Journal of Neuro-Ophthalmology, March 2003, Volume 23, Issue 1

In Other Journals

IN OTHER JOURNALS Editor's note: This section contains brief reviews of articles that have appeared in other journals within the past 6 months. From a comprehensive list of clinical and scientific medical journals, each reviewer has selected about 30 titles and reviewed the most pertinent articles. The March and September issues include reviews from oph­thalmology and medicine journals; the June and December issues include reviews from neuroscience and neuroclinical journals. Ophthalmology Journals Reviewer: Dilip A. Thomas, MD Medical College of Georgia Augusta, Georgia I. Visual Fields Szatmary G, Biousse V, Newman NJ. Can Swedish Interactive Thresholding Algorithm Fast Perimetry be used as an alternative to Goldmann perimetry in neuro- ophthalmic practice? Arch Ophthalmol 2002; 120: 1162- 73. This article compared the Swedish Interactive Thresholding Algorithm ( SITA) Fast algorithm to Gold­mann perimetry in a neuro- ophthalmology practice. Out­come measures included reliability, test duration, detection and quantification of visual field defects, and patient pref­erence. Reliability was considered poor on Goldmann pe­rimetry based on the technician's assessment or an inability to plot the blind spot. Fixation losses of greater than 50% were considered poor reliability on the SITA test. Direct comparisons of visual field defects in the central 24 degrees were made by the three investigators. Sixty- four patients were consecutively tested on Goldmann perimetry and the SITA Fast 24- 2 program on the same day. There were two groups: those with severe vision loss and mild or no neurologic disability ( 50 eyes) and those with severe neurologic disability ( 50 eyes). Patients not willing to have both studies on the same day were excluded. Visual fields were termed reliable in 77% of all Gold­mann and SITA Fast tests. In the neurologically impaired group, reliable results were found in 64% of Goldmann tests and 72% eyes of SITA Fast tests. In the severe vision loss group, reliable visual fields were obtained in 90% with Goldmann and 82% with SITA Fast. Reliable SITA Fast and unreliable Goldmann results occurred in 22% of eyes in patients with severe neurologic deficit and in 6% with se­vere vision loss. The authors conclude that SITA Fast testing can be performed more quickly and reliably than Goldmann perimetry in many neuro- ophthalmologic disorders. Gold­mann testing remains less cognitively demanding and better delineates occipital and noncentral visual field defects. They propose the development of a 60- degree SITA Fast program to compensate for the current SITA Fast deficiencies. II. Retinal Artery Occlusion Foroozan R, Savino PJ, Sergott RC. Embolic central retinal artery occlusion detected by orbital color Doppler imaging. Oph­thalmology 2002; 109: 744- 7. Orbital Color Doppler Imaging ( OCDI) was used to detect occult retinal emboli in 29 patients with cen­tral retinal artery occlusion ( CRAO) that lacked visible emboli on retinal exam. A retrospective analysis of these patients was performed, excluding those with a diagno­sis of temporal arteritis. In this study, 31% of OCDI stud­ies demonstrated hyperechoic plaques consistent with retrobulbar emboli; six demonstrated diminished flow velocities in the central retinal artery ( CRA), and three in both the CRA and posterior ciliary vessels. All nine pa­tients with occult emboli had a visual acuity of finger count­ing or worse. Six of these patients were examined within 2 days of onset and the remainder within 5 weeks. Typical risk factors for arterial occlusive disease were present in seven patients. The authors conclude that the incidence of embolic CRAO may be underestimated by funduscopic examin­ation alone. The detection of occult emboli by OCDI directs the work- up to a search for an embolic source, eliminates unnecessary temporal artery biopsies or cor­ticosteroid treatment, and avoids misdiagnosis of a throm­botic etiology. Weger M, Stanger O, Deutschmann H, et al. The role of hy-perhomocysteinemia and methylenetetrahydrofolate reductase ( MTHFR) C677T mutation in patients with retinal artery occlu­sion. Am J Ophthalmol 2002; 134: 57- 61. Elevated levels of homocysteine, an amino acid de­rived from methionine metabolism, have been associated with atherosclerosis, mechanism unknown. Elevated levels may be due to renal