PUPIL DISORDERS, IS PHARMACOLOGICAL TESTING NECESSARY? Evidence Presentation — Randy Kardon, M.D., Ph.D. University of Iowa, Hospitals & Clinics Iowa City, IA
Expert Opinion & Commentary — Jonathan D. Trobe, M.D. University of Michigan Ann Arbor
LEARNING OBJECTIVES
) OPEJC 2 @UO LNEKN SEPD LNHKJE@EJ.
1. J@NOPJ@ PD EJ@EPEKJO J@ IPDK@O BKN QOEJC PKLEH DKHEJNCE CJPO PK @EBBNJPEP QOO KB BBNJP LQLEH @BPO PDP NOQHP EJ JEOKKNE >EJC CNPN EJ >NECDP HECDP KJ@EPEKJO.
>) OPEJC 2 @UO LNEKN SEPD KEJ.
2. J@NOPJ@ PD @RJPCO J@ @EO@RJPCO KB QOEJC KEJ J@ LNHKJE@EJ PK @ECJKO KQHKOUILPDPE @BPO.
@) OPEJC 2 UNO UNO BPN PD @EOKRNU KB KNJN KNJN OUJ@NKI EJ J EJBJP BNKI KH@ LEPQNO.
3. TLHEJ SDU QO KB DU@NKTUILDPIEJ BKN HKHEVPEKJ KB PD OEP KB J KQHKOUILPDPE HOEKJ EO DHLBQH, NPDN PDJ EICEJC >KPD LN J@ LKOPCJCHEKJE OUILPDPE LPDSUO KRN PD JPEN JQNK-TEO.
) OPEJC 2 @UO BPN J EJPNJH NKPE@ NPNU @EOOPEKJ.
) OPEJC 2 @UO BPN PD @EOKRNU KB IPOPPE >NOP NEJKI EJ LPEJP SEPD JEOKKNE.
KEY WORDS 1. K KNJ NJN N UJ UJ@N @NKI KI 2. Q QL LNN-O OJO JOEPE EPEREP REPU U
CME QUESTIONS
3. U@ U@NKT NKTUI UILDP LDPIE IEJ J
1. DED KB PD BKHHKSEJC KJ@EPEKJO SEHH LNK@Q QJ@N-OJOEPEREPU PK PKLEH LEHKNLEJ?
4. ALN ALN HK HKJE JE@EJ @EJ 5. KEJ EJ
) EJP HH NPNEPEO SEPD JK OQ>OMQJP HECDPJN @EOOKEPEKJ
6. E EHK HK NL NLEJ EJ
>) ECD EJPNKQHN LNOOQN PD JECDP BPN PNP OQNCNU
EVIDENCE PRESENTA PRESENTATION TION
) NKPE@ NPNU OPJKOEO @) > J@ ) HH KB PD >KR 2. DED BPKN SKQH@ KQJP BKN MQERKH NOQHPO KB DKHEJNCE OQLN-OJOEPEREPU POPEJC BKN QJEHPNH BBNJP LQLEH @BP, KILNEJC PD QJBBP@ J@ BBP@ U NOLKJO?: ) OPEJC BPN KJHU 7 @UO BKHHKSEJC LNCJCHEKJE LNOUILPDPE HOEKJ BNKI L-KI JQNUOI >) JPE @EBBNJO EJ KNJH KNJH LNI>EHEPU PK @NQCO ) ALLHJPEKJ PKJKIPNU LNEKN PK POPEJC @) * *G G KB HECDP-J HECDP-JN N @EOOKE @EOOKEPE PEKJ KJ ) KN@EJC LQLEH @EIPNO >BKN J@ BPN @NKLO EJ @NGJOO 3. DED KB PD BKHHKSEJC OEPQPEKJO SKQH@ JKP @RNOHU BBP PD EJPNLNPPEKJ KB DU@NKTUILDPIEJ POP?
1. D8>34 >5 74 88 78=4 70 <0 4@84 70<0>;>68 48=6 K 7>;8=468 4-4=88E8 E. =34-4=88E8: DJ RHQPEJC J JEOKKNE PDP EJNOO EJ >NECDP HECDP J@ @NOO EJ @EI HECDP, PPJPEKJ QOQHHU ODEBPO PKSN@ PD LQLEH PDP EO HNCN EJ >NECDP HECDP PK @PNIEJ EB LNOEO KB PD ENEO OLDEJPN LNOEO EO LNOJP. D QOO N EPDN BNKI @JNRPEKJ KB PD ENEO OLDEJPN, >HKG@ KB PD DKHEJNCE NLPKNO, KN @IC PK PD ENEO OLDEJPN EPOHB. C7>;8=468 %4-4=88E8 &48=6 K "E4-8;843: J IKOP OO SDN @JNRPEKJ KB PD LNOUILPDPE JNRO PK PD ENEO OLDEJPN EO OQOLP@, PD QO KB @EHQP PKLEH DKHEJNCE CJPO BKN @PNIEJEJC OQLNOJOEPEREPU KB PD ENEO OLDEJPN J@ EHENU >K@U EO JKP JOONU. DEO EO >QO IKOP LKOPCJCHEKJE QOO KB DKHEJNCE @JNRPEKJ KB PD ENEO N K>REKQO KJ HEJEH TIEJPEKJ. D IKOP KIIKJ BEJ@EJC EO OPKNH OLDEJPN LHOU SDN OKI HKG-DKQN OCIJPO KB PD ENEO OLDEJPN KJPNP PK HECDP SDJ K>ONR@ QJ@N DECD ICJEBEPEKJ KB OHEP HIL KN SEPD EJBNN@ PNJOEHHQIEJPEKJ1 J@ @FJP OLDEJPN OCIJPO @K JKP NP. PKNH LNOEO EJPNLKO@ SEPD OPKNO PDP @K NP PK HECDP EO DHHING BPQN KB LKOPCJCHEKJE 2010 Annual Meeting Syllabus | 93
LNOUILPDPE @JNRPEKJ2, >QP PDEO IU HOK KQN SEPD @ENP @IC PK PD ENEO OLDEJPN IQOH (O >HKS). NHU, HH ENEO OLDEJPN OCIJPO J > MQHHU LNPE EJ PD O KB KILHP LKOPCJCHEKJE LNOUILPDPE HOEKJ, >QP EP EO PD NQH SEPD LNCJCHEKJE LNOUILPDPE HOEKJO. DR UP PK O O KB QP LNCJCHEKJE @JNRPEKJ BNKI LPDKHKCU KB PD KQHKIKPKN JNR PDP QO@ OAPKN=H LNOEO OAPKN=H LNOEO SEPD OKI EJPNRJEJC OPKNO OLN@. OQHHU PD OLDEJPN SGJOO EO OUIIPNE KRN HH HKG-DKQN OCIJPO SEPD QP LQLEH EJRKHREJC PDEN@ JNR LHOEO. KSRN, EJ PD O KB DNKJE LHOEO, SDJ >NNJP NCJNPEKJ EO LNOJP BNKI LNCJCHEKJE LNOUILPDPE HOEKJ, OPKNH N-EJJNRPEKJ IU KQN, >QP KJHU BPN LNEK@ KB P HOP 8 SGO BKHHKSEJC @JNRPEKJ. 8 SGO EO PD IEJEIH PEI NMQEN@ BKN N-CNKSPD KB @IC@ LNCJCHEKJE TKJO PK ND PD EHENU CJCHEKJ EJ PD KN>EP. AJKPDN EILKNPJP OECJ PDP E@O EJ PD @ECJKOEO KB ENEO OLDEJPN @JNRPEKJ PDP ENQIRJPO PD QO KB @EHQP DKHEJNCE CJPO EO HECDP-JN @EOOKEPEKJ, BKNI KB >NNJP NCJNPEKJ, OECJEBUEJC PDP @JNRPEKJ O KQNN@ J@ DO >J BKHHKS@ >U N-CNKSPD KB LKOPCJCHEKJE LNOUILPDPE DKHEJNCE BE>NO PDP SN LNREKQOHU KJHU EJJNRPEJC PD EHENU >K@U J@ DR JKS BKQJ@ PDEN SU PK PD ENEO OLDEJPN IQOH 3. D LNOJ KB HECDP JN @EOOKEPEKJ EO KBPJ IEOO@, EPDN >QO EP SO EJ@RNPJPHU KIEPP@ BNKI PD RHQPEKJ KN >QO EP SO JKP LNKLNHU POP@. KJOPNEPEKJ KB PD LQLEH PK JN BBKNP EJ PDEO OPPEJC PGO HKJCN PK @RHKL PDJ @KO JKNIH JN LQLEH KJPNPEKJ; PD LPEJP J@O PK IG KJNP@ JN BBKNP BKN P HOP 10-15 OKJ@O. KBPJ HEG IU PDQI> J@ EJ@T BEJCNJEHO PKCPDN EJ BNKJP KB PD LPEJPhO JKO O DN PDI KJ PK IG BKNBQH JN BBKNP d PD @@EPEKJH Q@EPKNU OPEIQHQO DHLO PDI BKQO J@ KJRNC P IU BEJCN J@ PDQI>. B @KJ KNNPHU, PD JN LQLEH KJOPNEPEKJ SEHH > OHKS PK @RHKL, >QP SEHH KBPJ T@ PD JKNIH JN KJOPNEPEKJ EJ PD KLLKOEP U J@ EP SEHH HOK > OHKS PK @EHP BPN HKKGEJC KBB EJ PD @EOPJ (PD HOOE ePKJEf JN NOLKJO). P ODKQH@ HOK > JKP@ PDP KJ LKOPCJCHEKJE JNRO DR CNKSJ >G EJPK PD @JNRP@ OLDEJPN OCIJPO, NLPKN OJOEPEREPU CKO @KSJ, OK EP EO JKP QJQOQH PK HKO DKHEJNCE OQLN-OJOEPEREPU KJ >NNJP NCJNPEKJ DO PGJ LH1. K OECJEBU HECDP-JN @EOOKEPEKJ, PD JN KJPNPEKJ KB PD LQLEH EJ @EI HECDP ODKQH@ T@ PD IKQJP KB IEKOEO PK >NECDP HECDP, NPDN PDJ J @@@ KJOPNEPEKJ PK JN BBKNP KJ PKL KB OEIQHPJKQO >NECDP HECDP OPEIQHQO. NEKQO BPKNO J KJBKQJ@ PD EJPNLNPPEKJ KB OQLNOJOEPEREPU POPEJC, @EOKQNCEJC EPO QO EJ IKOP OEPQPEKJO. DP >EJC OE@, SDJ DKHEJNCE OQLN-OJOEPEREPU POPEJC EO LNBKNI@ QOEJC @EHQP 0.1% LEHKNLEJ, PD @NKL ODKQH@ HSUO > CERJ PK >KPD UO, KILNEJC PD NOLKJO KB PD BBP@ U NHPER PK PD KLLKOEP U EJ @NGJOO BPN 30 IEJQPO. KSRN, PD NOQHPO J OPEHH > MQERKH. $KN TILH, LLHJPEKJ PKJKIPNU J@ 94 | North American Neuro-Ophthalmology Society
PKLEH KNJH JOPDPEO J @EONQLP PD LEPDHEH >NNEN J@ EJBHQJ PD LJPNPEKJ KB PD @EHQP PKLEH CJP PDNKQCD PD KNJ J@ EPO OQ>OMQJP BBP. J @@EPEKJ, PDN LLNO PK > SE@ NJC KB IEKPE BBP KB @EHQP LEHKNLEJ EJ JKNIH UO 4, KSEJC PK KNJH LNI>EHEPU @EBBNJO IKJC EJ@ERE@QHO, OKI KB SDED IU > CJPEHHU @PNIEJ@ 5. DJ @JNRPEKJ @KO PG LH, OQLN-OJOEPEREPU QOQHHU KJHU PGO 4-5 @UO PK @RHKL, SDED ODKQH@ HOK > GLP EJ IEJ@; OQLN-OJOEPEREPU KQNO SDPDN PD HOEKJ EO LN KN LKOPCJCHEKJE, OK EPO LNOJ EO JKP HKHEVEJC 6,7. $NKI PDA @EOQOOEKJ =>KRA, SDAJ ODKQH@ LD=NI=KHKCE PAOPEJC >A QOA@ EJ PDA OAPPEJC KB =J =JEOKKNE= PD=P EJNA=OAO EJ >NECDP HECDP, OECJEBUEJC =J ABBANAJP LQLEH @ABAP BNKI @UOBQJPEKJ KB PDA ENEO OLDEJPAN? D IEJ HEJEH @ECJKOO PDP J@ PK > @EBBNJPEP@ EJ PD OPPEJC KB J BBNJP LQLEH @BP @Q PK OLDEJPN @UOBQJPEKJ EJHQ@ PD BKHHKSEJC: . C7>;8=468 34=4E08>= @Q PK E.
