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Efficient eye movements provide a physical foundation for proficient reading skills. We investigated the effect of in-school saccadic training on reading performance. In this cross-over design, study participants (n = 327, 165 males; mean age [SD]: 7 y 6 mo [1y 1 mo]) were randomized into treatment and control groups, who then underwent eighteen 20-minute training sessions over 5 weeks using King-Devick Reading Acceleration Program Software. Pre- and posttreatment reading assessments included fluency, comprehension, and rapid number naming performance. The treatment group had significantly greater improvement than the control group in fluency (6.2% vs 3.6%, P = .0277) and comprehension (7.5% vs 1.5%, P = .0002). The high-needs student group significantly improved in fluency ( P < .001) and comprehension ( P < .001). We hypothesize these improvements to be attributed to the repetitive practice of reading-related eye movements, shifting visuospatial attention, and visual processing. Consideration should be given to teaching the physical act of reading within the early education curriculum.

Background Vision-based measures have been shown to be useful markers in multiple sclerosis (MS), Alzheimer and Parkinson disease. Therefore, these testing paradigms may have applications to populations explaining repetitive head trauma that has been associated with long-term neurodegenerative sequelae. We investigated retinal structure and visual function in professional collision sport athletes compared to age- and race-matched control participants. Methods In this cross-sectional study, participants underwent spectral-domain optical coherence tomography (OCT) measurements of peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC = ganglion cell + inner plexiform layers) thickness. High-contrast visual acuity (100% level), low-contrast letter acuity (LCLA) (1.25% and 2.5% levels), and King-Devick Test of rapid number naming performance were administered. Vision-specific quality of life (QOL) measures were assessed. Results Among 46 collision sport athletes (boxing, n = 14; football, n = 29; ice hockey, n = 3) and 104 control participants, average RNFL thickness was a significant predictor of athlete vs control status with athletes demonstrating 4.8-μm of thinning compared to controls (P = 0.01, generalized estimating equation [GEE] models accounting for age and within-subject, intereye correlations). Athlete vs control status was not a predictor of RNFL thickness for the subgroup of football players in this cohort (P = 0.60). Binocular (P = 0.001) and monocular (P = 0.02) LCLA at 2.5% contrast and vision-specific QOL (P = 0.04) were significant predictors of athlete vs control status (GEE models accounting for age and within-subject, intereye correlations). Rapid number naming performance times were not significantly different between the control and athlete groups. Conclusions This study showed that retinal axonal and neuronal loss is present among collision sport athletes, with most notable differences seen in boxers. These findings are accompanied by reductions in visual function and QOL, similar to patterns observed in multiple sclerosis, Alzheimer and Parkinson diseases. Vision-based changes associated with head trauma exposure that have the potential to be detected in vivo represent a unique opportunity for further study to determine if these changes in collision sport athletes are predictive of future neurodegeneration.

Efficient eye movements provide a physical foundation for proficient reading skills. We investigated the effect of in-school saccadic training on reading performance. In this cross-over design, study participants (n = 327, 165 males; mean age [SD]: 7 y 6 mo [1y 1 mo]) were randomized into treatment and control groups, who then underwent eighteen 20-minute training sessions over 5 weeks using King-Devick Reading Acceleration Program Software. Pre- and posttreatment reading assessments included fluency, comprehension, and rapid number naming performance. The treatment group had significantly greater improvement than the control group in fluency (6.2% vs 3.6%, P = .0277) and comprehension (7.5% vs 1.5%, P = .0002). The high-needs student group significantly improved in fluency ( P.001) and comprehension ( P.001). We hypothesize these improvements to be attributed to the repetitive practice of reading-related eye movements, shifting visuospatial attention, and visual processing. Consideration should be given to teaching the physical act of reading within the early education curriculum.