insufficiency, nutritional deficiencies ( folate, vitamins B12 and B6), medications, and genetic al­terations in enzymes coding for homocysteine metabolism. A point mutation has been identified in the methylenetet- Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Neuro- Ophthalmol, Vol. 23, No. 1, 2003 91 JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 IN OTHER JOURNALS rahydrofolate ( MTHTR) gene, which codes for an enzyme involved in the remethylation of methionine. Conflicting reports exist as to its association with cardiovascular dis­ease. This study is a retrospective case- control study of 105 patients with retinal artery occlusion ( RAO) and 105 age and sex matched controls. It aims to identify any association of RAO with hyperhomocysteinemia or the MTHFR C667T mutation. The authors identified 49 cases of BRAO, 56 cases of CRAO, and 105 controls. Blood samples were drawn after a mean interval of 14.2 months. Hypertension and stroke were more common in the RAO group compared with con­trols. Hyperhomocysteinemia was found in 20 ( 19%) of the RAO group and in 5 ( 4.8%) controls, with an odds ratio of 4.7. Adjustment for the higher prevalence of stroke and hy­pertension in the RAO group did not change these results. There was no difference in the distribution of the MTHFR C577T mutation between the two groups. Mean plasma folate levels were significantly lower in the RAO group, which may contribute to the higher plasma homocysteine level in this group. A major limitation of this study is the long time period between clinical RAO and sampling of homocysteine levels ( mean 14.2 months). Thus, the ho­mocysteine level measured may not be that which existed at the time of vision loss. HI. Ischemic Optic Neuropathy Newman NJ, Scherer R, Langenberg P, et al. The fellow eye in non- arteritic ischemic optic neuropathy: report from the Isch­emic Optic Neuropathy Decompression Trial Follow- up Study. Am J Ophthalmol 2002; 134: 311- 28. This report aims to clarify the 5- year prevalence and incidence of developing nonarteritic ischemic optic neurop­athy ( NAION) in the second eye following unilateral NAION. Also, it aims to identify factors that may be asso­ciated with second eye involvement and the severity of vi­sual loss. In this study, 418 patients aged 50 or older were enrolled. Among them, 258 were randomized to surgery or observation. An additional 160 patients were followed as a natural history cohort, comprised of those refusing random­ization and those excluded because of a visual acuity of bet­ter than 20/ 64 in the affected eye. At study onset, 80 patients ( 19%) already had fellow eye involvement. The incidence of NAION in the second eye was 48/ 326 ( 14.7%) over a median of 5.1 years. Median interval to the second event was 1.2 years, with 22/ 48 ( 49%) events occurring within the first year. The prevalence of bilateral NAION was 128/ 418 ( 30.6%), including second eyes in­volved at study entry and in the follow- up period. This may be an underestimate, since only 182/ 326 ( 55.8%) com­pleted 5- year follow- up. Diabetes and poor baseline visual acuity were the only baseline characteristics associated with second eye in­volvement ( 24% with diabetes versus 12% without). No as­sociation was found with age, gender, smoking, myocardial infarction, hypertension, transient ischemic attack, or stroke. Aspirin use had no effect on second eye involve­ment. No predictions about second eye acuity could be made based on first eye visual acuity. In addition, there was little change in first eye visual acuity from baseline to the time of second eye involvement with NAION. Mojon DS, Hedges TR, Ehrenberg B, et al. Association be­tween sleep apnea syndrome and nonarteritic anterior ischemic optic neuropathy. Arch Ophthalmol 2002; 120: 601- 5. A case- controled analysis was performed to deter­mine the prevalence of sleep apnea syndrome ( SAS) in pa­tients diagnosed with nonarteritic ischemic optic neuropa­thy ( NAION). Both conditions have been associated with nocturnal hypotension or hypoxia. Seventeen consecutive patients ( 15 men, two women) from two centers with a new diagnosis of NAION underwent polysomnography. Com­parison was made to 17 age- and sex- matched controls un­dergoing sleep studies for restless leg syndrome. Addition­ally, comparison was made to a previous large prevalence study in men. In this study, 12/ 17 ( 71%) NAION patients were di­agnosed with SAS compared