Browsing by Author "Micieli, Jonathan A."
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Item Cat Scratch Disease Presenting with Right Branch Retinal Artery Occlusion and Left Neuroretinitis(Karger, 2024-08-12) Jafari, Samira; Micieli, Jonathan A.Introduction: Bartonella henselae, the causative agent of cat scratch disease (CSD), presents with diverse ocular manifestations, posing diagnostic challenges. This study aimed to elucidate the diagnostic complexities through a unique case. Case Presentation: A 42-year-old male presented with vision loss in the right eye, subsequent to flu-like symptoms following exposure to a stray kitten. Clinical examination revealed branch retinal artery occlusion (BRAO) in the right eye and neuroretinitis in the left, indicating concurrent ocular manifestations of CSD. Thorough investigations, including serological testing, ruled out alternative causes, highlighting the rarity of such coexisting ocular complications. Conclusions: The coexistence of BRAO and neuroretinitis in different eyes underscores the variable presentation of CSD. Recognition of infectious etiologies, particularly Bartonella, is paramount in diagnosing ocular vasculopathies. This case emphasizes the importance of considering Bartonella infection in patients with ocular vascular occlusions, especially in the context of recent cat exposure and systemic symptoms suggestive of CSD.Item The Development of Indirect Carotid Cavernous Fistulas after Microvascular Ischemic 4th Nerve Palsies(2022-12) Pickel, Lauren; Micieli, Jonathan A.An indirect carotid cavernous fistula (CCF) is an abnormal connection between the cavernous sinus and internal or external carotid artery. Indirect CCFs often occur spontaneously, particularly in the setting of vascular risk factors such as hypertension, diabetes, and atherosclerosis. Microvascular ischemic nerve palsies (NPs) share these vascular risk factors. However, to date, no temporal relationship between microvascular ischemic NP and indirect CCF occurring sequentially has been reported. We describe the cases of 64- and 73-year-old women who developed indirect CCFs within 1–2 weeks after spontaneous resolution of a microvascular ischemic 4th NP. Both patients had complete resolution and an asymptomatic period between the 4th NP and CCF. This case highlights the shared pathophysiology and risk factors between microvascular ischemic NPs and CCFs, and emphasizes that CCFs should be kept in the differential diagnosis for red eye or recurrent diplopia in patients with previous microvascular ischemic NP.Item Factors influencing visor use among players in the National Hockey League (NHL)(Dove Press, 2014) Micieli, Robert; Micieli, Jonathan A.Eye, orbital, and facial injuries are significant risks to National Hockey League (NHL) players, and can be mitigated by the use of a partial visor - currently optional for all non-rookie players. The goal of the current study was to determine the overall use of visors among non-rookie NHL players in the 2013-2014 season and assess factors influencing their uptake. This was an observational, cross-sectional study using active NHL rosters and demographic information obtained from the official NHL website. Visor use was determined based on in-game video or images at two different time points in the 2013-2014 season. The use of visors during the 2013-2014 season was 75.2% among non-rookie players. When rookies were included, the overall use of visors was 77.8%. Compared to Canadian-born players, European players were significantly more likely to choose to wear a visor (odds ratio [OR] 3.48, 95% confidence interval [CI] 1.96-6.17). Players in the younger age-groups, particularly those younger than 24 years (OR 5.67, 95% CI 2.52-5.76) and those between 24 and 28 years (OR 2.18, 95% CI 1.23-3.87), were more likely to wear a visor compared to older players. Overall, visor use continues to grow in the NHL independently of new legislation, and is more likely in younger players and those of European origin.Item Hemodialysis-Related Vision Loss from Anterior Ischemic Optic Neuropathy(2022) Eshtiaghi, Arshia; Micieli, Jonathan A.Vision loss from nonarteritic anterior ischemic optic neuropathy (NAION) is a rare complication of hemodialysis. Here, we present a case in a young woman and discuss the pathophysiology and implications for the nephrologist. A 24-year-old woman with end-stage renal disease developed unilateral, painless vision loss following treatment with hemodialysis. Fundoscopy revealed severe left inferior chalky-white opticdisc edema, a presentation consistent with NAION. Her intradialytic blood pressure was reviewed and found to be significantly lower than her baseline, and a multidisciplinary meeting took place between her ophthalmologist and nephrologist to modify her dialysis sessions to minimize the chance of progression or involvement of her fellow eye. At the 2-month follow-up, the opticdisc edema resolved, and her visual function remained stable. Overall, NAION is a rare complication of hemodialysis and may be a result of intradialytic hypotension, platelet and endothelial dysfunction, anemia, and accumulations of toxins such as urea. As there are no established treatments for NAION, management should focus on optimizing modifiable risk factors to prevent further vision loss in the other eye. These factors include increasing the number of dialysis sessions and duration of sessions, reducing the temperature of the dialysate, discouraging eating, and increasing the dialysate’s calcium concentration. Prompt recognition of NAION and multidisciplinary teamwork can minimize the risk of NAION progression and involvement of the contralateral eye.Item Mitochondrial Neurogastrointestinal Encephalopathy Disease: A Rare Disease Diagnosed in Siblings with Double Vision(Karger, 2021-04-12) Farahvash, Armin; Kassardjian, Charles D.; Micieli, Jonathan A.Mitochondrial neurogastrointestinal encephalopathy disease (MNGIE) is a rare autosomal re- cessive condition characterized by gastrointestinal dysmotility, external ophthalmoplegia, leukoencephalopathy, and sensorimotor neuropathy. A 31-year-old man was referred for a 1-year history of horizontal diplopia related to a large exotropia from chronic progressive ex- ternal ophthalmoplegia. MRI revealed a diffuse leukoencephalopathy and his 3-year