Concussion is a form of mild traumatic brain injury (TBI) owing to structural, metabolic and functional changes involving white mater tracts of the central nervous system in the absence of macroscopic findings [1-4]. Sports-related concussion is a rapidly evolving condition stimulating interest among lay and scientific communities [3]. Recent studies have shown a high rate of underreporting of concussion signs and symptoms by athletes and sideline personnel [5,6]. Accordingly, reliable and validated testing strategies are necessary to insure timely detection and removal from play for individuals suspected of concussion. Vision and visual motor problems are commonly reported among athletes following concussion [7-15]. This is to be expected as it is estimated that approximately 50% of the brain is devoted to vision and visual motor processing [16]. As such, testing of vision and ocular motility function are critical to the evaluation of a concussed individual. While disorders of vision and ocular motility have been well-reported with TBI, most of these studies have focused on visual motor problems in the setting of combatrelated TBI resulting from blast injuries [8]. There are limited studies related to vision and visual motor abnormalities from sport-related concussion.

Objective Concussion, defined as an impulse blow to the head or body resulting in transient neurologic signs or symptoms, has received increasing attention in sports at all levels. The King–Devick (K–D) test is based on the time to perform rapid number naming and captures eye movements and other correlates of suboptimal brain function. In a study of boxers and mixed martial arts (MMA) fighters, the K–D test was shown to have high degrees of test–retest and inter-rater reliability and to be an accurate method for rapidly identifying boxers and mixed martial arts fighters with concussion. We performed a study of the K–D test as a rapid sideline screening tool in collegiate athletes to determine the effect of concussion on K–D scores compared to a pre-season baseline. Methods In this longitudinal study, athletes from the University of Pennsylvania varsity football, sprint football, and women's and men's soccer and basketball teams underwent baseline K–D testing prior to the start of the 2010–11 playing season. Post-season testing was also performed. For athletes who had concussions during the season, K–D testing was administered immediately on the sidelines and changes in score from baseline were determined. Results Among 219 athletes tested at baseline, post-season K–D scores were lower (better) than the best pre-season scores (35.1 vs. 37.9 s, P = 0.03, Wilcoxon signed-rank test), reflecting mild learning effects in the absence of concussion. For the 10 athletes who had concussions, K–D testing on the sidelines showed significant worsening from baseline (46.9 vs. 37.0 s, P = 0.009), with all except one athlete demonstrating worsening from baseline (median 5.9 s). Conclusion This study of collegiate athletes provides initial evidence in support of the K–D test as a strong candidate rapid sideline visual screening tool for concussion. Data show worsening of scores following concussion, and ongoing follow-up in this study with additional concussion events and different athlete populations will further examine the effectiveness of the K–D test.

Solar maculopathy can be a diagnostic challenge as clinical findings are often subtle and resemble other macular pathologies. Recent reports of chronic solar maculopathy have described characteristic loss of outer retinal layers. With the advent of spectral domain optical coherence tomography (SD-OCT), higher resolution of the chorioretinal architecture is possible and provides a unique means of assessing the organization and integrity of the retinal layers in cases of solar maculopathy. Two cases (four eyes) of chronic solar maculopathy were examined using Cirrus SD-OCT imaging (Carl Zeiss Meditec, Dublin, CA).OCT scans revealed a large fragment of hyporeflectance at the level of the outer and inner photoreceptor layer with an abrupt discontinuation of the inner segment/outer segment junction. Visual acuity was minimally but permanently reduced in both cases.These two cases demonstrate the reliability of SD-OCT as a biomarker of visual function in chronic solar maculopathy. The characteristic fragmented loss of the photoreceptor inner segment/outer segment junction correlates with decreased visual function in cases of solar maculopathy.

Retinitis as a feature of syphilitic uveitis in immunocompromised individuals is a common finding. We present spectral domain OCT images of early syphilitic retinitis pre and post treatment with penicillin. This case suggests that the inner retinal layers may be selectively involved with early syphilitic retinitis. Early treatment is important to avoid outer layer retinal involvement and to decrease ocular morbidity.ResumenEs frecuente el hallazgo de la retinitis como una característica de uveítis sifilítica en personas inmunodeprimidas. Presentamos imágenes de OCT Spectral Domain de retinitis sifilítica incipiente antes y después del tratamiento con penicilina. Este caso sugiere que las capas internas de la retina pueden estar afectadas selectivamente por retinitis sifilítica incipiente. Es importante llevar a cabo un tratamiento temprano para evitar la afectación de la capa externa de la retina y para reducir la morbilidad ocular.

