Peter Savino - Academia.edu (original) (raw)
Papers by Peter Savino
Archives of Ophthalmology, 2003
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, Jan 16, 2015
We evaluate if the relationship between optical coherence tomography (OCT) of the retinal nerve f... more We evaluate if the relationship between optical coherence tomography (OCT) of the retinal nerve fibre layer (RNFL) and visual outcome continued over long-term visual recovery in 107 patients undergoing pituitary decompression. Recently, it has been recognized that OCT of the RNFL has prognostic value in predicting visual outcomes after surgery for chiasmal compression caused by pituitary tumours. Patients were followed up at three time points: pre-operative (visit 1), 6-10weeks post-operative (visit 2) and 9-15months follow-up (visit 3). We found that patients with thin pre-operative RNFL had more severe visual field defects (mean deviation [MD] -9.22 versus -3.96 decibels [dB]; p=0.001), but pre-operative visual acuity (VA) was good in both normal and thin RNFL groups (Snellen VA 6/5 and 6/4; p=0.039). For those with thin RNFL the greatest improvement was between visit 2 and 3 (MD -7.1dB versus -3.4dB, respectively; p<0.001) compared with pre-operative -9.8dB. Normal RNFL patien...
Ophthalmology, 2006
The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory tests that h... more The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory tests that have been said to have a strong correlation with a positive temporal artery biopsy in patients with suspected giant cell arteritis (GCA). Published reports suggest that the CRP is a more sensitive diagnostic indicator of GCA and can be elevated when the ESR is normal. It is also clear that the CRP and ESR can both be normal or both be elevated in patients with biopsy-proven GCA and that the CRP can be elevated when the ESR is normal. The purpose of this study was to ascertain if the CRP can be normal when the ESR is elevated in biopsy-proven GCA. Retrospective, longitudinal, comparative study. One hundred nineteen patients from 6 major tertiary-care university-affiliated medical centers. The charts from 119 patients with temporal artery biopsies positive for GCA were reviewed for age, gender, pretreatment ESR, and pretreatment CRP. The ESR in millimeters per hour Westergren was graded as ...
American Journal of Ophthalmology, 2000
PURPOSE: To determine if tobacco or alcohol consumption is associated with vision loss among sibs... more PURPOSE: To determine if tobacco or alcohol consumption is associated with vision loss among sibships harboring pathogenic mitochondrial mutations associated with Leber hereditary optic neuropathy.METHODS: Retrospective case-control study with questionnaires obtained from both affected and unaffected siblings from 80 sibships with Leber hereditary optic neuropathy. Sibships harbored molecularly confirmed mitochondrial DNA mutations at nucleotide positions 11778 (63), 14484 (10), and
Survey of Ophthalmology, 1995
A young man developed bilateral, consecutive, optic neuropathy. His brother had had a similar pro... more A young man developed bilateral, consecutive, optic neuropathy. His brother had had a similar problem and recovered after one year. Mitochondrial DNA analysis showed that both had the 14484 mutation associated with Leber&amp;#39;s hereditary optic neuropathy.
Ophthalmology, 2003
To report a case of visual loss from posterior ischemic optic neuropathy (PION) after hemodialysi... more To report a case of visual loss from posterior ischemic optic neuropathy (PION) after hemodialysis. Observational case report. Neuro-ophthalmic examination, neuro-imaging including computed tomography (CT) scan, magnetic resonance imaging (MRI) of the head and orbits, and magnetic resonance angiography (MRA) of the neck and cerebral vasculature, as well as electrophysiologic testing including electroretinogram (ERG) and visually evoked response (VER) were performed. Acute onset of painless bilateral no light perception vision with absent pupillary response to light and normal funduscopic examination occurred shortly after completion of hemodialysis. Computed tomography scan and MRA results were normal. Magnetic resonance imaging scan showed small vessel ischemic white matter changes. Electroretinogram results were normal and the VER was unrecordable. Visual loss after hemodialysis is a rare complication and is associated with anemia and hypotensive events. The visual loss is usually a result of anterior ischemic optic neuropathy. We were unable to find another instance in the literature of visual loss after hemodialysis resulting from PION.
Ophthalmology, 2002
To compare the platelet counts, complete blood counts, and Westergren sedimentation rates (WESR) ... more To compare the platelet counts, complete blood counts, and Westergren sedimentation rates (WESR) of patients with a biopsy positive for giant cell arteritis (GCA) with those of patients with negative biopsies. Retrospective, case-control series. The medical records of 91 consecutive patients who underwent temporal artery biopsy for possible GCA, over an 8-year period, were reviewed. Values obtained for the complete blood counts, including platelet counts, WESR, and biopsy results of 91 consecutive patients undergoing temporal artery biopsy were analyzed. The mean platelet count of 47 patients with positive temporal artery biopsies (433 x 10(3)/microl) was significantly higher than that of 44 patients with negative temporal artery biopsies (277 x 10(3)/microl), P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001. There was no statistically significant difference in the mean WESR between the biopsy-positive (82 mm/hour) and biopsy-negative (70 mm/hour) groups, P = 0.12. The sensitivity of an elevated WESR for biopsy-positive patients was greater (79%; 95% confidence interval [CI], 64%-89%) than that of an elevated platelet count (57%; 95% CI, 42%-72%). However, the specificity (91% [95% CI, 78%-97%] versus 27% [95% CI, 15%-43%]), positive predictive value (87% [95% CI, 70%-96%] versus 54% [95% CI, 41%-66%]), and negative predictive value (67% [95% CI, 53%-78%] versus 55% [95% CI, 32%-76%]) favored an elevated platelet count compared with WESR, or to the combination of platelets and WESR, as a better test for diagnosing GCA in the 91 patients studied. The area under the receiver operating characteristic function for platelets (0.72) was greater than that for WESR (0.59) or the combination of platelets and WESR (0.65). In patients suspected of having GCA, an elevated platelet count greater than 400 x 10(3)/microl is a useful marker of a positive temporal artery biopsy.