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PD KLLKOEP LQLEH BPN 30 IEJQPO. DEO EO PD LDNIKHKCE POP PDP EO IKOP EJ@EP@ SDJ EP EO JKP HN SDPDN PDN EO @ENP @IC PK PD ENEO OLDEJPN IQOH KN SDPDN DKHEJNCE @JNRPEKJ DO KQNN@. EJ PD K>FPER KB OQD LDNIKHKCE POPEJC EO PK OOOO PD @ENP BBP KB DKHEJNCE CKJEOP KJ PD ENEO OLDEJPN IQOH, EP EO >OP PK OOOO PD BBP KB DKHEJNCE EJ KJ@EPEKJO KB @EI HECDP KN @NGJOO, HHKSEJC KJHU PD LDNIKHKCE BBP KJ PD OLDEJPN PK > @PNIEJ@ J@ JKP KJBKQJ@@ >U JU KEJE@JP HECDP BBP KJ LQLEH OEV. J@N PDO KJ@EPEKJO, LPDKHKCU KB PD ENEO OLDEJPN IQOH EPOHB SEHH NOQHP EJ HOO LQLEH KJPNPEKJ PK 0.5% LEHKNLEJ NHPER PK PD KLLKOEP, JKNIH U. AJKPDN LLNKD EO PK BENOP CER @EHQP 0.1% LEHKNLEJ PK >KPD UO, K>ONR BPN 30 IEJQPO, J@ PDJ BKHHKS PDEO SEPD 0.5% LEHKNLEJ EB PDN SO HOO NPEKJ KB PD EJRKHR@ U PK PD @EHQP LEHKNLEJ POP. 2. D8>34 >5 74 88 38;0> <;4 4@88=6 70<0>;>68 48=6: DJ RHQPEJC J JEOKKNE PDP EJNOO EJ @EI HECDP J@ @NOO EJ >NECDP HECDP, PPJPEKJ QOQHHU ODEBPO PKSN@ PD LQLEH PDP EO OIHHN EJ @EI HECDP PK @PNIEJ EB J KQHKOUILPDPE LNOEO EO LNOJP. D IKOP KIIKJ QO KB JEOKKNE EJ PDEO OPPEJC EO LDUOEKHKCE JEOKKNE, SDED EO PDKQCDP PK > @Q PK OUIIPNE OQLNJQHN EJDE>EPEKJ PK PD @EJCN-OPLDH QHQO. D IEJ QOO KB JEOKKNE EJ @EI HECDP N: ) QHKOUILPDPE LNOEO (KNJN OUJ@NKI) >) DUOEKHKCE JEOKKNE ) KLEH @NQC-EJ@Q@ KNJN OUJ@NKI (>NEIKJE@EJ) @) OQ@K KNJN OUJ@NKI QO@ >U @ENP @IC PK PD @EHPKN IQOH @Q PK: E.
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@ECJKOEO KB KNJN OUJ@NKI SEPD KJHU BS TLPEKJO (EJBJPO J@ HOEKJO KQNNEJC SEPDEJ PD BENOP 3 @UO KB LDNIKHKCE POPEJC). ALNHKJE@EJ $PKE@O: ) ALNHKJE@EJ SO @OECJ@ O OPNKJC HLD-2 @NJNCE CKJEOP PK HKSN EJPNKQHN LNOOQN >U OQLLNOOEJC MQKQO BKNIPEKJ. AHLD-2 NLPKN OPEIQHPEKJ KJ PD LNOUJLPE @NJNCE JNR PNIEJH EJDE>EPO PD NHO KB JKNLEJLDNEJ, OQLLNOOEJC OUILPDPE JNR PEKJ KJ EPO J@ KNCJ. >) ALNHKJE@EJ HOK DO SG HLD-1 @NJNCE CKJEOP PEREPU, >QP EJ JKNIH UO PDEO EO KILHPHU KRNOD@KS@ >U PD OPNKJC HLD-2 CKJEOP BBP SDED OQLLNOOO OUILPDPE EJ@Q@ BBPO KJ PD J@ KNCJ. J KJPNOP, >NEIKJE@EJ SO @RHKL@ O LQN HLD-2 CKJEOP J@ @KO JKP DR JU HLD-1 PEREPU. DNBKN, >NEIKJE@EJ ODKQH@ JKP > QO@ PK @ECJKO KNJN OUJ@NKI. J BP, EP SEHH LNK@Q LDNIKHKCE KNJN OUJ@NKI 36, HEG LNHKJE@EJ @KO EJ JKNIH U. ) ALNHKJE@EJ OEHU LJPNPO PD KNJ J@ @KO JKP N@EHU LJPNP PD JPNH JNRKQO OUOPI O >NEIKJE@EJ @KO (NJEJC: 3 NLKNPO KB PNJOEJP @LNOOEKJ EJ DEH@NJ BPN PKLEH LNHKJE@EJ @NKLO37-39, OK EPDN KJ ODKQH@ KJOE@N IKJEPKNEJC PDEO C CNKQL BKN DKQNO BPN LNHKJE@EJ KN OQ>OPEPQP KEJ POPEJC). @) DJ OQLN-OJOEPEREPU EO LNOJP, LNHKJE@EJhO SG HLD-1 CKJEOP PEREPU LN@KIEJPO, QOEJC OIKKPD IQOH KJPNPEKJ, NOQHPEJC EJ IU@NEOEO (BPN 30 IEJQPO) J@ NRNOH KB LPKOEO (BPN HOO PDJ 5 IEJQPO) EJ PD U SEPD OUILPDPE LNOEO. J PD JKNIH U, PD HLD-2 CKJEOP PEREPU LN@KIEJPO, QOEJC LDNIKHKCE KNJN SEPD PD LQLEH >KIEJC OIHHN EJ @NGJOO, PDQO NOQHPEJC EJ IJU OO KB eNRNOH KB JEOKKNEf BPN LNHKJE@EJ. ) ALNHKJE@EJ EO RNU QOBQH BKN @ECJKOEJC KNJN OUJ@NKI, >QP JKP BKN HKHEVPEKJ KB PD OEP KB PD HOEKJ. DJ OUILPDPE JNR OPEIQHPEKJ EO EJPNNQLP@, @JPNHEVPEKJ PGO LH SEPDEJ 3-7 @UO, QOEJC OQLN-OJOEPEREPU P PD @EOPH J@ KNCJ, RJ 1-2 OUJLOO @KSJOPNI. DNBKN, OQLNOJOEPEREPU KB PD @EHPKN IQOH SEHH KQN SEPD HOEKJO KB PD BENOP, OKJ@ KN PDEN@ KN@N JQNKJO. QLNOJOEPEREPU @KO JKP NMQEN @JNRPEKJ d KJHU @NO EJ OUILPDPE JNR PEREPU d BKN TILH, OUILPDPE CJCHEKJE >HKGEJC CJP CERJ PK JEIHO (DTIPDKJEQI) QOO OQLN-OJOEPEREPU. DNBKN, LNHKJE@EJ DO QJEMQ @RJPCO EJ PD @ECJKOEO KB KNJN OUJ@NKI. PO @ECJKOPE BBPO J > OEHU IKJEPKN@ EJ PSK J@-KNCJO; PD LQLEH J@ PD UHE@. DEO CERO EP TPN @@@ RHQ EJ EJPNLNPEJC PD NOQHPO KB POPEJC. P HOK EO QJEMQ >QO EP EO LKOEPERA PAOP EJ PDA =BBAPA@ AUA SEPD KQHKOUILPDPE LNOEO >U PERHU @EHPEJC PD LQLEH KJ PD BBP@ OE@ J@ 96 | North American Neuro-Ophthalmology Society
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10. KSE , ERN . KJE LQLEH J@ ONKE@KOEO. AI LDPDHIKH. 2003 N;135(3):417-9. 11. PH , JGEJO *, JFIEJ *, >>N . "EHP@ LQLEHO J@ HKOO KB KIIK@PEKJ BKHHKSEJC @EK@ LJNPEJH LDKPKKCQHPEKJ SEPD OQ>-PJKJ HKH JOPDPE EJ BKQN OO. U (*KJ@). 2002 L;16(5):628-32. 12. NO@ , KJ , HPP *. U@NEPE LQLEH EJ CEJP HH NPNEPEO. QNKH E. 2009 L 15;284(1-2):196-7. LQ> 2009 U 8. 13. $KNKKVJ , QKJK *, REJK , NCKPP . KJE LQLEHO BNKI CEJP HH NPNEPEO. N LDPDHIKH. 2003 ALN;87(4): 510-2. RES. 14. EV A, AJCQHK , $NJJ@V . APKJE LQLEH: J QJQOQH KILHEPEKJ KB PNP OQNCNU. LDPDHIE QNC. 1991 J;22(1):20-2. 15. ILHHKJ , C>KQPNKO A. A@EgO LQLEHO EJ LNJKLHOPE CJCHEKJKLPDU SEPD AA-1. HEJ QNKH QNKOQNC. 2006 P;108(7):712-4. LQ> 2005 AQC 31. 16. QHHN , NOO , ODJ@NHEJ . AJPE-Q JPE>K@EO, OJOKNU JQNKLPDU, J@ KHIO-A@E OUJ@NKI EJ LPEJP SEPD OIEJKI. QNKHKCU. 2005 J 11;64(1):164-5. Q>@ ": 15642929. 17. >>HO , HBHEJ , *KNJV , KHHEJC . EHPNH PKJE LQLEHO SEPD RE@J KB JPE-DQ JPE>K@EO O LNJKLHOPE IJEBOPPEKJ KB OIHH HH HQJC JN. LDPDHIKHKCE. 2004 N-ALN;218(2):141-3. Q>@ ": 15004505. 18. $QFEIKPK , QIIKPK , PK , JJKIEU , JQVQG , OQ@ . A HEJEKLPDKHKCEH OPQ@U KB LPEJP SEPD JPEQ-OOKEP@ LNJKLHOPE OJOKNU JQNKJKLPDU SEPD IQHPELH NJEH JNR LHOEO. HEJ QNKH QNKOQNC. 2002 U;104(2):98-102. 19. NQJK , EJPNGKNJ , @CN A, IH A, PQ>CJ . JEHPNH A@E LQLEH O OKH KLDPDHIE OECJ KB JPE-Q LNJKLHOPE OUJ@NKI. QNKKLDPDHIKH. 2000 ";20(4):248-9. 20. DKILOKJ , SOKI "A, *KSJBH@ . D BET@ @EHP@ LQLEH. Q@@J ENE@KLHCE KN IU@NEPE @NKLO? A OEILH @ECJKOPE POP. AND LDPDHIKH. 1971 QH;86(1):21-7. 21. KSNO , ECIKJ@ . *KHEVPEKJ KB JQNKJO EJ PD NP OQLNEKN NREH CJCHEKJ PDP LNKFP EJPK @EBB NJP LKOPCJCHEKJE PNQJGO. KIL QNKH. 1979 U 15;185(2):381-91. 22. N@KJ , "JEOKJ , NKSJ , DKILOKJ : NEPEH RHQPEKJ KB PD KEJ POP EJ PD @ECJKOEO KB KNJNhO OUJ@NKI. AND LDPDHIKH 108: 384-387, ND 1990. 23. UJO *, DKILOKJ , N@KJ , AHSN@ *. AOUIIPNE LECIJPNU @EOLNOEKJ OUJ@NKI IEIEGEJC KNJNhO OUJ@NKI. AI LDPDHIKH. 1991 P 15;112(4):463-4. 24. NPEJ . KNJNhO OUJ@NKI, OQ@K-KNJNhO OUJ@NKI, J@ OEILH JEOKKNE. QNN QNKH QNKOE L. 2007 L;7(5):397-406. RES. 25. KK@HU AA, LKKJN . ALNHKJE@EJ EJ PD @ECJKOEO KB KNJNhO OUJ@NKI. ABN @ . 2007 QH;97(7):506-7. Q>@ ":17824139. 26. DQ A, UNJ . DNIKHKCE NRNOH KB KNJNhO OUJ@NKI-NHP@ LPKOEO SEPD LNHKJE@EJ. N KO DNKP . 2007 U;86(5):270, 273. 27. DJ *, OEK , DJ , *Q ", DJ . BBEU KB LNHKJE@EJ 0.5% EJ PD @ECJKOEO KB KNJN OUJ@NKI EJ L@EPNE LPEJPO QJ@N HKS KN DECD EHHQIEJPEKJ. AI LDPDHIKH. 2006 L;142(3):469-74. 98 | North American Neuro-Ophthalmology Society
