Generating value “ CASE REPORT for optometrists “ SUPPORT An unusual case of myopic shift post acquired brain injury SAVINGS BY FARRAH F. SUNDERJI, OD & surgery and brain tumours; or a Farrah F. Sunderji, O.D. CATHERINE HEYMAN, OD, FAAO, traumatic brain injury (TBI) result- Resident, Pediatric Optometry CE Seminars FCOVD ing from an external insult (Table and Vision Therapy Centralized 1).3,4 Males are more at risk for Southern California College Billing both a CVA and TBI. Using Table of Optometry Background 1 for classification purposes, this 2006-2007 n the United States, approx- case report illustrates an unusual Catherine Heyman, O.D., Discount imately one person every 16 presentation of myopic shift post AUTONOMY Local Presence I F.A.A.O, FCOVD seconds suffers some form of ac- ABI due to the presence of mul- 1 Southern California College quired brain injury (ABI). An ABI tiple brain tumours, brain surgery of Optometry opto.com results from an event that occurs for removal of the tumours, shunt Faculty Advisor Optosys®2 suddenly and results in neurologi- placement for hydrocephalus, and Training cal dysfunctions.2 The two major a CVA post-surgery. Securo Vision CONTROL events that cause an ABI include Ocular and visual problems are In memory of the late Michael Rouse,OD VALUE an internal insult such as a cerebro- frequent consequences of an ABI. Web site vascular accident (CVA), brain Cohen1 explains that following a creation Marketing RÉSUMÉ UN CAS INHABITUEL D’ÉCART MYOPIQUE SURVENANT À LA SUITE D’UNE LÉSION CÉRÉBRALE ACQUISE Financing Contexte et 22,2 mmol/L; le patient a fait un AVC Lors d’une visite de suivi un mois plus tard, Des problèmes oculovisuels surviennent après l’intervention, ce qui a causé une sa meilleure acuité visuelle corrigée à une fréquemment après une lésion hémiparésie du côté gauche; un shunt a été distance s’était améliorée à 6/60 dans les cérébrale acquise (LCA). Une revue de la posé pour diminuer l’enflure dans la région deux yeux grâce à la nouvelle prescription. Succession OptoPlus documentation révèle que bon nombre de l’excision et dans les nerfs optiques. Liste Sa rétinoscopie sous cycloplégie n’a Planning Benchmarking de patients présentent un déplacement des médicaments : Cartia, lisinopril, Toprol présenté aucune variation de la myopie Banner myopique de l’erreur de réfraction après XL, prednisone, Reglan et Temodar. Le ou de l’astigmatisme, toutefois, l’œdème un traumatisme cérébral, qui est une patient a fait l’objet d’une chimiothérapie du disque s’est résorbé. pour traiter les restes de la tumeur. Son forme de LCA. Trois formes d’évolution Conclusion sont présentées. Le plus souvent, la dernier examen visuel en 2004 indiquait une Ce cas illustre une présentation myopie se résorbe sous cycloplégie. En erreur de réfraction de -2,50-1,25×080 dans inhabituelle d’un déplacement myopique deuxième lieu, le déplacement peut son œil droit et de -3,00-0,75×080 dans son JOIN the Largest Network of Optometrists in Canada à la suite d’une lésion cérébrale acquise. être temporaire et, en troisième lieu, cas œil gauche avec acuité visuelle de 6/7,5 L’état du patient n’a cessé de se détériorer, le moins courant, la myopie augmente dans les deux yeux. Il s’est présenté à notre et celui-ci n’y a pas survécu. On ne sait avec le temps. Le présent rapport de clinique avec une acuité visuelle assistée pas si la myopie et l’astigmatisme ont cas, même s’il n’est pas attribuable à un de 8/100 (6/110) dans les deux yeux et une CONTACT US AT: [email protected] pris de l’ampleur ou s’ils se sont stabilisés. traumatisme cérébral, est un exemple du hémianopsie homonyme gauche après Même si la cause de cet état n’est pas cas le moins courant. évaluation de la périmétrie par comptage • Purchasing Group des doigts. Une rétinoscopie sous pleinement comprise et qu’elle nécessite Rapport de cas cycloplégie a révélé -6,00-3,00×090 dans d’autres examens, une correction optique • Great Discounts Le patient, un homme de 63 ans, a subi, son œil droit et -6,00-2,00×090 dans son appropriée a toutefois permis d’améliorer 15 mois avant sa première évaluation, œil gauche. Un examen du fond d’œil sous la qualité de vie du patient. • MEMBERSHIP FREE OF CHARGE l’excision d’une tumeur dans le lobe pupille dilatée a indiqué une légère enflure Mots clés : tumeurs, traitement de la temporal frontal droit. Il a reçu avant et après des deux nerfs optiques. Les taux de glucose myopie, lésion cérébrale. l’intervention 4 mg QD qui a fait fluctuer sanguin ont varié entre 103 et 140. • 100 accredited suppliers son taux de glucose sanguin entre 5,72 • You control your price, your inventory, your clinic T.: 1-800-363-4096 or 514-762-2020 ext. 5773 • Multi-Services (marketing, IT) C AN ADIAN J OURN AL OF O PTOMETRY | R EV UE CAN ADIENNE D ’ OPTOMÉTRIE VOL 74 | NO 2 2012 39 ABSTRACT