Ophthalmology, 2006
To report the rate of occurrence of cerebral venous sinus thrombosis (CVST) in patients with pres... more To report the rate of occurrence of cerebral venous sinus thrombosis (CVST) in patients with presumed idiopathic intracranial hypertension (IIH). Retrospective chart review. All patients diagnosed with papilledema from November 1, 2002, through October 31, 2003, at 3 tertiary care neuro-ophthalmology centers. Consecutive patients with a diagnosis of papilledema from 3 tertiary care neuro-ophthalmology centers were identified. Patients with space-occupying lesions, hydrocephalus, or meningitis were excluded. The remaining patients were evaluated with lumbar puncture, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV). The rate of occurrence of CVST in patients with presumed IIH. One hundred thirty-one patients with papilledema were identified. Excluding patients with mass lesions, meningitis, or hydrocephalus, the occurrence of CVST was 10 (9.4%) of 106 patients with presumed IIH. Two additional patients had a diagnosis of suspected CVST. Cerebral venous sinus thrombosis was diagnosed in 1 of the 10 patients with MRI alone, whereas it was evident in all 10 patients with MRV. Underlying risk factors for CVST were identified in 9 of 10 patients. Cerebral venous sinus thrombosis accounts for 9.4% of patients with presumed IIH in 3 tertiary care neuro-ophthalmology services. Magnetic resonance venography in combination with MRI is recommended to identify this subgroup of patients.
Ophthalmology, 2003
To assess the visual function of patients with giant cell arteritis (GCA) who had visual loss fro... more To assess the visual function of patients with giant cell arteritis (GCA) who had visual loss from either anterior ischemic optic neuropathy (AION) or central retinal artery occlusion and had a subsequent improvement in visual acuity after treatment with corticosteroids. Retrospective, observational case series. Thirty-two consecutive patients with biopsy-proven GCA treated at one institution between January 1992 and December 1997. Treatment with intravenous methylprednisolone 250 mg every 6 hours for 3 days, followed by oral prednisone 1 mg/kg daily for at least 4 weeks duration. The number of patients with an improvement in visual acuity after treatment with intravenous methylprednisolone; neuro-ophthalmic evaluation, including visual acuity, funduscopy, and visual field examination of these patients. Improvement in visual acuity occurred in 5 of 39 eyes (13%) with visual loss from biopsy-proven GCA, and all 5 patients had AION. Despite the improvement of visual acuity in these 5 patients, perimetry revealed marked constriction of the visual field in each affected eye. The prognosis for visual improvement in GCA is poor. Although an improvement in visual acuity occurred in 5 of our patients, marked constriction of the visual field was present in all of them.
Ophthalmology, 2014
To compare optic disc topography in eyes with compressive optic neuropathy (CON) and open-angle g... more To compare optic disc topography in eyes with compressive optic neuropathy (CON) and open-angle glaucoma (OAG) using spectral-domain (SD) optical coherence tomography (OCT) and Heidelberg retinal tomograph (HRT) (Heidelberg Engineering GmbH, Heidelberg, Germany). Cross-sectional, observational study. A total of 200 eyes from 123 patients with CON (69 eyes) or OAG (58 eyes) and controls (73 eyes). Univariate and multivariate analyses of HRT parameters, SD-OCT circumpapillary retinal nerve fiber layer (RNFL) thickness, and optic nerve head (ONH) parameters. Circumpapillary RNFL, OCT ONH parameters, and HRT parameters. The univariate analysis of OCT parameters demonstrated significant differences between the temporal and nasal quadrants; clock hours 3 (55 vs. 73 μm), 4, 8 (93.9 vs. 70.7 μm), 9, and 10; vertical cup-to-disc ratio (C:D) (0.6 vs. 0.8) and cup volume (0.2 vs. 0.5) (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) between patients with CON and OAG, respectively. The CON discs were significantly different from normal discs for all OCT parameters except cup volume. The CON discs were not significantly different from normal discs for HRT parameters, except for mean RNFL thickness and cup shape measure. The OAG discs were significantly different from normal discs in all HRT and OCT parameters (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Multivariate analysis demonstrated that the OCT 3 o&amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;clock temporal sector, average C:D ratio, vertical C:D ratio, and cup volume measurements were able to differentiate OAG from CON. Compressive optic neuropathy is associated with significantly thinner nasal and temporal sectors compared with OAG, whereas OAG results in larger cups and cup volume with OCT measurements. The Heidelberg retinal tomograph is not able to differentiate CON from normal discs.