with 3/ 17 ( 18%) in the control group. All were men. A significantly higher incidence was also found in comparison to previous prevalence data. In the 45- to 64- year- old age group, 4/ 8 ( 50%) with NAION were diagnosed with sleep apnea versus 41/ 430 ( 10%) in the prevalence study. An even larger difference was noted in those older than 64 years: 89% NAION versus 24% controls. The authors cautioned that a causal relationship be­tween SAS and NAION cannot be established. They hy­pothesize that impaired vascular autoregulation or direct hypoxia induced by SAS may be involved. Further studies are needed to assess if continuous positive airway pressure may be helpful in treatment or prevention of NAION in these patients. Pomeranz HD, Smith KH, Hart Jr WM, et al. Sildenafil-associated nonarteritic anterior ischemic optic neuropathy. Oph­thalmology 2002; 109: 584- 7. Five new cases of nonarteritic ischemic optic neurop­athy ( NAION) associated with sildenafil ( Viagra) use are reported in this article, adding to the two previously pub­lished cases. Sildenafil, a phosphodiesterase inhibitor that en­hances cGMP and nitric oxide relaxation of vascular Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 92 © 2003 Lippincott Williams & Wilkins IN OTHER JOURNALS JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 smooth muscle, is used in treatment of erectile dysfunction. In this article, four of five patients had symptoms of vision loss within minutes to hours after ingestion of the drug. Four patients lacked the usual risk factors associated with NAION. All patients had a typical " disc at risk." Three pa­tients had recently commenced use of the drug. The authors point out that not all patients were forthcoming about their use of sildenafil. They recommend that direct inquiry about sildenafil use be made in a male patient with NAION. The youngest patient in the report was 42 years old, emphasiz­ing the need for a high clinical suspicion. They also recom­mend that sildenafil not be prescribed to individuals with a history of NAION. IV. Optic Nerve Sheath Meningioma Turbin RE, Thompson CR, Kennerdell JS, et al. A long- term visual outcome comparison in patients with optic nerve sheath meningioma managed with observation, surgery, or surgery and radiotherapy. Ophthalmology 2002; 109: 890- 900. This is a large, retrospective, long- term study of treat­ment outcomes in 64 patients with at least 50 months of follow- up. The four groups studied were those managed by observation, surgery ( biopsy, partial/ total resection, or op­tic nerve sheath fenestration), radiation, or combined radia­tion and surgery. Outcome parameters were visual acuity, radiographic progression and complications. Five patients with no light perception were excluded. The 50- month minimum follow- up may have precluded study entry to those treated with newer radiotherapy modalities. Most pa­tients were treated with multiport conventional or confor-mal radiotherapy, except for one patient treated with gamma knife. The 59 remaining patients were studied and followed for a mean of 138.5 months. Diagnosis was confirmed by biopsy in 32/ 59 ( 54%). Visual acuity did not differ be­tween the four groups. Thirteen patients were observed, 12 had surgery alone, 18 had radiation alone, and 16 had both radiation and surgery. Radiographic progression was documented in 21/ 59 ( 32.8%) patients, only two of whom had radiation prior to progression. Both of these pa­tients had had at least one surgery before radiation. Com­plications of treatment were fewer in those treated with ra­diation alone ( 33.3%) than in those treated with surgery alone ( 66.7%) or with a combination of both modalities ( 62.5%). Visual acuity at last follow- up was significantly re­duced in all groups except in that treated with radiation alone. Only 2/ 25 ( 8%) not treated with radiation showed a one- line improvement of vision. In contrast, 8/ 18 ( 44.4%) patients treated with radiation alone and 5/ 16 ( 31.3%) treated with a combination of radiation and surgery showed at least two lines of visual acuity improvement. An accompanying editorial ( by Steven Newman, MD) points out that no patient with unilateral disease progressed to bi­lateral involvement. The authors conclude that radiation should be consid­ered as initial therapy in adults with primary optic nerve sheath meningiomas that show clinical progression. V. Glaucoma Ahmed IIK, Feldman