history of chronic intermittent diarrhea, cachexia, and diffuse sensory more than motor peripheral neuropathy led to a unifying clinical diagnosis of MNGIE. This was later confirmed with ge- netic testing, which revealed a homozygous pathogenic mutation in the thymidine phosphor- ylase (TYMP) gene. His younger brother had an identical clinical syndrome and was similarly diagnosed. MNGIE diagnosis is important to establish to avoid unnecessary invasive testing for gastrointestinal, ophthalmological, and neurological symptoms and to ensure patients receive appropriate nutritional and genetic counselling. Gene therapy offers a potential future therapy for patients with this condition.Item Optical Coherence Tomography Abnormalities as the Presenting Sign of an Involuted Sellar/Suprasellar Mass(Karger, 2024-10-25) Vosoughi, Arshia; Micieli, Jonathan A.Introduction: Pituitary adenomas are benign tumours that can lead to visual loss through compression of the optic chiasm. Patients with pituitary adenomas often present with visual field defects (commonly bitemporal hemianopia), but some may be asymptomatic. In such cases, abnormalities may only be detected through visual field testing or optical coherence tomography (OCT) of the ganglion cell-inner plexiform layer (GCIPL), which may provide a more sensitive method for detecting such abnormalities. Case Presentation: A 72-year-old man was incidentally found to have binasal OCT-GCIPL thinning during a routine eye examination. Visual acuity was 20/20 in both eyes. Pupils were equal and reactive without a relative afferent pupillary defect. His Humphrey 24-2 SITA-Fast visual field test results were normal. A magnetic resonance imaging (MRI) revealed a nonenhancing (cystic) sellar/suprasellar mass measuring 1.7 cm craniocaudal by 2.1 cm anteroposteriorly, without associated optic chiasm compression. The lesion was suspected to be either a cystic pituitary adenoma or a Rathke’s cleft cyst. Follow-up examination 1 year later showed all findings remained stable, including an unchanged visual acuity, visual fields, OCT-GCIPL, and MRI. Conclusion: The binasal thinning observed on OCT-GCIPL in this case, despite the absence of chiasmal compression on MRI, is suggestive of previous compression of the optic chiasm. This case highlights the potential for spontaneous regression of pituitary adenomas and underscores the importance of OCT-GCIPL as a vital tool for detecting optic chiasmal damage.Item Resolution of Fulminant Idiopathic Intracranial Hypertension Treated with Acetazolamide(2022-12) Srivastava, Ojas; Micieli, Jonathan A.Idiopathic intracranial hypertension (IIH) is a condition of elevated intracranial pressure commonly seen in obese women of childbearing age. Fulminant IIH is a rare subset of IIH that is characterized by rapidly progressive vision loss in less than 4 weeks, and typically requires surgical intervention for treatment. We describe a 36-year-old man with a 3-week history of acute onset vision loss and fulminant IIH in whom severe bilateral hemorrhagic optic disk edema was identified. There were also associated moderate visual field defects. Given the rapid onset of symptoms and severity of papilledema, surgical management was discussed but the patient had opted for medical management and close follow-up. He began oral acetazolamide, which was escalated to the maximal dose of 4 g and seen regularly with close follow-up. Four months after presentation, he was completely symptom free and the bilateral optic disk edema had resolved. His visual fields had also improved . We emphasize the importance of close follow-up in fulminant IIH and highlight that although most cases often require surgical intervention, some patients may show improvement with medical management only.Item Superior Division Third Nerve Palsy as the Presenting Sign of Metastatic Breast Cancer(2022) Vosoughi, Amir R.; Micieli, Jonathan A.The third cranial nerve divides into superior and inferior branches at the level of anterior carotid sinus and superior orbital fissure. In extremely rare scenarios, metastatic lesions at this location may present with divisional third nerve involvement. We here describe an 85-year-old woman who presented with superior division third nerve palsy due to breast cancer metastasis. Our case demonstrates the rare presentation of double vision and ptosis because of superior division third nerve palsy. The differential diagnosis for this examination finding should include metastatic disease even in the absence of a known cancer diagnosis. This case also reiterates that the “rule of the pupil” should not be applied to superior division third nerve palsy.Item Transient Visual Obscurations as the Presenting Symptom of Papilledema from COVID-19-Related Cerebral Venous Sinus Thrombosis(Karger, 2022) Cioana, Milena; Ranalli, Paul J.; Micieli, Jonathan A.Coronavirus disease-19 (COVID-19) patients are at an increased risk of cerebral venous sinus thrombosis (CVST). Rapid diagnosis and treatment are vital to ensure a favorable outcome for CVST, so clinicians need to be aware of all its potential presentations. We describe a unique case where transient visual obscurations (TVOs) from papilledema were the presenting symptoms of COVID-19-related CVST. A 43-year-old woman, who had tested positive for severe acute respiratory syndrome coronavirus-2 1 month earlier, developed holocephalic headache, TVOs, and bilateral disc edema. She did not seek medical attention until she developed TVOs. Visual acuity was 20/20 and Humphrey visual field testing showed enlarged blind spots in both eyes. She was diagnosed with papilledema and underwent magnetic resonance imaging and magnetic resonance venography of the brain, which revealed right transverse sinus thrombosis. Lumbar puncture was performed, showing elevated opening pressure and normal cerebrospinal fluid contents. Her optic disc edema resolved and visual function remained normal 6 weeks following warfarin and topiramate therapy. Recanalization of the right transverse sinus occurred after 3 months. Although rare, TVOs are important presenting symptoms of COVID-19-related CVST. Ophthalmologists, who may be the first physicians to assess patients with this presentation, should be aware of TVOs as potential presenting symptoms of CVST, so diagnoses can be made in a timely manner.