New England Journal of Medicine, 1992
The use of corticosteroids to treat optic neuritis is controversial. At 15 clinical centers, we r... more The use of corticosteroids to treat optic neuritis is controversial. At 15 clinical centers, we randomly assigned 457 patients with acute optic neuritis to receive oral prednisone (1 mg per kilogram of body weight per day) for 14 days; intravenous methylprednisolone (1 g per day) for 3 days, followed by oral prednisone (1 mg per kilogram per day) for 11 days; or oral placebo for 14 days. Visual function was assessed over a six-month follow-up period. Visual function recovered faster in the group receiving intravenous methylprednisolone than in the placebo group; this was particularly true for the reversal of visual-field defects (P = 0.0001). Although the differences between the groups decreased with time, at six months the group that received intravenous methylprednisolone still had slightly better visual fields (P = 0.054), contrast sensitivity (P = 0.026), and color vision (P = 0.033) but not better visual acuity (P = 0.66). The outcome in the oral-prednisone group did not differ from that in the placebo group. In addition, the rate of new episodes of optic neuritis in either eye was higher in the group receiving oral prednisone, but not the group receiving intravenous methylprednisolone, than in the placebo group (relative risk for oral prednisone vs. placebo, 1.79; 95 percent confidence interval, 1.08 to 2.95). Intravenous methylprednisolone followed by oral prednisone speeds the recovery of visual loss due to optic neuritis and results in slightly better vision at six months. Oral prednisone alone, as prescribed in this study, is an ineffective treatment and increases the risk of new episodes of optic neuritis.
Neurosurgery, 2001
Many subfrontal and orbitofrontal craniotomy techniques have been developed. We present our resul... more Many subfrontal and orbitofrontal craniotomy techniques have been developed. We present our results with the transorbital roof craniotomy, a frontal craniotomy that incorporates the orbital roof and is performed via a suprabrow incision. This technique was used in 72 patients, primarily for tumor resection. Charts were retrospectively reviewed for all patients undergoing transorbital procedures. A total of 72 patients underwent 82 transorbital craniotomies from September 1995 to July 1999. The primary indication for the transorbital approach was mass lesion of the orbit, anterior fossa, or parasellar region. A total of 47 women and 25 men with a mean age of 53 years underwent 82 procedures. The primary pathological finding was meningioma, which occurred in 40 patients (55.6%), followed by craniopharyngioma (6.9%), pituitary macroadenoma (6.9%), schwannoma (5.5%), and hemangioma (5.5%). Simpson Grade I or II resection was achieved in 54% of patients, with Simpson Grade III to V resection achieved in the remaining 46%. Forty-one patients presented with visual loss in 43 cases, with 44.2% experiencing postoperative visual improvement, 46.5% remaining unchanged, and 9.3% worsening. Overall morbidity was 18.4%, with cerebrospinal fluid leak being the most common complication (6.6%). No patients died. The transorbital roof craniotomy is an evolutionary approach that provides excellent exposure to the orbit, anterior fossa, and parasellar region with little significant morbidity and, in our series, no mortality. Although we have used this approach primarily for resection of mass lesions, future directions for this procedure will likely lie in treating vascular lesions and lesions of the interpeduncular fossa.
Journal of Neurosurgery, 1985
Chiasmatic optic glioma is a rare tumor with an erratic natural history, usually seen in young ch... more Chiasmatic optic glioma is a rare tumor with an erratic natural history, usually seen in young children. A prior study from this institution demonstrated that these lesions were frequently lethal, despite initial clinical stabilization following radiation therapy, and that visual, intellectual, and late endocrinological disabilities were prevalent. A novel approach was developed in 1977, when an initial clinical response to vincristine was recorded in a child with a recurrent optic glioma. Since then, all children with recurrent optic glioma and all children aged 6 years old and under with newly diagnosed optic glioma have been offered a program of initial therapy with vincristine and actinomycin D for six cycles over 18 months. The four children with recurrent tumor who were treated with that regimen remain clinically stable 13 to 115 months after chemotherapy. Twelve children (eight under 24 months old) with newly diagnosed optic glioma have been treated with this program, and three are still on therapy. Four developed progression while on therapy, and five remain stable from 1 to 60 months posttherapy. The four children who developed progressive disease have been treated with radiation therapy and remain stable. Six of the 12 children showed shrinkage of their tumor on computerized tomography while receiving chemotherapy. This program may serve as an alternative to initial radiation therapy in young children.
Journal of Clinical Neuroscience, 2014
Our purpose was to analyse the demographics, prevalence and pattern of visual field defects in pa... more Our purpose was to analyse the demographics, prevalence and pattern of visual field defects in patients with pituitary adenoma. We prospectively recruited 103 consecutive patients (206 eyes) presenting to a neurosurgical unit with pituitary adenoma. Ophthalmological examination and standard automated perimetry (Humphrey, 24-2 threshold) was performed. Severity of visual field defects was also assessed. The mean population age was 53.9 years (standard deviation=15). Visual loss was the most common reason for presentation (39%) followed by endocrine abnormality (21%) and headache (15%). Patients with endocrine abnormality on presentation were 10.9 years younger than those presenting with visual loss (p=0.001). Bitemporal defects were the most prevalent pattern (n=22, 41%) followed by homonymous defects (n=7, 13%). Of the patients with visual field loss, 33% had unilateral visual field defects. The mean visual acuity in those with bitemporal defects was 6/7.5 with half of these patients having 6/6 vision in both eyes. In conclusion, the majority of patients with pituitary adenoma have visual acuity better than 6/7.5 despite having visual field defects. While a bitemporal pattern of visual field loss is the most common, a significant proportion of patients had unilateral and altitudinal defects. Assessment of the visual field is essential to rule out chiasmal compression.