F, Kucharczyk W, et al. Neuroradiolog-ic screening in normal- pressure glaucoma: study results and lit­erature review. J Glaucoma 2002; 11: 279- 86. Cupping of the optic nerve can be seen both with glaucomatous and compressive optic neuropathy. The au­thors aimed to determine the prevalence of intracranial le­sions in patients with normal pressure glaucoma ( NPG) compared with IOP- controlled, progressive primary open angle glaucoma ( POAG). A total of 62 patients with NPG and 70 with IOP- controlled progressive POAG consecu­tively underwent neuroimaging. The goal was to study only those in whom neuroimaging would not routinely be recommended. Therefore, exclusion criteria included those with pallor greater than cupping of the optic nerve, cen­tral or hemianopic visual field defects, afferent pupil de­fect, dyschromatopsia, focal neurologic findings, or endo­crine dysfunction. In this study, four ( 6.5%) scans in the NPG group were clinically relevant. They included two pituitary ade­nomas, one suprasellar meningioma, and one arachnoid cyst. All lesions were causing anterior visual pathway com­pression. No compressive lesions were found in the pro­gressive IOP- controlled POAG group. The authors conclude that NPG patients without clas­sic " neurologic signs" still may be harboring a compressive optic nerve lesion. They hypothesize that in these cases cup­ping may be due either directly to compression or a compression- induced increase in the susceptibility of the optic nerve to normal IOP. They propose that the clinical findings in these cases are so innocuous that they would evade diagnosis, even if evaluated by a neuro- ophthal-molgist. They therefore advocate screening neuroimaging in NPG patients. VI. Idiopathic Intracranial Hypertension Lee AG, Golnik K, Kardon R, et al. Sleep apnea and intracra­nial hypertension in men. Ophthalmology 2002; 109: 482- 5. A multicenter, retrospective review was undertaken to assess the association of sleep apnea syndrome ( SAS) in Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 93 JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 IN OTHER JOURNALS men with idiopathic intracranial hypertension ( IIH). Of 18 patients who met the modified Dandy criteria for IIH, six were found to have SAS. Not all of thel 8 patients had sleep studies performed, however. All six patients with SAS were overweight and had resolution of papilledema after treat­ment with acetazolamide, continuous positive airway pres­sure ( CPAP), or both. Limitations of the study, including small sample size and retrospective design, do not allow a valid prevalence to be determined, but the 6/ 18 ( 33%) patients identified is higher than the reported incidence of 0.4 to 5.9%. The au­thors conclude that the diagnosis of sleep apnea should be entertained in men with IIH. VII. Carotid- Cavernous Fistula Meyers PM, Halbach W, Dowd CF, et al. Dural carotid cav­ernous fistula: definitive endovascular management and long-term follow- up. Am J Ophthalmol 2002; 134: 85- 92. The authors present a large retrospective case series of clinical outcomes following endovascular treatment of dural carotid cavernous fistulas ( CCF). In this study, 133/ 135 ( 98%) patients with angiographically documented dural CCFs underwent endovascular treatment. The pa­tients had a mean follow- up of 56 months. Clinical cure was defined as absence of signs or symptoms of CCF. Anatomic cure was defined as angiographic resolution of the fistula. Post- treatment angiography was performed at 6 months in 72 ( 54%) patients with " high- risk" features such as retro­grade cortical drainage, persistent fistula after emboliza­tion, or persistent/ recurrent signs or symptoms. A majority of the embolization procedures were transvenous. Forty pa­tients ( 29%) required two or more procedures. Complete anatomic and clinical cure was achieved in 121/ 135 ( 90%) patients after one or more treatments. Ca­rotid compression was used as an adjunct in 46 patients, and was curative by itself in one patient. Eight patients ( 6%) developed symptomatic complications attributable to treat­ment. Cranial neuropathy failed to resolve in 6 ( 4%) after treatment. At final follow- up, 97%> were classified as hav­ing a good recovery; 1% had moderate disability and 2% had severe disability. There was no operative or periopera­tive mortality. The authors cite a spontaneous resolution rate for du­ral CCFs of up to 10%. After diagnostic