children with neurofibromatosis type 1: a minute. The patient’s blood pres- longitudinal study. J Pediatr. 1994;125:63- Transient Cortical Blindness sure was controlled with low-dose 66. 3. Balcer LJ, Liu GT, Heller G, et al. Visual loss With Leptomeningeal oral metoprolol. in children with neurofibromatosis type 1 and Enhancement After After the procedure, the patient optic pathway gliomas: relation to tumor lo- Attempted Peripherally complained of progressive visual cation by magnetic resonance imaging. Am J Inserted Central Venous loss, headache, and malaise, which Ophthalmol. 2001;131:442-445. progressed to complete binocular 4. Poussaint TY, Barnes PD, Nichols K, et al. Catheter Placement Diencephalic syndrome: clinical features and visual loss during the ensuing 4 imaging findings. AJNR Am J Neuroradiol. 1997; hours. Ophthalmic examination re- 18:1499-1505. Transient cortical blindness is an in- vealed no light perception vision 5. Dutton JJ. Gliomas of the anterior visual frequent complication of endovas- bilaterally and briskly reactive pu- pathway. Surv Ophthalmol. 1994;38:427-452. 1-3 6. Hoyt WF, Meshel LG, Lessell S, et al. Malig- cular procedures. We describe a pils, without a relative afferent nant optic glioma of adulthood. Brain. 1973; patient who developed transient cor- pupillary defect. The anterior seg- 96:121-132. tical blindness associated with fo- ment, extraocular motility, and di- 7. Djalilian HR, Shah MV, Hall WA. Radio- cal leptomeningeal enhancement on lated funduscopy findings were nor- graphic incidence of multicentric malignant gliomas. Surg Neurol. 1999;51:554-558. contrast-enhanced T1-weighted mal in each eye. Findings from the 8. Van Tassel P, Lee YY, Bruner JM. Synchro- magnetic resonance imaging (MRI) remainder of the neurologic exami- nous and metachronous malignant gliomas: CT following attempted placement of a nation were otherwise normal. findings. AJNR Am J Neuroradiol. 1988;9:725- peripherally inserted central ve- Contrast-enhanced MRI ob- 732. 9. Spoor TC, Kennerdell JS, Martinez AJ, et al. nous catheter (PICC). tained 4 hours after the onset of vi- Malignant gliomas of the optic nerve pathways. sual loss revealed focal leptomenin- Am J Ophthalmol. 1980;89:284-292. Report of a Case. A 57-year-old geal enhancement in the occipital 10. Taphoorn MJ, Willemien AE, de Vries-Knoppert woman with metastatic carcinoma lobes and superior cerebellum WA, et al. Malignant optic glioma in adults. of the colon, which had spread to the (Figure 1). Diffusion-weighted im- J Neurosurg. 1989;70:277-279. 11. Barbaro NM, Rosenblum ML, Maitland CG, et al. liver and peritoneum, was hospital- ages showed no evidence of ische- Malignant optic glioma presenting radiologi- ized for partial small-bowel obstruc- mia, and magnetic resonance angi- cally a ‘cystic’ suprasellar mass: a case report tion. Placement of a PICC for total ography demonstrated normal and review of the literature. Neurosurgery. 1982; parenteral nutrition (TPN) was at- cerebral vasculature. 11:787-789. 12. Condon JR, Rose FC. Optic nerve glioma. Br J tempted with inadvertent cannula- Lumbar puncture showed an el- Ophthalmol. 1967;51:703-706. tion of the brachial artery and infu- evated protein level of 119 mg/dL 13. Gibberd FB, Miller TN, Morgan AD. Glioblas- sion of 10 mL of nonheparinized and a normal glucose level of 81 toma of the optic chiasm. Br J Ophthalmol. 1973; normal saline. The catheter was mg/dL with a normal opening pres- 57:788-791. 14. Hamilton AM, Garner A, Tripathi RC, et al. promptly removed; however, the sure. No atypical cells or white blood Malignant optic nerve glioma. Br J Ophthalmol. patient began to complain of cells were seen. The results for ce- 1973;57:253-264. blurred vision in each eye approxi- rebrospinal fluid cultures and blood 15. Harper CG, Steward-Wynne EG. Malignant op- mately 15 minutes after the at- cultures were negative. Twenty- tic gliomas in adults. Arch Neurol. 1978;35: tempted PICC placement. During four hours after the onset of visual 731-735. 16. Danesh-Meyer HV, Savino PJ, Sergott RC. the procedure, the patient was hy- loss, the patient experienced 2 gen- The prevalence of cupping in end-stage arte- pertensive and tachycardic with a eralized seizures, which were con- ritic and nonarteritic anterior ischemic optic blood pressure of 170/120 mm Hg trolled with intravenous dexameth- neuropathy. Ophthalmology. 