Letters to the Editor
Waldenstrom Macroglobulinemia Mimicking Temporal Arteritis
I
read with great interest the very interesting article by Hughes et al (1) on “Isolated optic nerve, chiasm and tract involvement in Bing-Neel syndrome.” In 1985, we reported a case of a 65-year-old woman who reported sudden visual loss in 1 eye associated with an inferior altitudinal visual field defect and optic disc edema with peripapillary and peripheral retinal hemorrhages (2). Over the preceding months, she experienced malaise, intermittent fever, and muscle pains. Her evaluation revealed a hypochromic anemia and sedimentation rate of 122 mm/h. Although giant cell arteritis was believed to be a likely diagnosis, the findings of hepatomegaly, lymphadenopathy, a reversed albumin/globulin ratio, and an elevated serum concentration of immunoglobulin M led to a diagnosis of Waldenstrom macroglobulinemia. Despite appropriate treatment, including plasmapheresis, the patient experienced ischemic optic neuropathy in the fellow eye. The ischemic events likely were triggered by hyperviscosity due to Waldenstrom macroglobulinemia although other potential mechanisms in-
Palinopsia and Other Reversible Visual Disturbances Induced by Topiramate
W
e read with interest the article by Yun et al (1) describing 9 new patients with topiramate-induced palinopsia. Palinopsia, consisting of the persistence of visual images after the removal of the initial stimulus, may be observed in different medical conditions, especially migraine (2), but may also be provoked by different medications. Topiramate is an antiepileptic drug useful for migraine prophylaxis and for the treatment of both partial and generalized seizures (3). Topiramate has been rarely associated with adverse ocular events, in particular ciliochoroidal effusion syndrome, but patients with transitory visual disturbances induced by topiramate are being increasingly recognized (1). We evaluated 2 patients with other types of visual disturbances that were severe but transitory and fully reversible and appear related to beginning topiramate or dosage increase of the medication. Patient 1: A 19-year-old woman had a 1-year history of migraine with aura. Her headaches usually were preceded by visual symptoms (teichopsia or visual distortion) lasting for about 20–30 minutes and occurred monthly. Topiramate was started at a daily dose of 25 mg. Within 5 days, she complained as if looking “through a veil.” This visual disturbance was continuous, and she was not taking any other medications.
Letters to the Editor: J Neuro-Ophthalmol 2015; 35: 329-332
cluded an autoimmune reaction or invasion of the optic nerve and brain by lymphocytoplasmoid cells. This case teaches us that even when facing signs and symptoms which perfectly match a likely diagnosis (giant cell arteritis in our patient), we should not close our mind to other diagnostic possibilities. Frenchmen have a saying: “En medicine comme dans l-amour Il n'y a pas de jamais il n'y a pas de toujours” (In medicine, like in love, there is not such a thing as never, there is not such a thing as always). Riri S. Manor, MD Neuro-Ophthalmology Unit, Department of Ophthalmology, Rabin Medical Center, Sharon Campus, Petah Tikva, Israel
The author reports no conflicts of interest.
REFERENCES 1. Hughes MS, Atkins AJ, Cestair DM, Stacy RC, Hochberg F. Isolated optic nerves, chiasm and tract involvement in Big-Neel Syndrome. J Neuroopthalmol. 2014;34;340–345. 2. Manor RS, Axer-Sigel R, Hart M. Anterior ischemic optic neuropathy. Am J Ophthalmol. 1985;99:608–609.
