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Show /. Clin. Neuro-ophtfldlmol. 1: 83-84. l':jSI. Editorial The 1981 Frank Walsh Society Meeting The 13th .mnuJI m('('tin~ llf thl' fr,lIl" W.\lsh Society W.1S held in H,'ush1n. Te"ls, FC'bru.lry 2728, 1081 This SllCi<'tv \\',lS h\rnle'rly cliled th(' N('uro-ophth.llnll'll'~il·r.lthl\I,\~y 5ymp,\sium. ,'nd WJS well Jtlended by lWl'r 100 physi,'iJns p,HticuIdrly interested in the disdpline l,f neuHl-ophthJl. molotty· Th(' mE'('tin~ \\..lS held und('r th(' oluspices ,..,f B.1ylor University. with Dr. J0hn A. McCrilry, 111 olS hosl. This \\'JS thE' first meNin~ of this society thJ.t I h,)\'e personJ.lly J.1t('nded; it WdS pdrticul.Hly well run, J.nd l"d certJ.inly like to congr.,tuIJt(' Dr, McCrdry for a job well done, I thou~ht it mi~ht be of interest to our reolders t(, see J brief reviE'w of some of the "peolrls" gleilned from the meeling. The first pdper, "Steroid Responsive Blindness," WdS by Drs. John L. Keltner. Aloln M. Roth, olnd Cully A. Cobb. of Dolvis. CJlifornid. It WolS so terrific that I inlerviewed the dulhors on the currenl issue of Neuro-ophthJlmology Tdpes to help get the messdge out! They presented J 61-yNr-old woman who began 10 note foggy vision in one eyr in October 1978, who was found to have 20/25 right eye Jnd 20/200 left eye in Nov('mber 1978 with an afferent pupillary reaction on the left. Extensive laboratory and rddiologic studies were negative. The patient responded to oral prednisone so that by Janudry 1979 vision had improved in the left eye to 20/30. Subsequently dense ring scotomas were found in Ihe visual fields. dnd the steroids were tapered. In FebruJry 1979 a few cells were noted in the vitreous of both eyes, .lnd .1 beaten melal appearance WilS not('d 10 the retin.l in in both eyes The electroretinogram was photupically flat and scotopiCdlly very reduced in both eyes. The patient was followed carefully, and later a pelvic mass was identified dnd tredted with chemotherapy. The pdtient later died, Jnd histologic examination of tile' eyes r('ve.lled totJI de~cneration of the photoreceptors in both ey('s. This phenomenon-photoreceptor d('generJtion JS.J rl" mote effect of canc!?r on the retin.l-wd5 reportl'd with oat cell carcinomd of the lung in .l paper by Sawyer et al. (Am.). Ophlhdlmol. 18: 606, ]Q76). The point of the paper by Dr. Keltner ,md associates was that when you encounter <1 p.ltient with an unexplained "vitritis," an "<1cquired tJpetoretinal degeneration," subtll' fundus chdn~es, d!?nse ring scotomas, dnd with some r('sponse to steroids-thilt you must consider the pOSSibility June 1981 th.1t this is .l ro;>mot(' cffo;>ct of In occult mJli~ndnCY. Thl'ir pJtient hJd ('y(' compl.lints ov('r 8 months bl'fore tho;> pelvic mJli~niln,y Wils d('tect('d l This W.15 J hi~hly undifferentiJted tumor IhJt could be 5('('n Mi5ing from the uterino;> C('rvix <1t pelvic ('xJmin. 1tion, olnd d complete physical eX.lmination by dn oncologist thfo' dJy before the pelvic examinMion h.ld olhervYise been quite negativfo'. They found some dntibody in the outer retinJ by indirect immunofluorescence in this C<1se that was not found in .1 control retinol. These studies were quite prl'limin<1ry dnd will be extended, but the point for the practitioner is that when you begin to think of J similar case, .lsk more cdrdul questions about weight loss, menometrorrh.lgiJ, smoking, chest xray, .1I1d the like, dnd don't be satisfied with a consultation thJt r('ports "pelvic dnd rectJI-de( erred." My experience has been thJt this doesn't meJn the pelvic Jnd rectJI