroid therapy pending results of histopathologic examination of temporal artery biopsy specimens and to review the appropriate management of GCA once the clinical diagnosis is made. STUDY DESIGN: Case series. SETTING: University-affiliated eye hospital. PATIENTS: Three women with biopsy-proven GCA and bilateral visual loss due to delayed institution or discontinuation of corticosteroid therapy. MAIN OUTCOME MEASURES: Visual acuity and onset, and time course of corticosteroid therapy. RESULTS: Permanent visual loss resulted from delayed initiation of corticosteroid therapy in two patients and discontinuation of therapy in one patient with clinically suspected diagnosis of GCA. In two of these patients, visual loss was preceded by amaurosis fugax and other visual disturbances, although one patient did not volunteer this information to her physician. CONCLUSIONS: Giant cell arteritis may cause rapid and profound loss of vision bilaterally, often without warning. It is essential that systemic corticosteroid therapy be initiated as soon as the diagnosis of GCA is made clinically. Corticosteroid therapy should not be delayed until results of examination of the temporal artery biopsy specimen are obtained. Biopsy specimen interpretation will not be affected if the biopsy is performed within 7 to 10 days of starting therapy.
Assuntos
Corticosteroides/uso terapêutico , Cegueira/etiologia , Arterite de Células Gigantes/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Biópsia , Feminino , Arterite de Células Gigantes/complicações , Arterite de Células Gigantes/patologia , Humanos , Injeções Intravenosas , Hemissuccinato de Metilprednisolona/administração & dosagem , Hemissuccinato de Metilprednisolona/uso terapêutico , Artérias Temporais/patologia , Fatores de TempoRESUMO
PURPOSE: The purpose of this study is to examine changes in color Doppler imaging parameters before and after optic nerve sheath decompression (ONSD) for chronic papilledema caused by pseudotumor cerebri (PTC). METHODS: Color Doppler imaging was performed within 48 hours before surgery and within 48 hours after the procedure using a color Doppler unit with a 7.5-MHz phased linear transducer. Pulsed Doppler spectrum analyses were recorded digitally on videotape from the ophthalmic, central retinal, and short posterior ciliary arteries, using a 0.4 x 0.6-mm sample volume. RESULTS: Blood flow velocities in the ophthalmic, short posterior ciliary, and central retinal arteries of 24 eyes were significantly decreased compared with a healthy age-matched group. Eyes with visual acuities worse than 20/30 before surgery had significantly decreased velocities in the ophthalmic, short posterior ciliary, and retinal arteries, whereas in eyes with visual acuities better than 20/30, only the short posterior ciliary and central retinal arteries demonstrated decreased velocities. In addition, Gosling's pulsatility index was increased for the central retinal artery but not the ophthalmic or short posterior ciliary arteries. Thirteen eyes improving in visual acuity and field after ONSD demonstrated significant improvement in all color Doppler imaging parameters for the short posterior ciliary arteries. The ophthalmic artery diastolic velocity also increased significantly but the central retinal artery parameters did not change. The eyes that remained stable or worsened did not demonstrate significant postoperative changes. CONCLUSION: These results suggest that some of the visual loss from chronic papilledema may be due to ischemia, and worsening visual acuity correlates with greater impairment of the retrobulbar circulation. One of the mechanisms by which ONSD improves visual function may be reversal of this ischemic process.
Assuntos
Velocidade do Fluxo Sanguíneo , Nervo Óptico/cirurgia , Papiledema/fisiopatologia , Artérias/diagnóstico por imagem , Artérias/fisiologia , Velocidade do Fluxo Sanguíneo/fisiologia , Doença Crônica , Corpo Ciliar/irrigação sanguínea , Feminino , Seguimentos , Hemodinâmica , Humanos , Estudos Longitudinais , Masculino , Artéria Oftálmica/diagnóstico por imagem , Artéria Oftálmica/fisiologia , Papiledema/etiologia , Papiledema/cirurgia , Pseudotumor Cerebral/complicações , Artéria Retiniana/diagnóstico por imagem , Artéria Retiniana/fisiologia , Ultrassonografia , Acuidade VisualRESUMO
We evaluated 37 patients with hemifacial spasm and 16 age-matched control patients with other neurological disorders using magnetic resonance (MR) imaging, MR angiography, and MR tomographic angiography. MR tomographic angiography is a new technique using computer reconstruction of MR angiographic images to create coronal angiotomes that display tissue and arterial structures on the same image. Twenty-four of 37 (64.9%) patients with hemifacial spasm had ipsilateral vascular compression of cranial nerve VII or the pons noted by this technique, whereas only 1 of 16 (6.3%) control patients had compression. MR imaging and MR angiography were less sensitive and less specific in evaluating for vascular compression. This study supports vascular compression of cranial nerve VII or the pons as a cause of hemifacial spasm, and demonstrates MR tomographic angiography's value as an excellent, noninvasive technique to demonstrate the compression.