Investigative Ophthalmology & Visual Science, 2007
To characterize the relationship between brightness sensitivity and color perception and relative... more To characterize the relationship between brightness sensitivity and color perception and relative afferent pupillary defect (RAPD) in patients with optic neuropathy. The &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;swinging flashlight test&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; was used to diagnose RAPD, the degree of which was quantified by neutral density filters, in 325 consecutive patients in a case-control study. A separate examiner, masked to the pupillary findings, then assessed participants for Ishihara color plate reading, brightness sense, and red perception. The latter two were quantified by asking the patient to score (out of 100%) brightness (of a light source) or redness (of an object) of the two eyes relative to each other. Pearson correlation coefficients and receiver operating characteristic (ROC) curves were calculated. Brightness sense (r = -0.79; 95% confidence interval [CI], -0.84 to -0.73; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), red perception (r = -0.73; 95% CI, -0.79 to -0.65; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), and Ishihara color plate reading (r = -0.68; 95% CI, -0.79 to -0.66; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) were each strongly and highly significantly correlated with the diagnosis and degree of RAPD. Brightness sense and red perception were each able to discriminate almost all the area under ROC for the diagnosis of RAPD (area of 0.99; 95% CI, 0.98-1.00; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001; area of 0.93; 95% CI, 0.90-0.96; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001, respectively). Sensitivity and specificity of brightness sense in detection of RAPD were 99% (95% CI, 0.97-1.00) and 95% (95% CI, 0.91-0.98), respectively. The red perception test was only slightly less accurate. Rapid, simple assessments of brightness sense and color perception provide accurate methods to facilitate the diagnosis of optic neuropathy and may prove to be valuable in screening for optic neuropathy or alternatives to the swinging flashlight test.
Investigative Ophthalmology & Visual Science, 2008
Restoration of visual function after neurosurgery for parachiasmal tumors is variable and unpredi... more Restoration of visual function after neurosurgery for parachiasmal tumors is variable and unpredictable. The current study was conducted to determine whether in vivo retinal nerve fiber layer (RNFL) thickness measurements predict the visual recovery of such patients. Forty patients undergoing surgical resection of parachiasmal lesions were prospectively assessed before surgery with a neuro-ophthalmic examination, involving standard automated visual field (VF) testing and optical coherence tomography (OCT) measurements of RNFL thickness, which was the prespecified marker for axonal loss. Tests were repeated within 6 weeks after surgery. Thinner preoperative RNFL thickness was associated with worse visual acuity (VA) and VF mean deviation (MD). Patients with normal preoperative RNFL had significant improvement in mean VA after surgery, from 20/40 to 20/25 (P = 0.028), whereas patients with thin RNFL did not improve (20/80 to 20/60, P = 0.177). Eyes with normal RNFL showed improvement in MD (-7.0 dB before surgery, -3.5 dB after surgery, P = 0.0007) unlike eyes with thin RNFLs, which had no significant improvement after surgery (-15.3 dB before and -13.3 dB after surgery, P = 0.191). RNFL thickness increased by 1% after surgery among all eyes (P = 0.04). Eyes with severe VF defects (MD &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/= -10 dB) but normal preoperative RNFL thickness showed a postoperative improvement in MD of 14.6 dB compared with 1.6 dB (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) in eyes with thin RNFL before surgery, despite no difference in MD before surgery (normal RNFL MD, -22.3 dB; thin RNFL MD, -20.8 dB; P = 0.7). Patients who have objectively measurable RNFL loss at the time of surgery for chiasmal compressive lesions are less likely to have return of VA or VF after surgery.
Investigative Ophthalmology & Visual Science, 2010
International Journal of Radiation Oncology*Biology*Physics, 2007
International Journal of Radiation Oncology*Biology*Physics, 1996
To evaluate the efficacy and toxicity of fractionated, stereotactic radiotherapy (SRT) for acoust... more To evaluate the efficacy and toxicity of fractionated, stereotactic radiotherapy (SRT) for acoustic neuromas. Twelve patients with acoustic neuroma were treated with SRT between June 1992 and October 1994. Follow-up ranged from 16-44 months. Patient age ranged from 27-70 (median: 45). Eight patients were treated with primary SRT and four patients were treated after primary surgical intervention for recurrent [3] or persistent [1] disease. Tumor volumes were 1.2-18.4 cm3 (median: 10.1 cm3). Collimator sizes ranged from 30-50 mm (median: 37.5). Tumors received 1.8 Gy/day normalized to the 95% isodose line. Patients received a minimum prescribed dose of 54 Gy in 27-30 fractions over a 6-week period. After a median follow-up of 26.5 months, local control was obtained in 12 out of 12 lesions. Tumor regression was noted in three patients, and tumor stabilization was found in the remaining nine patients. No patient developed a new cranial nerve deficit. One patients developed worsening of preexisting Vth cranial neuropathy and another experienced a decrease in hearing. However, all nine patients with useful hearing prior to SRT maintained useful hearing at last follow-up. Stereotactic radiotherapy provided excellent local control without new cranial nerve deficits. These results must be viewed as tentative in nature because of the small number of patients and the short median follow-up period.
