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Optic Disc Edema, Globe Flattening, Choroidal Folds, and Hyperopic Shifts Observed in Astronauts After Long-Duration Space Flight

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Optic Disc Edema, Globe Flattening, Choroidal Folds, and Hyperopic Shifts Observed in Astronauts After Long-Duration Space Flight Optic Disc Edema, Globe Flattening, Choroidal Folds, and Hyperopic Shifts Observed in Astronauts after Long-duration Space Flight Thomas H. Mader, MD,1 C. Robert Gibson, OD,2 Anastas F. Pass, OD, JD,3 Larry A. Kramer, MD,4 Andrew G. Lee, MD,5 Jennifer Fogarty, PhD,6 William J. Tarver, MD,6 Joseph P. Dervay, MD,6 Douglas R. Hamilton, MD, PhD,7 Ashot Sargsyan, MD,7 John L. Phillips, PhD,8 Duc Tran, DO,2 William Lipsky, MD,2 Jung Choi, OD,2 Claudia Stern, MD, PhD,9 Raffi Kuyumjian, MD,10 James D. Polk, DO6 Purpose: To describe the history, clinical findings, and possible etiologies of ophthalmic findings discovered in 7 astronauts after long-duration space flight, and document vision changes in approximately 300 additional astronauts. Design: Retrospective, observational examination of ophthalmic findings in 7 astronauts and analysis of postflight questionnaires regarding in-flight vision changes in approximately 300 additional astronauts. Participants: Seven astronauts with ophthalmic anomalies upon return from long-duration space missions to the International Space Station and 300 additional astronauts who completed postflight questionnaires regarding in-flight vision changes. Methods: Before and after long-duration space flight, all 7 subjects underwent complete eye examinations, including cycloplegic and/or manifest refraction and fundus photography. Six underwent postmission optical coherence tomography (OCT) and magnetic resonance imaging (MRI); 4 had lumbar punctures (LP). Approxi- mately 300 astronauts were queried regarding visual changes during space missions. Main Outcome Measures: Refractive change, fundus photograph examination, retina OCT, orbital MRI, LP opening pressures, and examination of visual acuity data. Results: After 6 months of space flight, 7 astronauts had ophthalmic findings, consisting of disc edema in 5, globe flattening in 5, choroidal folds in 5, cotton wool spots (CWS) in 3, nerve fiber layer thickening by OCT in 6, and decreased near vision in 6 astronauts. Five of 7 with near vision complaints had a hyperopic shift Նϩ0.50 diopters (D) between pre/postmission spherical equivalent refraction in 1 or both eyes (range, ϩ0.50 to ϩ1.75 D). These 5 showed globe flattening on MRI. Lumbar punctures performed in the 4 with disc edema documented opening pressures of 22, 21, 28, and 28.5 cm H2O performed 60, 19, 12, and 57 days postmission, respectively. The 300 postflight questionnaires documented that approximately 29% and 60% of astronauts on short and long-duration missions, respectively, experienced a degradation in distant and near visual acuity. Some of these vision changes remain unresolved years after flight. Conclusions: We hypothesize that the optic nerve and ocular changes we describe may result from cephalad fluid shifts brought about by prolonged microgravity exposure. The findings we report may represent parts of a spectrum of ocular and cerebral responses to extended microgravity exposure. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article. Ophthalmology 2011;xx:xxx © 2011 by the American Academy of Ophthalmology. Physiologic and pathologic changes associated with the space flight. The similarities of the setting and clinical microgravity environment have been studied extensively. features of these patients suggests a common etiology in- However, the effect of this environment on the eye and herent to the microgravity environment. Because of the brain is largely unknown. Over the last several years, the paucity of in-flight data, the specific cause of these disorders National Aeronautics and Space Administration’s (NASA) remains obscure. The authors propose that these findings Space Medicine Division has documented astronauts pre- may represent manifestations of a pathologic process related senting with varying degrees of disc edema, globe flatten- to ocular, optic nerve (ON), or perhaps intracranial cephalad ing, choroidal folds, and hyperopic shifts after long-duration fluid shifts experienced during microgravity exposure. To © 2011 by the American Academy of Ophthalmology ISSN 0161-6420/11/$–see front matter 1 Published by Elsevier Inc. doi:10.1016/j.ophtha.2011.06.021 Ophthalmology Volume xx, Number x, Month 2011 Table 1. Neuroophthalmic Changes in Astronauts Intraocular Pressure ISS Mission Refractive Change (mmHg) Crew Duration Fundoscopic Examination Member (mos) Preflight Postflight Preflight Postflight Postflight 1 6 OD: Ϫ1.50 sph OD: Ϫ1.25 Ϫ 0.25 ϫ 005 15 OU 10 OU Choroidal folds OD OS: Ϫ2.25 Ϫ 0.25 ϫ 135 OS: Ϫ2.50 Ϫ 0.25 ϫ 160 Cotton wool spot OD 2 6 OD: ϩ0.75 OD: ϩ2.00 sph 14 OU 14 OU Bilateral disc edema OD Ͼ OS OS: ϩ0.75 to 0.25 ϫ 165 OS: ϩ2.00 Ϫ 0.50 ϫ 140 Choroidal folds OD Ͼ OS Cotton wool spot OS 3 6 OD: Ϫ0.50 sph Plano 10 OU 10 OU Bilateral