Purpose The Vision of Hope Health Alliance (VOHHA) was developed to provide an integrated system of eye and primary medical services to low-income and uninsured patients who were referred from nonmedical and medical agencies. Methods Partnerships were formed to facilitate patient referrals. Eye examinations and ophthalmic materials were provided at no cost to patients. Interpretation services and follow-up care were provided as needed. If applicable, patients were scheduled with a primary care physician at a Federally Qualified Health Center. Findings were documented by VOHHA team members or obtained through retrospective record review. Results Over a 2-year period, 1,753 patients were examined. About half (52.5%) were women. Most (80%) were black or Hispanic. Average age was 49.4 years (range, 18 to 83). Of those with diabetes mellitus (DM), 30.9% reported a last eye examination within 15 months. Of those without DM, 23.6% reported last eye examination within 15 months. Most (60%) reported last medical examination to be within 1 year. Most (85.7%) received spectacle prescriptions. Follow-up eye care appointments were kept by 367. Appointments with primary care physicians were scheduled for 165. Of those, 121 kept appointments. Conclusions VOHHA demonstrated a model program that provided eye care and referral for primary medical care to individuals without the means to otherwise obtain care.

Introduction Sinonasal undifferentiated carcinoma (SNUC) are uncommon, highly aggressive neoplasms arising in the nasal cavity and paranasal sinuses. Unlike the majority of sinonasal carcinomas, SNUC possess an uncertain histological origin and pleomorphic composition. Their heterogeneous composition prohibits their distinction from other more commonly encountered nasal tumors on the basis of imaging alone. Patients afflicted with SNUC often complain of symptoms of chronic, progressive sinus congestion, and epistaxis. Imaging studies of SNUC often illustrate rapidly enlarging masses involving multiple sinonasal sites with frequent evidence of extension beyond the sinonasal tract. Orbital extension is a frequent finding encountered during radiographic investigations. Case report A 28-year-old white man presented complaining of diplopia in superior gaze, pain on eye movement, and gaze-evoked amaurosis which progressed during a 2-day period. Funduscopic examination revealed choroidal folds in the papillomacular region OS. Magnetic resonance imaging (MRI) revealed a 3 cm x 3.5 cm x 4 cm mass emanating from the left ethmoid sinus with bony destruction of the left orbital floor, nasal wall of the left and right orbits, and the cribriform plate. A transcutaneous aspiration fine-needle biopsy confirmed the presence of a SNUC. After a 7-wk course of combined chemoradiotherapy marked regression in the mass was attained with resolution of the ophthalmic symptoms. Conclusion SNUC is an aggressive malignancy that is often discovered in its advanced stages after having afflicted serious insult on the nasal and sinus cavities. Ocular involvement is feasible owing to the thin composition of the orbital walls and the fast growing nature of the neoplasm.