2001;108:593- and a heart rate of 120 beats per asone and phenytoin. 598. 17. Abu el-Asrar AM, al Rashaed SA, Abdel Gader AG. Anterior ischaemic optic neuropathy as- sociated with central retinal vein occlusion. Eye. 2000;14:560-562. 18. Repka MX, Savino PJ, Schatz NJ, Sergott RC. Clinical profile and long-term implications of anterior ischemic optic neuropathy. Am J Ophthalmol. 1983;96:478-483. 19. Ischemic Optic Neuropathy Decompression Trial Research Group. Optic nerve decompres- sion surgery for nonarteritic anterior ische- mic optic neuropathy (NAION) is not effec- tive and may be harmful. JAMA. 1995;273: 625-632. 20. Lee AG, Eggenberger ER, Kaufman DI, Man- rique C. Optic nerve enhancement on mag- netic resonance imaging in arteritic ischemic optic neuropathy. J Neuroophthalmol. 1999; 19:235-237. 21. Fivgas GD, Newman NJ. Anterior ischemic op- tic neuropathy following the use of a nasal decongestant. Am J Ophthalmol. 1999;127: 104-106. Figure 1. Sagittal (left) and axial (right) contrast-enhanced T1-weighted magnetic resonance images reveal focal leptomeningeal enhancement (arrows) in the occipital lobes and superior cerebellum, and an old right basal ganglia infarct.

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Infection Bacterial meningitis Spirochetal meningitis (Lyme disease, neurosyphilis) Tuberculous meningitis Fungal meningitis (Aspergillus, Cryptococcus, Coccidioides) Viral meningitis

Cerebrovascular Disorders Areas adjacent to area of early cerebral infarction Subarachnoid hemorrhage Hemosiderin deposition (eg, recurrent subarachnoid hemorrhage) Sturge-Weber syndrome Figure 2. Interval sagittal and axial contrast-enhanced T1-weighted magnetic resonance images after Meningioangiomatosis visual improvement reveal resolution of the contrast enhancement in the occipital lobes. Neoplasia Primary neoplasms (meningioma, During the following week, the pa- sual hallucinations occurred fol- glioblastoma multiforme, lymphoma, tient’s symptoms gradually im- lowing TPN infusion into the right sarcoma, melanoma, melanocytoma) proved. After 72 hours from the time subclavian artery. This patient expe- Metastasis of onset of visual loss, she had light rienced sudden bilateral visual loss Inflammatory Conditions perception in both eyes, and after 5 after the onset of TPN infusion, which Connective-tissue disease days, visual acuity was 20/400 OD improved after several minutes, and Sarcoidosis and 20/800 OS. Nine days after the flashes of light each time her central Wegener granulomatosis initial insult, the patient’s visual acu- line was flushed with normal saline. Demyelinating disease ity was 20/20 OD and 20/30 OS with Ophthalmic examination showed a Vasculitis normal visual fields by confronta- left homonymous hemianopia that Iatrogenic tion, and repeat MRI revealed reso- resolved after 3 days. Magnetic reso- Introduction of foreign substances into lution of the focal leptomeningeal en- nance imaging showed multifocal in- cerebrospinal fluid (eg, blood, chemical agents, contrast material) hancement (Figure 2). A repeat farcts in the occipital and parietal cor- Postoperative enhancement following 5 lumbar puncture revealed a protein tices and in the right cerebellum. craniotomy level of 54 mg/dL, a glucose level of The mechanisms causing visual Post-lumbar puncture 126 mg/dL, and a normal opening loss following contrast and TPN in- pressure. No abnormal cells were fusion remain unclear. However, seen on cytologic examination. several authors have postulated that uting factor was the patient’s el- the hyperosmolarity of these agents evated blood pressure because Comment. Transient cortical blind- may lead to osmotic disruption of the hypertensive encephalopathy may ness following vascular interven- blood-brain barrier and subse- cause transient cortical blindness as- tion has been described primarily af- quent cortical blindness through di- sociated with reversible cerebral 6,7 ter contrast-enhanced coronary, rect neurotoxic effects. Experi- edema on neuroimaging.9 cerebral, and other arterial perfu- mental