Idiopathic intracranial hypertension leading to bilateral optic atrophy in a patient with recent COVID-19 infection: a case report

Neurologic complications are common in patients hospitalised with COVID-19 infection. Most common complications are myalgias, headaches, encephalopathy and dizziness. Uncommon complications are stroke, motor and sensory deficits, seizures, ataxia and movement disorders. Multiple neuro-ophthalmological manifestations have also been reported in association with COVID-19. These complications may be the result of a range of pathophysiological mechanisms like hypoxic neuronal injury during active COVID-19 infection, RAS dysfunction, immune dysfunction and direct injury by the virus etc throughout the course of the disease. Here we reported a case of neuro-ophthalmic complication of Idiopathic intracranial hypertension (IIH) followed by bilateral optic atrophy in a middle-aged man with recent COVID-19 infection. He presented to the emergency with complaints of headache, dizziness and sudden painless bilateral diminution of vision for 3 days. His fundus examination was suggestive of bilateral papilledema, his MRI brain was normal and opening pressure of CSF was raised on lumbar puncture. His MRV was normal, there was no evidence of CSVT. He was started on steroids and acetazolamide. His headache improved but there was no improvement in visual acuity. Repeat fundus showed pale disc and MRI orbit was suggestive of bilateral optic atrophy.

Ophthalmic complications in patients with nonvalvular atrial fibrillation and type 2 diabetes prescribed rivaroxaban or warfarin

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Bayer AG Berlin, Germany INTRODUCTION Patients with type 2 diabetes (T2D) are at an increased risk of ophthalmic complications compared to those without. Ophthalmic complications in T2D patients with comorbid nonvalvular atrial fibrillation (NVAF) may include ophthalmic bleeding and/or diabetic retinopathy. PURPOSE We sought to evaluate ophthalmic complications in patients with NVAF and T2D prescribed rivaroxaban or warfarin for stroke prevention. METHODS Optum® de-identified electronic health record (EHR) data from 11/2010-3/2020 were utilized. Adults with NVAF and T2D, newly started on rivaroxaban or warfarin and with ≥12 months of prior EHR activity were included. Patients were excluded if they received any oral anticoagulation in the prior 12 months, had valvular disease or pre-existing diabetic retinopathy. Our primary outcome was the incidence rate of any ophthalmic complication including non-traumatic bleeding (choroidal, intraocular, retinal, vitreous) or diabetic retinopathy. Ophthalmic bleeds typically associated with trauma (hyphema, orbital) were excluded from our outcomes. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated using propensity score-overlap weighted Cox regression. RESULTS We included 26,537 rivaroxaban and 61,690 warfarin patients. The average age of patients was 69 ± 9 years, CHA2DS2VASc score was 4.1 ± 1.5 and HASBLED 1.5 ± 0.9. Thirty-two percent of patients had an a1c ≥7.0 and 16% an a1c≥8.0. Rivaroxaban was associated with a 15% (95%CI = 8-21%) relative hazard reduction of any ophthalmic complication (incidence rate = 1.25 vs. 1.46%/year) (Table), driven by reductions in both ophthalmic bleeding (HR = 0.80) and diabetic retinopathy (HR = 0.85). CONCLUSIONS Rivaroxaban was associated with a reduction in ophthalmic complications compared to warfarin. Table. Ophthalmic Complications Outcome Rivaroxaban, %/yearN = 26,537 Warfarin, %/yearN = 61,690 PS OLW HR (95%CI) Any Ophthalmic Complication 1.25 1.46 0.85 (0.79-0.92) Any Ophthalmic Bleed 0.15 0.19 0.80 (0.63-1.00) Choroidal Bleed 0.003 0.005 0.59 (0.11-3.17) Intraocular Bleed 0.01 0.01 0.75 (0.26-2.13) Retinal Bleed 0.08 0.09 0.93 (0.68-1.28) Vitreous Bleed 0.07 0.10 0.66 (0.47-0.92) Any Type of Diabetic Retinopathy 1.15 1.34 0.85 (0.79-0.93) Diabetic Retinopathy, non-proliferative 0.35 0.44 0.80 (0.69-0.93) Diabetic Retinopathy, proliferative 0.09 0.12 0.79 (0.59-1.05) Diabetic Retinopathy, unspecified 0.82 0.94 0.87 (0.79-0.97) CI = confidence interval; HR = hazard ratio; OLW = overlap weighted; PS = propensity score