angiography, cure may be as high as 43 %. Yet, high- risk cortical venous drain­age was found in 31 %> of patients studied, with an untreated risk of intracerebral hemorrhage quoted at 40% o. Clinical manifestations may not always reflect this risk. Thus, the authors advocate an initial trial of carotid compression therapy followed, if necessary, by transvenous emboliza­tion if high- risk features are present, including progressive visual loss, cortical venous drainage, neurologic deficit, or hemorrhage. They recommend that low- risk patients be observed. VIE. Sixth Nerve Palsy Sanders SK, Kawasaki A, Purvin VA. Long- term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002; 134: 8L^. The majority of microvascular sixth nerve palsies re­solve within 2 to 3 months of onset without residual deficit. The authors' retrospective chart review aimed to determine the percentage of patients that had complete resolution of symptoms and the rate of recurrent ocular motor mononeur-opathy. Complete resolution was defined as complete dis­appearance of diplopia and/ or normalization of ocular duc-tions and alignment. Recurrent ocular motor nerve palsy was determined by patient report of recurrent diplopia on questionnaire. The report was not always corroborated by patient examination or review of outside physician records. In this study, 59 total patients were identified with vasculopathic sixth nerve palsies. Among them, 86% o had complete resolution, whereas 14% had persistent diplopia. All patients with persistent symptoms had normal neuroim-aging. As many as 31% had a total of 24 recurrences in­volving the same or different ocular motor nerves over a follow- up interval of 2 to 13 years. Among them, 10 were ipsilateral to the sixth nerve palsy. Six patients reported a subsequent Bell's palsy. There were no predisposing pa­tient characteristics associated with recurrence. Several sources of bias or error were identified such as incomplete exclusion of other etiologies for the sixth nerve palsy, lack of confirmation of subjective patient questionnaire reports, and incomplete follow- up. IX. Optic neuritis Foroozan R, Buono LM, Sergott RC, et al. Retrobulbar optic neuritis associated with infliximab. Arch Ophthalmol 2002; 120: 985- 6. Infliximab, an IgG antibody against tumor necrosis factor alpha ( TNF- a), is administered as an intravenous in­fusion in the treatment of rheumatoid arthritis. Reported side effects include exacerbation of symptoms and radio­graphic evidence of demyelinating disease. The authors re­port a potentially new adverse effect of infliximab: optic neuritis in a 55- year- old woman with rheumatoid arthritis. The onset of optic neuritis was 3 days after her twelfth dose Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 94 © 2003 Lippincott Williams & Wilkins IN OTHER JOURNALS JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 of the drug. Magnetic resonance imaging ( MRI) showed gadolinium enhancement of the affected optic nerve. The patient was treated with IV and PO steroids with improved visual acuity and resolution of the visual field defect. Medicine Journals Reviewer: Thomas R. Mizen, MD Rush Medical College Chicago, Illinois I. Ischemic Optic Neuropathy Cheng MA, Tempelhoff R. Postoperative visual loss, still no answers yet. Anesthesiology 2002; 96: 1531- 3. The authors discuss the fact that while the exact eti­ology of visual loss after prone lumbar spine surgery re­mains unknown, the informed consent must include visual loss. Monitoring of the vision in the recovery room should be documented; detection of visual loss with ophthalmo­logic consultation should follow, but there is no definitive treatment of postoperative visual loss. Benumof JL, Mazzei W. Multifactorial etiology of postopera­tive vision loss. Anesthesiology 2002 96: 1531- 2. The authors discuss the limitations of checking the orbits with a soft foam cushion: the mere checking of the globes would involve removing the cushion, which changes the relationship of the orbits to the support from the foam cushion. A newer model allows direct visualization of the globes without removing the device. Additionally, the fa­cial anatomy may preclude globe compression in patients with a low nasal bridge. The positioning of the patient with the head lower than the abdomen may alter facial and or­bital venous pressure. Neosynephrine infusion to prevent hypotension may be used clinically, but its