Background 5.72-22.2 mmol/l; a stroke occured post- follow-up, his best corrected visual acuity Ocular and visual problems are frequent surgery causing hemiparesis on his left at a distance improved to 6/60 in both consequences of an acquired brain side; and shunt surgery to decrease the right and left eye through the new injury (ABI). The literature suggests that swelling to the area of excision and the prescription. His cycloplegic retinoscopy many patients demonstrate a myopic optic nerves. Medications included: did not show any change in myopia or shift in refractive error after a traumatic Cartia, lisinopril, Toprol XL, prednisone, astigmatism and the disk edema was brain injury (TBI), a form of an ABI. Three Reglan, and Temodar. The patient resolved. was receiving chemotherapy to treat reported courses are suggested. Most Conclusion commonly the myopia resolves under remnants of the tumour. His last eye exam This case illustrates an unusual cycloplegic conditions, secondly the in 2004 indicated a refractive error of presentation of myopic shift post ABI. shift is transient, and least commonly the -2.50-1.25X080 in his right eye and -3.00- The patient’s condition continued to myopia increases over time. This case 0.75X080 in his left eye with visual acuity deteriorate eventually taking his life. It report, although not due to a TBI, is an of 6/7.5 in both the right and left eye. remains unclear whether the myopia and example of the least common subgroup. He presented to our clinic with an aided visual acuity of 8/100 (6/110) in both the astigmatism continued to increase or Case Report right and left eye and a left homonymous remained stable. Although, the cause of The patient, a 63 year-old male, presented hemianopsia on finger counting fields. this change is not fully understood and with a history (15 months prior to initial Cycloplegic retinoscopy revealed -6.00- needs further investigation, providing evaluation) of an excised right frontal 3.00X090 in his right eye and -6.00- appropriate optical correction did temporal lobe tumour. The history 2.00X090 in his left eye. Dilated fundus improve the patient’s quality-of-life. included dexamethasone 4mg QD pre- exam showed mild swelling of both Key words: tumours, myopia – treatment, and post-surgery which caused blood optic nerves. The patient reported blood brain injury. glucose levels to fluctuate between glucose levels of 103-140. At a one-month Table 1: The Categories and Components of Acquired Brain Injury of pseudomyopia (58% persisted) as one of common visual problems ACQUIRED BRAIN INJURY (ABI) seen among 161 patients with head 6 EXTERNAL INSULT - TBI INTERNAL INSULT injury. 1. Closed 1. Cerebrovascular accidents (CVA) – i.e., stroke London et al. suggest that many 2. Penetrating 2. Brain surgery patients demonstrate a myopic GLASGOW COMA SCALE 3. Arteriovenous malformations (AVM) shift in refractive error after TBI 1. Severe 4. Brain tumours – malignant and benign and refer to this myopic shift as 7 2. Moderate 5. Vestibular dysfunctions “post-traumatic pseudomyopia”. 3. Mild Three reported courses have been suggested in non-presbyopic patients. Most commonly, the neurological event, there is often an problems associated with trauma to myopia resolves under cycloplegic interruption to the neurological sys- the visual system (Table 2).1, 3 Due to conditions, secondly the shift is tem which innervates the extraocular the similarities in the pathogenesis transient, and least commonly the muscles controlling eye movement of TBI and stroke, there is consider- myopia increases over time. This as well as the system that regulates able overlap in the ocular and visual case report, although not due to focusing. Neuro-optometrists have symptoms. One such visual problem a TBI, is an example of the least identified a syndrome, the post is a change in refractive error with an common subgroup. trauma vision syndrome (PTVS), increase in myopia. Kowal identi- which includes visual symptoms and fied a 19 per cent prevalence rate 40 VOL 74 | NO 2 2012 C AN ADIAN J OURN AL OF O PTOMETRY | R EV UE CAN ADIENNE D ’ OPTOMÉTRIE Table 2: Visual Sequelae and Symptoms of ABI 1. Visual field losses Central, congruous, and incongruous homonymous hemianopias and quadrantanopias, altitudinal, neglect 2. Eye movement dysfunctions Fixation, pursuit, saccade, nystagmus 3. Ocular muscle dysfunctions Strabismus, anisocoria, lagophthalmos, ptosis 4. Binocular dysfunctions Exophoria, convergence insufficiency, vertical phorias, fusional instabilities 5. Accommodative dysfunctions Amplitude, flexibility, sustainability 6. Perceptual dysfunctions Contrast sensitivity, colour vision, body image, left-right discrimination, spatial relationships, agnosias, “subjective visual disturbances.” e.g., wavy and shimmering vision, photosensitivity 7.