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Pituitary adenoma: diagnosis and management.

This article is a review and update on pituitary adenomas and their effects on the visual system. Current diagnostic characteristics and tests of importance to the optometrist are highlighted. Major clinical manifestations of pituitary adenomas during various parts of the visual examination are discussed. Neuroradiologic testing and treatment modalities are also briefly covered. Finally, a case report illustrates how routine optometric care can lead to diagnosis of pituitary adenoma in a visually asymptomatic patient. This case underscores the importance of investigating every case of unexplained vision loss.

Adenoma↗

Cavitary developmental defects of the optic disc. Visual loss associated with optic pits and colobomas.

Congenital cavitary anomalies of the optic disc (optic pit and coloboma) are uncommon and frequently go unrecognized. Patients with these defects have a high incidence of visual loss and the abnormal appearance of the discs may be mistaken for atrophy due to acquired neurological disease. Occasionally, associated midline neurological developmental malformations will be found associated with pits, colobomas, or other dysplastic optic discs, as in one of our cases. A group of patients with optic pits and colobomas referred for neurological evaluation of visual loss are presented to remind the neurologist of the appearance of these congenital crater-like defects and of the causes of loss of vision.

Adult↗

Traumatic porencephalic cyst of the brain.

BACKGROUND: A porencephalic cyst is a cavity within the cerebral hemisphere, filled with cerebrospinal fluid, that communicates directly with the ventricular system. It is a rare condition probably caused by vascular occlusion resulting from an insult during fetal development or an injury occurring later in life. Porencephaly is often associated with various ophthalmic and neurologic signs, including visual-field defects, abnormal pupillary responses, optic nerve hypoplasia, decreased vision, nystagmus, strabismus, hemi-inattention, seizures, and mental deficiencies. CASE REPORTS: Two cases are presented of patients in whom porencephalic cysts developed as a result of traumatic head injuries. Both had demonstrable visual-field defects, with diagnosis of porencephaly verified by computed tomography scans of the head. CONCLUSIONS: Visual-field defects resulting from porencephalic cysts can mimic those observed with strokes or brain tumors. A thorough case history and complete neurologic workup can assist with differential diagnosis. The clinical features of porencephaly, different theories of brain recovery after trauma, and treatment options are discussed.

Adult↗

Primary optic nerve sheath meningiomas. Report of nine cases.

Between 1979 and 1987 the authors treated nine cases of primary optic nerve sheath meningioma. The definitive treatment for these lesions is surgical resection, although no single best plan for optimal management has been determined. The data indicate that only small anterior tumors may be removed with preservation of useful vision. With posterior circumferential tumors, there have been no cases of tumor removal with preservation of vision. A management strategy directed toward preservation of vision is discussed.

Cranial Nerve Neoplasms↗

Problems in the diagnosis and management of unilateral retinoblastoma.

The improved prognosis for life in retinoblastoma challenges us to readdress the severe morbidity associated with late presentation and treatment, particularly in unilateral disease. Three cases of unilateral sporadic retinoblastoma are presented to illustrate the range of therapeutic options that need to be considered in management and to show that early recognition of the tumour and local treatment have the potential to minimise morbidity and to enable binocular vision to be retained.

Antineoplastic Agents↗

Chalazion-induced hyperopia as a cause of decreased vision.

This article presents three cases of decreased vision due to acquired hyperopia, which were caused by a chalazion of the upper eyelid. Through manifest refraction and computerized corneal topographic analysis, acquired hyperopia associated with central corneal flattening was revealed. These findings were responsible for the blurred vision that was reversed by chalazion resolution or removal. Although not usually considered a risk factor for refractive disorders other than astigmatism, chalazia of the upper eyelid can present as a decrease in vision associated with reversible central corneal flattening and acquired hyperopia.

Aged↗

Monocular nystagmus in infancy and early childhood.

Of 11 young children (six girls and five boys, ranging in age from 4 to 14 months) with monocular nystagmus, six were found to have chiasmal tumors whereas only four had spasmus nutans. Differentiating features between these two groups included decreased vision and optic nerve anomalies (including four cases of optic nerve hypoplasia) in the tumor group. However, we found that no consistent clinical finding absolutely separates these groups. We therefore recommend that all infants and children with monocular nystagmus or the other features of spasmus nutans should undergo computed tomographic scanning.

Cranial Nerve Neoplasms↗

The use of flash visual evoked potentials in the early diagnosis of suspected optic nerve lesions due to craniofacial trauma.

