oped by EMI Laboratories, Ltd, Middlesex, England). These scanners, for the most part newly installed, are usually overseen by a neuroradiologist or neurologist who may have little experience with the wide range of pathologic processes that occur within the orbit.
Specifically, the swollen extraocular muscles associated with Graves disease or orbital myositis present an appearance that has been confused with an orbital tumor when viewed in tomographic section. There are several features that serve to distinguish the appearance of the swollen muscle from an orbit tumor. The swollen inferior or superior rectus muscle is seen in the orbit apex. The edge of the image formed by the obliquely sectioned muscle has a feathered or "paintbrush" appearance. This is caused by the muscle descending out of the scan plane. In contrast, the orbit tumor has a sharp edge. It is unusual in Graves disease for isolated extraocular mus¬ cles to be swollen. Careful inspection of the scan series almost always reveals additional swollen muscles. Swollen extraocular muscles may be distinguished from optic nerve sheath tumors because the entire length of the optic nerve can be seen in another plane of focus. The size of orbit structures are at the limit of resolution of the standard EMI scanner. Improvements that in¬ crease resolution have been reported (Hilal S, Trokel SL, Coleman DJ: High resolution computerized tomography and ultrasonography. Trans Am Acad Ophthalmol Otolaryngol, to be pub¬ lished) and substantially aid in recog¬ nizing extraocular muscles. We are calling attention to this matter in this fashion because we are aware of seven patients with swollen extraocular muscles who have had surgery on the basis of false diagnosis of tumor at the orbit apex. As with any new diagnostic tech¬ niques, caution must be urged in interpreting data that has not been properly correlated with patients' clinical status. Stephen L. Trokel, MD Sadek K. Hilal, MD, PhD New York Ibuprofen and Visual Function To the Editor.\p=m-\We read with interest the article by Dr Melluish et al (the
Archives 93:781, 1975)
their doupatients with osteoarthritis who received either ibuprofen (Motrin) or buffered aspirin. The authors were unable to find any statistically significant alteration in visual acuity or visual field due to the use of ibuprofen. Their findings, along with the observations of many others, suggest that the two reports of visual function abnormality associated with the use of ibuprofen must be carefully scrutinized for other, more probable causes of the visual abnormalities. In neither the study by Collum and Bowen1 or by Palmer2 was ibuprofen administered after recovery of vision to demonstrate a causal relationship between the administration of the drug and the visual abnormalities noted. We have had the opportunity to on
ble-blind, prospective study of
study a 72-year-old woman prior to and following the administration of ibuprofen in a dosage of 400 mg four times a day. We first saw this woman one year prior to the beginning of ibuprofen therapy because of a sud¬
den loss of vision in her left eye. She was found to have a left central retinal artery occlusion with complete loss of vision. No emboli were observed. The visual acuity in her right eye was 6/9 (20/30) with a full field. During her hospitalization, she complained of numbness and weak¬ ness on the right side of her body, which were believed to be the result of a left middle cerebral vascular acci¬ dent. She also complained of episodic blurring of vision in her right eye, but we were unable to verify any decrease in acuity. At that time she was receiving aspirin and indomethacin for her rheumatoid arthritis. The patient was next seen by us a year later, complaining of blurring of vision in her remaining good eye eight weeks after the beginning of therapy with 400 mg of ibuprofen four times daily. Her best corrected visual acuity was 1.5/30.7 (5/100) in the right eye. Schirmer testing revealed less than 5 mm of wetting, but the cornea, lens, vitreous, retina, and optic nerve all appeared normal. Electrophysiologic testing was undertaken. The ampli¬ tude of the B-wave of the electroretinogram (ERG) under both scotopic and photopic conditions was approxi¬ mately 60% of normal. The transsclerally stimulated visual evoked response with both white and red stimuli was delayed and diminished in amplitude.
The ibuprofen was discontinued and the patient returned to see us three weeks later. At that time, her visual acuity had improved to 6/21.5 (20/70) in the right eye. Electrophysiologic studies were repeated and revealed no appreciable change in either the ERG or the visual evoked response. Medication was withheld and the patient was next seen eight weeks later. Visual acuity in the right eye had dropped to counting fingers at ten feet, despite the fact that ibuprofen had not been employed since the previous visit. Electrophysiologic studies were repeated and revealed no appreciable change in the ERG but a decrease in the amplitude and in¬ crease in latency of the visual evoked response. No medications were pre¬ scribed, and when the patient was seen three weeks later, the visual acuity had improved to 6/18 (20/60) in the right eye. This patient's course is described to illustrate the variations in visual acuity that can occur with advanced rheumatoid arthritis and diffuse vas¬ cular disease. Such variations were not related to the use of ibuprofen. Carefully documented studies have not been performed that demonstrate that ibuprofen therapy is associated with visual side-effects. Norman S. Levy, MD, PhD Thomas Hanscom, MD Gainesville, Fla 1. Collum LMT, Bowen DI: Ocular side-effects ibuprofen. Br. J Ophthalmol 55:472-577, 1971. 2. Palmer CAL: Toxic amblyopia from ibuprofen. Br Med J 3:765, 1972. of
In Reply.\p=m-\Theexperience of Drs
Levy Hanscom and their interpretation nicely complement the initial reports of ibuprofen-associated visual problems and illustrate the difficulty of proving drug causality in such occurrences. Our study and the paucity of later reports of eye complications during ibuprofen therapy suggest and
that such occurrences must be rare and idiosyncratic. Only with carefully documented individual patient experiences, submitted as letters to journals or reported to the Food and Drug Administration or the manufacturer, will we learn whether or not this is any problem at all. Carter D. Brooks, MD James W. Melluish, MD Kalamazoo, Mich