28. ENVE , ON $. KJCJEPH KNJNhO OUJ@NKI J@ PD QOBQHJOO KB PD LNHKJE@EJ POP EJ EPO @ECJKOEO. J@EJ LDPDHIKH. 2006 L;54(3):197-9. 29. DJ *, DJ , *Q ", DJ , OEK . KILNEJC BBEEO KB 0.5% LNHKJE@EJ SEPD 4% KEJ EJ PD @ECJKOEO KB DKNJN OUJ@NKI EJ L@EPNE LPEJPO. QH DNIKH DN. 2006 QJ;22(3):182-7. 30. NE>H@E ", EJ@IJ , NJP , HEBB , N>O *. BBP KB 0.5% LNHKJE@EJ KJ LPKOEO EJ KNJN OUJ@NKI. LDPDH HOP KJOPN QNC. 2006 J-$>;22(1):53-5. 31. K $, RQJQ , JOQ , ANKCHQ , $ENP . D OJOEPEREPU J@ OLEBEEPU KB 0.5% LNHKJE@EJ EJ PD @ECJKOEO KB KQHKOUILPDPE LNOEO. N LDPDHIKH. 2005 KR;89(11):1442-4. 32. $N@IJ A, NKSJ . KLEH LNHKJE@EJ EJ PD @ECJKOEO KB OQOLP@ KNJN OUJ@NKI. QNKKLDPDHIKH. 2005 QJ;25(2):83-5. 33. N@KJ . AN S N@U PK NLH KEJ SEPD LNHKJE@EJ EJ PD LDNIKHKCE @ECJKOEO KB KNJN OUJ@NKI? QNKKLDPDHIKH. 2005 QJ;25(2):69-70. 34. H "A, *RU . D QO KB LNHKJE@EJ EJ PD @ECJKOEO KB DKNJN OUJ@NKI EJ L@EPNE LPEJPO. AND LDPDHIKH. 2004 $>;122(2):276-9. 35. NKSJ , AKQDED , $N@IJ A. D QPEHEPU KB 0.5% LNHKJE@EJ EJ PD @ECJKOEO KB DKNJN OUJ@NKI. AND LDPDHIKH. 2003 AQC;121(8):1201-3. 36. "EJOHC , PNQOO , KN@J $, "EOPHDKNOP , NECHOPEJ . D BBP KB >NEIKJE@EJ KJ PD LQLEHHNU NBHT. A LQLEHHKCNLDE OPQ@U EJ DHPDU RKHQJPNO. LDPDHIKHKC. 2005 L;102(9):879-87. NIJ. 37. JCJ , RNOKJ , JPNHH $*. JPNH HLD-2 @NJNCE U @NKLO: O ONEO KB 3 L@EPNE OUOPIE LKEOKJEJCO. @EPN INC N. 2008 N;24(3):167-9. 38. PPO , PPNBEH@ ", *EI . A@RNO BBPO KB LNHKJE@EJ QO@ EJ PD @ECJKOEO KB KNJN OUJ@NKI EJ EJBJPO. AA. 2007 QJ;11(3):282-3. 39. NECDP , $N@IJ $. TLKOQN PK PKLEH LNHKJE@EJ EJ DEH@NJ SEPD CHQKI. HQKI. 2009 QJ QH;18(5):395-8. 40. SOGE A, KNNQP $. $HO JCPER LNHKJE@EJ POP EJ PSK LPEJPO SEPD KNJN OUJ@NKI. HEJ KJ>H AQCJDEHG@. 2008 U;225(5):520-2. 41. "SJ A, NNEOKJ A, * . $HO-JCPER LNHKJE@EJ POPEJC EJ QP KNJN OUJ@NKI. J LDPDHIKH. 2009 $>;44(1):109-10. 42. "ECN , IKGN , KDJOPKJ , NUDQO , DKILOKJ , KT A, QD . HPER EICEJC LLNKD BKN RHQPEKJ KB LPEJPO SEPD KNJNhO OUJ@NKI. A AI QNKN@EKH. 1992 J-$>;13(1):223-7. 43. @ "*, NKJ , IKGN , N@KJ . KNJNhO OUJ@NKI: HEJEH J@ N@EKCNLDE RHQPEKJ. QNKEICEJC HEJ AI. 2008 U;18(2):369-85, TE. RES. 44. NIN A, DKILOKJ , "ECN , N@KJ : U@NKTUILDPIEJ IU@NEOEO EJ KNJNhO OUJ@NKI. AI LDPDHIKH 110(1): 71-76, QHU 1990. 45. QHHKI " N, QHHKI , N@KJ , "ECN . SK JQNKKLDPDHIE LEOK@O OLNP@ EJ PEI J@ OL. QNR LDPDHIKH. 1995 KR-";40(3):217-24. 46. "KJDQ , *REJ , "ECN . $HO-JCPER DU@NKTUILDPIEJ (N@NEJ) POP EJ QP KNJNhO OUJ@NKI. AI LDPDHIKH. 1996 ";122(6):900-1.
47. EHDHI , EHDHI , NEC>QI . JPNPEKJ KB PD EJ@ENPHU PEJC PKLEH OUILPDKIEIPEO KEJ J@ LDKH@NEJ. N LDPDHIKH. 1996 U;5(3):168-70. 48. EJOPEJ , SEBH , DKILOKJ . KJCJEPH KNJNhO OUJ@NKI. AND LDPDHIKH. 1980 QJ;98(6):1074-8.
EXPERT OPINION & COMMENTARY "N. N@KJ DO LOQHEV@ PD EOOQO SEPD HKCE, OEJ, NED HEJEH TLNEJ, J@ LNPEH @RE. DR BS d J@ IKOPHU IEJKN d @EOCNIJPO. 1. NEO DKHEJNCE @EOKN@NO. DEO EO SDN PD BBP@ LQLEH KJOPNEPO NHPERHU LKKNHU PK @ENP HECDP >QO KB BBNJP @UOBQJPEKJ. "N. N@KJ >HERO PDP POPEJC SEPD PKLEH QO KB @EHQP (0.1%) LEHKNLEJ EO JKP OOJPEH EJ PDEO OPPEJC. CN, J@ SEHH OQIINEV PD LKEJPO. . #460=6;8>=8 E >60=6;8>=8 00<0748 35=8>=. KJQN SEPD "N. N@KJ EJ OUEJC PDP LKOPCJCHEKJE HOEKJO ODKQH@ > OEHU @EOPEJCQEOD@ BNKI LNCJCHEKJE LHOEO >QO LKOP-CJCHEKJE HOEKJO SEHH QJEMQHU DR A* A*, *-A "A, J@ A *A $ KPDN IJEBOPPEKJO KB EJPNNJEH @EOO (PD JEOKKNE EO eEOKHP@f). NCJCHEKJE HOEKJO, D OPPO, JRN LNK@Q OPKNH LHOEO EJ PD QP LDO;. SEPD NEJJNRPEKJ KB PD EHENU CJCHEKJ, OPKNH LHOU IECDP KQN (JSO PK I). SKJ@N EB D EO KILHPHU NECDP >KQP OPKNH LHOEO JKP KQNNEJC EJ QP LNCJCHEKJE HOEKJO. AQP eIE@>NEJ KNPKLEf DO >J NLKNP@ 1,2 J@ DR OJ EP. QP IE@>NEJ d J@ TPN-TEH d LNCJCHEKJE HOEKJO SEHH =HS=UO @EOLH=U KPDAN @EOPEJPERA JAQNKHKCE BA=PQNAO, IGEJC PD @EOPEJPEKJ BNKI LKOPCJCHEKJE HOEKJ OU. NBQH DN, O PDKO BPQNO IU > OQ>PH. "N. N@KJ JKPO PDP EJ LKOPCJCHEKJE HOEKJO, ENEO OLDEJPN OQLNOJOEPEREPU PK PKLEH DKHEJNCE CJPO @RHKLO SEPDEJ 4-5 @UO (RHQ>H >QP QJLQ>HEOD@ EJBKNIPEKJ) J@ NIEJ@O QO PDP OQD OQLANOAJOEPEREPU =J >A OAAJ EJ LNAC=JCHEKJE HAOEKJO (SHH-LQ>HEOD@ EJBKNIPEKJ3, LNOQI>HU >QO OKI LNCJCHEKJE BE>NO @K JKP OUJLO EJ PD EHENU CJCHEKJ. DP OQD OQLNOJOEPEREPU J KQN EJ LNCJCHEKJE J@ LKOPCJCHEKJE HOEKJO EO NOKJ JKQCD JKP PK @LJ@ KJ @EHQP LEHKNLEJ POPEJC EJ @EBBNJPEPEJC >PSJ PDO PSK OEPO. DN N KPDN LNK>HIO SEPD QOEJC @EHQP LEHKNLEJ EJ PDEO OPPEJC. AO "N. N@KJ LKEJPO KQP, EJPNKQHN @EBBNJO EJ KNJH LJPNPEKJ J IOO QL PD NOQHPO. KI LPEJPO DR OIHH LQLEHO KJ >KPD OE@O J@ IU JKP DR JKQCD OQLNOJOEPEREPU PK HHKS PD I@EPEKJ-EJ@Q@ IEKOEO PK >KI LLNJP. QN DKOLEPH LDNIU JK HKJCN KJKPO PD @EHQP OKHQPEKJ, HREJC I KN IU OOEOPJPO PK IG PD @EHQPEKJH NNKNO. $KN HH PDO NOKJO, DR OPKLL@ QOEJC EP TLP O @IKJOPNPEKJ PK PNEJO KB JEBPU >QP JPEMQ LLNKD PK LNPEEJC JQNKKLDPDHIKHKCU.