effects on ocular circulation are unknown. Roth S, Barach P. In reply. Anesthesiology 2002; 95: 1532. The authors report the difficulty in establishing the diagnosis of postoperative visual loss from the standpoint of recovery room evaluation. Patients recovering from an­esthesia may not always be able to cooperate, anesthesiolo­gists do not perform fundus examinations, and interval test­ing over several days may be required, not necessarily a cost- effective procedure to implement. The authors believe that palpating the globe during a procedure is not difficult and should be recorded in the chart. Lam A, Lee LA. In Reply. Anesthesiology 2002; 96: 1532- 3. The authors provide additional data regarding the pa­tient discussed with respect to nasal bridge anatomy and placement of the foam support. They reiterate that the cause of visual loss is posterior ischemic optic neuropathy ( PION), and pressure on the globe results in central retinal artery occlusion. Future research should focus on the cir­culatory aspects of PION and not on the positioning of the patient. Gupta R, Singh S, Tang R, et al. Anterior ischemic optic neu­ropathy caused by interferon alpha therapy. Am J Med 2002; 112: 683- 84. The authors discuss a case of interferon- a therapy as­sociated with visual loss and a condition they diagnose as ischemic optic neuropathy. The patient had controlled hy­pertension and chronic hepatitis C. Interferon was started 8 months before the onset of visual loss. The marked im­provement in visual function 4 weeks after discontinuation of therapy suggests to me the diagnosis of optic neuritis rather than ischemic optic neuropathy. II. Complications of Lumbar Puncture Diaz JH. Permanent paraparesis and cauda equina syndrome af­ter epidural blood patch for postdural puncture headache. Anes­thesiology 2002; 96: 1515- 7. A case is presented and mechanisms discussed re­garding the severe neurologic sequella of epidural blood patch for post- lumbar puncture headache. The patient in the study received a slow infusion of 30 ml of autologous blood and was placed at supine bedrest. Improvement of 90 to 95% in the headache was reported and the patient was discharged 30 minutes after the procedure. Current recommendations are for 10 to 20 ml of blood volume, with larger volumes reserved for refractory cases. A period of observation of 1 to 2 hours should follow to allow the blood to clot and adhere, and to allow performance of a neurologic evaluation. III. Myasthenia Gravis Salazar Cabrera C, de Saa Alvarez M, Aparicio Perez MS, et al. Myasthenia gravis: the otolaryngologist's perspective. Am J Otolaryngol 2002: 23: 169- 72. After a brief discussion of the general pathophysiol­ogy of myasthenia gravis, the authors present five patients Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 95 JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 IN OTHER JOURNALS whose myasthenic symptoms were rhinolalia, dysphagia, or dysphonia. Following an appropriate medical treatment regimen, these symptoms improved. This report is a re­minder of the multifaceted presentation of myasthe­nia gravis. IV. Medical Manpower Cooper RA. There's a shortage of specialists. Is anyone listen­ing? Acad Med 2002; 77: 761- 6. The director of the Health Policy Institute of the Medical College of Wisconsin reports that there is a short­age rather than a surplus of physicians, especially special­ists. The physician work- effort, provision of services by nonphysicians, increasing growth of the population, and economic expansion drive a system where disaster looms should the infrastructure to train physicians not expand. V. Stroke Somma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: Patent Fo­ramen Ovale in Cryptogenic Stroke Study. Circulation 2002; 105: 2625- 31. In a study of patients assigned to warfarin or aspirin following recurrent stroke, transesophageal echocardio-graphic findings were analyzed. Patent foramen ovale ( PFO) was present in 33.8%. End points were recurrent ischemic stroke or death. There was no difference in time to primary end points in patients with and without PFO. There was no difference in the time to primary end points in pa­tients with PFO treated with aspirin or warfarin. In stroke patients on medical therapy, the presence of PFO did not increase the chance of adverse events. Hollander M, Bots ML, del Sol AL et al. Carotid plaques in­crease the risk of stroke and subtypes of cerebral