studies have demonstrated Leptomeningeal enhancement 1-3 sion studies. Inadvertent arterial en- that hyperosmolar agents induce va- may occur from infection, cerebro- try during venous catheterization has sodilation, shrinkage of cerebrovas- vascular disorders, neoplasia, in- resulted in cortical blindness in 2 cular endothelial cells, and wid- flammatory conditions, and iatro- 4,5 8 prior reports. In both of those pa- ened endothelial tight junctions. genic causes10,11 (Table). In our tients, arterial infusion of TPN re- The focal leptomeningeal enhance- patient, the pattern of radiographic sulted in transient bilateral visual loss ment noted on the contrast-en- enhancement could have been at- with occipital lobe abnormalities on hanced MRI in our patient suggests tributed to carcinomatous menin- neuroimaging. In the first report, MRI that disruption of the blood-brain bar- gitis. However, repeat cerebrospi- showed leptomeningeal enhance- rier occurred in the vertebrobasilar nal fluid examinations revealed no ment around the occipital cortices, distribution. It is unclear whether the atypical cells. Although cerebrospi- similar to that seen in our patient, fol- nonheparinized normal saline rinse nal fluid cytology is falsely nega- lowing TPN infusion into the right disrupted the blood-brain barrier in tive in 10% of patients,12 the rapid vertebral artery. The visual symp- our patient, but the timing of the vi- resolution of the radiographic and toms improved in 2 weeks with a re- sual symptoms with the catheteriza- clinical abnormalities makes the di- sidual right homonymous hemi- tion of the brachial artery suggests an agnosis of carcinomatous meningi- anopia.4 In the second report, a left iatrogenic vascular cause for the pa- tis unlikely. Infectious meningitis homonymous hemianopia and vi- tient’s symptoms. A possible contrib- was also considered in the differen-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 tial diagnosis, but the patient dem- 11. Fukui MB, Meltzer CC, Kanal E, Smirnioto- grew vancomycin-resistant Entero- poulos JG. MR imaging of the meninges, pt II: onstrated no signs of infection and neoplastic disease. Radiology. 1996;201:605- coccus faecium and she was started laboratory studies did not reveal a 612. on a regimen of linezolid. source of infection. Scattered cere- 12. Grossman SA, Krabak MJ. Leptomeningeal On examination, visual acuity carcinomatosis. Cancer Treat Rev. 1999;25: bral infarction from arterial air em- 103-119. was hand motion in both eyes. At the boli was unlikely because no evi- bedside, the portable slitlamp ex- dence of ischemia was detected on amination demonstrated mild (1ϩ) a diffusion-weighted MRI. cells and flare in the aqueous of both The timing of cortical blindness in Disseminated Fusarium eyes and a small fibrin clot on the our patient, shortly after inadvert- surface of both crystalline lenses. Infection Presenting ent arterial entry during attempted The funduscopic examination re- PICC line placement, and the focal as Bilateral Endogenous vealed a hazy view due to signifi- leptomeningeal enhancement on MRI Endophthalmitis in cant vitritis in both eyes. The pe- suggest that breakdown of the blood- a Patient With Acute ripheral retina appeared white with brain barrier was iatrogenic. The pre- Myeloid Leukemia nonperfused vessels. cise mechanisms underlying this pro- A pars plana vitreous aspirate was cess remain unclear, but we postulate Fusarium is a fungal pathogen that performed in both eyes. Samples that transient hyperosmolarity and may cause local, as well as poten- were sent for gram stain, culture, and hypertension may have been in- tially fatal, systemic infection. Fu- polymerase chain reaction studies. volved in the pathogenesis of our pa- sarium species are the most com- Vancomycin (1 mg/0.1 mL) and ami- tient’s symptoms. mon cause of keratomycosis in the kacin sulfate (400 µg/0.1 mL) were southeastern United States, and ex- injected into the vitreous cavity of Steven Yeh, MD ogenous endophthalmitis is well both eyes; the patient was allergic to Sheila Bazzaz, MD documented in this patient popula- ceftazidime sodium. Two days af- Rod Foroozan, MD tion. Endogenous Fusarium endoph- ter the vitreous tap, vitreous