Journal of Neuro-Ophthalmology, December 2002, Volume 22, Issue 4

Neuro-Ophthalmology at Large

NEURO- OPHTHALMOLOGY AT LARGE 14th International Neuro- Ophthalmology Society ( INOS) Meeting, Buenos Aires, Argentina, May 5- 8, 2002 The 14th International Neuro- Ophthalmology Soci­ety ( INOS) meeting was attended in Buenos Aires, Argen­tina by 155 delegates with 18 accompanying persons repre­senting 19 countries. The meeting took place in the Sheraton Hotel and Convention Center May 5- 8, 2002 and was organized by Roberto Ebner, MD ( Buenos Aires, Ar­gentina), and Sergio Carmona, MD ( Rosario, Argentina), with the support of a local scientific committee. The hon­ored guest was William Hoyt, MD ( San Francisco, CA). There were 7 wide- ranging symposia, including 33 invited speakers, 8 free paper sessions ( 48 papers), one poster session ( 34 posters), one round table, and one break­fast session. The official language of the congress was En­glish, but simultaneous translation into Spanish was also available and a large trade exhibition was open for partici­pants throughoutthe congress sessions. An opening address and words of welcome from Enrique Malbran, MD ( Buenos Aires, Argentina), provided a fitting introduction to the sci­entific program. SYMPOSIUM: OPTIC NERVE DISORDERS In a session on the optic nerve, Robert McFadzean, MD ( Glasgow, Scotland), updated the audience on the use of multifocal ERG and VEP. He showed how these tests correlate well with visual field defects and have the poten­tial to become a method of " objective" perimetry. Neil Miller, MD ( Baltimore, MD), approached the challenging subject of neuroprotection, reviewing different mecha­nisms and potential clinical strategies. Thomas Hedges III, MD ( Boston, MA), shared his experience with optical co­herence tomography, presenting examples of nonarteritic ischemic optic neuropathy, papilledema, and pseudo-papilledema. Roberto Ebner, MD, showed how Heidelberg retinal tomography can be used to monitor clinical progres­sion of papilledema. Hypercholesterolemia appeared to be a statistically significant risk factor in 37 patients with non­arteritic ischemic optic neuropathy studied by Peter Savino, MD ( Philadelphia, PA). Neil Miller, MD, added that ho­mocysteine might be another unrecognized risk factor in this condition. SYMPOSIUM: MULTIPLE SCLEROSIS Leonor Gold, MD ( Buenos Aires, Argentina), re­viewed the current knowledge on immunomodulatory therapy in multiple sclerosis, emphasizing the results of the latest clinical trials. Jorge Kattah, MD ( Peoria, IL), began his presentation on diagnostic criteria and early treatment in multiple sclerosis by recognizing the contributions of Larry Jacobs, MD, recently deceased. He reminded the audience of basic but often overlooked concepts of multiple sclerosis and reviewed the data of the CHAMPS trial. SYMPOSIUM: THE CAVERNOUS SINUS In a comprehensive session on cavernous sinus dis­orders, Armando Basso, MD ( Buenos Aires, Argentina), addressed the controversial issue of neurosurgical interven­tion for cavernous sinus lesions, differentiating between sphenocavernous lesions in the lateral wall and intracavern-ous lesions. Resection of the former was rarely uncompli­cated by significant disabling sequela, whereas removal of nonmeningiomatous intracavernous lesions was possible without undue bleeding. Adjunctive radiosurgery was dis­cussed along with some impressive surgical results. Luis Lemme Plaghos, MD ( Buenos Aires, Argentina), described the endovascular treatment of carotid- ophthalmic artery an­eurysms with coiling, and there was agreement about the satisfactory nature of this technique and the outcome in most patients. After a review of the clinical and diagnostic tests for and treatment of carotid- cavernous fistulas, Neil Miller, MD, demonstrated an impressive video of his supe­rior ophthalmic vein embolization technique. The defini­tion and investigation of the Tolosa- Hunt syndrome was considered by Anthony Arnold, MD ( Los Angeles, CA), accompanied by discussion of the value of cerebrospinal examination and biopsy in the assessment of this disorder. SYMPOSIUM: IDIOPATHIC INTRACRANIAL HYPERTENSION The diagnostic criteria for idiopathic intracranial hy­pertension in men and children were reviewed by Deborah Friedman, MD ( Syracuse, NY). In children, the importance of underlying causes, such as inflammation and exogenous Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Neuro- Ophthalmol, Vol. 22, No. 4, 2002 305 JNeuro- Ophthalmol, Vol. 22, No. 4, 2002 