Purpose Chiari I malformations are rare, congenital anomalies involving the caudal herniation of the cerebellar tonsils into the upper cervical spinal canal. Osseous abnormalities of the skull permit the extension of the hindbrain below the foramen magnum and engender syringohydromyelia formation. Neuroophthalmic manifestations are not uncommon; nevertheless, this is the first report of concomitant bilateral abducens palsies and facial nerve impairment as presenting manifestations of a Chiari I malformation. Case report A 30-year-old black female presented with a recent history of blurred vision and binocular diplopia in both left and right gazes. Headaches, dizziness, and orofacial sensorimotor impairments were noted in conjunction with the onset of her diplopia. No history of surgery, trauma, or systemic illness was elicited. Extraocular motility testing confirmed a complete bilateral abduction deficit. Additional cranial nerve testing revealed bilateral facial nerve weakness and tactile hypesthesia in the perioral region. No taste disturbances were reported. Nuclear magnetic resonance imaging studies revealed a Chiari I malformation with a syringohydromyelia formation in the vicinity of the patient's sixth cervical vertebrae. Foramen magnum decompression surgery was performed. Two months after surgery, abduction capacity was restored along with resolution of symptoms of perioral numbness and signs of facial weakness. Conclusion Bilateral sixth nerve palsies are rare clinical commodities especially when they do not occur in isolation. Intracranial neoplams, trauma, subarachnoid hemorrhaging, demyelinating disease, and meningeal infarcts have all been shown to induce mixed cranial neuropathies. The concomitant bilateral abducens palsy and concomitant facial nerve weakness reported in this case represents an atypical and previously unreported presentation of a Chiari I malformation.

Purpose. Waldenstrom’s macroglobulinemia is a rare, malignant lymphoplasmacytic disorder characterized by the monoclonal proliferation of immunoglobulin type M (IgM) producing B-lymphocytes. Ocular manifestations of Waldenstrom’s macroglobulinemia have been described in association with the conjunctiva, cornea, uvea, retina, and periocular adnexa. Only rarely have macular findings, particularly serous macular detachments, been described in the presence of monoclonal hypergammaglobulinemias. The majority of reports to date have documented resolution of these serous macular detachments after treatment with blood plasmapheresis. This report presents a case of bilateral, persistent serous macular detachments in the presence of Waldenstrom’s macroglobulinemia. Case Report. A 53-year-old black man presented with gradual bilateral reduction in visual acuity over the last 2 months. He revealed having been diagnosed with Waldenstrom’s macroglobulinemia approximately 1 month before presentation. He also reported having undergone multiple plasmapheresis treatments in conjunction with systemic chemotherapy over the same period. Funduscopic and fluorescein angiographic examination revealed bilateral, serous macular detachments in the presence of mild venous stasis retinopathy secondary to serum hyperviscosity. Subsequent funduscopic evaluations and serial optical coherence tomography readings confirmed the persistence of the serous detachments despite multiple plasmapheresis treatments. Conclusions. Although the funduscopic manifestations of excess serum immunoglobulins are typically the sequelae of circulatory stasis, the serum hyperviscosity induced in Waldenstrom’s macroglobulinemia has been shown on rare occasions to induce serous macular detachments. Physical elimination of the excess macroglobulins through plasmapheresis is quite effective in resolving the neurosensory detachments induced by Waldenstrom’s macroglobulinemia. Only a fraction of neurosensory detachments resulting from Waldenstrom’s macroglobulinemia persist despite multiple plasmapheresis treatments. Novel angiographic evidence of retinal pigment epithelium atrophy beneath the area corresponding to the serous detachment provides a plausible explanation for unresponsive nature of this presentation. Identification of this rare variant of the classic angiographically silent macula known to occur with Waldenstrom’s macroglobulinemia can aid the clinician in determining a patient’s potential response to plasmapheresis and their final visual prognosis.

Background. Eye movements are necessary for the physical act of reading and have been shown to relate to underlying cognitive and visuoattentional processes during reading. The purpose of this study was to determine the effect of saccadic training using the King-Devick remediation software on reading fluency. Methods. In this prospective, single-blinded, randomized, crossover trial, a cohort of elementary students received standardized reading fluency testing pre- and posttreatment. Treatment consisted of in-school training 20 minutes per day, 3 days per week for 6 weeks. Results. The treatment group had significantly higher reading fluency scores after treatment ( P < .001), and posttreatment scores were significantly higher than the control group ( P < .005). Conclusion. Saccadic training can significantly improve reading fluency. We hypothesize that this improvement in reading fluency is a result of rigorous practice of eye movements and shifting visuospatial attention, which are vital to the act of reading.