cul- thalmitis, however, is a rare condi- tures from both eyes were positive Financial Disclosure: None. tion with only a few cases reported.1-8 for Fusarium species. The blood cul- Correspondence: Dr Foroozan, Almost all cases involve dissemi- tures (drawn 1 day after the vitre- Neuro-Ophthalmology Service, nated infection in immunocompro- ous tap) became positive for organ- Cullen Eye Institute, Baylor Col- mised patients, either owing to leu- isms 3 days later, and biopsy results lege of Medicine, 6565 Fannin NC- kemia or other severe systemic from a 2ϫ2-cm skin lesion with 205, Houston, TX 77030 (foroozan conditions. The visual prognosis is white-yellow discharge (per- @bcm.tmc.edu). poor and disease-related mortality is formed 3 days after the vitreous tap)

1. Hinchey J, Sweeney PJ. Transient cortical blind- high despite local and systemic an- were also positive for Fusarium spe- ness after coronary angiography. Lancet. 1998; tifungal treatment. We describe a pa- cies post mortem. Two days after the 351:1513-1514. tient with a history of acute my- vitreous tap, Amphotericin B (5 µg/ 2. Shyn PB, Bell KA. Transient cortical blindness following cerebral angiography. JLaStateMed eloid leukemia who developed 0.1 mL) was injected into the vitre- Soc. 1989;141:35-37. bilateral visual loss secondary to en- ous cavity of both eyes and the pa- 3. Alsarraf R, Carey J, Sires BS, Pinczower E. dogenous Fusarium endophthalmi- tient was started on a regimen of Angiography contrast-induced transient cor- tical blindness. Am J Otolaryngol. 1999;20: tis. The patient was subsequently di- intravenous amphotericin B (0.7 130-132. agnosed as having disseminated mg/kg per day) and oral flucona- 4. Petrus LV, Lois JF, Lo WW. Iatrogenically in- duced cortical blindness associated with lep- fusariosis and died 5 days after she zole (400 mg/d). The following day, tomeningeal enhancement. AJNR Am J was first examined. the patient died from multiorgan fail- Neuroradiol. 1998;19:1522-1524. ure. Post mortem, the vitreous and 5. Wang RC, Katz SE, Lubow M. Visual loss and central venous catheterization: cortical blind- Report of a Case. A 70-year-old blood fungal polymerase chain re- ness and hemianopsia after inadvertent sub- white woman was referred for evalu- action assay results showed both Fu- clavian artery entry. J Neuroophthalmol. 2000; ation for a 3-day history of visual sarium species and Candida gla- 20:32-34. 6. Junck L, Marshall WH. Neurotoxicity of radio- loss. The medical history was sig- brata (Figure). logical contrast agents. Ann Neurol. 1983; nificant for myelodysplastic syn- 13:469-484. 7. Lantos G. Cortical blindness due to osmotic dis- drome that converted to acute my- Comment. The Fusarium species are ruption of the blood-brain barrier by angio- eloid leukemia 4 months prior to the ubiquitous filamentous molds that graphic contrast material: CT and MRI studies. onset of her visual symptoms. The are commonly found in soil and on Neurology. 1989;39:567-571. 8. Rapoport SI. Osmotic opening of the blood- patient had been treated with a plants. Fusarium infection may oc- brain barrier: principles, mechanism, and thera- course of chemotherapy which was cur as toxicosis following inges- peutic applications. Cell Mol Neurobiol. 2000; completed 19 days prior to her ini- tion; however, Fusarium infections 20:217-230. 9. Marra TR, Shah M, Mikus MA. Transient cor- tial visit. During chemotherapy, she are usually local and are associated tical blindness due to hypertensive encepha- developed Klebsiella pneumoniae, with trauma (keratomycosis) or al- lopathy: magnetic resonance imaging correlation. J Clin Neuroophthalmol. 1993; which was treated with piperacillin- tered body surface (superficial burn- 13:35-37. tazobactam, ciprofloxacin hydro- wound infections). In the setting of 10. Meltzer CC, Fukui MB, Kanal E, Smirnioto- chloride, and vancomycin hydro- severe immunosuppression and poulos JG. MR imaging of the meninges, pt I: normal anatomic features and nonneoplastic chloride. One day prior to the onset neutropenia, Fusarium species may disease. Radiology. 1996;201:297-308. of visual symptoms, blood cultures cause potentially fatal dissemi-

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