Journal of Neuro-Ophthalmology最新文献

Background: Serial fundus photography is commonly used to differentiate between papilledema and pseudopapilledema, but there are limited data on the interrater reliability and accuracy of interpreting these images in children. The purpose of this study was to evaluate the agreement and accuracy of pediatric neuro-ophthalmologists in classifying fundus photographs of children with papilledema and pseudopapilledema.

Methods: For this cross-sectional study, 3 masked experts (pediatric neuro-ophthalmologists) classified a multicenter image collection from children with a clinical diagnosis of either papilledema or pseudopapilledema, which was determined based on the results of history, examination, ancillary ophthalmic imaging, neuroimaging, and/or lumbar puncture. Fleiss kappa (κ) was calculated to assess interrater agreement; accuracy, sensitivity, and specificity were calculated to determine expert performance. Subgroup analyses according to papilledema grade and expert certainty were performed.

Results: Six hundred fifty-nine photographs from 171 children were included. The full data set, papilledema, and pseudopapilledema κ values were 0.36 (0.32-0.42), 0.40 (0.32-0.49), and 0.28 (0.22-0.34), respectively. Accuracy, sensitivity, and specificity ranged from 58.9% to 63.9%, 54.3% to 76.0%, and 56.1% to 62.6%, respectively, among the 3 experts. Grade 1 papilledema was associated with inaccurate agreement (misinterpretation as pseudopapilledema by all 3 experts) in 31.8% and disagreement in 59.0% of cases. Higher grades of papilledema were associated with higher rates of accurate agreement. All experts achieved high sensitivity in classifying photographs of moderate-to-high-grade papilledema (85%-94%).

Conclusions: Overall agreement was low among pediatric neuro-ophthalmologists when classifying fundus photographs of children with papilledema and pseudopapilledema. When interpreting low-grade papilledema images, inaccurate agreement and disagreement were more likely than accurate agreement among experts. Our study highlights the limitations of interpreting fundus photographs of children with papilledema and pseudopapilledema in isolation, stressing the importance of obtaining a complete neuro-ophthalmologic history and examination, as well as other ancillary ophthalmic imaging, to guide decision making regarding systemic workup.

Abstract: Photon-counting detector CT is an emerging technology that has the promise to dramatically transform clinical practice. It largely overcomes the limitations of traditional CT, offering ultra-high spatial resolution, suppression of metallic artifact, and reduced radiation dose. We report the case of a 44-year-old patient presenting with gaze-evoked vision loss and history of a retained orbital foreign body. Localization of the foreign body on conventional CT was limited by metallic artifacts, and magnetic resonance imaging was contraindicated. Photon-counting detector CT effectively localized the foreign body and guided management. The potential applications of this newer technology in neuro-ophthalmology are still being explored.

Background: Intraventricular blockage of cerebrospinal drainage by brain tumors has been proposed as a more powerful mechanism of producing high intracranial pressure (ICP) than tumor size. We tested that hypothesis by investigating the MRI signs closely associated with high ICP in brain tumors.

Methods: We conducted a single-institution retrospective chart review of patients with brain tumors between 1990 and 2023. We selected 100 cases from a larger eligible cohort without regard to clinical or imaging features. Based on ophthalmologic examination, 57 patients had papilledema and 43 patients did not. The study neuroradiologist, masked as to the presence of papilledema, noted relevant MRI brain and eye signs. Associations between these MRI signs and papilledema were analyzed statistically.

Results: The median age of patients with papilledema was significantly younger than that of patients without papilledema. Among the MRI brain signs, the degree of ventriculomegaly was most highly associated with papilledema, and a temporal horn size of greater than 10 mm predicted a 100% chance of papilledema in patients aged 20 years or younger. Tumor size was not associated with papilledema. Posterior scleral flattening and optic disc protrusion were also highly associated with papilledema but were often difficult to identify because of their subtlety.

Conclusions: The degree of ventriculomegaly, especially of the temporal horn, was the MRI brain sign most associated with papilledema, whereas tumor size was not associated with papilledema. These findings support the idea that intraventricular obstruction of cerebrospinal fluid flow is more likely than tumor size to elevate ICP. Together with posterior scleral flattening and optic disc protrusion, ventriculomegaly can be used to predict with high probability the presence of elevated ICP and as a substitute for finding papilledema on ophthalmologic examination, a service that may not be available in low resource settings.

Background: Idiopathic intracranial hypertension (IIH) mainly occurs in women of a reproductive age who are overweight or obese. As pregnancy occurs in this age group, it is important to understand whether there are associations between IIH and pregnancy. The purpose of this study was to determine the incidence of IIH development during a pregnancy and whether IIH is associated with hypertensive disorders of pregnancy (HDP).

Methods: In this retrospective cohort analysis, electronic health records from a tertiary care center were used to identify patients with IIH. Patients who had a diagnostic code for IIH or papilledema and were seen between June 1, 2012, and September 1, 2023, were included. After meeting the revised Dandy diagnostic criteria, patients were evaluated for a history of pregnancy before, during, or after their IIH diagnosis and hypertensive disorders including preeclampsia/eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, and hypertension. Incidence and risk ratios (RR) were calculated comparing patients with IIH with controls without IIH. To corroborate these results while controlling for obesity and migraine, the TriNetX platform housing more than 100 million patients was used to design a case-control analysis evaluating the odds of an IIH patient having an HDP.

Results: Two hundred ninety-two IIH patients with a prior pregnancy were identified of which 7% developed new onset IIH during pregnancy. Patients had increased risks of all HDP including eclampsia (RR: 12.92, 95% CI: 5.35, 31.22), preeclampsia (2.39, CI 1.84, 3.10), and HELLP syndrome (6.72, CI 2.16, 20.90) compared with controls. Patients with IIH also had higher risks of ectopic pregnancies and miscarriages ( P < 0.05). When controlling for obesity and migraine, patients continued to have increased odds of all HDP and eclampsia ( P < 0.05).

Conclusions: Patients with IIH had an increased risk of having an HDP, especially eclampsia and HELLP syndrome highlighting a need for increased clinical monitoring of these patients during pregnancy.