Archives of Ophthalmology, 2003
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, Jan 16, 2015
We evaluate if the relationship between optical coherence tomography (OCT) of the retinal nerve f... more We evaluate if the relationship between optical coherence tomography (OCT) of the retinal nerve fibre layer (RNFL) and visual outcome continued over long-term visual recovery in 107 patients undergoing pituitary decompression. Recently, it has been recognized that OCT of the RNFL has prognostic value in predicting visual outcomes after surgery for chiasmal compression caused by pituitary tumours. Patients were followed up at three time points: pre-operative (visit 1), 6-10weeks post-operative (visit 2) and 9-15months follow-up (visit 3). We found that patients with thin pre-operative RNFL had more severe visual field defects (mean deviation [MD] -9.22 versus -3.96 decibels [dB]; p=0.001), but pre-operative visual acuity (VA) was good in both normal and thin RNFL groups (Snellen VA 6/5 and 6/4; p=0.039). For those with thin RNFL the greatest improvement was between visit 2 and 3 (MD -7.1dB versus -3.4dB, respectively; p<0.001) compared with pre-operative -9.8dB. Normal RNFL patien...
Ophthalmology, 2006
The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory tests that h... more The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory tests that have been said to have a strong correlation with a positive temporal artery biopsy in patients with suspected giant cell arteritis (GCA). Published reports suggest that the CRP is a more sensitive diagnostic indicator of GCA and can be elevated when the ESR is normal. It is also clear that the CRP and ESR can both be normal or both be elevated in patients with biopsy-proven GCA and that the CRP can be elevated when the ESR is normal. The purpose of this study was to ascertain if the CRP can be normal when the ESR is elevated in biopsy-proven GCA. Retrospective, longitudinal, comparative study. One hundred nineteen patients from 6 major tertiary-care university-affiliated medical centers. The charts from 119 patients with temporal artery biopsies positive for GCA were reviewed for age, gender, pretreatment ESR, and pretreatment CRP. The ESR in millimeters per hour Westergren was graded as ...
American Journal of Ophthalmology, 2000
PURPOSE: To determine if tobacco or alcohol consumption is associated with vision loss among sibs... more PURPOSE: To determine if tobacco or alcohol consumption is associated with vision loss among sibships harboring pathogenic mitochondrial mutations associated with Leber hereditary optic neuropathy.METHODS: Retrospective case-control study with questionnaires obtained from both affected and unaffected siblings from 80 sibships with Leber hereditary optic neuropathy. Sibships harbored molecularly confirmed mitochondrial DNA mutations at nucleotide positions 11778 (63), 14484 (10), and
Survey of Ophthalmology, 1995
A young man developed bilateral, consecutive, optic neuropathy. His brother had had a similar pro... more A young man developed bilateral, consecutive, optic neuropathy. His brother had had a similar problem and recovered after one year. Mitochondrial DNA analysis showed that both had the 14484 mutation associated with Leber&amp;#39;s hereditary optic neuropathy.
Ophthalmology, 2003
To report a case of visual loss from posterior ischemic optic neuropathy (PION) after hemodialysi... more To report a case of visual loss from posterior ischemic optic neuropathy (PION) after hemodialysis. Observational case report. Neuro-ophthalmic examination, neuro-imaging including computed tomography (CT) scan, magnetic resonance imaging (MRI) of the head and orbits, and magnetic resonance angiography (MRA) of the neck and cerebral vasculature, as well as electrophysiologic testing including electroretinogram (ERG) and visually evoked response (VER) were performed. Acute onset of painless bilateral no light perception vision with absent pupillary response to light and normal funduscopic examination occurred shortly after completion of hemodialysis. Computed tomography scan and MRA results were normal. Magnetic resonance imaging scan showed small vessel ischemic white matter changes. Electroretinogram results were normal and the VER was unrecordable. Visual loss after hemodialysis is a rare complication and is associated with anemia and hypotensive events. The visual loss is usually a result of anterior ischemic optic neuropathy. We were unable to find another instance in the literature of visual loss after hemodialysis resulting from PION.
Ophthalmology, 2002
To compare the platelet counts, complete blood counts, and Westergren sedimentation rates (WESR) ... more To compare the platelet counts, complete blood counts, and Westergren sedimentation rates (WESR) of patients with a biopsy positive for giant cell arteritis (GCA) with those of patients with negative biopsies. Retrospective, case-control series. The medical records of 91 consecutive patients who underwent temporal artery biopsy for possible GCA, over an 8-year period, were reviewed. Values obtained for the complete blood counts, including platelet counts, WESR, and biopsy results of 91 consecutive patients undergoing temporal artery biopsy were analyzed. The mean platelet count of 47 patients with positive temporal artery biopsies (433 x 10(3)/microl) was significantly higher than that of 44 patients with negative temporal artery biopsies (277 x 10(3)/microl), P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001. There was no statistically significant difference in the mean WESR between the biopsy-positive (82 mm/hour) and biopsy-negative (70 mm/hour) groups, P = 0.12. The sensitivity of an elevated WESR for biopsy-positive patients was greater (79%; 95% confidence interval [CI], 64%-89%) than that of an elevated platelet count (57%; 95% CI, 42%-72%). However, the specificity (91% [95% CI, 78%-97%] versus 27% [95% CI, 15%-43%]), positive predictive value (87% [95% CI, 70%-96%] versus 54% [95% CI, 41%-66%]), and negative predictive value (67% [95% CI, 53%-78%] versus 55% [95% CI, 32%-76%]) favored an elevated platelet count compared with WESR, or to the combination of platelets and WESR, as a better test for diagnosing GCA in the 91 patients studied. The area under the receiver operating characteristic function for platelets (0.72) was greater than that for WESR (0.59) or the combination of platelets and WESR (0.65). In patients suspected of having GCA, an elevated platelet count greater than 400 x 10(3)/microl is a useful marker of a positive temporal artery biopsy.