. #>60=6;8>=8 E. 88 78=4 35=8>=. DEO @EOPEJPEKJ J > PKQCD. $KNPQJPHU, EP EO NNHU REPH. "N. N@KJ LKEJPO KQP PDP HOEKJO EJ EPDN LH J LNK@Q OPKN LHOU. "JNRPEKJ OQLNOJOEPEREPU ODKQH@ JKP, KB KQNO, KQN EJ OLDEJPN @UOBQJPEKJ. J BP, PD @UOBQJPEKJH OLDEJPN ODKQH@ > PK DKHEJNCE CJPO. K, O "N. N@KJ OQCCOPO d J@ CN d SDU JKP PG @RJPC KB PDP BPQN J@ POP SEPD LEHKNLEJ KJJPNPEKJ PDP *" A** $ $** AA** $ A$$" . DP LEHKNLEJ KJJPNPEKJ EO 0.5%, JKP 0.1%. ABPN EJOPEHHPEKJ, PD JEOKKNE SEHH EJNO EJ OO KB LKOPCJCHEKJE LHOU, @NO EJ OO KB ENEO OLDEJPN @UOBQJPEKJ, J@ NIEJ PD OI EJ OO KB LNCJCHEKJE LHOU. 2. I8 034=468 38>34. DEO EO SDN PD ENEO @EHPKN EO @UOBQJPEKJH, OK PDP PD JEOKKNE EO CNPN EJ @NGJOO PDJ EJ HECDP, J@ PD BBP@ LQLEH DO @EHPEKJ HC O NKKI EHHQIEJPEKJ EO MQEGHU N@Q@. D DHHJC DN EO IQD IKN EILKNPJP PDJ PK OLNP LDUOEKHKCE JEOKKNE BNKI KNJN OUJ@NKI. AO "N. N@KJ ILDOEVO, PDEO @EOPEJPEKJ J > @EBBEQHP >QO KNJN OUJ@NKI IU DR OQ>PH HEJEH IJEBOPPEKJO.4-6 PKOEO IU > >OJP. AJEOKKNE IU > >OJP.7 AP >OP, D BEJ@EJC EO IEJEIH. AJ@ D BEJ@EJC J > CJNP@ >U KPDN QOO. 8 "N. N@KJ OPPO PDP @EHPEKJ HC EO QOQHHU LNOJP EJ KNJN OUJ@NKI, >QP DR JKP BECQN@ KQP NHE>H SU PK >NEJC KQP PDP LDJKIJKJ. QO JJKP KQJP KB HEJEH BEJ@EJCO, @LJ@ KJ PKLEH LDNIKHKCE POPEJC BKN KJBENIPEKJ KB KNJN OUJ@NKI. QP SDP GEJ@? DR OPKLL@ QOEJC PKLEH KEJ TLP EJ DEH@NJ QJ@N PD C KB KJ UN (>QO LNHKJE@EJ, IU DKE, IU QO ORN QPKJKIE OE@ BBPO EJ PDP C CNKQL 9. EPD KEJ POPEJC, UKQ @LJ@ KJ BEJ@EJC N@Q@ @EHPEKJ EJ PD BBP@ U, >QP PDEO OQ>OPJ d RJ EJ 10% KJJPNPEKJ d EO SG @EHPKN KB PD JKNIH ENEO. KNKRN, EP EO KJPNKHH@ OQ>OPJ; KQN DKOLEPH NCQHPEKJO NMQEN PDP EP NIEJ EJ HKG@ OB! DU >KPDN SEPD KEJ SDJ LNHKJE@EJ 0.5% DO OK BN JRN HP I @KSJ. DN N JKS NLKNPO PDP RJ JPNH KNJN OUJ@NKI SEHH ODKS NRNOH KB JEOKKNE SEPDEJ PDN @UO!10 D BHO LKOEPER NP LLNO PK > HKS. KN @P SKQH@ > DHLBQH DN, OLEHHU PK ONPEJ PD BHO JCPER NP. 11-14 hI HN@U >HERN, >QP I LHO@ PK HNJ PDP "N. N@KJhO BKNIH KILNEOKJ KB KEJ J@ LNHKJE@EJ ODKS@ PDP PD PSK CJPO N KILN>H EJ @PPEJC @JNRPEKJ OQLNOJOEPEREPU EJ KNJN OUJ@NKI.
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10. *>O , NKN , ">NKQGN . KOEPER LNHKJE@EJ POP 36 DKQNO BPN QP KJOP KB KNJN OUJ@NKI EJ LKJPKI@QHHNU OPNKG. QNK-LDPDHIKHKCU, EJ LNOO. 11. K $, RQJQ , JOQ , ANKCHQ , $ENP . D OJOEPEREPU J@ OLEBEEPU KB 0.5% LNHKJE@EJ EJ PD @ECJKOEO KB KQHKOUILPDPE LNOEO. N LDPDHIKHKCU 2005;89: 1442-1444. 12. QCDH , *KJCIQEN . QNNJP LDNIKHKCE POPEJC BKN KNJN OUJ@NKI. QNN QNKH QNKOE L 2009;9:384-389. 13. "SJ A, NNEOKJ A, * . $HO-JCPER LNHKJE@EJ POPEJC EJ QP KNJN OUJ@NKI. J LDPDHIKH 2009;44:109-110. 14. N@KJ . AN S N@U PK NLH KEJ SEPD LNHKJE@EJ EJ PD LDNIKHKCE @ECJKOEO KB KNJN OUJ@NKI? QNKKLDPDHIKH 2005;25:69-70. 15. HKJU $, KQJC , KUN . RHQPEKJ KB PD QOO J@ QNU KB LDNIKHKCE HKHEVPEKJ EJ KNJNhO OUJ@NKI. AI LDPDHIKH 1980;90:394-402. 16. AHIKC , LOPEJ , OHN A. "ECJKOPE RHQ KB EICEJC EJ KNJN OUJ@NKI EJ @QHPO. QNK-LDPDHIKHKCU (EJ LNOO). 17. EKQOO , "hAJCHFJ-DPEHHKJ , KQ>KQH , AINJK , KQOON . EI KQNO KB OUILPKIO EJ TPNNJEH NKPE@ NPNU @EOOPEKJ. A ONEO KB 80 LEJPO. PNKG 1995;26: 235-239. 18. NK> ". D RHQPEKJ KB KNJN OUJ@NKI. QNK-LDPDHIKHKCU (EJ LNOO).
CME ANSWERS 1. ) HH KB PD >KR; HH KB PDO QOO @ENPHU BBP PD OLDEJPN IQOH @Q PK EODIE J@ SKQH@ IG PD ENEO QJ@N-OJOEPER PK 0.5% LEHKNLEJ. 2. ) LLHJPEKJ PKJKIPNU IU @EONQLP PD KNJH >NNEN J@ IU BBP PD LJPNPEKJ KB @EHQP LEHKNLEJ EJ KJ U IKN PDJ PD KPDN. 3. A) LNHKJE@EJ SEHH JKP BBP PD QLPG J@ NOQHPO KB DU@NKTUILDPIEJ POPEJC LNBKNI@ PD JTP @U.
NEUROMYELITIS OPTICA, IS IT A DISTINCT ENTITY FROM MS AND WHAT ARE THE TREATMENT IMPLICATIONS? Evidence Presentation — Jeffrey L. Bennett, M.D., Ph.D. University of Colorado Denver Aurora, CO
Expert Opinion & Commentary — Steven Galetta, M.D. University of Pennsylvania Philadelphia, PA
LEARNING OBJECTIVES
EVIDENCE PRESENTATION
1. K TIEJ PD SE@ RNE>EHEPU KB PD @EOKN@N SKNH@SE@.
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2. K @EOQOO OKI KB PD GU HEJEH IJEBOPPEKJO KB . 3. K @EOQOO PD QNNJP IJCIJP KB .