A complete ophthalmologic examination was unremarkable. Physical examination, numerous blood tests, brain magnetic resonance imaging (MRI), and electroencephalography were normal. Topiramate was discontinued, and within 2 days, her visual symptoms completely disappeared. She was prescribed amitriptyline for migraine prophylaxis. There was no recurrence of her visual symptoms in 6 years of follow-up. Patient 2: A 21-year-old man had a 6-year history of juvenile myoclonic epilepsy. Initially, he was treated with levetiracetam 3 g/d, with reduction of seizure frequency. At age 20 years, topiramate 100 mg/d was added, and he remained seizure-free for 5 months. He then experienced 2 generalized tonic–clonic seizures, and his topiramate was gradually increased by 50 mg/ wk up to 200 mg/d. Two days after reaching the maximal dosage, the patient complained of severe blurred vision (“I see all black”) that lasted for approximately 30 minutes. He had no similar symptoms in the past and was taking no other medications. Neurologic and ophthalmologic examinations were normal. Topiramate was gradually reduced to 50 mg/ d and valproate was given at 1,000 mg/d. In the ensuing 9 years, he has not experienced seizures or visual disturbances. Our 2 patients had reversible visual disturbances associated with use of topiramate. In our first patient, visual complaints began after institution of topiramate, whereas in the second patient, visual symptoms were associated with an increase in the dose of medication. Either discontinuing the medication (patient 1) or lowering the dose (patient 2) led to 329
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Waldenstrom Macroglobulinemia Mimicking Temporal Arteritis
I
read with great interest the very interesting article by Hughes et al (1) on “Isolated optic nerve, chiasm and tract involvement in Bing-Neel syndrome.” In 1985, we reported a case of a 65-year-old woman who reported sudden visual loss in 1 eye associated with an inferior altitudinal visual field defect and optic disc edema with peripapillary and peripheral retinal hemorrhages (2). Over the preceding months, she experienced malaise, intermittent fever, and muscle pains. Her evaluation revealed a hypochromic anemia and sedimentation rate of 122 mm/h. Although giant cell arteritis was believed to be a likely diagnosis, the findings of hepatomegaly, lymphadenopathy, a reversed albumin/globulin ratio, and an elevated serum concentration of immunoglobulin M led to a diagnosis of Waldenstrom macroglobulinemia. Despite appropriate treatment, including plasmapheresis, the patient experienced ischemic optic neuropathy in the fellow eye. The ischemic events likely were triggered by hyperviscosity due to Waldenstrom macroglobulinemia although other potential mechanisms in-
Palinopsia and Other Reversible Visual Disturbances Induced by Topiramate
W
e read with interest the article by Yun et al (1) describing 9 new patients with topiramate-induced palinopsia. Palinopsia, consisting of the persistence of visual images after the removal of the initial stimulus, may be observed in different medical conditions, especially migraine (2), but may also be provoked by different medications. Topiramate is an antiepileptic drug useful for migraine prophylaxis and for the treatment of both partial and generalized seizures (3). Topiramate has been rarely associated with adverse ocular events, in particular ciliochoroidal effusion syndrome, but patients with transitory visual disturbances induced by topiramate are being increasingly recognized (1). We evaluated 2 patients with other types of visual disturbances that were severe but transitory and fully reversible and appear related to beginning topiramate or dosage increase of the medication. Patient 1: A 19-year-old woman had a 1-year history of migraine with aura. Her headaches usually were preceded by visual symptoms (teichopsia or visual distortion) lasting for about 20–30 minutes and occurred monthly. Topiramate was started at a daily dose of 25 mg. Within 5 days, she complained as if looking “through a veil.” This visual disturbance was continuous, and she was not taking any other medications.
Letters to the Editor: J Neuro-Ophthalmol 2015; 35: 329-332
cluded an autoimmune reaction or invasion of the optic nerve and brain by lymphocytoplasmoid cells. This case teaches us that even when facing signs and symptoms which perfectly match a likely diagnosis (giant cell arteritis in our patient), we should not close our mind to other diagnostic possibilities. Frenchmen have a saying: “En medicine comme dans l-amour Il n'y a pas de jamais il n'y a pas de toujours” (In medicine, like in love, there is not such a thing as never, there is not such a thing as always). Riri S. Manor, MD Neuro-Ophthalmology Unit, Department of Ophthalmology, Rabin Medical Center, Sharon Campus, Petah Tikva, Israel
The author reports no conflicts of interest.
REFERENCES 1. Hughes MS, Atkins AJ, Cestair DM, Stacy RC, Hochberg F. Isolated optic nerves, chiasm and tract involvement in Big-Neel Syndrome. J Neuroopthalmol. 2014;34;340–345. 2. Manor RS, Axer-Sigel R, Hart M. Anterior ischemic optic neuropathy. Am J Ophthalmol. 1985;99:608–609.
A complete ophthalmologic examination was unremarkable. Physical examination, numerous blood tests, brain magnetic resonance imaging (MRI), and electroencephalography were normal. Topiramate was discontinued, and within 2 days, her visual symptoms completely disappeared. She was prescribed amitriptyline for migraine prophylaxis. There was no recurrence of her visual symptoms in 6 years of follow-up. Patient 2: A 21-year-old man had a 6-year history of juvenile myoclonic epilepsy. Initially, he was treated with levetiracetam 3 g/d, with reduction of seizure frequency. At age 20 years, topiramate 100 mg/d was added, and he remained seizure-free for 5 months. He then experienced 2 generalized tonic–clonic seizures, and his topiramate was gradually increased by 50 mg/ wk up to 200 mg/d. Two days after reaching the maximal dosage, the patient complained of severe blurred vision (“I see all black”) that lasted for approximately 30 minutes. He had no similar symptoms in the past and was taking no other medications. Neurologic and ophthalmologic examinations were normal. Topiramate was gradually reduced to 50 mg/ d and valproate was given at 1,000 mg/d. In the ensuing 9 years, he has not experienced seizures or visual disturbances. Our 2 patients had reversible visual disturbances associated with use of topiramate. In our first patient, visual complaints began after institution of topiramate, whereas in the second patient, visual symptoms were associated with an increase in the dose of medication. Either discontinuing the medication (patient 1) or lowering the dose (patient 2) led to 329
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