Ophthalmology, 2006
To report the rate of occurrence of cerebral venous sinus thrombosis (CVST) in patients with pres... more To report the rate of occurrence of cerebral venous sinus thrombosis (CVST) in patients with presumed idiopathic intracranial hypertension (IIH). Retrospective chart review. All patients diagnosed with papilledema from November 1, 2002, through October 31, 2003, at 3 tertiary care neuro-ophthalmology centers. Consecutive patients with a diagnosis of papilledema from 3 tertiary care neuro-ophthalmology centers were identified. Patients with space-occupying lesions, hydrocephalus, or meningitis were excluded. The remaining patients were evaluated with lumbar puncture, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV). The rate of occurrence of CVST in patients with presumed IIH. One hundred thirty-one patients with papilledema were identified. Excluding patients with mass lesions, meningitis, or hydrocephalus, the occurrence of CVST was 10 (9.4%) of 106 patients with presumed IIH. Two additional patients had a diagnosis of suspected CVST. Cerebral venous sinus thrombosis was diagnosed in 1 of the 10 patients with MRI alone, whereas it was evident in all 10 patients with MRV. Underlying risk factors for CVST were identified in 9 of 10 patients. Cerebral venous sinus thrombosis accounts for 9.4% of patients with presumed IIH in 3 tertiary care neuro-ophthalmology services. Magnetic resonance venography in combination with MRI is recommended to identify this subgroup of patients.
Ophthalmology, 2003
To assess the visual function of patients with giant cell arteritis (GCA) who had visual loss fro... more To assess the visual function of patients with giant cell arteritis (GCA) who had visual loss from either anterior ischemic optic neuropathy (AION) or central retinal artery occlusion and had a subsequent improvement in visual acuity after treatment with corticosteroids. Retrospective, observational case series. Thirty-two consecutive patients with biopsy-proven GCA treated at one institution between January 1992 and December 1997. Treatment with intravenous methylprednisolone 250 mg every 6 hours for 3 days, followed by oral prednisone 1 mg/kg daily for at least 4 weeks duration. The number of patients with an improvement in visual acuity after treatment with intravenous methylprednisolone; neuro-ophthalmic evaluation, including visual acuity, funduscopy, and visual field examination of these patients. Improvement in visual acuity occurred in 5 of 39 eyes (13%) with visual loss from biopsy-proven GCA, and all 5 patients had AION. Despite the improvement of visual acuity in these 5 patients, perimetry revealed marked constriction of the visual field in each affected eye. The prognosis for visual improvement in GCA is poor. Although an improvement in visual acuity occurred in 5 of our patients, marked constriction of the visual field was present in all of them.
Ophthalmology, 2014
To compare optic disc topography in eyes with compressive optic neuropathy (CON) and open-angle g... more To compare optic disc topography in eyes with compressive optic neuropathy (CON) and open-angle glaucoma (OAG) using spectral-domain (SD) optical coherence tomography (OCT) and Heidelberg retinal tomograph (HRT) (Heidelberg Engineering GmbH, Heidelberg, Germany). Cross-sectional, observational study. A total of 200 eyes from 123 patients with CON (69 eyes) or OAG (58 eyes) and controls (73 eyes). Univariate and multivariate analyses of HRT parameters, SD-OCT circumpapillary retinal nerve fiber layer (RNFL) thickness, and optic nerve head (ONH) parameters. Circumpapillary RNFL, OCT ONH parameters, and HRT parameters. The univariate analysis of OCT parameters demonstrated significant differences between the temporal and nasal quadrants; clock hours 3 (55 vs. 73 μm), 4, 8 (93.9 vs. 70.7 μm), 9, and 10; vertical cup-to-disc ratio (C:D) (0.6 vs. 0.8) and cup volume (0.2 vs. 0.5) (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001) between patients with CON and OAG, respectively. The CON discs were significantly different from normal discs for all OCT parameters except cup volume. The CON discs were not significantly different from normal discs for HRT parameters, except for mean RNFL thickness and cup shape measure. The OAG discs were significantly different from normal discs in all HRT and OCT parameters (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Multivariate analysis demonstrated that the OCT 3 o&amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;clock temporal sector, average C:D ratio, vertical C:D ratio, and cup volume measurements were able to differentiate OAG from CON. Compressive optic neuropathy is associated with significantly thinner nasal and temporal sectors compared with OAG, whereas OAG results in larger cups and cup volume with OCT measurements. The Heidelberg retinal tomograph is not able to differentiate CON from normal discs.
