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Ophthalmic Artery Blood Flow in Humans

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Ophthalmic Artery Blood Flow in Humans EDITORIAL 1197 Br J Ophthalmol: first published as 10.1136/bjo.86.11.1198 on 1 November 2002. Downloaded from Ophthalmic artery blood flow can be identified, but in many others ................................................................................... only a very short segment can be seen at any one time. Although the authors state “there is no need for assumptions about Ophthalmic artery blood flow in turbulence of flow,” “since each pixel within the image of moving blood humans contains a single velocity measurement,” we still remain concerned that turbu- T R Hedges lence of blood flow within the ophthal- mic artery may add another source of ................................................................................... error especially with regard to velocity The tortuosity and the variable course of the ophthalmic artery measurements. Furthermore, the oph- thalmic artery contains many branches, remain a problem which are also known to affect blood flow velocity. fforts to analyse the complex vascu- contains many branches. Among differ- A variety of other issues have been lature of the eye have been frustrat- ent individuals, ophthalmic arteries also raised by others involved in attempting Eing to say the least. We still must have large variations in size and configu- to measure blood flow velocity using rely very much on fluorescein angio- ration, which will inherently make com- Doppler ultrasound. These include non- graphy. Laser Doppler flowmetry has not paring blood flow between different uniform insonation of the blood vessel, yet yielded the results that had been patients subject to error. These issues differential attenuation between soft tis- hoped for. The same has been true of col- require that the technicians performing sue and blood, intrinsic spectoral broad- our Doppler imaging. In a recent attempt each study employ a great deal of ening, frequency dependent scattering, on my part to make sense of many tech- judgment, which in turn adds another high pass filtering designed to reduce niques used to study the circulation of layer of variability to any study, espe- high amplitude, low frequency, Doppler the optic nerve, my conclusion was that cially if this technique is to be applied to shifts due to vessel wall motion, sheer much work still needs to be done.1 Harris patients with disease. rate and haematocrit, as well as poor sig- and colleagues are to be commended for With regard to size of the artery, previ- nal to noise ratio.2 relentlessly struggling to find better ous efforts to measure blood flow, using Although Ogre et al show that blood ways to determine how blood flow can similar methods employed by Ogre et al, flow within the ophthalmic artery can be change under a variety of clinical set- have been made with veins, particularly estimated, variability, due to the small tings using several techniques, especially shunts for renal dialysis. Even with this numbers generated from changes colour Doppler imaging. application, accuracy is limited. With measured in small arteries, limits colour Until recently, colour Doppler imaging respect to measuring arteries elsewhere Doppler imaging to more qualitative has been limited to visualising blood in the body, there is evidence that large rather than accurate quantitative analy- vessels may be accurately measured. vessels, identifying direction of blood sis of ophthalmic artery blood flow. Even However, the error in measuring smaller flow, and calculating blood velocity only. if the resolution of the method could be vessels is obvious. In one study, mean Pulsatility and resistive indices provide refined, the problem of the tortuosity flow and standard errors in the common indirect evidence of resistance at or and the variable course of the ophthal- femoral artery was calculated to be 284 nearby the ultrasound probe, but volu- mic artery remains an issue. Finally, http://bjo.bmj.com/ (SE 21) ml/min, whereas in the dorsalis metric blood flow (amount of blood/ 2 blood flow in any blood vessel is subject pedis it was 3 (1) ml/min. As Orge et al to systemic haemodynamics. Harris and time) has not been measurable. The point out, one is limited to measuring his coworkers may have reached the main problem with accurately assessing only a very few pixels on the screen. With point where blood flow can be measured the orbital vessels has been the small size regard to an artery as small as the of the ophthalmic artery and especially ophthalmic artery, which is about 2 mm in the ophthalmic artery to a limited the central retinal and ciliary arteries. In in diameter, one is basically counting degree. However, at this time, we should the paper by Orge et al in this issue of the about 10 pixels. If one considers that remain cautious regarding application of on September 29, 2021 by guest. Protected copyright. BJO (p 1216) the ophthalmic artery, converting a diameter measurement to this method to clinical studies. because of its relatively larger size, was the measurement of area, the error Br J Ophthalmol 2002;86:1197 measured