NEURO- OPHTHALMOLOGY AT LARGE Peter Savino, MD ( Philadelphia, PA), caught in a humorous exchange during an address at the 14th Annual Interna­tional Neuro- Ophthalmology Society ( INOS) meeting in Buenos Aires, Argen­tina. Panel (/ eft to right): Roberto Ebner, MD ( Buenos Aires, Argentina, co- host), Thomas Hedges III, MD ( Boston, MA), Neil Miller, MD, ( Baltimore, MD), Robert McFadzean, MD ( Glasgow, Scotland), and James Garrity, MD ( Rochester, MN). agents, was emphasized, whereas in men, despite the pau­city of studies, the role of essential hypertension was iden­tified and the place of magnetic resonance venography in the diagnosis of cerebral venous sinus thrombosis dis­cussed. Valerie Biousse, MD ( Atlanta, GA), explored in further detail the issue of cerebral venous sinus occlusion, emphasizing that MRI was essential, possibly accompanied by MRV. Thrombophilic risk factors were highlighted, and cerebral venous sinus thrombosis management was ad­dressed. Complications of optic nerve sheath decompres­sion and lumboperitoneal shunting were compiled based on a literature review by Anthony Arnold, MD. Overall, there was a 13% complication rate after optic nerve sheath de­compression with significant variability from one series to another. Reoperation particularly predisposed to the risk of new visual loss. Revision of lumboperitoneal shunts in 50% of patients remained a problem, but the data on postopera­tive new visual loss was considered weak. In reviewing the indications for surgery, James Corbett, MD ( Jackson, MS), called on his wide experience to outline the problems and offer some cautionary tales. SYMPOSIUM: HEADACHE Christopher Kennard, MD ( London, England), com­prehensively reviewed headache associated with vascular disorders and the appropriate investigations, while James Corbett, MD, focused on the management of headache in intracranial hypertension. Epidemiologic studies of head­ache disorders in Latin America and the professional hurdles involved were discussed by Lorenzo Gardella, MD ( Rosario, Argentina), and the session concluded with a characteristic consideration of ophthalmoplegic and retinal migraine from the standpoint of Robert Daroff, MD ( Cleve­land, OH). He considered retinal migraine rare, but under­scored the value of gadolinium- enhanced MRI in diagnosis of the oculomotor palsy of ophthalmoplegic migraine. SYMPOSIUM: FUNCTIONAL NEUROIMAGING Positron emission tomography may reveal cerebro­vascular lesions unrecognized by conventional CT and MRI, as illustrated by Motohiro Kiyosawa, MD, ( Tokyo, Japan), in a small series of patients with varying visual dis­orders. Similarly, Sergio Carmona, MD, demonstrated the value of SPECT scanning in the diagnosis, management, and follow- up of occipital disease. The challenge of the clinical relevance of functional MRI was addressed by Rob­ert McFadzean, MD. Overall, there was agreement that all three modalities have an important place in clinical neuro-ophthalmological practice. SYMPOSIUM: CONTROL OF EYE MOVEMENTS In a session devoted to ocular movements, Jean Butt-ner- Ennever, PhD ( Munich, Germany), suggested that the premotor inputs to twitch and nontwitch muscle fibers might be different. This was followed by a review of cer­ebellar control of eye movements, particularly centripetal and downbeat nystagmus, by Ulrich Buttner, MD ( Munich, Germany). He proposed that downbeat nystagmus is a mis­match between the neural integrator and the saccade gen­erator. The parvocellular and magnocellular pathways were reviewed by James Sharpe, MD ( Toronto, ON). Christo­pher Kennard, MD, showed his work on visual search scan Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 306 © 2002 Lippincott Williams & Wilkins NEURO- OPHTHALMOLOGY AT LARGE JNeuro- Ophthalmol, Vol. 22, No. 4, 2002 Robert Daroff, MD ( Cleveland, OH) (/ eft), William Hoyt, MD ( San Francisco, CA), and Deborah Friedman, MD ( Rochester, NY), assess the alcohol content in their wine glasses at the INOS wine- tasting soiree. paths and the difference between visuospatial attention and spatial working memory. Using an impressive display of audiovisual technology, David Zee, MD ( Baltimore, MD), facilitated the understanding of common but sometimes complicated neuro- otologic conditions. John Leigh, MD ( Cleveland, OH), finished the session with a discussion of treatment of ocular oscillations, including the use of prisms when convergence or divergence dampens nystagmus. FREE PAPERS Thomas Hedges III, MD, diagnosed various retinal conditions in ten