Craniofacial trauma encroaching on the orbital apex and optic canal can result in direct or indirect optic nerve lesions, leading to visual impairment or blindness. Early diagnosis of a visual loss and immediate therapy are generally considered crucial for a successful restoration of vision in indirect trauma. However, in comatose or sedated patients the assessment of optic nerve function by testing pupillary reactivity may be severely compromised or impossible because of tensely swollen eyelids, conjunctival oedema, concussion of the ciliary muscle or pharmacological effects. In the event that clinical ophthalmic examination, computer tomography or nuclear magnetic resonance scanning fail to clarify the state of the optic nerve, visual evoked potentials (VEPs) to flash stimulation appear to provide reliable information on function within the visual pathway. On this basis, treatment with corticosteroids and/or surgical decompression can be rapidly initiated. Our results in a preliminary patient series confirm the value of acutely monitored VEPs as an objective test of optic nerve function in cases of suspected optic nerve injury immediately after admission to the emergency care unit. The imaging techniques usually applied may be complemented by VEPs to show the functional significance of structural abnormalities found in the vicinity of the optic nerve.

Adult↗

Inverted vision after frontal lobe disease.

A case of bifrontal abscesses is reported. The patient claimed that he sometimes saw the world as if it were upside-down. A review of the literature reveals that, since 1805, 21 similar cases have been documented. The present case is unusual in that the neuropsychological status of the patient is investigated in some detail, and in that it seems to be the first report of inverted vision in a case of frontal lobe disease.

Brain Abscess↗

Visual loss reversed after treatment of acute bacterial sinusitis.

Visual loss is a rare complication of acute bacterial sinusitis (ABS). Very few cases have been reported in the literature. Only two cases of visual loss reversed after treatment of ABS are found in the English-language literature. We present three cases in which significant visual loss was reversed after treatment of ABS. The experience with visual loss associated with ABS is small; therefore, no definitive statement about treatment can be made. However, on the basis of our experience, it appears that immediate surgical drainage with antibiotic therapy may be important in restoring vision.

Acute Disease↗

Bilateral optic nerve sheath enlargement.

A 43-year-old man presented with progressive visual loss in each eye associated with bilateral optic nerve sheath enlargement. At surgery, the left optic nerve sheath was diffusely distended with clear fluid, but biopsy of the optic nerve and its sheath revealed only normal structures. Decompression of the right optic nerve prevented further deterioration of vision in this eye. The etiology of this condition and pathogenesis of visual loss is unknown.

Adult↗

Paraocular sinus mucoceles.

BACKGROUND: Patients with paraocular sinus masses may manifest ocular complications, including orbital displacement, proptosis, diplopia, restricted extraocular muscles, decreased vision, chemosis, pain, and optic neuritis. METHODS: Two patients with paraocular sinus masses came to our clinic for examination. One had proptosis and orbital displacement and a chief symptom of increasing diplopia, along with dull brow pain and sudden decreased vision of the left eye. He was diagnosed with polypoid disease and mucoceles of the ethmoidal and frontal sinuses. The second patient experienced pain and swelling under his left eye. He had an upper respiratory tract infection with sinusitis, which in turn increased the size of the sinus cyst. RESULTS: Computed tomography (CT) of the sinuses and orbits was ordered for both patients and confirmed the presence of mucoceles in each case. The first patient's signs and symptoms decreased over 2 weeks, so surgical intervention at that time was not necessary. The second patient was treated with 60-mg pseudoephedrine q.i.d. and 250-mg amoxicillin/potassium clavulanate q.i.d. CONCLUSIONS: Mucoceles are slow-growing polyp-like cysts of the sinuses; these cysts may be sterile in composition or harbor purulent infection (mucopyocele). In either case; they are space-occupying lesions that increase in size as mucus secretions continue, and can be exacerbated by active sinusitis. Differential diagnosis includes thyroid eye disease, orbital pseudotumor, infection, trauma, benign or malignant tumors, encephalocele, or meningiocele.

Aged↗

Steroid-induced visual recovery in fibrous dysplasia.

Fibrous dysplasia is a rare disorder of bone that may be associated with acute loss of vision. Surgical intervention is generally advocated and sometimes restores vision in these patients. We report a case of a patient with unilateral optic neuropathy from fibrous dysplasia who suffered two acute episodes of visual impairment. The first episode of vision loss was reversed by surgery and the second by corticosteroid treatment. A trial of corticosteroid therapy may be beneficial in cases of acute vision loss due to fibrous dysplasia.

Adult↗