CME QUESTIONS 1. KS IJU OLEJH OCIJPO N PULEHHU EJRKHR@ EJ LPEJP SEPD QNKIUHEPEO KLPE? . 1 >. 2 . 3 KN IKN 2. DP LNJP KB LPEJPO N HCHHU >HEJ@ EJ P HOP KJ U SEPD QNKIUHEPEO LPE? . 10 >. 20 . 30 @. 40 . 50 3. DED N KB PD BKHHKSEJC CJPO EO J LP@ PNPIJP BKN ? . JPNBNKJ >P 1- >. JPNBNKJ >P 1-> . HPENIN APP @. AVPDEKLNEJ
KEY WORDS 1. LPE JQNEPEO 2. QNKIUHEPEO KLPE 3. QHPELH HNKOEO
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fOQCCOPEJC PDP JPKIE @EOPNE>QPEKJ KB EJBHIIPKNU @EOO EJ PD JPNEKN J@ NPNK>QH>N JNRO EO JKP @EOPEJP >PSJ PD PSK KJ@EPEKJO. D JPQNH DEOPKNU KB REOQH BQJPEKJ EJ , DKSRN, LLNO PK > 2010 Annual Meeting Syllabus | 101
OECJBEJPHU SKNO PDJ EJ 5. KS NKRNU NHPO PK PPG BNMQJU J@ PDNLU NIEJO LKKNHU @BEJ@. I<068=6: D EJEPEH IK@NJ NEPNE BKN NMQEN@ JKNIH >NEJ . JPHU, OPQ@EO DR BKQJ@ PDP 60% KB LPEJPO SEPD @IKJOPNP >NEJ SDEP IPPN >JKNIHEPEO SEPD 10% KB EJ@ERE@QHO ODKSEJC @EOPNE>QPEKJ DECDHU OQCCOPER KB 6. DEH OIHH OQ>OP KB EJPNNJEH HOEKJO EJ LPEJPO SN K>ONR@ EJ NCEKJO KB DECD A4 TLNOOEKJ EJ NK@JP >NEJ, PD KIIKJ LN@EHPEKJ KB J@ HOEKJO PK PD OLEJH KN@ J@ KLPE JNR NIEJO QJTLHEJ@. DEH LLNO QJ>H PK @EOPEJCQEOD >PSJ KLPE JNR EJBHIIPEKJ NEOEJC BNKI KN , KQHN KDNJ PKIKCNLDU () DO E@JPEBE@ JPQP@ NPEJH JNR BE>N HUN ($*) J@ IQHN RKHQI HKOO EJ UO SDJ KILN@ PK UO 7-10. J RNC, OEJCH LEOK@ KB EJ J LPEJP SO OPEIP@ PK QO J @@EPEKJH 24 ` KB $* HKOO SDJ KILN@ PK J RJP EJ . D @EBBNJ EJ $* HKOO NIEJ@ OECJEBEJP BPN KJPNKHHEJC BKN PD BNMQJU KB 10 J@ REOQH QEPU9. K OPQ@U, DKSRN, DO EJROPECP@ SDPDN PD DJCO N LQNHU TKJH KN NLNOJP PD HKOO KB QHHN HH J@BP. L0>0>: JP OPQ@EO DR NLP@HU BKQJ@ PDP ONQI C JPE>K@EO PK A4 N OOKEP@ OLEBEHHU SEPD 2,4. D POP BKN JPEc-C, DKSRN, EO BN BNKI @ECJKOPE CKH@ OPJ@N@. A OECJEBEJP BNPEKJ KB LPEJPO @K JKP DR ONQI -C, EJ@EPEJC PDP EPDN A-4 JPE>K@EO N JKP JOONU BKN HEJEH @EOO KN PDP HPNJPER PNCP JPECJO N OQBBEEJP BKN LPDKCJOEO. "OLEP PD QO KB IQHPELH OJOEPER OOUO, 10-39% KB LPEJPO SEPD HEJEHHU @BEJEP N ONKJCPER BKN A-4 C, J@ ONQI A-4 JPE>K@U PEPNO @K JKP NHE>HU KNNHP SEPD HEJEH PEREPU12,13. J @@EPEKJ, LPEJPO @K JKP DR EJNO@ IKQJPO KB $ C1 LNKPEJ14, J@ KJHU 10% KB BBP@ EJ@ERE@QHO @IKJOPNP EJPNPDH JPE>K@U LNK@QPEKJ 13,15. JPNOPEJCHU, IKN PDJ 70% KB @QHP LPEJPO N LKOEPER BKN JPEJQHN JPE>K@EO 16, J@ 42% KB DEH@NJ SEPD DR KTEOPEJC QPKEIIQJ @EOKN@N 17. RNH BPQNO KB PD N>NKOLEJH BHQE@ ($) IU DHL PK @EOPEJCQEOD BNKI . A OECJEBEJP LHKUPKOEO (SDEP >HKK@ HH KQJP _ 50 T 10 3/`*) J@ PD >OJ KB KHECKHKJH >J@EJC N IKN LNRHJP EJ PDJ 1,15. RNPDHOO, PD $ LNKBEHO ODKS OECJEBEJP KRNHL. J@@, S DR NJPHU @IKJOPNP@ PDP QPKJPE>K@EO CEJOP A4 IU > EJPNPDHHU OUJPDOEV@ EJ (JJPP P H., AJJ QNKH, EJ LNOO). H8>07>;>6: KPD J@ N EJBHIIPKNU @IUHEJPEJC @EOKN@NO PDP BBP LPEJPO KB OEIEHN C. EIEHN PK K>ONRPEKJO EJ 18, LPDKHKCU IU TDE>EP @EBBNEJC OQ>PULO19,20. LJO LPEJPO SEPD KLPEKOLEJH IUHEPEO () DR KJHU BS KOEJKLDEHO J@ JQPNKLDEHO KILN@ PK OO KB OPNJ . KSRN, OEIEHN PK OPNJ HOEKJO J@ QP LHMQ, HOEKJO QJEBKNIHU @IKJOPNP - HH J@ INKLDC EJBEHPNPEKJ. DEH EIIQJKHK>QHEJ J@ 102 | North American Neuro-Ophthalmology Society
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
SUMMARY O @EOPEJP JPEPU BNKI ? J KN@N PK JOSN PDEO MQOPEKJ, S J@ PK @@NOO IKN @EBBEQHP EOOQ, SDP @KO EP IJ BKN PSK @EOKN@NO PK > @EOPEJP? "K PD PSK KJ@EPEKJO NMQEN @EOPEJP OIEKHKCEO, @EBBNEJC LPDKCJOEO, KN HPNJPER PEKHKCEO? N HPNJPERHU, ODKQH@ PD @EOPEJPEKJ > LNCIPE? DP EO, EO EP KJHU EILKNPJP PDP PD PSK KJ@EPEKJO > @EOPEJCQEOD@ @ECJKOPEHHU J@ PDNLQPEHHU? AP PD LNOJP PEI, JK IPPN DKS S PNU PK @EOPEJCQEOD J@ , PD PSK @EOKN@NO IEJPEJ J EJPNECQEJC @CN KB KRNHL. K, N UKQ eHQILNf KN eOLHEPPNf?
FIGURE 1: Prototypic NMO pathology induced by intravenous transfer of an AQP4-specific recombinant antibody into guinea pig MBP72-85-induced EAE rats. (H&E), Hematoxylin-eosin staining showing perivascular polymorphonuclear and lymphocytic cellular infiltrates with associated tissue destruction. (GFAP), glial fibrillary acidic protein staining demonstrates perivascular astrocyte loss. (LFB), Luxon fast blue staining shows perivascular myelin loss. (MBP) Myelin basic protein immunohistochemistry shows relative preservation of mylein basic protein staining.
11. *JJKJ, .A., NUVN, .., EPPKG, .., NGIJ, A.. & EJOKJ, .. C INGN KB KLPE-OLEJH IQHPELH OHNKOEO >EJ@O PK PD MQLKNEJ-4 SPN DJJH. TL @ 202, 473-477 (2005). 12. UN, A.., J@EJCN, .., E>NP, ., ODJ@NHEJ, . & HDIP, . QNKIUHEPEO KLPE EJ LPEJP SEPD J NHU KJOP @IUHEJPEJC LEOK@: HEJEH J@ QPKJPE>K@U BEJ@EJCO. HEJEH JQNKHKCU J@ JQNKOQNCNU 109, 926-930 (2007). 13. GDODE, ., P H. AJPE-MQLKNEJ-4 JPE>K@U EO EJRKHR@ EJ PD LPDKCJOEO KB : OPQ@U KJ JPE>K@U PEPN. NEJ 130, 1235-1243 (2007). 14. GODEI, ., P H. A>OJ KB C1 NOLKJO EJ PD N>NKOLEJH BHQE@ KB NHLOEJC JQNKIUHEPEO KLPE. QNKHKCU 62, 144-146 (2004). 15. DVVE, A., P H. HEJEH DNPNEOPEO, KQNO J@ LNKCJKOEO KB NHLOEJC "RE'O QNKIUHEPEO LPE. QNKH 251, 47-52 (2004). 16. EJODJGN, .., P H. QNKIUHEPEO KLPE C LN@EPO NHLO BPN HKJCEPQ@EJHHU TPJOER PNJORNO IUHEPEO. AJJ QNKH 59, 566-569 (2006). 17. KJ, A., P H. MQLKNEJ-4 QPKEIIQJEPU EJ DEH@NJ. QNKHKCU 71, 93-100 (2008). 18. *QDEJPPE, ., P H. PNKCJEPU KB IQHPELH OHNKOEO HOEKJO: EILHEPEKJO BKN PD LPDKCJOEO KB @IUHEJPEKJ. AJJ QNKH 47, 707-717 (2000). 19. *QDEJPPE, .$., P H. A NKH BKN DQIKNH IDJEOIO EJ PD LPDKCJOEO KB "RE'O JQNKIUHEPEO KLPE. NEJ 125, 1450-1461. (2002).
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EXPERT OPINION AND COMMENTARY (1UHH=>QO IK@EBEA@ BNKI %HEOOKJ !! =J@ %=HAPP= 1*. "N=SEJC PDA *EJA APSAAJ + =J@ +1. N=P AQNKH. 6:33-37, 2007) $KN PD JQNK-KLDPDHIKHKCEOP, PD >EHEPU PK NKCJEV PD IJEBOPPEKJO KB DO EILKNPJP EILHEPEKJO. EOEKJ HKOO EJ IU > >EHPNH J@ ORN, J@ PD LKPJPEH BKN HKJCEPQ@EJHHU-TPJOER OLEJH KN@ EJRKHRIJP J NOQHP EJ OECJEBEJP @EO>EHEPU. AHPDKQCD PD LH KB SEPDEJ PD BNISKNG KB @IUHEJPEJC @EOO EO RKHREJC, J QJ@NOPJ@EJC KB PD HEJEH DNPNEOPEO J@ PD @ECJKOPE OPQ@EO REH>H IU OOEOP EJ @BEJEJC PDNLQPE OPNPCU BKN LPEJPO LNOJPEJC SEPD KLPE JQNEPEO KN IUHEPEO.
THE CLINICAL DIAGNOSIS D LNOJPEJC OUILPKIO KB N KLPE JQNEPEO J@/KN IUHEPEO. NHU, PD LPEJP IU LNOJP SEPD I@QHHNU KN TPJOER >NEJOPI HOEKJO. D NOQHPJP JQNKHKCEH @BEEPO N QOQHHU ORN, J@ EJ KJPNOP PK PULEHHU @K JKP EJRKHR PD >NEJ. 1 P EO EILKNPJP PK ILDOEV PDP HH KB PD HEJEH BPQNO KB JQNKIUHEPEO KLPE IU JKP > RE@JP P PD EJEPEH LNOJPPEKJ. D KRNSDHIEJC IFKNEPU KB LPEJPO SEPD DR NHLOEJC KQNO,2 J@ ORN JQNKHKCEH @EO>EHEPU QIQHPO KRN PEI. D HKJC-PNI LNKCJKOEO EO LKKN; DKSRN, NPEJ OQ>OP KB LPEJPO SEHH DR NHPERHU >JECJ KQNO, IEJPEJEJC CKK@ IOQN KB REOQH QEPU J@ IK>EHEPU (QJLQ>HEOD@ K>ONRPEKJO) RJ SEPDKQP PNPIJP. D @ECJKOPE @EHII EJRKHRO @EOPEJCQEODEJC PD LPEJPO EJ SDED J EJ@T RJP LKNPJ@O PD OLPNQI KB , SDED IU JKP >KI IJEBOP BKN UNO. J NHLOEJC @EOO, 60% KB LPEJPO @RHKL OKJ@ HEJEH RJP SEPDEJ KJ UN, J@ 90% SEPDEJ 3 UNO. 1 J @EOPEJPEKJ BNKI , NKRNU BNKI PPGO EO EJKILHP, >QP OKJ@NU LNKCNOOER KQNO EJ EO QJKIIKJ (>H 1).
TABLE 1: Clinical Features of NMO versus Multiple Sclerosis Neuromyelitis Optica
Multiple Sclerosis
Severe myelopathy, visual loss unilateral early in course, often bilateral late
Mild to moderate myelopathy, visual loss is usually unilateral
Attacks more severe with less complete remission
Attacks mild to moderate with initially good recovery
Secondary progressive course is uncommon
Secondary progressive course is common
Patients may not respond to conventional MS therapy, often require immunosuppression
Patients often respond to conventional MS therapy, immunosuppressive drugs often not needed
104 | North American Neuro-Ophthalmology Society
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JKP EILHU @EBBNJP PDNLQPE NOLKJO. PEJPO SEPD J@ SEPDKQP PD JPE>K@U NOLKJ@ OEIEHNHU PK EIIQJKOQLLNOOER PDNLU J@ KPDN PDNLQPE IK@HEPEO.fe D C JPE>K@U IU > K>ONR@ EJ KPDN KJJPER PEOOQ @EOKN@NO OQD O OUOPIE HQLQO NUPDIPKOQO KN FKCNJhO OUJ@NKI, LNPEQHNHU PDKO SEPD RE@J KB JQNK-IUHEPEO KLPE. A OQNRU KB LPEJPO SEPD NHLOEJC PNJORNO IUHEPEO J@ LKOEPER JPE>K@U POPO EJ@EP@ PDP >KQP 50% HOK D@ LKOEPER POP NOQHPO BKN JPEJQHN JPE>K@EO, J@ LLNKTEIPHU 75% KB LPEJPO SEPD NQNNJP @IUHEJPEKJ @IKJOPNP@ PD LNOJ KB QPKEIIQJ JPE>K@EO.18 DO KPDN QPKEIIQJ KJ@EPEKJO OQD O HQLQO N IKOP NHE>HU @EOPEJCQEOD@ BNKI SDJ PDN N HEJEH J@ >EKLOU BPQNO PDP OQCCOP OUOPIE EJBHIIPKNU LNKOO. KSRN, OKI LPEJPO SEPD PD LDJKPUL SEHH FQOP DR KPDN QPKEIIQJ JPE>K@EO SEPDKQP RE@J KB OUOPIE EJBHIIPKNU
[email protected] $QNPDN OPQ@U KB PDO LPEJPO SEHH DHL HQE@P PD QPKEIIQJ KRNHL PDP IU TEOP >PSJ PDO KJ@EPEKJO.