infarction in asymptomatic elderly: The Rotterdam Study. Circulation 2002; 105: 2872- 7. The Rotterdam study included 4,217 neurologically asymptomatic subjects aged 55 years and older. A study was undertaken to understand the relationship between the location of plaque and the risk and subtype of stroke. The study demonstrated an increased risk of anterior circulation infarction in patients with carotid plaques, regardless of lo­cation. The author's conclusion is that carotid plaque is both a marker of generalized atherosclerosis and a source of emboli. Wong TY, Klein R, Sharrett AR, et al. Cerebral white matter lesions, retinopathy, and incident clinical stroke. JAMA 2002; 288: 67- 74. The Atherosclerosis Risk in Communities ( ARIC) study is a cohort study of cardiovascular disease among 15,972 persons aged 45 to 64 years. The study population for this report consisted of 1,684 persons. Strokes were identified in patients following an MRI scan at their second visit from 1993 to 1994 and occurring before 1998, a mean follow- up of 4.7 years. The strokes were classified as thrombotic, hemorrhagic, or both. White matter lesions ( WML) were identified on the MRI. Fundus photography, completed at the third visit, which occurred 3 years after the second visit, included an assessment of retinal microaneu­rysms or retinal hemorrhage. Patients with retinopathy were more likely to have WML on MRI. The 5- year cumulative incidence of stroke was greater in those with WML. Patients with both WML and retinopathy had a significantly higher 5- year cumula­tive incidence of stroke than those without either WML or retinopathy. The authors conclude that evaluation of retinal blood vessels may provide the primary care physician with a predictive marker for stroke. Straus SE, Majmudar SR, McAlister FA. New evidence for stroke prevention: scientific review. JAMA 2002; 288: 1388- 95. Control of blood pressure, treatment of hyperlipid-emia, use of antithrombotic agents in patients with atrial fibrillation, and use of antiplatelet therapy in patients with myocardial infarction play a role in primary prevention of stroke. Effective strategies for secondary prevention in­clude carotid endarterectomy for patients with severe ca­rotid stenosis. Strauss SE, Majmudar SR, McAlister FA. New evidence for stroke prevention: clinical applications. JAMA 2002; 288: 1396- 8. Strategies for stroke reduction cannot always be glo­bally applied, and individual patient analysis is still neces­sary for effective outcomes. Case presentations are used to help formulate a treatment strategy. Specialized clinics for disease management ( coronary artery disease) or special­ized service clinics ( anticoagulation management services) may improve overall management. Moake JL. Thrombotic microangiopathies. A review. N Engl J Med 2002; 347: 589- 600. The thrombotic microangiopathies are microvascular occlusive disorders characterized by intrarenal or systemic Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 96 © 2003 Lippincott Williams & Wilkins IN OTHER JOURNALS JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 aggregation of platelets, thrombocytopenia, and mechani­cal injury to erythrocytes. Mechanisms of thrombotic thrombocytopenic purpura and hemolytic uremia syndrome are discussed. VI. Giant Cell Arteritis Hellman DB. Temporal arteritis: a cough, toothache, and tongue infarction. JAMA 2002; 287: 2996. The authors discuss a patient with temporal arteritis with an initial atypical presentation who developed visual loss. They appropriately identify the erythrocyte sedimen­tation rate as elevated in 89% of patients, and that 40% of patients present with atypical symptoms. The table of atypi­cal manifestations of temporal arteritis serves as a useful guide in the earlier diagnosis of temporal arteritis. Salvarani C, Cantini, F, Bioardi L, et al. Polymyalgia Rheu-matica and giant cell Arteritis. N Engl. J Med 2002; 347: 261- 71. This is a useful update on a disease providing an over­lay between polymyalgia rheumatica and giant cell arteritis. Salvarani CS, Silingardi M, Ghiraduzzi A, et al. Is Duplex ultrasonography useful for the diagnosis of giant cell arteritis? Ann Intern Med 2002; 137: 323- 8. The authors present a series of patients over a 2- year period who underwent temporal artery biopsy guided by ul­trasound. The results demonstrate that the physical exami­nation of the temporal artery had a higher