Assuntos
Angiografia , Tronco Encefálico/patologia , Músculos Faciais , Nervo Facial , Processamento de Imagem Assistida por Computador/métodos , Imageamento por Ressonância Magnética , Síndromes de Compressão Nervosa/diagnóstico , Espasmo/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artéria Basilar/diagnóstico por imagem , Encefalopatias/diagnóstico , Cerebelo/irrigação sanguínea , Feminino , Lateralidade Funcional , Humanos , Masculino , Pessoa de Meia-Idade , Síndromes de Compressão Nervosa/complicações , Artéria Vertebral/diagnóstico por imagemRESUMO
PURPOSE: This study describes hemodynamic characteristics of the ophthalmic, central retinal, and posterior ciliary arteries in 16 eyes of 11 patients with the ocular ischemic syndrome. Understanding the hemodynamic characteristics of the retrobulbar circulation may elucidate the natural history and pathophysiology of the ocular ischemic syndrome and perhaps form the basis for rational treatment of this condition. METHODS: Color Doppler imaging, a procedure that permits rapid noninvasive imaging of the ophthalmic, central retinal, and posterior ciliary arteries, was used to quantitate peak systolic blood flow velocities and vascular resistance (pulsatility index) within these vessels in study group eyes and in an age-matched control population. RESULTS: We demonstrated markedly reduced ocular ischemic syndrome central retinal and posterior ciliary artery peak systolic velocities compared with control group eyes. Central retinal and posterior ciliary artery vascular resistance (pulsatility index) was greater in ocular ischemic eyes versus control group eyes. Reversal of ophthalmic artery blood flow was detected in 12 of 16 ocular ischemic syndrome eyes. Study group eyes with poor vision had no detectable posterior ciliary arterial blood flow. CONCLUSION: Color Doppler imaging quantitates hemodynamic characteristics of the retrobulbar circulation in the ocular ischemic syndrome. There is markedly reduced peak systolic velocity and increased vascular resistance in ocular end arteries such as the central retinal and posterior ciliary arteries. Ophthalmic artery reversal of flow seems to represent collateral blood flow to lower resistance vascular beds. Posterior ciliary artery hypoperfusion may correlate with poor vision in the ocular ischemic syndrome.
Assuntos
Olho/irrigação sanguínea , Olho/diagnóstico por imagem , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Velocidade do Fluxo Sanguíneo , Corpo Ciliar/diagnóstico por imagem , Olho/fisiopatologia , Feminino , Fundo de Olho , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Oftálmica/diagnóstico por imagem , Artéria Retiniana/diagnóstico por imagem , Síndrome , UltrassonografiaRESUMO
Six patients with thyroid ophthalmopathy presented with what appeared to be a unilateral superior oblique paresis by the three-step test, which was eventually followed by more typical findings of thyroid disease. This early motility defect in thyroid ophthalmopathy may be caused by a restrictive process due to involvement of the inferior rectus muscle. Clues to the proper diagnosis included an increase in vertical deviation in upgaze, elevation of intraocular tension in upgaze, and the lack of excyclodeviation. These features should be assessed in patients with isolated superior oblique paresis.
Assuntos
Doença de Graves/diagnóstico , Paralisia/diagnóstico , Nervo Troclear , Adulto , Idoso , Doenças dos Nervos Cranianos/diagnóstico , Doenças dos Nervos Cranianos/etiologia , Diplopia/diagnóstico , Movimentos Oculares , Feminino , Doença de Graves/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Oftalmoplegia/diagnóstico , Acuidade VisualRESUMO
BACKGROUND: Pituitary adenomas that arise from the gonadotroph cells are being recognized with increasing frequency in men, but they are still rarely recognized in women. This rarity could be the result of an actual difference in occurrence or of greater difficulty in recognition. The tumors are usually recognized in men more than 50 years old, but elevated serum gonadotropin levels in women of that age could be produced by normal gonadotroph cells. METHODS: Because the stimulation of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and the beta subunit of LH (LH beta) by thyrotropin-releasing hormone (TRH) is a characteristic of gonadotroph adenomas in men, we administered TRH to 16 women with apparently nonsecreting pituitary macroadenomas and measured serum FSH, LH, LH beta, and the glycoprotein hormone alpha subunit every 15 minutes for 90 minutes before and 90 minutes after. The results were compared with the responses in 16 healthy women matched for age and in 10 women with macroadenomas secreting prolactin, growth hormone, or corticotropin. The tumors from 12 of the women with nonsecreting adenomas were cultured, and the secretion of FSH, LH, and LH beta in culture was determined. RESULTS: Eleven of the 16 women with apparently nonsecreting adenomas had significant increases in serum LH beta in response to TRH, 3 had FSH responses, and 4 had LH responses. None of the 16 healthy women and none of the 10 women with secreting macroadenomas had LH beta, FSH, or LH responses to TRH. Ten of the 12 adenomas that were cultured secreted readily detectable amounts of FSH, LH, and LH beta, and their secretion in vitro correlated with the patients' responses to TRH in vivo. CONCLUSIONS: Most apparently nonsecreting pituitary macroadenomas in women arise from gonadotroph cells. The majority of these can be recognized, even in postmenopausal women, by the serum LH beta responses to TRH, and some can be recognized by the responses of serum FSH and LH.