Chiari I malformation (CM1) is the caudal herniation of the cerebellar tonsils into the foramen magnum. It can cause several neurological signs and symptoms, or be asymptomatic. Papilledema is a potential, but unusual, manifestation of CM1. While CM1 is often asymptomatic, papilledema is less likely to be. We present the first reported case of a progressive, asymptomatic papilledema as the sole presenting sign of a CM1;A 39 year old woman presented without neurological symptoms and was found to have optic disc edema. Humphrey visual fields were normal and B-scan showed no drusen. On a subsequent visit, optical coherence tomography showed advanced disc edema. Neuroimaging revealed a CM1. The patient was referred for neurological consultation for the management of the papilledema secondary to CM1;This case represents the importance of a thorough ocular examination, as the patient's asymptomatic neurologic condition would not have been diagnosed without the discovery of the papilledema.

Sports-related concussion has received increasing attention as a cause of short- and long-term neurologic symptoms among athletes. The King-Devick (K-D) test is based on measurement of the speed of rapid number naming (reading aloud single-digit numbers from 3 test cards), and captures impairment of eye movements, attention, language, and other correlates of suboptimal brain function. We investigated the K-D test as a potential rapid sideline screening for concussion in a cohort of boxers and mixed martial arts fighters.The K-D test was administered prefight and postfight. The Military Acute Concussion Evaluation (MACE) was administered as a more comprehensive but longer test for concussion. Differences in postfight K-D scores and changes in scores from prefight to postfight were compared for athletes with head trauma during the fight vs those without.Postfight K-D scores (n = 39 participants) were significantly higher (worse) for those with head trauma during the match (59.1 ± 7.4 vs 41.0 ± 6.7 seconds, p0.0001, Wilcoxon rank sum test). Those with loss of consciousness showed the greatest worsening from prefight to postfight. Worse postfight K-D scores (r(s) = -0.79, p = 0.0001) and greater worsening of scores (r(s) = 0.90, p0.0001) correlated well with postfight MACE scores. Worsening of K-D scores by ≥5 seconds was a distinguishing characteristic noted only among participants with head trauma. High levels of test-retest reliability were observed (intraclass correlation coefficient 0.97 [95% confidence interval 0.90-1.0]).The K-D test is an accurate and reliable method for identifying athletes with head trauma, and is a strong candidate rapid sideline screening test for concussion.

PURPOSE Recent reports of torpedo maculopathy have disclosed underlying irregularities within the chorioretinal tissue that have not been shown to induce disturbances in visual function. Optical coherence tomography (OCT) provides a unique means of assessing the chorioretinal organization and integrity of torpedo lesions in an in vivo setting that has yet to be explored. In agreement with reported cases, torpedo maculopathy appears to be a benign, non-progressive condition that subtends the horizontal raphe in the juxtafoveal region and imparts no disturbance in visual function. CASE REPORTS Three cases of torpedo maculopathy were examined using Stratus OCT3 imaging (Carl Zeiss Meditec, Dublin, CA). OCT scans revealed intact, attenuated retinal layers with hyper-reflectivity of the retinal pigmented epithelium (RPE). The RPE subtending these lesions appears of normal thickness, yet, there is an abrupt transition between intact-organized and intact-disorganized retinal tissue in scans transitioning from normal retina to torpedo lesions. Our imaging studies revealed significant attenuation and disorganization of the inner and outer retinal layers overlying a hyper-reflective RPE, which was of normal thickness and devoid of any structural defects. CONCLUSIONS An analysis of the OCT images collected suggests anomalies in retinal architecture. This finding implies that these lesions may represent atypical colobomas whereby retinal tissues are present but, perhaps, not fully developed. In light of these imaging studies, we propose that this uncommon condition may arise from deficits in cellular migration and/or organization.

