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Show 2. Hsuan JD, Selva D, McNab AA, Sullivan TJ, Saeed P, O'Donnell BA. Idiopathic sclerosing orbital inflammation. Arch Ophthalmol. 2006;124:1244-1250. 3. Rootman J, McCarthy M, White V, Harris G, Kennerdell J. Idiopathic sclerosing inflammation of the orbit. A distinct clinicopathologic entity. Ophthalmology. 1994;101:570-584. 4. Liu CH, Ma L, Ku WJ, Kao LY, Tsai YJ. Bilateral idiopathic sclerosing inflammation of the orbit: a report of three cases. Chang Gung Med J. 2004;27:758-765. 5. Brannan PA. A review of sclerosing idiopathic orbital inflammation. Curr Opin Ophthalmol. 2007;18:402-404. 6. Berry-Brincat A, Rose GE. Idiopathic orbital inflammation: a new dimension with the discovery of immunoglobulin G4-related disease. Curr Opin Ophthalmol. 2012;23:415-419. 7. Cheuk W, Yuen HK, Chan AC, Shih LY, Kuo TT, Ma MW, Lo YF, Chan WK, Chan JK. Ocular adnexal lymphoma associated with IgG41 chronic sclerosing dacryoadenitis: a previously undescribed complication of IgG4-related sclerosing disease. Am J Surg Pathol. 2008;32:1159-1167. Intracranial Hypertension in a Patient Preparing for Gestational Surrogacy With Leuprolide Acetate and Estrogen We read with great interest the editorial (1) and series of articles dealing with intracranial hypertension recently published in the Journal of Neuro-Ophthalmology. Gestational surrogacy, the process by which a genetically unrelated woman is implanted with an embryo, requires preparation with leuprolide acetate and estrogen. It is increasing as a management option for infertility. Intracra-nial hypertension is a rare adverse effect of sterility manage-ment with leuprolide acetate occurring after months or years of administration. We evaluated a 23-year-old mul-tiparous woman being prepared for gestational surrogacy with injections, daily leuprolide acetate and twice weekly estrogen, who developed intracranial hypertension within 7 days of starting therapy. She developed gradual onset of holocephalic pounding headache that increased in intensity over the course of 1 week and was made worse by maneu-vers that increase intracranial pressure such as laying flat. She also had blurry vision and binocular horizontal diplo-pia. She had been on this regimen the previous year for gestational surrogacy and tolerated it well. She was not obese and her weight had been stable. Visual acuity was 20/20, right eye, and 20/25, left eye, with normal color vision (Hardy-Rand-Rittler plates) and confrontation visual field testing. Extraocular movements demonstrated a right sixth nerve paresis, and funduscopy revealed bilateral optic disc swelling. Brain magnetic reso-nance imaging and MR venography were normal. Lumbar puncture was significant for an opening pressure of 440 mm of water. Closing pressure was 100 mm of water following removal of 20 mL of cerebrospinal fluid. Her headache improved immediately after the lumbar puncture and con-tinued to improve following cessation of hormone therapy. Leuprolide acetate is a synthetic gonadotrophin-releasing hormone or luteinizing hormone-releasing hor-mone analog used to treat sterility in women and prostate cancer in men (2). More recently, it has been used for gestational surrogacy. There are 2 reports describing in-tracranial hypertension in patients taking leuprolide, one in a patient on pulsatile pump for 2 years for sterility management and in another following discontinuation of the drug after 5 months of treatment (3,4). Fraunfelder and Edwards (5) suggested that cases in their review lacked sufficient data to determine whether intracranial hyperten-sion was due to leuprolide. In contrast, we documented intracranial hypertension occurring within 7 days of initiating treatment with leupro-lide. The role of the two doses of estrogen she received and of previous treatment from previous gestational surrogacy is unclear. Although our patient was in the age group affected by idiopathic intracranial hypertension, she did not have associ-ated comorbid conditions such as obesity or recent weight gain (6,7). Additionally, she improved rapidly with discontin-uation of hormonal therapy suggesting that daily leuprolide likely induced the intracranial hypertension. Considering the increasing numbers of gestational surrogacy, the lack of similar case reports would imply that intracranial hypertension is a rare occurrence in this context. However, this diagnosis should be considered if a patient being prepared for surrogacy has new onset of headache, and a fundus examination should be performed to look for papilledema. Joshua Alexander, DO, MPH Department of Neurosciences University of California San Diego San Diego California joalexander@ucsd.edu Leah Levi, MBBS Departments of Ophthalmology and Neurosciences University of California San Diego San Diego California The authors report no conflicts of interest. 310 Letters to the Editor: J Neuro-Ophthalmol 2013; 33: 307-318 Letters to the Editor Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. REFERENCES 1. Wall M. Idiopathic Intracranial Hypertension and the Idiopathic Intracranial Hypertension Treatment Trial. J Neuroophthalmol. 2013;33:1-3. 2. Micromedex Healthcare Series. Greenwood Village, CO: Thomson Reuters Healthcare Inc. Available at: http://roger.ucsd. edu:80/record=b4385157~S9. Accessed August 28, 2012. 3. Arber N, Shirin H, Fadila R, Melamed E, Pinkhas J, Sidi Y. Pseudotumor cerebri associated with leuprorelin acetate. Lancet. 1990;335:668. 4. Boot J. Pseudotumor cerebri as a side effect of leuprorelin acetate. Irish J Med Sci. 1996;165:60. 5. Fraunfelder F, Edwards R. Possible ocular adverse effects associated with leuprolide injections. JAMA. 1996;273: 773-774. 6. Digre K. Idiopathic intracranial hypertension headache. Curr Pain Headache Rep. 2002;6:217-225. 7. Biousse V, Bruce B, Newman N. Update of the pathophysiology and management of idiopathic intracranial hypertension. J Neurol Neurosurg Psychiatry. 2012;83:488-494. Pseudo-doubling of Optic Disc in a Case of Proliferative Diabetic Retinopathy True optic disc duplication with 2 independent retinal vasculatures is rare (1). Lesions reported to simulate the optic disc include colobomas and inflammatory foci (2-4). We report a case of pseudo-optic disc doubling in a patient with proliferative diabetic retinopathy (PDR). A 38-year-old man with advanced PDR and visual acuity of 20/400 in each eye was examined in our clinic. Fundus examination revealed retinal hemorrhages and fibrovascular proliferation over the optic disc and along the vascular arcades in both eyes. A disc-like structure was FIG. 1. An optic disc-like structure is present along the superotemporal vascular arcade. The media is hazy due to vitreous hemorrhage. FIG. 2. A. Fluorescein angiogram (venous phase) shows that the blood vessels emerging from the pseudo-disc are actually continuation of those arising from the true optic disc. B. Fluorescein angiogram (late phase) demonstrates leakage from new vessels overlying both the true and pseudo-optic discs. Letters to the Editor: J Neuro-Ophthalmol 2013; 33: 307-318 311 Letters to the Editor Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