Downloaded From: http://archopht.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
Specifically, the swollen extraocular muscles associated with Graves disease or orbital myositis present an appearance that has been confused with an orbital tumor when viewed in tomographic section. There are several features that serve to distinguish the appearance of the swollen muscle from an orbit tumor. The swollen inferior or superior rectus muscle is seen in the orbit apex. The edge of the image formed by the obliquely sectioned muscle has a feathered or "paintbrush" appearance. This is caused by the muscle descending out of the scan plane. In contrast, the orbit tumor has a sharp edge. It is unusual in Graves disease for isolated extraocular mus¬ cles to be swollen. Careful inspection of the scan series almost always reveals additional swollen muscles. Swollen extraocular muscles may be distinguished from optic nerve sheath tumors because the entire length of the optic nerve can be seen in another plane of focus. The size of orbit structures are at the limit of resolution of the standard EMI scanner. Improvements that in¬ crease resolution have been reported (Hilal S, Trokel SL, Coleman DJ: High resolution computerized tomography and ultrasonography. Trans Am Acad Ophthalmol Otolaryngol, to be pub¬ lished) and substantially aid in recog¬ nizing extraocular muscles. We are calling attention to this matter in this fashion because we are aware of seven patients with swollen extraocular muscles who have had surgery on the basis of false diagnosis of tumor at the orbit apex. As with any new diagnostic tech¬ niques, caution must be urged in interpreting data that has not been properly correlated with patients' clinical status. Stephen L. Trokel, MD Sadek K. Hilal, MD, PhD New York Ibuprofen and Visual Function To the Editor.\p=m-\We read with interest the article by Dr Melluish et al (the
Archives 93:781, 1975)
their doupatients with osteoarthritis who received either ibuprofen (Motrin) or buffered aspirin. The authors were unable to find any statistically significant alteration in visual acuity or visual field due to the use of ibuprofen. Their findings, along with the observations of many others, suggest that the two reports of visual function abnormality associated with the use of ibuprofen must be carefully scrutinized for other, more probable causes of the visual abnormalities. In neither the study by Collum and Bowen1 or by Palmer2 was ibuprofen administered after recovery of vision to demonstrate a causal relationship between the administration of the drug and the visual abnormalities noted. We have had the opportunity to on
ble-blind, prospective study of
study a 72-year-old woman prior to and following the administration of ibuprofen in a dosage of 400 mg four times a day. We first saw this woman one year prior to the beginning of ibuprofen therapy because of a sud¬
den loss of vision in her left eye. She was found to have a left central retinal artery occlusion with complete loss of vision. No emboli were observed. The visual acuity in her right eye was 6/9 (20/30) with a full field. During her hospitalization, she complained of numbness and weak¬ ness on the right side of her body, which were believed to be the result of a left middle cerebral vascular acci¬ dent. She also complained of episodic blurring of vision in her right eye, but we were unable to verify any decrease in acuity. At that time she was receiving aspirin and indomethacin for her rheumatoid arthritis. The patient was next seen by us a year later, complaining of blurring of vision in her remaining good eye eight weeks after the beginning of therapy with 400 mg of ibuprofen four times daily. Her best corrected visual acuity was 1.5/30.7 (5/100) in the right eye. Schirmer testing revealed less than 5 mm of wetting, but the cornea, lens, vitreous, retina, and optic nerve all appeared normal. Electrophysiologic testing was undertaken. The ampli¬ tude of the B-wave of the electroretinogram (ERG) under both scotopic and photopic conditions was approxi¬ mately 60% of normal. The transsclerally stimulated visual evoked response with both white and red stimuli was delayed and diminished in amplitude.
The ibuprofen was discontinued and the patient returned to see us three weeks later. At that time, her visual acuity had improved to 6/21.5 (20/70) in the right eye. Electrophysiologic studies were repeated and revealed no appreciable change in either the ERG or the visual evoked response. Medication was withheld and the patient was next seen eight weeks later. Visual acuity in the right eye had dropped to counting fingers at ten feet, despite the fact that ibuprofen had not been employed since the previous visit. Electrophysiologic studies were repeated and revealed no appreciable change in the ERG but a decrease in the amplitude and in¬ crease in latency of the visual evoked response. No medications were pre¬ scribed, and when the patient was seen three weeks later, the visual acuity had improved to 6/18 (20/60) in the right eye. This patient's course is described to illustrate the variations in visual acuity that can occur with advanced rheumatoid arthritis and diffuse vas¬ cular disease. Such variations were not related to the use of ibuprofen. Carefully documented studies have not been performed that demonstrate that ibuprofen therapy is associated with visual side-effects. Norman S. Levy, MD, PhD Thomas Hanscom, MD Gainesville, Fla 1. Collum LMT, Bowen DI: Ocular side-effects ibuprofen. Br. J Ophthalmol 55:472-577, 1971. 2. Palmer CAL: Toxic amblyopia from ibuprofen. Br Med J 3:765, 1972. of
In Reply.\p=m-\Theexperience of Drs
Levy Hanscom and their interpretation nicely complement the initial reports of ibuprofen-associated visual problems and illustrate the difficulty of proving drug causality in such occurrences. Our study and the paucity of later reports of eye complications during ibuprofen therapy suggest and
that such occurrences must be rare and idiosyncratic. Only with carefully documented individual patient experiences, submitted as letters to journals or reported to the Food and Drug Administration or the manufacturer, will we learn whether or not this is any problem at all. Carter D. Brooks, MD James W. Melluish, MD Kalamazoo, Mich
Downloaded From: http://archopht.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