Background Choroidal neovascularization (CNV) occurs in association with a variety of retinochoroidal disorders. However, it is not normally known to form after an untreated macular hole. Case report A 75-year-old black male presented with a 12-month history of visual loss in his right eye. Funduscopy showed a full-thickness macular hole in the right eye. No treatment was recommended because the decrease in vision appeared to be long standing. Fourteen months later, the patient was noted to have a subretinal hemorrhage superior to the macular hole. Fluorescein angiography revealed an adjacent choroidal neovascular membrane, and focal krypton laser photocoagulation was performed. Recurrent CNV was noted 6 months later, and additional photocoagulation was performed. Discussion This case represents the 10th case reported of CNV with a full-thickness macular hole and only the second of a patient with an untreated macular hole and no other risk factors for CNV.

Purpose To explore the association of angiographic nonperfusion in focal and diffuse recalcitrant diabetic macular edema (DME) in diabetic retinopathy (DR). Design A retrospective, observational case series of patients with the diagnosis of recalcitrant DME for at least 2 years placed into 1 of 4 cohorts based on the degree of DR. Methods A total of 148 eyes of 76 patients met the inclusion criteria at 1 academic institution. Ultra-widefield fluorescein angiography (FA) images and spectral-domain optical coherence tomography (SD OCT) images were obtained on all patients. Ultra-widefield FA images were graded for quantity of nonperfusion, which was used to calculate ischemic index. Main outcome measures were mean ischemic index, mean change in central macular thickness (CMT), and mean number of macular photocoagulation treatments over the 2-year study period. Results The mean ischemic index was 47% (SD 25%; range 0%-99%). The mean ischemic index of eyes within Cohorts 1, 2, 3, and 4 was 0%, 34% (range 16%-51%), 53% (range 32%-89%), and 65% (range 47%-99%), respectively. The mean percentage decrease in CMT in Cohorts 1, 2, 3, and 4 were 25.2%, 19.1%, 11.6%, and 7.2%, respectively. The mean number of macular photocoagulation treatments in Cohorts 1, 2, 3, and 4 was 2.3, 4.8, 5.3, and 5.7, respectively. Conclusions Eyes with larger areas of retinal nonperfusion and greater severity of DR were found to have the most recalcitrant DME, as evidenced by a greater number of macular photocoagulation treatments and less reduction in SD OCT CMT compared with eyes without retinal nonperfusion. Areas of untreated retinal nonperfusion may generate biochemical mediators that promote ischemia and recalcitrant DME.

PURPOSE. To evaluate contrast threshold and contrast gain in patients with optic neuritis under conditions designed to favor mediation by either the inferred magnocellular (MC) or parvocellular (PC) pathway. METHODS. Achromatic and chromatic contrast discrimination was measured in 11 patients with unilateral or bilateral optic neuritis and in 18 age-matched controls with normal vision, using achromatic steady- and pulsed-pedestal paradigms to bias performance toward the MC or PC pathway, respectively. In addition, L-M chromatic discrimination at equiluminance was evaluated using the steady-pedestal paradigm. A physiologically plausible model could describe the data with parameters accounting for contrast gain and contrast sensitivity in the inferred MC or PC pathway. The fitted parameters from the eye affected by optic neuritis were compared with those from the normal eye using generalized estimation equation (GEE) models that can account for within-subject correlations. RESULTS. Compared with normal eyes, the affected eyes had significantly higher saturation parameters when measured with both the achromatic pulsed-pedestal paradigm (GEE: [SE] 0.35 [0.06]; P 0.001) and the chromatic discrimination paradigm ( [SE] 0.18 [0.08]; P 0.015), suggesting that contrast gain in the inferred PC pathway is reduced; the affected eyes also had reduced absolute sensitivity in the inferred MC pathway measured with the achromatic steady-pedestal paradigm ( [SE] 0.12 [0.04]; P 0.005). CONCLUSIONS. Optic neuritis produced large sensitivity losses mediated by the MC pathway and contrast gain losses in the inferred PC pathway. A clinical framework is presented for interpreting contrast sensitivity and gain loss to chromatic and achromatic stimuli in terms of retinal and postretinogeniculate loci contributions to detection and discrimination. (Invest Ophthalmol Vis Sci. 2011;52:8900‐8907) DOI:10.1167/ iovs.11-7644