disc edema OD Ͼ OS OS: Ϫ0.25 sph Plano Small hemorrhage OD 4 6 OD: Ϫ0.75 to 0.50 ϫ 100 OD: ϩ0.75 Ϫ 0.50 ϫ 105 15/13 11/10 Disc edema OD OS: plano to 0.50 ϫ 090 OS: ϩ0.75 Ϫ 0.75 ϫ 090 Choroidal folds OD 5 6 OD: Ϫ5.75 to 1.25 ϫ 010 OD: Ϫ5.00 Ϫ 1.50 ϫ 015 14/12 14/12 Normal OS: Ϫ5.00 Ϫ 1.50 ϫ 180 OS: Ϫ4.75 Ϫ 1.75 ϫ 170 6 6 OD: ϩ0.25 OD: ϩ2.00 Ϫ 0.50 ϫ 028 14 OU 14 OU Disc edema OD OS: ϩ0.25 to 0.50 ϫ 152 OS: ϩ1.00 sph Cotton wool spot OS 7 6 OD: ϩ1.25 sph OD: ϩ2.75 sph 16 OU 12/14 Disc edema OU OS: ϩ1.25 sph OS: ϩ2.50 sph Choroidal folds OD Ͼ OS CSF ϭ cerebral spinal fluid; MRI ϭ magnetic resonance imaging; NFL ϭ retinal nerve fiber layer; OCT ϭ optical coherence tomography; OD ϭ right; Disc edema was graded with the modified Frisén scale. our knowledge, this is the first published report document- Results ing ophthalmic anomalies in astronauts or cosmonauts dur- ing or after space flight. After approximately 6 months of continuous orbital flight, 7 as- tronauts (all male; age 50.2Ϯ4.2 years) were documented to have findings as summarized in Table 1. Table 2 is a summary of data from postflight questionnaires completed by approximately 300 Subjects and Methods A postflight survey of approximately 300 astronauts, some of Table 2. Reported In-Flight Subjective Visual Changes and whom were repeat flyers, revealed that vision changes were com- Postflight Refraction Changes of National Aeronautics and monly observed during and after long-duration space missions. Space Administration Astronauts (Not Including International Since 1989, as part of the postflight eye examination, astronauts Partners) from 1989 to 2009 were queried as to whether they perceived a subjective improve- ment or degradation in distant or near vision (none, mild, moder- Description Shuttle % (n) ISS-Long Duration % (n) ate, or severe) during their short- and long-duration missions. Decreased DVA Prompted by persistent reports of vision changes, NASA began a Total (n) 581 44 stepwise operational process to determine the etiology. Several None 93.5 (543) 88.1 (39) ophthalmic procedures were initiated on astronauts, including di- Mild 5.7 (33) 2.4 (1) lated fundus examinations with binocular ophthalmoscopy, cyclo- Moderate 0.9 (5) 4.8 (2) plegic refraction, optical coherence tomography (OCT), magnetic Severe 0 (0) 4.8 (2) resonance imaging (MRI) of orbits, and fundus photos of astro- Decreased NVA nauts before and after space missions. Total (n) 581 44 Space flight causes bone loss. As a countermeasure, it is rec- None 76.7 (448) 52.3 (23) ommended that all astronauts take 800 international units (IU) of Mild 17.6 (103) 13.6 (6) vitamin D supplements daily during short- and long-duration space Moderate 5.5 (32) 27.3 (12) flights. Unless otherwise stated, the past medical history of all 7 Severe 0.2 (1) 6.8 (3) astronauts was negative for systemic hypertension, connective Refraction change Total (n) 587 44 tissue disorders, iron deficiency, diabetes mellitus, or renal disease. None 88.9 (522) 65.9 (29) Again, unless stated otherwise, none of our subjects had ever used Mild 9.2 (54) 25.0 (11) any medication that could produce increased intracranial pressure Moderate 1.9 (11) 2.3 (1) (ICP); (e.g., vitamin A, tetracycline, corticosteroids, or nalidixic Severe 0 (0) 6.8 (3) acid.) The NASA Space Medicine Division approves of the use of this routinely acquired and not attributable data to be used in this DVA ϭ distance visual acuity; ISS ϭ International Space Station; NVA ϭ manner. These data are acquired under occupational surveillance near visual acuity. Source: Lifetime Surveillance of Astronaut Health (LSAH) Program, and their use in this article is permitted under governance 10 NASA Johnson Space Center. Health Information Management System. 2 Mader et al ⅐ Eye Changes after Long-duration Space Flight after Long-duration Space Flight Globe CSF Pressure Disc Edema (Frisén) OCT Postflight Eye MRI Postflight Flattening Postflight (cmH2O) No disc edema Choroidal folds still visible inferior to MRI not performed Not assessed Not measured the OD disc (RϩϾ5 yrs) Grade 1 OD and OS NFL thickening c/w disc edema Optic nerve sheath distension OD and OS Elevated OD and OS 22 at Rϩ66 days; 26 at Rϩ17 months; 22 at Rϩ19 months) Grade 3 OD Severe NFL thickening OD Ͼ OS Optic nerve sheath distension None observed Elevated Grade 1 OS c/w Disc edema OD 21 at Rϩ19 days Grade 1 OD Mild NFL thickening OD Ͼ OS c/w Optic nerve sheath distension OD Ͼ OS Elevated disc edema and tortuous optic nerves 28.5 at Rϩ57 days Choroidal folds OD OD Ͼ OS No disc edema Subclinical disc edema Optic nerve sheath distension OD and OS Not measured Mild/moderate NFL thickening OD and tortuous optic nerves Grade 1 OD Mild NFL thickening c/w disc edema Optic nerve sheath distension OD Ͼ OS Not measured Choroidal folds OD OD Ͼ OS Grade 1 OD and OS Moderate NFL thickening c/w disc Optic nerve sheath distension OD and OS Elevated edema OD and OS OD and OS 28 at Rϩ12 days Choroidal folds OD and OS OS ϭ left; OU ϭ both eyes; Rϩϭreturn to Earth (eg, Rϩ19 is 19 days after return to Earth); sph ϭ sphere.
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