CSF TESTING N>NKOLEJH BHQE@ JHUOEO DO >J @RKP@ O J @@EPEKJH IJO KB @EBBNJPEPEJC BNKI . D LNOJ KB $ LHKUPKOEO (SDEP >HKK@ HH KQJP KB CNPN 50 HHO, KBPJ SEPD JQNPNKLDEHO) EO RNU NN EJ , >QP IU > OJ EJ QL PK KJ-PDEN@ KB OO KB . $QNPDNIKN, KHECKHKJH >J@EJC IU > @PP@ EJ 70 PK 90% KB LPEJPO SEPD , >QP EJ KJHU 20 PK 30% KB LPEJPO SEPD .
NEURO-IMAGING DNPNEOPEHHU EJ , PDN EO HKJCEPQ@EJHHU TPJOER OLEJH KN@ HOEKJ PDP TPJ@O KRN PDN KN IKN RNP>NH OCIJPO (>H 2). AO KLLKO@ PK PD HOEKJ EJ PD KN@ PJ@O PK > JPNH. J @@EPEKJ, PD HOEKJ EO KBPJ DULKEJPJO KJ 1 EICEJC NBHPEJC TKJH @CJNPEKJ5 PQ@EO DR ODKSJ PDP QL PK 60% KB LPEJPO SEHH DR JKJOLEBE SDEP IPPN BEJ@EJCO. KSRN, EP EO QJKIIKJ BKN PDI PK BQHBEHH PD NGKB NEPNE BKN . $EJHHU, PULEH HOEKJO PDP EJRKHR PD JPNH I@QHH J@ DULKPDHIQO HOK IU OQCCOP PD LNOJ KB J LDJKPUL. DR OJ HNC OUILPKIPE HOEKJO KB PD >NEJ OLKJPJKQOHU NIEP EJ PDEO @EOKN@N. LPEH KDNJ PKIKCNLDU ODKSO IKN ORN HKOO KB NPEJH JNR BE>N HUN HKOO ($*) BPN >KQP KB KLPE JQNEPEO EJ LPEJPO. J CJNH, HKOO KB CNPN PDJ 15 IENKJO KB $* BPN KLPE JQNEPEO ODKQH@ OQCCOP PD LKOOE>EHEPU KB . 25
TABLE 2: Radiographic Features of NMO versus Multiple Sclerosis Neuromyelitis Optica
Multiple Sclerosis
Brain MRI: often normal, particularly early in the disease course.
Brain MRI: typically show periventricular and subcortical lesions
Cord MRI: long, central lesions (> 3 vertebral segments), hypointensity on T1 images
Cord MRI: peripheral lesions, usually short in length (2 vertebral segments or less)
Lesions involving cental medulla, hypothalamus and diencephalon
Brainstem lesions involve the medial longitudinal fasciculus or peripheral brainstem
TREATMENT STRATEGIES IN NMO P EO EILKNPJP PK ILDOEV PDP S N QJHEGHU PK DR HNC NJ@KIEV@ KJPNKH PNEHO KB LPEJPO, OK KQN PNPIJP LNKPKKHO N HEGHU PK > >O@ KJ TLNP KLEJEKJ J@ J@KPH RE@J. P EO QOBQH PK PDEJG KB PNPIJP O >KPD QP J@ DNKJE. $KN QP PDNLU, S QO EJPNRJKQO IPDUHLN@JEOKHKJ 1 CNI BKN 5 @UO J@ LDNOEO BKN ORN PPGO. 20 D ORNEPU KB PPGO IU > @BEJ@ O J QEPU KB 20/200 KN HOO J@ J " OKN KB 4.0 KN HOO SDJ OLEJH KN@ @UOBQJPEKJ LN@KIEJPO. P EO HOK EILKNPJP PK ILDOEV PDP LPEJPO SEPD PD LDJKPUL KB NOLKJ@ PK PDNLU NCN@HOO KB PD JPE>K@U OPPQO. DEO EJHQ@O PD NOLKJO PK OPNKE@O, LDNOEO J@ NEPQTEI>. *EGSEO, PDN N LPEJPO SDK CKEJC PK BEH RJ NEPQTEI> J@ IU NMQEN KI>EJPEKJ KB PDNLEO EJHQ@EJC EIIQJKOQLLNOOER @NQCO OQD O VPDEKLNEJ. KJPDHU KN RNU 6 SG PDNLU NIEJO KJOE@NPEKJ, J@ NLKNP KB PSK LPEJPO 21 OQCCOP@ PDP NHLOO IU > IEJEIEV@ >U PDEO LLNKD. QO KB EPO REH>EHEPU J@ KOP, QOQHHU OPNP LPEJPO SEPD PD LDJKPUL KJ VPDEKLNEJ. 22 DR JK PNKQ>H SEPD PDKO PDP EJEPEP PDNLU SEPD NEPQTEI>, >QP EP J > J JKNIKQO DOOH PK CP PD EJOQNJ KILJU PK LLNKR EP. DN N JQI>N KB SUO NEPQTEI> J > QO@. J EO PK CP HKH NDQIPKHKCEOP KN KJKHKCEOP PK @IEJEOPN PD @NQC PDNKQCD PDEN EJBQOEKJ JPN. D KPDN IFKN IDJEOI PK CP NEPQTEI> @IEJEOEPN@ EO PK @IEP PD LPEJP BKN PDEN EJBQOEKJ. DN N ORNH @EBBNJP NCEIJO BKN NEPQTEI> EJHQ@EJC 375 IC/I2 SGHU BKN IKJPD BKHHKS@ >U NLP @KO EJ 6 IKJPDO. AHPNJPERHU, UKQ KQH@ CER 1000 IC @KO BKHHKS@ PSK SGO HPN >U JKPDN 1000 IC @KO. A NLP @KO KQH@ > CERJ EJ 6 IKJPDO. 23,24 P EO JKP QJKIIKJ BKN PK > OOKEP@ SEPD KPDN QPKEIIQJ KJ@EPEKJO OQD O FKCNJO, *QLQO J@ RJ IUOPDJE CNREO. U KJOJOQO, EB LPEJP BQHBEHHO PD NEPNE BKN *QLQO KN JKPDN QPKEIIQJ KJ@EPEKJ, PDU DR PDP KJ@EPEKJ. KJPDHOO, PDO LPEJPO PJ@ PK NOLKJ@ PK PD PNPIJPO @RKP@ BKN . 2010 Annual Meeting Syllabus | 105
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10. J@HN , "REO *, BBNU ", KNJBH@ . "REhO JQNKIUHEPEO KLPE: HEJEKLPDKHKCEH OPQ@U KB 8 LPEJPO.fAJJ QNKH 1993; 34: 162-168. 11. LPE QNEPEO PQ@U NKQL. *KJC-PNI >NEJ ICJPE NOKJJ EICEJC DJCO BPN KLPE JQNEPEO EJ LPEJPO SEPDKQP HEJEHHU @BEJEP IQHPELH OHNKOEO. AND QNKH 2004: 61: 1538-1541. 12. $EHELLE , K A, KEKH *, NPEJHHE , DVVE A, LN , P H.f J@ ICJPEVPEKJ PNJOBN EICEJC DJCO EJ PD >NEJ J@ NREH KN@ KB LPEJPO SEPD "REhO JQNKIUHEPEO KLPE.fQNKHKCU 1999; 53: 1705-1710. 13. K A, ACKOP $, VVLO ", NPEJHHE , HRE $, DVVE A, P H.fCJPEVPEKJ PNJOBN J@ @EBBQOEKJ PJOKN ODKS CNU IPPN @IC EJ JQNKIUHEPEO KLPE.fQNKHKCU 2004; 10: 476-478. 14. NGDKB $, $EHELLE , EHHN ", DHPJO , ILE A, KHIJ , P H.fKILNEOKJ KB EICEJC NEPNE P BENOP LNOJPPEKJ PK LN@EP KJRNOEKJ PK HEJEHHU @BEJEP IQHPELH OHNKOEO.fNEJ 1997; 120: 2059-2069. 15. EPPKG , *JJKJ A, EJCNDQG ", *QDEJPPE $, EJODJGN .fNEJ >JKNIHEPEO EJ JQNKIUHEPEO KLPE.fAND QNKH 2006; 63: 390-396. 16. *JJKJ A, EJCNDQG ", NUVN , EPPKG , *QDEJPPE $, $QFEDN , GODEI J@ EJODJGN . A ONQI QPKJPE>K@U INGN KB JQNKIUHEPEO KLPE: @EOPEJPEKJ BNKI IQHPELH OHNKOEO. *JP 2004;364:2106-2112.
106 | North American Neuro-Ophthalmology Society
17. *JJKJ A, NUVN , EPPKG , NGIJ A, EJOKJ . C INGN KB KLPE-OLEJH IQHPELH OHNKOEO >EJ@O PK PD MQLKNEJ-4 SPN DJJH. TL @ 2005;202:473-477. 18. EJODJGN , EJCNDQG ", QGQOE , *EJ>K, *, EPPKG , *QDEJPPE $, *JJKJ A. LN@EPO NHLO BPN HKJCEPQ@EJHHU TPJOER PNJORNO IUHEPEO. AJJ QNKH 2006;59:566-569. 19. QIINO *, NEODJJ , OEKHcKOJ *, KOJ A, KNNEO , DKJU A, NN "A, ECHU $. QNNJP PNJORNO IUHEPEO OOKEPO SEPD JPE-K (A) JPE>K@EO. QNKHKCU 2004;62:147-149. 20. EJODJGN , hNEJ , PPNOKJ , KOSKNPDU , *QDEJPPE $, "K@EG ", EJ@ AA, PRJO *, K@NECQV . A NJ@KIEV@ PNEH KB LHOI TDJC EJ QP JPNH JNRKQO OUOPI @IUHEJPEJC @EOO. AJJ QNKH 1999;46:878-86. 21. GGN , PV *. "REhO JQNKIUHEPEO KLPE PNP@ SEPD EJPNRJKQO CII CHK>QHEJ (). J QNKH E 2004;31:265-267. 22. J@HN , ADI@ , "JKBB . "REhO JQNKIUHEPEO KLPE: LNKOLPER OPQ@U KB ORJ LPEJPO PNP@ SEPD LN@JEOKJ J@ VPDEKLNEJ. QNKHKCU 1998;51:1219-1220. 23. N A, *I> , KNCJ , DJ A, Q>JP , JEJ . AJ KLJ H>H OPQ@U KB PD BBPO KB NEPQTEI> EJ JQNKIUHEPEO KLPE. QNKHKCU 2005;64:1270-1272. 24. K> A. EJODJGN . EKHED .P H. NPIJP KB JQNKIUHEPEO KLPE SEPD NEPQTEI>: NPNKOLPER JHUOEO KB 25 LPEJPO. AND QNKH, 2008 ;65(11):1443-8 25. PDBKN@ , QECC , KJCN A P H. LPEH KDNJ PKIKCNLDU DHLO @EBBNJPEP JQNKIUHEPEO KLPE J@ KLPE JQNKLPDEO. QNKHKCU 2009;73:302-308. 26. KJJJ , HJPEJK , HEJ@K P H. HOI TDJC EJ RN LEJH APPGO AOOKEP@ SEPD QNKIUHEPEO LPE LPNQI "EOKN@N QHPELH HNKOEO 2009; 15:487-492 27. K> A, PEHHK , EJODJGN P H. NPIJP KB QNKIUHEPEO LPE SEPD UKLDJKHP KBPEH: NPNKOLPER JHUOEO KB 24 LPEJPOfAND QNKH. 2009; 66:1128-1133.
