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Show Journal of Neuro- Ophthalmology 21( 3): 235, 2001. © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia Letters Ankylosing Spondylitis in a Case of Recurrent Optic Neuritis A 20- year- old man presented with sudden diminution of vision OD in February 1997. Examination revealed a visual acuity of light perception OD and 20/ 20 OS with a relative afferent pupillary defect OD and a normal fundus. The intraocular pressures and slit- lamp examination in both eyes were also unremarkable. With the provisional diagnosis of retrobulbar neuritis OD, the patient was examined. He had mild anemia (- Hb 11 gm%), an erythrocyte sedimentation rate ( ESR) of 5 mm ( Wintrobe), normal urine, and normal chest and paranasal plain x- rays. Indirect hemagglutination ( IHA) for toxoplasma was negative and VDRL was nonreactive. Blood cultures showed no growth. The visual evoked response showed increased latency and decreased amplitude in the OD. Brain magnetic resonance imaging study was not suggestive of multiple sclerosis or any other neurologic abnormality. The patient was given 1 g methylprednisolone in 5% dextrose intravenously for 3 days followed by 60 mg oral prednisolone once daily for 10 days in a tapering dose. By the third day of intravenous methylprednisolone treatment, visual acuity OD improved to 20/ 30. Six weeks later, he returned with recurrent retrobulbar neuritis OD, which was again treated with the same regimen. In November 1998 and June 1999, he presented with similar recurrent attacks of optic neuritis OS. He was treated with the same regimen and fully recovered his vision. However, in June 1999, the patient complained of some stiffness of the neck and lower back. He was referred to the rheumatology clinic where inflammation of the back, lumbar motion limitations, and limited chest expansion were detected. On examination, the white blood cell count was 10,200 mm3, hemoglobin was 10.5 g/ dL, ESR was 53 mm ( Wintrobe), and C- reactive protein was 8.70 mg/ dL ( normal, < 0.5 mg/ dL). Rheumatoid factor and antinuclear antibodies were negative, whereas HLA- B27 was positive. Plain x- rays of the lumbar spine and sacroiliac joint showed minimal bilateral sacroiliitis and syndesmophytes. He was diagnosed as having ankylosing spondylitis and was treated with 75 mg slow-release indomethacin once daily. To the best of our knowledge, this is the first reported case of bilateral optic neuritis and ankylosing spondylitis. Optic neuritis and multiple sclerosis are known to be From the Center for Ophthalmic Sciences, A. 1.1. M. S., New Delhi, India Address correspondence and reprint requests to Sudarshan Khokhar, New Delhi, India. E- mail: skhokhar38@ hotmail. com. associated ( 1), and a relationship between ankylosing spondylitis and multiple sclerosis has been reported ( 2). Therefore, there is a possibility of incipient multiple sclerosis in our case. Vimala Menon, MS Sudarshan Khokhar, MD New Delhi, India REFERENCES 1. Adams RD, Victor M, Ropper AH, eds. Multiple sclerosis and allied demyelinative disease. In: Principles of Neurology, 6th ed. Edited by Martin J, Wonsiewicz, Michael P. Medina, Muza Nvaro-zov. New York: McGraw- Hill, 1997: 902- 27. 2. Khan MA, Kushner I. Ankylosing spondylitis and multiple sclerosis. A possible association. Arthritis Rheum 1979; 22: 784- 6. Pseudotumor and Sleep Apnea Kesler et al. ( 1) reported 18 male patients with pseudotumor cerebri ( PTC) and compared them with 116 female patients with PTC. These authors found that the clinical features were identical in male patients compared with female patients. There were significantly fewer overweight patients ( 25%) in the male group, however, than in the female group ( 78%). The authors listed several associated factors in the male patients ( e. g., hypertension, smoking, high cholesterol). Purvin et al. ( 2) noted papilledema in four patients with sleep apnea syndrome. I have also been impressed by several cases of sleep apnea in our male patients with PTC. I was wondering if the authors looked at sleep apnea as an associated condition in the male versus female groups in their study. Andrew Lee, MD Iowa City, IA REFERENCES 1. Kesler A, Goldhammer Y, Gadoth N. Do men with pseudotumor cerebri share the same characteristics as women. A retrospective review of 141 cases. J Neuroophthalmol 2001; 21: 15- 7. 2. Purvin VA, Kawasaki A, Yee RD. Papilledema and obstructive sleep apnea syndrome. Arch Ophthalmol 2000; 118: 1626- 30. Author's Reply We thank Dr. Lee for reminding us that the association of sleep apnea and IIH is documented. However, sleep apnea was not documented in any of our IIH patients. Anat Kesler MD Y. Goldhammer, MD N. Gadoth, MD Kfar Saba, Israel |