sensitivity and specificity than ultrasound. Even with modification of the ultrasound characteristics, the physical examination still re­mained superior to ultrasound. VII. Interferon Therapy Durelli L, Verdun E, Barbero P, et al. Every- other- day inter­feron beta- lb versus once- weekly interferon beta- 1 a for multiple sclerosis: results of a 2- year prospective randomized multicenter study ( TNCOMTN). Lancet 2002; 359: 1453- 60. A trial was completed comparing the different inter­feron therapies for multiple sclerosis. The results indicate that interferon ( 3- lb therapy every other day is more effec­tive than weekly interferon ( 3- la. More patients who re­ceived interferon ( 3- lb remained relapse free, and remained free from new T2 lesions on MRI. The differences between the two treatment groups were more significant during the second year. VIII. Herpes Zoster Gnann JW, Whitley RJ. Herpes zoster. NEnglJMed 2002; 347: 340- 6. Clinical management of herpes zoster is discussed in this review. Over 90% of adults in the United States have serologic evidence of varicella- zoster virus infection with an annualized incidence of 1.5 to 3 cases per 1,000 persons. Postherpetic neuralgia is directly related with the patient's age. Oral antiviral therapy shortens the duration of viral shedding, halts formation of new lesions, and accelerates healing. While combination therapy with oral corticoste­roids accelerates the rate of healing, there was no effect on the incidence or duration of postherpetic neuralgia. While early institution of therapy is advisable, even those patients who present after 72 hours of symptoms may benefit from therapy. IX. Dural Sinus Thrombosis Friemel SP, Mackey DW, Fenves AZ, et al. Nephrotic syn­drome presenting as a dural sinus thrombosis. Am J Med 2002; 113: 258- 60. Thrombotic episodes have been reported in patients with established glomerular disease based on activation of the hemostatic system with a complex interplay between increased hepatic synthesis and intravascular consumption of coagulation factors and increased urinary loss of pro­teins. The levels of hemostatic factors normalize after clini­cal remission of the nephrotic syndrome. Anticoagulation may be difficult in patients with nephrotic syndrome. In this letter to the editor, a patient presented with neuro- ophthalmic signs as the first manifestation of ne­phrotic syndrome. An otherwise healthy 46- year- old pa­tient presented with accelerating headache and a cranial nerve VI palsy. Evaluation revealed a dural sinus thrombo­sis. Despite intravenous heparin, the dural thrombosis progressed, requiring superior sagittal sinus catheter-administered continuous tissue plasminogen activator infu­sion. He may have had minimal change nephropathy be­cause of the rapid resolution of the nephrotic syndrome with corticosteroid therapy. X. Mucormycosis Bienfang D, Karluk D. An 80- year- old woman with sudden unilateral blindness. NEnglJMed imi-^ m^^. In this clinical- pathologic conference of a pa­tient whose presentation suggested giant cell arteritis, addi­tional orbital symptoms and an arterial occlusion in the presence of sinus disease led to the correct diagnosis of rhi-noorbital mucormycosis. Congestive splenomegaly and Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 97 JNeuro- Ophthalmol, Vol. 23, No. 1, 2003 IN OTHER JOURNALS chronic pancytopenia with additional medical problems were contributory. XI. Antiphospholipid Antibody Syndrome Levine JS, Branch D, Rauch J. The antiphospholipid syn­drome. N Engl.) Med 2002; 346: 752- 63. This review nicely summarizes the information known about antiphospholipid antibodies, a family of au­toantibodies that exhibit a broad range of target specificities associated with a syndrome of hypercoagulability. The clinical criteria include vascular thrombosis with one or more clinical episodes of arterial, venous, or small- vessel thrombosis. The authors review a recent consensus state­ment that has simplified the criteria for diagnosis of the antiphospholipid syndrome to include at least one of two clinical criteria, vascular thrombosis or complication of pregnancy, and at least one of two laboratory criteria, anti-cardiolipin antibodies, or lupus anticoagulant antibodies. There is a beneficial role for anticoagulation in decreasing the rate of recurrent thrombosis. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 98 © 2003 Lippincott Williams & Wilkins