with regard to diameter in would be squared. When we attempted order to calculate volume and, ulti- to measure ophthalmic artery diameter ..................... mately, blood flow. However, it is evident in our own laboratory, we found that Author’s affiliations that these investigators are still wrestling repeated measurements could easily be T R Hedges, Tufts University School of with considerable variability in measure- wrong by at least one or two pixels. We Medicine, New England Medical Center, ments within their own laboratory. do not have the advantage of the Boston, Massachusetts, USA The limitations of the authors’ meth- modified software that Ogre et al refer to ods are reflected in their interobserver in their paper, but even when we REFERENCES coefficients of variability of 40% and employed a new technique called “B 1 Hedges TR. Assessing the vascular supply of intraobserver variability of almost 30% the optic disc. Presented at the North flow,” our accuracy in measuring oph- American Neuro-ophthalmology Society for calculations of blood flow. This wide thalmic artery diameters was still, in our Meeting, Rancho Mirage, California, 21 range of measurements may simply have opinion, poor. February 2001. been due to the small size of the The ophthalmic artery is also quite 2 Holland CK, Brown JM, Scoutt LM, et al. Lower extremity volumetric arterial blood flow ophthalmic artery, but it may also be due tortuous. In some individuals a consist- in normal subjects. Ultrasound Med Biol to its tortuous course and the fact that it ently measurable segment of the artery 1998;24:1079–86. www.bjophthalmol.com 1198 EDITORIAL Br J Ophthalmol: first published as 10.1136/bjo.86.11.1198 on 1 November 2002. Downloaded from Optic nerve sheath meningiomas the lesion, whereas the technique de- ................................................................................... scribed by the authors is basically the same as conventional fractionated radia- tion therapy (for example, 1.8–2 Gy per The evolving management of optic day to a total dose of about 50 Gy), except that much more precise delivery nerve sheath meningiomas of radiation is achieved through use of a three dimensional stereotactic system, N R Miller thus reducing the extent of spread of radiation and, therefore, the potential for ................................................................................... damage to surrounding structures, par- Consider using stereotactic fractionated irradiation ticularly the globe, the optic chiasm, and the contralateral optic nerve. In their study, Pitz et al found that over a mean he management of optic nerve tamoxifen (an anti-oestrogen agent) and follow up period of 37 months after sheath meningiomas (ONSMs) has mefipristone (an antiprogesterone completion of treatment, there was no Tbeen a controversial and sometimes agent), have been disappointing. Thus, evidence of tumour growth or extension, contentious issue for a number of until recently, the most popular manage- none of the treated seeing eyes experi- reasons. In the first place, these tumours ment options for a patient with a enced deterioration of vision, and several are not associated with any mortality or presumed ONSM have been observation eyes improved with respect to visual significant neurological morbidity. In the without intervention and surgical exci- acuity, visual field, or both. Perhaps, most second place, although they theoretically sion of the tumour along with the optic importantly, none of the radiated eyes can spread across the planum sphenoi- nerve. developed radiation retinopathy or optic 1 dale to affect the opposite optic nerve, Earlier this year, Turbin et al provided neuropathy, and none of the contra- they rarely do so and, thus, almost never substantial data indicating that conven- lateral eyes showed evidence of radiation cause loss of vision in the opposite eye. tional fractionated radiation therapy is a injury. Although the follow up period The major manifestation of ONSMs, better treatment for ONSMs than either may have been too short to observe therefore, is monocular visual loss, and surgery or no intervention. Although spread of an inadequately treated other authors had reported similar their management should reflect these 23 tumour or to observe any major ocular issues. results, the study by Turbin et al is the complications of the radiation, the re- Because primary ONSMs arise from most comprehensive to date. Over a sults of Pitz et al suggest that stereotactic mean follow up period of 10 years, the the arachnoid cap cells surrounding the fractionated radiation therapy for ONSM patients in their study who received con- intracanalicular or intraorbital portions may produce a better long term visual ventional fractionated radiation therapy of the nerve, they almost always are inti- result with fewer vision threatening side alone had a substantially better visual mately associated with the nerve and effects than conventional fractionated outcome than did patients who were tend to surround the nerve by the time radiation therapy. If this is truly the case, observed without intervention or pa- they become clinically apparent.
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