CME ANSWERS 1. 2. 3. "
HEREDITARY OPTIC NEUROPATHY, IS THERE A TREATMENT? Evidence Presentation — Nancy Newman, M.D. Emory University School of Medicine Atlanta, GA
Expert Opinion & Commentary — Alfredo Sadun, M.D. Doheny Eye Institute Los Angeles, CA
LEARNING OBJECTIVES
KEY WORDS
1. JKS PD JPQNH DEOPKNU KB PD PSK IKOP KIIKJ BKNIO KB DN@EPNU KLPE JQNKLPDU, *>N DN@EPNU KLPE JQNKLPDU (*) J@ @KIEJJP KLPE PNKLDU ("A).
1. *>N N@EPNU LPE QNKLPDU
2. JKS PD REH>H RE@J EJ PD HEPNPQN KJ PD PNPIJP KB PD IEPKDKJ@NEH @EOOO EJ CJNH J@ KB PD DN@EPNU KLPE JQNKLPDEO EJ LNPEQHN.
4. N@EPNU KLPE JQNKLPDU
3. BIEHEN SEPD PD BQPQN KLPEKJO BKN PNPIJP KB PD DN@EPNU KLPE JQNKLPDEO. 4. K GJKS PD NJC KB LNOJPPEKJO J@ KQNO BKN *>NhO DN@EPNU KLPE JQNKLPDU (*) J@ @KIEJJP KLPE PNKLDU ("A). 5. K QJ@NOPJ@ PD LKOOE>H LPDKLDUOEKHKCEH IDJEOIO >U SDED * J@ "A IU QO HKOO. 6. K @MQPHU SECD PD RE@J BKN PNPIJP KB * J@ "A.
CME QUESTIONS 1. NQ KN $HO? PQNH DEOPKNU OPQ@EO DR ODKSJ PDP HH IHO SDK DR DKIKLHOIE IP"A IQPPEKJO BKN * SEHH DR REOQH HKOO OKI PEI @QNEJC PDEN HEBPEI. 2. NQ KN $HO? D RE@J OQLLKNPO PNPIJP KB QP * SEPD Q>EMQEJKJ, REPIEJO J@ JPEKTE@JPO. 3. NQ KN $HO? J PDNLU EJ * EJRKHRO @ENP EJONPEKJ KB NLHIJP IP"A EJPK PD IEPKDKJ@NE. 4. NQ KN $HO? AHH OO KB * >CEJ SEPD J QP KN OQ>QP HKOO KB REOEKJ. 5. NQ KN $HO? PEJPO SEPD * SDK DR REOQH HKOO J@ KLPE PNKLDU @K JKP NKRN JU OQ>OPJPEH HRH KB REOQH QEPU KN REOQH BEH@O.
2. "KIEJJP LPE APNKLDU 3. EPKDKJ@NEH "EOO
5. *
EVIDENCE PRESENTATION D LOP PSK @@O DR SEPJOO@ NING>H @RJO EJ KQN QJ@NOPJ@EJC KB PD HEJEH LNOJPPEKJ, CJPEO J@ RJ PD LPDKLDUOEKHKCU KB PD DN@EPNU KLPE JQNKLPDEO, OLEBEHHU *>N DN@EPNU KLPE JQNKLPDU (*) J@ @KIEJJP KLPE PNKLDU ("A) 1-4. JKS GJKS PDP IKOP KB PD DN@EPNU KLPE JQNKLPDEO, EJHQ@EJC * J@ "A, DR LPDKLDUOEKHKCU NBHPEJC BEJH KIIKJ LPDSU EJ IEPKDKJ@NEH @UOBQJPEKJ, @OLEP PDEN CJPE KNECEJ EJ PSK @EBBNJP CJKIO (* NOQHP KB LKEJP IQPPEKJO EJ PD IEPKDKJ@NEH "A, J@ "A KJOMQJ KB IQPPEKJO EJ JQHN DNKIKOKIO). KSRN, EJROPECPEKJO EJPK LKPJPEH PDNLEO BKN PDO J@ KPDN IEPKDKJ@NEH @EOKN@NO N OPEHH EJ PDEN JOJU. BKN NRESEJC PD RE@J QNNJPHU REH>H KJ PD PNPIJP KB PDO @EOKN@NO, EP EO EILKNPJP PK @EOQOO PD JPQNH DEOPKNU KB REOQH HKOO EJ PDO HEJEH OPPEJCO, OLEBEHHU PD LNKCJKOEO BKN OLKJPJKQO REOQH NKRNU.
NATURAL HISTORY OF VISUAL LOSS IN LHON AND DOA LH"! J IKOP LPEJPO SEPD *, REOEKJ HKOO EO @ROPPEJC J@ LNIJJP, SEPD REOQH QEPEO PULEHHU SKNO PDJ 20/200 EJ >KPD UO. 2 ALLNKTEIPHU 50% KB LPEJPO SEPD REOQH HKOO BNKI * SEHH NKCJEV OMQJPEH U OUILPKIO, SEPD EJPNRHO >PSJ BBP@ UO NJCEJC BNKI @UO PK IKJPDO, SEPD PULEH EJPNRH KB 2 PK 4 IKJPDO.5,6 AP HOP 97% KB LPEJPO SEPD REOQH HKOO EJ KJ U SEHH DR OKJ@ U EJRKHRIJP SEPDEJ 1 UN. 7 J OKI LPEJPO, REOQH NKRNU IU KQN BPN QP REOQH HKOO, OKIPEIO IJEBOP@ O eBJOPNPEKJf SEPDEJ REOQH BEH@ @BP (PD OK-HH@ @KJQP KN >CH OKPKI) KN SEPD IKN @EBBQO NPQNJ KB JPNH REOQH QEPU J@ KHKN REOEKJ, QOQHHU >EHPNHHU. 2,8-10 EOQH NKRNU, SDJ 2010 Annual Meeting Syllabus | 107
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
KIIQJEPEKJ, CEJBQH ILHKUIJP, JRECPEKJ, J@ OHB-KLNPEKJ KB IKPKN-RDEH. 27 *KS REOEKJ E@O IU >JBEP LPEJPO SEPD ORN REOEKJ HKOO BNKI KLPE JQNKLPDEO.28 J LNPEQHN, LPEJPO SEPD * J@ "A N KBPJ UKQJC @QHPO SEPD LNONR@ LNELDNH REOEKJ, J@ IG THHJP J@E@PO BKN HKS REOEKJ ND>EHEPPEKJ. AHPDKQCD RKE@EJC CJPO PDP IU P O IEPKDKJ@NEH eOPNOOKNOf EO JKJ-OLEBE NKIIJ@PEKJ BKN HH LPEJPO SEPD @EOKN@NO SEPD LNOQI@ IEPKDKJ@NEH LPDKLDUOEKHKCU, PDN EO JK OPQ@U SDED DO ODKSJ LNKRJ >JBEP.29 J NJP LE@IEKHKCE OPQ@U OQCCOP@ PDP REOEKJ HKOO @KO EJ@@ KQN IKN KBPJ EJ EJ@ERE@QHO P NEOG BKN * SDK OIKG, J@ LKOOE>HU PDKO SEPD DRU HKDKH EJPG. 30 P IU > LNQ@JP PK QPEKJ LPEJPO PK RKE@ PK>K QO, TOOER HKDKH EJPG, UJE@-KJPEJEJC LNK@QPO, I@EPEKJO SDED IU DR IEPKDKJ@NEH PKTEEPU, J@ JRENKJIJPH PKTEJO, OLEHHU @QNEJC PD QP LDO KB REOQH HKOO.31
DISEASE-MODIFYING TREATMENTS D"A EOQH HKOO EJ "A EO @PP@ >PSJ CO 4 J@ 6 EJ PD IFKNEPU KB LPEJPO, 17 J@ 58-84% KB LPEJPO SEPD "A NLKNP REOQH EILENIJP >U C 11. 18,19 KILN@ PK *, REOEKJ HKOO EO PULEHHU IEH@ EJ "A, SEPD IJ REOQH QEPU KB 20/80 PK 20/120. 20-22 KN PDJ 80% KB LPEJPO NPEJ REOEKJ KB 20/200 KN >PPN, 22 HPDKQCD REOQH QEPEO J NJC BNKI 20/20 PK HECDP LNLPEKJ.2,23 AHPDKQCD JKP O NLE@ KN O @ROPPEJC O *, "A IU JRNPDHOO OECJEBEJPHU EILEN MQHEPU KB HEB EJ PD IFKNEPU KB LPEJPO. NKCNOOER @HEJ EJ REOQH QEPU KQNO EJ 19-67% KB "A LPEJPO.18,22-26 D NP KB LNKCNOOEKJ RNEO KJOE@N>HU IKJC J@ SEPDEJ BIEHEO; 22 DKSRN, EJ CJNH, @EOO LNKCNOOEKJ EJ "A BKHHKSO NHPERHU EJ@KHJP KQNO, J@ EO EJ@LJ@JP KB REOQH QEPU P @ECJKOEO.24 J KJ HKJC-PNI BKHHKS-QL OPQ@U KB 69 LPEJPO SEPD KJBENI@ "A-QOEJC IQPPEKJ, KB SDKI 58 (84%) SN OUILPKIPE, 43 (62%) D@ OP>H REOQH QEPU EJ P HOP KJ U P 10 UN BKHHKS-QL. 18 AHPDKQCD 10% KB LPEJPO EJ PDP OEJCH OPQ@U D@ EILNKRIJP EJ PDEN REOEKJ, PDEO IU NBHP EILNKR@ POPEJC O DEH@NJ C; PNQ OQ>OPJPEH OLKJPJKQO EILNKRIJP KB REOEKJ @KO JKP LLN PK > BPQN KB "A. J IKN NJP OPQ@U KB "A LPEJPO EJ PD JKNPD KB JCHJ@, REOQH BQJPEKJ SKNOJ@ EJ 29 KB 43 LPEJPO (67.4%) BKN SDKI PDN SO HKJCEPQ@EJH BKHHKS-QL (IJ BKHHKS-QL PEI KB 15 UNO). 26
TREATMENTS FOR LHON AND DOA: REVIEW OF THE LITERATURE %<><08 &40<4= UILPKIPE PNPIJPO ODKQH@ > KJOE@N@ EJ HH LPEJPO SEPD REOEKJ-EILENEJC KLPE JQNKLPDEO PK EILNKR MQHEPU KB HEB, EJ LNPEQHN PK E@ SEPD N@EJC,
108 | North American Neuro-Ophthalmology Society