patients with unexplained visual loss based on multifocal ERG and concluded that this test is very helpful in identifying macular dysfunction. James Sharpe, MD, showed that patients with monocular eye muscle weakness who are viewing binocularly can selectively ad­just innervation of one eye to improve the performance of the vestibuloocular reflex, a concept that was first intro­duced in monkeys ( Snow Hore J, Vilis T. Adaptation of saccadic and vestibulo- ocular systems after extraocular muscle tenectomy. Invest Ophthalmol Vis Sci 1985; 26: 924- 31) and that defies Hering's law of motor correspondence. Despite distinct facial features, Alexandre Taleb, MD ( Goiania, Brazil), found that natives of the Amazon region have exophthalmometric values in the ranges reported in other populations around the world. Alejandra Iurescia, John Keltner, MD ( Davis, CA) (/ eft), and his wife, Nancy, Robert McFadzean, MD, and Jorge Kattah, MD ( Peoria, IL), and his daughter, Deanna, raise their glasses at the wine tasting. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 307 JNeuro- Ophthalmol, Vol. 22, No. 4, 2002 NEURO- OPHTHALMOLOGY AT LARGE The eye movement Mafia: John Leigh, MD ( Cleveland, OH), and his wife, Jo (/ eft), David Zee, MD ( Baltimore, MD), and James Sharpe, MD ( Toronto, ON). INOS founders Freddie Huber, MD ( Zurich, Switzerland), with his wife, Elizabeth, (/ eft) and Thomas Hedges II, MD ( Philadelphia, PA). The INOS 2002 co- hosts: Sergio Carmona, MD ( Rosario, Argentina), and Roberto Ebner, MD. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 308 © 2002 Lippincott Williams & Wilkins NEURO- OPHTHALMOLOGY AT LARGE JNeuro- Ophthalmol, Vol. 22, No. 4, 2002 MD ( Buenos Aires, Argentina), found a broad spectrum of visual impairment in 42 children with optic nerve hypopla­sia. A case of autoimmune optic neuropathy and a diagnos­tic algorithm were presented by Haydee Martinez, MD ( Buenos Aires, Argentina). Lymphocytic hypophysitis was reported in the 22nd week of pregnancy, the earliest recorded occurrence of this condition, by D. P. Kydd, MD, ( London, England). In 149 patients with a chiasmal syndrome, features suggestive of a pituitary neoplasm were documented by Luis Mejico, MD ( Syracuse, NY), including an absence of visual symptoms, the presence of bilateral normal or atrophic optic discs, in­complete bitemporal visual field defects, and a visual field defect greater superiorly than inferiorly. The long- term vi­sual prognosis for suprasellar meningiomas followed for at least 10 years was studied in 21 patients by Carlos Chicani, MD ( Sao Paulo, Brazil), who emphasized the risk of tumor recurrence, even after gross total removal of the lesion, and the importance of long- term follow- up. Radiotherapy shortly after surgery was recommended in cases of incom­plete removal. The visual results 2 years after surgery on 100 pituitary tumors ( followed by radiotherapy in 30% of cases) were analyzed by Cristian Luco, MD ( Santiago, Chile). Pinar Aydin, MD, PhD ( Ankara, Turkey), recom­mended the use of botulinum toxin injections for patients with severe corneal problems after facial palsy, and Alfred Huber, MD ( Zurich, Switzerland), described a recurrent case of Tolosa- Hunt syndrome with a review of clinical fea­tures and management of this condition. Louis Dell'Osso, PhD ( Cleveland, OH), presented an assessment of the effects of gaze angle and vergence varia­tion in patients with congenital nystagmus. His extended " nystagmus acuity function" can be used to document quantitatively the effects of therapies on the characteristics of target foveation in congenital nystagmus wave forms. Optic neuropathy ascribed to sinus or dental pathology was described by Haydee Martinez, MD, while D. P. Kydd, MD, clearly presented a case of paroxysmal intracranial hy­pertension and speculated on the etiology. A new model for saccadic oscillations was proposed by John Leigh, MD, with an intersaccadic interval that was present in cerebral/ cerebellar disease but absent in brain stem disease. The role of the omnipause neurons was stressed. The effect of recombinant intravenous tissue plas­minogen activator and short- term anticoagulation in the treatment of central retinal artery occlusion was considered in a pilot study of 12 patients by Jorge Kattah, MD. Ten of 12 patients appeared to show visual improvement, and fur­ther studies were recommended. The value of positron emission tomography was demonstrated by Motohiro Kiy-osawa, MD, in a group of patients with cerebral cortical lesions