New England Journal of Medicine, 1992
The use of corticosteroids to treat optic neuritis is controversial. At 15 clinical centers, we r... more The use of corticosteroids to treat optic neuritis is controversial. At 15 clinical centers, we randomly assigned 457 patients with acute optic neuritis to receive oral prednisone (1 mg per kilogram of body weight per day) for 14 days; intravenous methylprednisolone (1 g per day) for 3 days, followed by oral prednisone (1 mg per kilogram per day) for 11 days; or oral placebo for 14 days. Visual function was assessed over a six-month follow-up period. Visual function recovered faster in the group receiving intravenous methylprednisolone than in the placebo group; this was particularly true for the reversal of visual-field defects (P = 0.0001). Although the differences between the groups decreased with time, at six months the group that received intravenous methylprednisolone still had slightly better visual fields (P = 0.054), contrast sensitivity (P = 0.026), and color vision (P = 0.033) but not better visual acuity (P = 0.66). The outcome in the oral-prednisone group did not differ from that in the placebo group. In addition, the rate of new episodes of optic neuritis in either eye was higher in the group receiving oral prednisone, but not the group receiving intravenous methylprednisolone, than in the placebo group (relative risk for oral prednisone vs. placebo, 1.79; 95 percent confidence interval, 1.08 to 2.95). Intravenous methylprednisolone followed by oral prednisone speeds the recovery of visual loss due to optic neuritis and results in slightly better vision at six months. Oral prednisone alone, as prescribed in this study, is an ineffective treatment and increases the risk of new episodes of optic neuritis.
Neurosurgery, 2001
Many subfrontal and orbitofrontal craniotomy techniques have been developed. We present our resul... more Many subfrontal and orbitofrontal craniotomy techniques have been developed. We present our results with the transorbital roof craniotomy, a frontal craniotomy that incorporates the orbital roof and is performed via a suprabrow incision. This technique was used in 72 patients, primarily for tumor resection. Charts were retrospectively reviewed for all patients undergoing transorbital procedures. A total of 72 patients underwent 82 transorbital craniotomies from September 1995 to July 1999. The primary indication for the transorbital approach was mass lesion of the orbit, anterior fossa, or parasellar region. A total of 47 women and 25 men with a mean age of 53 years underwent 82 procedures. The primary pathological finding was meningioma, which occurred in 40 patients (55.6%), followed by craniopharyngioma (6.9%), pituitary macroadenoma (6.9%), schwannoma (5.5%), and hemangioma (5.5%). Simpson Grade I or II resection was achieved in 54% of patients, with Simpson Grade III to V resection achieved in the remaining 46%. Forty-one patients presented with visual loss in 43 cases, with 44.2% experiencing postoperative visual improvement, 46.5% remaining unchanged, and 9.3% worsening. Overall morbidity was 18.4%, with cerebrospinal fluid leak being the most common complication (6.6%). No patients died. The transorbital roof craniotomy is an evolutionary approach that provides excellent exposure to the orbit, anterior fossa, and parasellar region with little significant morbidity and, in our series, no mortality. Although we have used this approach primarily for resection of mass lesions, future directions for this procedure will likely lie in treating vascular lesions and lesions of the interpeduncular fossa.
Journal of Neurosurgery, 1985
Chiasmatic optic glioma is a rare tumor with an erratic natural history, usually seen in young ch... more Chiasmatic optic glioma is a rare tumor with an erratic natural history, usually seen in young children. A prior study from this institution demonstrated that these lesions were frequently lethal, despite initial clinical stabilization following radiation therapy, and that visual, intellectual, and late endocrinological disabilities were prevalent. A novel approach was developed in 1977, when an initial clinical response to vincristine was recorded in a child with a recurrent optic glioma. Since then, all children with recurrent optic glioma and all children aged 6 years old and under with newly diagnosed optic glioma have been offered a program of initial therapy with vincristine and actinomycin D for six cycles over 18 months. The four children with recurrent tumor who were treated with that regimen remain clinically stable 13 to 115 months after chemotherapy. Twelve children (eight under 24 months old) with newly diagnosed optic glioma have been treated with this program, and three are still on therapy. Four developed progression while on therapy, and five remain stable from 1 to 60 months posttherapy. The four children who developed progressive disease have been treated with radiation therapy and remain stable. Six of the 12 children showed shrinkage of their tumor on computerized tomography while receiving chemotherapy. This program may serve as an alternative to initial radiation therapy in young children.
Journal of Clinical Neuroscience, 2014
Our purpose was to analyse the demographics, prevalence and pattern of visual field defects in pa... more Our purpose was to analyse the demographics, prevalence and pattern of visual field defects in patients with pituitary adenoma. We prospectively recruited 103 consecutive patients (206 eyes) presenting to a neurosurgical unit with pituitary adenoma. Ophthalmological examination and standard automated perimetry (Humphrey, 24-2 threshold) was performed. Severity of visual field defects was also assessed. The mean population age was 53.9 years (standard deviation=15). Visual loss was the most common reason for presentation (39%) followed by endocrine abnormality (21%) and headache (15%). Patients with endocrine abnormality on presentation were 10.9 years younger than those presenting with visual loss (p=0.001). Bitemporal defects were the most prevalent pattern (n=22, 41%) followed by homonymous defects (n=7, 13%). Of the patients with visual field loss, 33% had unilateral visual field defects. The mean visual acuity in those with bitemporal defects was 6/7.5 with half of these patients having 6/6 vision in both eyes. In conclusion, the majority of patients with pituitary adenoma have visual acuity better than 6/7.5 despite having visual field defects. While a bitemporal pattern of visual field loss is the most common, a significant proportion of patients had unilateral and altitudinal defects. Assessment of the visual field is essential to rule out chiasmal compression.