dre deferred, but simply not done. Dr. Neil R. Miller pre5l'nted an importdnt pdper. A 10-yeJr-old boy hJd 20/20 vision in ri~ht eye dnd 20/25 in left eye <1t J routine examin"tion. However, 14 months later, he began to note blurred vision in thl' left eye. EX.lminJtion then revl'JI('d 20/20 in right eye .lnd 20/200 in left eye with qucstiondble pJllor of the left disc. X-rJys rev('.lled In enlJrged optic CJndl on the left. and a computed tomogrdphic SC,lll showed J 1.1r~e left optic nl'rve. The diJ~nosis of optic gliom,l WJS m.ldfo'. The problem, howevN. W,ls th.ll I y('.u I.Jlfo'r, the lfo'ft <'ye vi5iCln W.15 20/-100; 1 y<"H .JftN tholt. thfo' left l'yl' visiCln W.15 1/200 ,md ,1 t('mPlH.11 cut W.1S now found in the fi{'ld of the rii:hl eyc. A r('p(',11 computed tomographic SCJn then showed the tUl1wr extendin~ .l1I the W,ly bJck fwm left Clplie nerve on through chiasm .lnd into third ventricle, A 1ivdy discussion foll,Hvl'd this p.lper. The p\lssibility of multic<'ntric ,'ri~in of thl'se ~liomJs WJS r.lised. Hllw<,v('r, in my opinion. this p.llient shou Id hJVo;> b('cn Opl'r.II<,d on ,It the sec,'lld f"lIowup, wh('n vision h.ld dropp<'d from 20/200 to 20/ 400 olnd tho;> tumor h.ld bCl'n sh(lI'vn to hJvfo' enl. lrged on foll\,w-up computed hmlO~rolphic SCdn. I believl' that m.lny \'ptic gliomJs .lrl." "bad Jclors," .lnd th.1t we now must move bdCk to ,I position of b<11dnce and opt'r<1te such CJses dS this long before things get to such d serious st.lle. Dr. Miller's p.1ti('nt hJd .1 crJniotomy Jnd .1 biopsy of the .3 Editori.JJ: Fr.Jnk W<llsh Society chiasm which WdS reported.Js "benign glioma," so th.Jt the di.Jgnosis W<lS histologicJlIy established in his p.1tient. There were many, m.Jny other good papers presented ..It the meeling ,Ind cert.Jinly not ,III of these could be summ.Hized hert'. I me,ln no offcnse at .111 to thosc whose p,lpers .Jrt' not revicwed, and indeed I did not he.Jr .J1I of the Cilses prescnted. The c.Jses w('re so f.lnt<lstic th.Jl one could get "br.Jin f,1Iigue" if he stayed in the met·ting too long! Dr. D. W_ Lwei of Indi<ln<lpolis reported a 56yc, lT-old white woman who had biopsy of an exophytic optic nerve she.lth meningiom.l in the intr.lcrdnial optic nerve segment in Decemb('r 1977. The patient was treJted with 6()(X) rads of radiation therapy postoperatively. The visual fields improved, and the patient's acuity at the time of 3yeu follow-up was 20/15. This was cert.linly a nicely documented case of an optic nerve sheath meningioma that responded well to irradiation therapy! Dr. Thomas L. Slamovits and associates pre~ sented a 59-year-old woman with .l I~year history of head.lches. Skull x-rays revealed an enluged sella. Three months after onset of headaches, the p.ltient developed herpes zoster ophthalmicus on the right and experienced a sudden loss of vision in the right eye. The computed tomographic scan was repeated and showed an enhancing sellar and suprasellar mass. The serum prolactin was 172 and laboratory studies also showed p.lnhypopituitarism. The patient had a huge aneurysm on the right-filling the selJa! In other words, this was a "full empty sella"! Immediately postoperatively, the prolactin was 177; 1 month later it was 70.2, and 3 months later it was down to 6.7. There was no prolactinoma in this patient. Therefore, the old adage that if the serum prolactin is over 100. the patient must have a prolactinoma-although an excellent general rule-seemed to have an exception in this patient. One might want to study the prolactin levels on a series of patients with herpes zoster as