Assuntos
Adenoma/diagnóstico , Neoplasias Hipofisárias/diagnóstico , Adenoma/metabolismo , Adulto , Idoso , Feminino , Hormônio Foliculoestimulante/metabolismo , Humanos , Hormônio Luteinizante/metabolismo , Menopausa , Pessoa de Meia-Idade , Adeno-Hipófise , Neoplasias Hipofisárias/metabolismo , Fatores Sexuais , Hormônio Liberador de Tireotropina , Células Tumorais CultivadasRESUMO
A systemically healthy 22-year-old man presented with unilateral acute retinal necrosis (ARN) that featured diffuse retinal whitening throughout the posterior retina, exudative retinal detachment, and a visual acuity of no light perception. Diagnostic vitrectomy revealed necrotic retinal cells containing intranuclear inclusions visible with light microscopy. On electron microscopy, viral particles consistent with a herpes family virus were detected. Culture of the vitrectomy specimen showed herpes simplex, type 1 (HSV 1) and rising convalescent serum ELISA titers to HSV 1 confirmed a recent infection. This case of ARN is unusual for its severity, early macular involvement, and development of exudative retinal detachment. In addition, it represents one of the few reported cases in which HSV 1 has been confirmed by both vitreous culture and serum titers as the etiologic agent. A review of the literature suggests that posterior segment inflammatory conditions secondary to HSV 1 can be associated with exudative retinal detachment, a clinical finding that may help differentiate such conditions from other infectious causes of chorioretinitis.
Assuntos
Ceratite Dendrítica/complicações , Doenças Retinianas/etiologia , Adulto , Antígenos Virais/sangue , Ensaio de Imunoadsorção Enzimática , Angiofluoresceinografia , Fundo de Olho , Humanos , Masculino , Necrose , Descolamento Retiniano/etiologia , Descolamento Retiniano/patologia , Doenças Retinianas/patologia , Simplexvirus/isolamento & purificação , Simplexvirus/ultraestrutura , Acuidade Visual , Vitrectomia , Corpo Vítreo/microbiologia , Corpo Vítreo/ultraestruturaRESUMO
The authors prospectively evaluated 387 consecutive patients with proliferative diabetic retinopathy (PDR) for asymmetry in posterior segment neovascularization and its relationship to carotid artery disease. For the purpose of this study, asymmetry is defined as the presence of PDR with high-risk characteristics (as per the Diabetic Retinopathy Study) in one eye, with neither proliferative nor preproliferative changes in the opposite eye. Over the 2-year time period of the study, 20 (5.2%) of 387 patients manifested asymmetric PDR by this definition. All 20 patients underwent carotid artery noninvasive testing and 4 (20%) were found to have hemodynamically significant carotid artery disease. Two of the four patients had their proliferative retinopathy ipsilateral to their severe carotid artery stenosis. This finding does not support the hypothesis that a hemodynamically significant carotid artery stenosis protects against the development of PDR.
Assuntos
Doenças das Artérias Carótidas/complicações , Retinopatia Diabética/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Angiofluoresceinografia , Fundo de Olho , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Acuidade VisualRESUMO
Between October, 1978 and August, 1986, 35 patients with thyroid ophthalmopathy were treated with radiotherapy. Twenty-eight patients had treatment with corticosteroids prior to radiotherapy and either progressed on steroids or relapsed during tapering. Seven patients with contraindications to steroids were treated primarily with radiotherapy. After radiotherapy, 25 patients (71%) did not require any further steroids or orbital decompression and ten (29%) failed. Patients who required steroids or decompression for active disease after radiotherapy were considered treatment failures. A total of 14 (40%) patients required eye muscle or lid surgery for correction of stable soft tissue defects after radiotherapy, more commonly in patients treated with radiotherapy after steroids or decompression than those irradiated primarily; the median time between radiotherapy and surgery was 8 months (range 1-48). Various factors were examined for prognostic significance in predicting radiotherapy failure. Review of the interval between onset of eye disease and radiotherapy demonstrated that six of ten (60%) failures versus only five of 25 (20%) successful treatments received radiotherapy within 6 months of onset of eye disease. No relation between outcome and sex, age or hyperthyroid versus euthyroid Graves' disease was apparent. Radiotherapy has been used for patients with thyroid ophthalmopathy who failed steroids, decompression, or had steroid contraindications. Morbidity of radiotherapy was minimal and most patients were spared the morbidity of continued steroid therapy.