Clinical Pathways in Neuro-ophthalmology : An ... - E-Lib FK UWKS

176 Clinical Pathways in Neuro-Ophthalmology, second edition
83 cases of TVL or ocular infarction before age 45 years. These authors found that
cerebral transient ischemic attacks occurred in nine patients but no case of stroke was
found (Tippin, 1989). Forty-one percent of the patients had headaches or orbital pain
accompanying their TVL spells and an additional 25.3% had severe headaches independent
of the visual loss. Of the original 83 patients, 42 were reexamined after a mean
period of 5.8 years. None of the patients in this group had a stroke. The clinical status at
follow-up did not correlate with duration of visual loss (TVL or ocular infarction),
frequency (single or recurrent episodes), gender, presence of headache or heart disease,
cigarette smoking, use of oral contraceptives, or abnormal findings on echocardiogram
or blood studies. The authors concluded that TVL and ocular infarction occurring in the
younger patient are probably associated with a more benign clinical course than that
seen in older persons, and that migraine is a likely cause for visual loss in a majority in
this group. O’Sullivan et al described nine young adults (median age 19.5 years) who
suffered from TVL (O’Sullivan, 1992). The attacks of TVL were short in duration and
associated with premonitory symptoms in five patients and a migrainous headache in
two. In five patients the visual loss progressed in a lacunar pattern (vision was lost in a
series of blobs), unlike the ‘‘curtain’’ pattern characteristic of TVL in older patients.
Investigation revealed no evidence of an embolic or atheromatous etiology. In two
patients a minor abnormality was found on echocardiography. The authors conclude
that TVL in young adults has a different clinical pattern and may have a different
etiology, possibly migraine, compared with that seen in older patients. The pattern of
visual loss in some of the cases suggests that the choroidal circulation rather than the
retinal circulation is primarily affected.
TVL lasting 15 to 20 minutes (occasionally up to 7 hours) may occur during episodes
of spontaneous anterior chamber hemorrhage (hyphema) (Kosmorsky, 1985; Miller,
1991). In these patients TVL may be associated with erythropsia (seeing red) and color
desaturation. Such hemorrhages are most likely to occur after cataract extraction and are
particularly apt to occur after placement of an iris fixation lens implant. Other potential
causes of spontaneous anterior chamber hemorrhages include vascular anomalies of the
iris (e.g., in myotonic dystrophy or Sturge-Weber syndrome), microhemangiomas,
diffuse hemangiomatosis of childhood, neoplasms (e.g., melanoma or retinoblastoma),
diseases of blood or vessels (e.g., leukemia, hemophilia, scurvy, lymphoma), rubeosis
iridis, severe iritis, fibrovascular membranes, juvenile xanthogranuloma, occult trauma
or delayed bleeding after trauma, hydro-ophthalmos, malignant exophthalmos, histiocytosis
X, and postsclerotomy with cautery (Kosmorsky, 1985). Episodes of TVL lasting
up to 24 hours have been described with recurrent hyphema after deep sclerotomy with
collagen implant (DSCI) (Ambresin, 2001). The uveitis-glaucoma-hyphema (UGH)
syndrome is an unusual cause of monocular TVL following cataract extraction and
intraocular lens implantation (Cates, 1998). Patients may present with the full triad or
with its individual elements, with symptoms often developing at an interval, often
years, after cataract surgery. Table 8–1 compares the symptoms of TVL in retinal emboli
compared with the UGH syndrome (Cates, 1998).
Intermittent angle closure glaucoma may also cause brief episodes of monocular TVL
that are usually, though not always, associated with ipsilateral eye pain and occasionally
simultaneous dilation of the pupil (Miller, 1991). Exercise-induced visual disturbances
may also occur during attacks of pigmentary glaucoma (Jehn, 2002). Episodes of
monocular TVL lasting 2 to 3 minutes induced by changes in posture have been
described following scleral buckle procedure, likely due to intermittent obstruction of