Associations Between Retinal Artery/Vein Occlusions and Risk of Vascular Dementia

Background: Vascular disease is a risk factor for Alzheimer’s disease (AD) and related dementia in older adults. Retinal artery/vein occlusion (RAVO) is an ophthalmic complication of systemic vascular pathology. Whether there are associations between RAVO and dementia risk is unknown. Objective: To determine whether RAVOs are associated with an increased risk of developing vascular dementia or AD. Methods: Data from Adult Changes in Thought (ACT) study participants were analyzed. This prospective, population-based cohort study followed older adults (age ≥65 years) who were dementia-free at enrollment for development of vascular dementia or AD based on research criteria. RAVO diagnoses were extracted from electronic medical records. Cox-regression survival analyses were stratified by APOE ɛ4 genotype and adjusted for demographic and clinical factors. Results: On review of 41,216 person-years (4,743 participants), 266 (5.6%) experienced RAVO. APOE ɛ4 carriers who developed RAVO had greater than four-fold higher risk for developing vascular dementia (Hazard Ratio [HR] 4.54, 95% Confidence Interval [CI] 1.86, 11.10, p = 0.001). When including other cerebrovascular disease (history of carotid endarterectomy or transient ischemic attack) in the model, the risk was three-fold higher (HR 3.06, 95% CI 1.23, 76.2). No other conditions evaluated in the secondary analyses were found to confound this relationship. There was no effect in non-APOE ɛ4 carriers (HR 1.03, 95% CI 0.37, 2.80). There were no significant associations between RAVO and AD in either APOE group. Conclusion: Older dementia-free patients who present with RAVO and carry the APOE ɛ4 allele appear to be at higher risk for vascular dementia.

Long-term visual outcome in patients treated by flow diversion for carotid-ophthalmic aneurysms

BackgroundFlow-diverter stents (FDSs) are an upgrade in the treatment of intracranial aneurysms. However, complications concerning covered branches have been reported, especially the ophthalmic artery (OA). The purpose of our study was to evaluate the long-term ophthalmic complication rate of carotid-ophthalmic aneurysms (COA) without visual pathways compression, treated by a FDS covering the OA by performing an exhaustive ophthalmic examination.Material and methodsRetrospective analysis of a single-center database screening the patients treated from October 2009 to April 2015 for an intracranial aneurysm with a FDS. The patients treated for a non-compressive COA with coverage of the OA by the device were studied (n=30). Among these patients, 15 (50%) were excluded. The remaining 15 patients underwent a systematic and extensive ophthalmic examination at least 2 years after the stent placement by two ophthalmologists.ResultsFifteen patients with 16 COAs treated with a FDS were included. Mean follow-up was 4.1±2 years. Six patients (40%), presented ophthalmic complications, including three fugax amauroses (18.8%) and four significant visual field defects (25%). After comparing each eye’s visual field’s patients, we observed a significant difference between the eye on the FDS side compared with the contralateral eye, with a mean deviation of −1.58 dB versus −0.67 dB respectively (P=0.003). Visual acuity was preserved in all patients.ConclusionPatients treated by FDS for COA have a good long-term clinical ophthalmic outcome. However, extensive ophthalmic examination shows a high percentage of minor ophthalmic modifications. Interventional neuroradiologists should be aware of these possible complications when choosing to treat these aneurysms with FDS.

Mechanisms of perioperative corneal abrasions: alterations in tear film proteome

Perioperative corneal abrasion is an ophthalmic complication commonly found in patients underwent general anesthesia. In this study, correlations between development of corneal injury and proteomic changes in tear film during general anesthesia were examined using an animal (rabbit) model. Being started after 1-h anesthesia, the process of accumulation of pathological changes in the cornea unequivocally led clinically significant abrasions following 3-6 h of the narcosis. The corneal damage was associated with alterations in profiles of major proteins of the tear film. Analysis of the tear proteome pointed to depression of lachrymal glands function, and suggested serotransferrin, serum albumin and annexin A1 as potential tear markers of the complication. The tear film alterations included fast drop of total antioxidant activity and activity of superoxide dismutase, and decrease in interleukin-4 and increase in interleukin-6 content indicating development of oxidative and pro-inflammatory responses. These findings suggest antioxidant and anti-inflammatory therapy as prospective approach for prevention/treatment of perioperative corneal abrasions. The observed anesthesia-induced effects should be considered in any study of ocular surface diseases employing anesthetized animals.