Investigative Ophthalmology & Visual Science, 2007
To characterize the relationship between brightness sensitivity and color perception and relative... more To characterize the relationship between brightness sensitivity and color perception and relative afferent pupillary defect (RAPD) in patients with optic neuropathy. The &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;swinging flashlight test&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; was used to diagnose RAPD, the degree of which was quantified by neutral density filters, in 325 consecutive patients in a case-control study. A separate examiner, masked to the pupillary findings, then assessed participants for Ishihara color plate reading, brightness sense, and red perception. The latter two were quantified by asking the patient to score (out of 100%) brightness (of a light source) or redness (of an object) of the two eyes relative to each other. Pearson correlation coefficients and receiver operating characteristic (ROC) curves were calculated. Brightness sense (r = -0.79; 95% confidence interval [CI], -0.84 to -0.73; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), red perception (r = -0.73; 95% CI, -0.79 to -0.65; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), and Ishihara color plate reading (r = -0.68; 95% CI, -0.79 to -0.66; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) were each strongly and highly significantly correlated with the diagnosis and degree of RAPD. Brightness sense and red perception were each able to discriminate almost all the area under ROC for the diagnosis of RAPD (area of 0.99; 95% CI, 0.98-1.00; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001; area of 0.93; 95% CI, 0.90-0.96; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001, respectively). Sensitivity and specificity of brightness sense in detection of RAPD were 99% (95% CI, 0.97-1.00) and 95% (95% CI, 0.91-0.98), respectively. The red perception test was only slightly less accurate. Rapid, simple assessments of brightness sense and color perception provide accurate methods to facilitate the diagnosis of optic neuropathy and may prove to be valuable in screening for optic neuropathy or alternatives to the swinging flashlight test.
Investigative Ophthalmology & Visual Science, 2008
Restoration of visual function after neurosurgery for parachiasmal tumors is variable and unpredi... more Restoration of visual function after neurosurgery for parachiasmal tumors is variable and unpredictable. The current study was conducted to determine whether in vivo retinal nerve fiber layer (RNFL) thickness measurements predict the visual recovery of such patients. Forty patients undergoing surgical resection of parachiasmal lesions were prospectively assessed before surgery with a neuro-ophthalmic examination, involving standard automated visual field (VF) testing and optical coherence tomography (OCT) measurements of RNFL thickness, which was the prespecified marker for axonal loss. Tests were repeated within 6 weeks after surgery. Thinner preoperative RNFL thickness was associated with worse visual acuity (VA) and VF mean deviation (MD). Patients with normal preoperative RNFL had significant improvement in mean VA after surgery, from 20/40 to 20/25 (P = 0.028), whereas patients with thin RNFL did not improve (20/80 to 20/60, P = 0.177). Eyes with normal RNFL showed improvement in MD (-7.0 dB before surgery, -3.5 dB after surgery, P = 0.0007) unlike eyes with thin RNFLs, which had no significant improvement after surgery (-15.3 dB before and -13.3 dB after surgery, P = 0.191). RNFL thickness increased by 1% after surgery among all eyes (P = 0.04). Eyes with severe VF defects (MD &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/= -10 dB) but normal preoperative RNFL thickness showed a postoperative improvement in MD of 14.6 dB compared with 1.6 dB (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) in eyes with thin RNFL before surgery, despite no difference in MD before surgery (normal RNFL MD, -22.3 dB; thin RNFL MD, -20.8 dB; P = 0.7). Patients who have objectively measurable RNFL loss at the time of surgery for chiasmal compressive lesions are less likely to have return of VA or VF after surgery.
Investigative Ophthalmology & Visual Science, 2010
International Journal of Radiation Oncology*Biology*Physics, 2007
International Journal of Radiation Oncology*Biology*Physics, 1996
To evaluate the efficacy and toxicity of fractionated, stereotactic radiotherapy (SRT) for acoust... more To evaluate the efficacy and toxicity of fractionated, stereotactic radiotherapy (SRT) for acoustic neuromas. Twelve patients with acoustic neuroma were treated with SRT between June 1992 and October 1994. Follow-up ranged from 16-44 months. Patient age ranged from 27-70 (median: 45). Eight patients were treated with primary SRT and four patients were treated after primary surgical intervention for recurrent [3] or persistent [1] disease. Tumor volumes were 1.2-18.4 cm3 (median: 10.1 cm3). Collimator sizes ranged from 30-50 mm (median: 37.5). Tumors received 1.8 Gy/day normalized to the 95% isodose line. Patients received a minimum prescribed dose of 54 Gy in 27-30 fractions over a 6-week period. After a median follow-up of 26.5 months, local control was obtained in 12 out of 12 lesions. Tumor regression was noted in three patients, and tumor stabilization was found in the remaining nine patients. No patient developed a new cranial nerve deficit. One patients developed worsening of preexisting Vth cranial neuropathy and another experienced a decrease in hearing. However, all nine patients with useful hearing prior to SRT maintained useful hearing at last follow-up. Stereotactic radiotherapy provided excellent local control without new cranial nerve deficits. These results must be viewed as tentative in nature because of the small number of patients and the short median follow-up period.