well. Dr. R. L. Sogg reported a patient with a large suprasellar mass, a serum prolactin of 219, and the patient had stopped breastfeeding of a newborn only 3 months before that figure, who was found to have G.lgel's granuloma. Dr. Nancy Newman presented a 33-year-old woman physician who presented with bil.lteral visUJI loss in the 37th week of pregnancy ,md W.lS found to have lymphoid adenohypophysitis when d trans-sphenoidal operation was performed after delivery. An impor~ tant reference is by one of our editors, Dr. Robert M. Quencer. His paper, "lymphocytic Adenohypophysitis: Autoimmune Disorder of the Pituitary Gland," was published in the Amcric.1n 10um,11 of N('uror~ld;olonY [1(4): 343-345, July/August 101"0°1_ Il, IJtJenc('r reported.l 25-year-old woman, gravida 5, para 5, who was seen 5 months postpartum with headaches, weight gain, amenorrhea, and galactorrhea. Serum prolactin was 60 (normal 525), and skull films revealed an enlarged sella with erosion of the dorsum. A computed tomographic scan showed an enhancing intrasellar mass with no suprasellar or parasellar extension. Because a pituitary .ldenoma was suspected, a trans-sphenOidal operation was performed. Pathologic examination of the tissue removed revealed a lymphocytic infiltration of adenohyphysis characterized by lymphoid follicles, bands of fibrosis, and well-differentiated lymphocytes. The patient did wef[galactorrhea and headaches disappeared and the serum gammaglobulin and prolactin levels returned to normal. This was the sixth reported case of lymphocytic adenohypophysitis and is an entity that must be considered in the differential diagnosis of a pituitary tumor when seen in a young woman in the postpartum state. Drs. Costin, Sweeney, and Tomsak reported a 65-year-old farmer with giant-cell arteritis on temporal artery biopsy associated with multiple intracranial and extracranial aneurysms. They reminded us that the causes for multiple aneurysms include: I) arteriosclerosis, 2) trauma, 3) syphilis, 4) contiguous infection, 5) cystic medial necrosis, 6) fibromuscular dysplasia, 7) Marfan's syndrome, 8) pseudoxanthoma elasticum, and 9) polyarteritis nodosa. Finally, it seemed that many of the cases were due to various forms of unusual lymphomas, and histiocytosis, and there were also many fascinating and unusual cases of bilateral carotid aneurysms. Dr_ Nick R. Bryan of Houston gave an interesting talk on "Neuroradiology Update" and gave a particularly interesting talk on the technique of nuclear magnetic resonance. That seems to be something for the future, and I hope that we can get Dr. Bryan to write up a feature on that topic for a future issue. In the last analysis, as technology explodes with complicated and expensive advances, it is evident that we are going to have to become better physicians- to know whdt specific studies to order and under what circumstances they are indicated. It seems that neuro-ophthalmology is reaUy just beginning to take off as a particular discipline, and the interest in this field really could not hdve been ,mticipated, by me dt least, when I started becoming interested in it in 1955. Please let us hear from you with suggestions as to the type of papers and presentations that you want in this Joumal. This is because Proverbs 2:5 tells us: "A wise man will hear, and will increase learning: and a man of understanding shall attain unto wise counsels." Therefore, we want to hear from you, so that we can continue to learn how to better help our patients- together! J. Lawton Smith, M.D. Journal of Clinical Neuro-ophtnalmology |