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. NEIKJE@EJhO BBEU O LNKLDUHPE CJP BKN OKJ@ U REOQH HKOO EJ * SO RHQP@ EJ J KLJ-H>H@, JKJ-NJ@KIEV@, IQHPEJPN OPQ@U KB JEJ LPEJPO SEPD QP REOEKJ HKOO EJ KJ U BNKI *. 7 "OLEP PD QO KB PD @NQC, HH LPEJPO D@ @PNEKNPEKJ KB REOQH QEPU, J@ ORJ KB ECDP LPEJPO BKHHKS@ BKN HKJCN PDJ PSK IKJPDO D@ REOQH QEPU EJ PD OKJ@ U KB 20/200 KN SKNO P PD J@ KB PD OPQ@U. "OLEP PD PNPIJP BEHQN KB PD >NEIKJE@EJ OPQ@U, * KBBNO QJEMQ eH>KNPKNUf BKN PD EJROPECPEKJ KB JS EJPNRJPEKJO EJ IEPKDKJ@NEH @EOO. EJ * REOEKJ HKOO KBPJ KQNO EJ >EHPNH OMQJPEH BODEKJ, SEJ@KS KB KLLKNPQJEPU TEOPO BKN LKOOE>H PDNLQPE EJPNRJPEKJ BPN REOEKJ HKOO EJ PD BENOP U >QP >BKN OKJ@ U EJRKHRIJP. 7 * DO PD @@EPEKJH @OEN@ LNKLNPU PDP @NQCO, @JKRENQO CJ RPKNO, J@ KPDN CJPO IU > OEHU J@ @ENPHU @HERN@ PK PD PEOOQ P NEOG, PD O J@ KLPE JNR, >U REPNKQO EJFPEKJ (O >HKS). AHPDKQCD * HKJ LNOJPO PDEO KLLKNPQJEPU BKN TLNEIJPPEKJ, EJPNRJPEKJ OPQ@EO EJ PDEO eH>KNPKNUf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
DISEASE-SPECIFIC TREATMENT OF DOA DN N JK NLKNPO KB PNPIJP KB "A LPEJPO KB SDED I SN J@ JK KJCKEJC HEJEH PNEHO KB JU CJP. G4=4 740 J PDNLU ODKSO OECJEBEJP LNKIEO EJ PD PNPIJP KB IEPKDKJ@NEH @EOOO. JU EJCJEKQO OPNPCEO DR >J @REO@ QOEJC PNJOBP@ JQHN J@ IEPKDKJ@NEH CJO PK N@Q PD KRNHH LNKLKNPEKJ KB DPNKLHOIE IQPJP IP"A EJ REPNK, EJ UOP IK@HO, J@ EJ JEIH IK@HO d OPNPCU HH@ eCJ ODEBPEJCf. 32 AHPDKQCD EP EO LKOOE>H PK EJPNK@Q "A EJPK PD HH JQHQO QOEJC RNEPU KB RPKNO, PD PDJEMQO NMQEN@ PK EJPNK@Q CJO @ENPHU EJPK IEPKDKJ@NE DR UP PK > @RHKL@.70 "ENPHU PNCP@ NLEN KN NLHIJP KB IQPP@ IEPKDKJ@NEH CJO EO PDNBKN JKP QNNJPHU 110 | North American Neuro-Ophthalmology Society
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74. QU , E , KEHGKJ@ ", P H. BBEEJU J@ OBPU KB AA I@EP@ CJ @HERNU KB PD DQIJ "4 KILHT OQ>QJEP EJ PD IKQO REOQH OUOPI. JROP LDPDHIKH EO E. 2009;50:4205-14
58. IEPD *, O ", UNJ $, P H. LPE JNR ODPD @EOPJPEKJ EJ *>NhO KLPE JQNKLPDU J@ PD OECJEBEJ KB PD eHH IQPPEKJf. HEJ QNK-KLDPDHIKH. 1990;10: 231-238
75. E , QJ *, *SEJ A, QOSENPD , QU . D IQPJP DQIJ "4 OQ>QJEP KB KILHT EJ@QO KLPE JQNKLPDU EJ PD IKQO. JROP LDPDHIKH EO E. 2007;48:1-10
59. EHOKJ ", HEJ *. *>NhO DN@EPNU KLPE JQNKLPDU SEPD >EHPNH @EOPJ@@ KLPE JNR ODPDO. HEJ QNKKLDPDHIKH. 1992;12:73-74
76. HHKQV , AQCQOPEJ , KQEP A, P H. LPEIEV@ HHKPNKLE TLNOOEKJ KB PD DQIJ IEPKDKJ@NEH "4 LNRJPO >HEJ@JOO EJ NP IK@H KB IEPKDKJ@NEH @UOBQJPEKJ. AI QI JP 2008;83:373-387
60. ODEI , EE@ , CQDE . IEOOEKJ KB *>NhO DN@EPNU KLPE JQNKLPDU SEPD E@>JKJ. *JP. 1992;340:368-369 61. KNPHHE , KJPCJ , ENJCHE , P H. HEJEH J@ >NEJ >EKJNCPEO EILNKRIJP SEPD E@>JKJ EJ LPEJP SEPD *>N DN@EPNU KLPE JQNKLPDU: A HEJEH J@ - OPQ@U. QNKH E. 1997;148:25-31 62. NHHE , N>KJE , DEJE A, P H. *>NhO DN@EPNU KLPE JQNKLPDU (*) SEPD 14484/"6 IQPPEKJ EJ KNPD ABNEJ LPEJP. QNKH E. 1998;160:183-188 63. ODEI , ECOS , GGQN , CQDE . "K E@>JKJ J@ REPIEJ PDNLU ODKNPJ PD PEI PK DER REOQH NKRNU EJ *>N DN@EPNU KLPE JQNKLPDU? QNK-KLDPDHIKH. 2000;20:166-70 64. QJC , QK , DQ , K *. LE@ REOQH NKRNU BPN KJVUI 10 PNPIJP KB *>N DN@EPNU KLPE JQNKLPDU. QNK-KLDPDHIKH. 2002;22:66 65. NJEHO , O , QJKV , $NNN-ANPKH A, ANNQC . OLKJO PK E@>JKJ J@ IQHPEREPIEJ PDNLU EJ *>NhO DN@EPNU KLPE JQNKLPDU. AND K OL BPHIKH. 2007;82:377-380
77. E , QJ *, QOSENPD , P H. O KB IEPKDKJ@NEH JPEKTE@JP @BJOO BKN NOQ KB HHO SEPD *>N DN@EPNU KLPE JQNKLPDU-QOEJC IQPPEKJ. AND LDPDHIKH. 2007;125:268-72 78. $HKNJE , LKHE , NPEJQVVE A, P H. AJPEKTE@JP @BJO EJ U>NE@O DN>KNEJC IP"A IQPPEKJO OOKEP@ SEPD *>NhO DN@EPNU KLPE JQNKLPDU. $ . 2005;272: 1124-35 79. E , *SEJ A, QJ *, P H. "2 CJ PNJOBN LNKPPO CEJOP KLPE JQNKLPDU EJ@Q@ >U @BEEJU KB KILHT . AJJ QNKH. 2004;56:182-91 80. JG , KNCH@ , DJC , P H. J PDNLU BKN IEPKDKJ@NEH @EOO >U @HERNEJC NOPNEPEKJ J@KJQHO I EJPK IEPKDKJ@NE. EKI@ E. 2002;9:534-41 81. IJ , EHHEIO *, NJJ@V ", P H. K@QHPEJC IP"A DPNKLHOIU >U IEPKDKJ@NE-PNCP@ NOPNEPEKJ J@KJQHOO EJ g@EBBNJPEH IQHPELH HRC-OEPh IK@H. J DN. 2007;14:1309-18
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114 | North American Neuro-Ophthalmology Society
1. J PDNLU
CME ANSWERS 1. $HO 2. $HO 3. $HO 4. $HO 5. $HO
PLATFORM PRESENTATION SUSTAINED NEUROPROTECTION AFTER A SINGLE INTRAVITREAL INJECTION OF PGJ2 IN A RODENT MODEL OF NAION Valerie Touitou2, Mary A. Johnson1, Neil R. Miller 2, Yan Guo1, David Bernstein1, Steve L. Bernstein1 1
University of Maryland, Baltimore, MD, United States Johns Hopkins Hospital, Baltimore, MD, United States
2
INTRODUCTION
CONCLUSION
NKOPCHJ@EJ-2 (2) DO >J LNKLKO@ O LKPJPEH JQNKLNKPPER CJP. SJP@ PK RHQP PD PKTEEPU/BBEU KB OEJCH EJPNREPNH () EJFPEKJ KB 2 EJ NK@JP IK@H KB JKJNPNEPE JPNEKN EODIE KLPE JQNKLPDU (A).
A OEJCH -EJFPEKJ KB 2 LNK@QO JK RE@J KB NPEJH KN PKTEEPU >U BQJPEKJH/ OPNQPQNH JHUOEO EJ NPO. D -NKQP KB @IEJEOPNPEKJ J>HO @HERNU KB DECD KJJPNPEKJ KB PD @NQC EJ HKS RKHQI, SEPD IEJEIH NEOGO BNKI OUOPIE OE@ BBPO. A OEJCH EJFPEKJ KB 2 LNONRO O J@ PDEN TKJO J@ LNKRE@O OQOPEJ@ JQNKLNKPPEKJ BKN P HOP 1 IKJPD BKHHKSEJC PD EJEPEH EODIE RJP EJ NK@JP IK@H KB A. JCKEJC OPQ@EO N KJ@QP@ PK RHQP SDPDN OEIEHN BBP EO K>ONR@ EJ LNEIPO.
METHODS QO@ PD HON-PERP@ NKO JCH EJ@QPEKJ IPDK@ PK LNK@Q A EJ *KJC-RJO NPO. RHQP@ 2 NPEJH J@ PKTEEPU. $KHHKSEJC EJ@QPEKJ, 2 SO EJPNREPNHHU EJFP@ EJ PD PNPIJP-CNKQL. LDKOLDP->QBBN@-OHEJ () SO QO@ O KJPNKH. $QJPEKJH OPQ@EO () SN LNBKNI@ P >OHEJ J@ P 7@UO LKOP-PNPIJP. PNQPQNH OPQ@EO EJHQ@@ EIIQJKDEOPKDIEH (), HPNKJ IENKOKLE () JHUOEO KB PD KLPE JNR (), J@ OPNKHKCE JHUOEO KB NPEJH CJCHEKJ HH () JQI>NO 30-@UO LKOPEJ@QPEKJ.
RESULTS
REFERENCES KJ
KEY WORDS ODIE LPE QNKLPDU, QNKLNKPPEKJ, NKOPCHJ@EJ, PEJH JCHEKJ HH
FINANCIAL DISCLOSURE:
&>G828CH: 2 (5 UO) @E@ JKP EJ@Q JU OPPEOPEHHUOECJEBEJP BQJPEKJH KN OPNQPQNH DJCO EJ PD NPEJ KN KB PNP@ JEIHO KILN@ SEPD JEIHO EJFP@ SEPD HKJ (5 UO) 30 @UO LKOP-EJFPEKJ. E558202H: $KHHKSEJC OEJCH -EJFPEKJ, @U7 O EJ PD 2-PNPIJP CNKQL (J=7) D@ ILHEPQ@O 103.6% KB >OHEJ NOLKJO, SDNO PD -PNP@ CNKQL (J=6) D@ O PDP SN 42.4% KB PD >OHEJ NOLKJO. 30@UO LKOP-OPNKG, REOQHEVPEKJ KB BNKI PD PNPIJP-CNKQL @IKJOPNP@ OECJEBEJP LNONRPEKJ KB TKJO J@ @NO@ @IUHEJPEKJ. PNKHKCEH KQJPO KJBENI@ OECJEBEJP (L<0.04) LNONRPEKJ EJ 2-PNP@ JEIHO (1462.6 HHO/jI2) KILN@ SEPD PD OPNKG+ CNKQL (1156.5 HHO/jI2).
2010 Annual Meeting Syllabus | 115