affecting the visual system. An unfortunate schizo­phrenic patient reported by John Crompton, MD ( Adelaide, Australia), developed blindness and a high cervical Brown- Sequard lesion as a consequence of attempted suicide on an airplane. The hazards of hypoperfusion of the occipital lobes during surgery under general anesthesia were empha­sized by Dolores Ribero, MD ( Buenos Aires, Argentina). A. Poonyathalang, MD ( Bangkok, Thailand), treated 15 patients with thyroid eye disease with retrobulbar triam­cinolone injections. Despite a high rate of subjective im­provement, only 24% had decreased proptosis, 10% im­proved visual acuity, and 5% improved ocular motility. This therapeutic technique was further explored by Roberto Ebner, MD, who reported a patient with dramatic improve­ment after 12- week treatment. FinnBremner, MD ( London, England), examined pupillary function with infrared pupil-lography and ocular examination in 35 patients with Neuro- ophthalmology night out with plenty of " asado" ( barbecued beef) at INOS 2002. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 309 JNeuro- Ophthalmol, Vol. 22, No. 4, 2002 NEURO- OPHTHALMOLOGY AT LARGE systemic amyloidosis and found that pupil abnormalities were the commonest ocular manifestation ( 60% of sub­jects). Most patients were also likely to have other auto­nomic test abnormalities. Louis Dell'Osso, PhD, provided further evidence that tenotomy dampens congenital nystagmus, including peri­odic alternating nystagmus. Jorge Kattah, MD, suggested that occipital lobe seizures might cause ictal nystagmus by activating the ipsilateral temporo- occipito- parietal region. He reported an elderly man with Alzheimer disease and episodic ictal nystagmus who had an occipital lobe seizure focus on EEG and whose SPECT scan demonstrated in­creased blood flow in this area during the ictal period. Lu-crecia Lopez, MD ( Buenos Aires, Argentina), encountered high frequency of antiphospholipid antibodies in 17 pa­tients with acute vestibular syndrome due to brain stem ischemia. Louis Dell'Osso, PhD, described a case of classic migraine aura that oscillated in the plane of congenital nys­tagmus. Pendular nystagmus did not appear to correspond to the laterality of signal changes in the inferior olivary nucleus in 10 patients with oculopalatal tremor studied by James Sharpe, MD. V. Abudi, MD ( Buenos Aires), re­viewed 49 consecutive patients with NF1 and found that 16% had optic nerve gliomas, a frequency comparable to that previously reported. SOCIAL PROGRAM To complement the scientific proceedings, there was a splendid social program initiated by a welcome reception at the monastery of Santa Catalina de Siena with traditional Argentine beef and red wine. Of course, a trip to Buenos Aires would have been incomplete without going to a Tango Show. INOS meeting organizers rose to the occa­sion. After a dinner of yet more delicious Argentine beef and wine, we were swept away by an evening of beautiful costumes, intricate and sensual dancing, and traditional singing. The meeting concluded with some classic, rodizio style indulgence, a buffet of Argentine gastronomy. Ac­companying persons enjoyed tours of the Parana River Delta and the city of Buenos Aires, including the fabulous Colon Theatre and Museum, and the " Galerias Pacifico" shopping mall. The meeting closed with a backwards look, including a well deserved tribute to William Hoyt, MD, a fascinating study of the Bible, medicine, and the eye, a further tribute to the founder of Chilean Neuro- Ophthalmology [ Abraham Dan Boghen, MD ( Montreal, QC), waves good- bye from the peaks of Patagonia. Schweitzer, MD ( Santiago, Chile)], and a recollection of the highlights of past INOS meetings. Roberto Ebner, MD, and Sergio Carmona, MD, are to be congratulated on the organization of an excellent meeting despite the constraints of their country's difficult circumstances. International col­leagues much appreciated their best efforts and many took the opportunity to enjoy the natural beauty and splendid wonders of Argentina from the tumbling grandures of the Iguazu falls in the North to the snow- covered spectacles of Patagonia in the South, enhanced by the warmth and friend­liness of the Argentine people. INOS 2004 will be held in Geneva, Switzerland on July 18- 21, under the auspices of Avinoam Safran, MD ( Geneva, Switzerland). Robert M. McFadzean, MD Glasgow, Scotland Luis J. Mejico, MD Syracuse, New York Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 310 © 2002 Lippincott Williams & Wilkins