Neuro-Ophthalmology Division


		Neuro-Ophthalmology Division

Neuro-Ophthalmology Division

The Neuro-Ophthalmology Division at the INN, under the direction of Mark J. Kupersmith, M.D. is committed to patient care, educational, and research service. We specialize in the evaluation, diagnosis, and treatment of neurological and systemic disorders that affect the eye or brain or both. These problems cause sensory, visual, ocular motor, lid, or pupillary dysfunction. A clinical fellowship in Neuro-ophthalmology at the INN and the New York Eye and Ear Infirmary is to one qualified board eligible ophthalmologist or neurologist yearly.

Close collaborative efforts with the Interventional Neurovascular, Neurology, and Neurosurgical Services have been established to create multidisciplinary teams to manage complex problems - one of the principal goals at the INN. However, the Neuro-ophthalmology Division is also committed to the judicious use of resources so unnecessary testing is never performed as a substitute for clinical acumen and knowledge.

Mark J. Kupersmith, M.D. is the director of the Neuro-ophthalmology Division. As board certified Ophthalmologist and Neurologist, Dr. Kupersmith can communicate well with ophthalmologists and neurologist/neurosurgeons, as well as general medical physicians. He can understand when ocular diseases such as glaucoma or macula degeneration or a brain tumor is the cause of the patient's symptoms. He can determine when the problem is minor and requires no additional evaluation and when the potential medical problem might be serious. For the first eleven years of his career, Dr. Kupersmith's research pursuits in addition to observations in various diseases, was the understanding of the human visual system, using new electrophysiological methods of evaluating the retina, optic nerve, and brain processing of vision. For the last eight years, Dr. Kupersmith has directed and participated in numerous clinical treatment trials of systemic and neurological diseases which cause visual disorders.

The faculty of the Neuro-Ophthalmology Service teach courses and present original research at the Academy of Ophthalmology, The Association of Research in Vision and Ophthalmology, The American Academy of Neurology, The Frank Walsh Society, and The North American Neuro-Ophthalmology Society.

The Neuro-ophthalmology Division offers special expertise in many areas by virtue of a vast experience and research interest in these and many other areas:

Optic neuritis1: Inflammatory optic nerve diseases can be associated with multiple sclerosis 2,3 but other systemic inflammatory diseases 3,4 may be the cause of a patient's visual loss. An accurate diagnosis may require a systemic immunological evaluation. Treatment to improve vision and reduce the advancement to MS must be considered.

Swollen optic nerves, pseudotumor cerebri: Patients with swollen optic nerves (papilledema) can have increased intracranial pressure which causes blurred or loss of vision, double vision, and headaches. In young overweight women, the increased pressure develops without a tumor, but they can still lose vision. The diagnosis must be correctly established, eliminating lesions and dural venous sinus diseases as the cause, and treatment must be individualized. We consider pseudotumor cerebri (idiopathic intracranial hypertension)as a significant women's health care issue that we are treating and investigating.6 Also, we can determine whether the optic disc elevation is not indicative of a significant or neurological problem.

Double vision: Double vision typically but does not always arise from a misalignment between the eyes. It may simply occur from a decompensation of a previously known or unknown strabismus, but in most cases it is a symptoms of neurological disease. Some of these disorders are transient or resolve spontaneously while others deteriorate because of serious illness, such as tumor, multiple sclerosis, aneurysms, and systemic diseases. Ocular myasthenia gravis often requires expertise to definitively diagnose and outline a treatment plan which normalizes vision with few side effects.7

Meningioma 8, pituitary tumor 9,10, aneurysm 11, and craniopharyngioma 12 can cause visual loss from optic pathway compression or double vision. Some cases will need surgery, others some type of radiotherapy 8 and others only require optical therapy and expectant follow up unless there is deterioration. This can be particularly difficult during pregnancy. 13

Unexplained visual loss: The evaluation of acquired visual loss from complications of systemic cancer or other diseases begins with determining whether the problem is with the brain, optic nerves, retina, an interference with the visual axis. Once the site of dysfunction is determined, the work up is targeted, such as electroretinography and blood antibody measurement for cancer associated retinopathy.

Systemic disorders can cause visual loss. In children a minor viral illness can cause optic nerve related visual loss. In the elderly, temporal arteritis causes characteristic symptoms which are often misdiagnosed as arthritis and frequently ends in blindness unless treated early.

Neurovascular disorders such as stroke, AVM 14, aneurysm 15,16, arteriovenous fistula 17,18 must be properly diagnosed before irreversible visual loss, major neurological deficits, or death occurs.19

Current and pending clinical research investigations include:

1) Longitudinal Optic Neuritis Study

2) Methotrexate Giant Cell (Temporal) Arteritis Treatment Trial

3) Interferon Beta 1A Treatment Trial of the First Episode of Multiple Sclerosis

4) Weight Reduction Treatment of Pseudotumor Cerebri

5) Aspirin Treatment to Prevent Second Eye Involvement of Non-Arteritic Anterior Ischemic Optic Neuropathy

6) Evaluation of Embolization for Pial and Dural Arteriovenous Malformations

7) Thrombolysis and neuronal protection for acute ischemic visual loss from central retinal artery occlusion and ischemic optic neuropathy

Selected publications:

1. Beck RW, Cleary PA, Anderson MM, Kupersmith MJ, et al: A Randomized, Controlled Trial of Corticosteroids in the Treatment of Acute Optic Neuritis. N Engl J Med 1992; 326:581-588

2. Beck RW, Cleary PA, Trobe JD, Kaufman DI, Kupersmith MJ, Paty DW, Brown CH, and the Optic Neuritis Study Group: The Effect of Corticosteroids on the Development of New Clinical Manifestations of Multiple Sclerosis in Patients with Acute, Isolated Optic Neuritis. "Corticosteroids Reduce MS Attack Rate". N Engl J Med 1993;329:1764-1769

3. Kupersmith MJ, Kaufman D, Paty W, Ebers G, McFarland H, Johnson K, Reingold S, Whitaker J. Megadose Corticosteroids in Multiple Sclerosis. Neurology 1994; 44:1-4

4. Gelwan M, Kupersmith MJ: Sarcoid Optic Neuropathy - Treatment Considerations. J Neurology, Neurosurg Psych 1988; 51:1473-1480

5. Kupersmith MJ, Burde RM, Warren FA, Klingele TG, Frohman LP, Mitnick H: Autoimmune Optic Neuropathy - Evaluation and Treatment. J Neurol, Neurosurg, Psych 1988; 51:1381-1386

6. Kupersmith MJ,Gamell L, Turbin R, Peck V, Spiegel P, Wall M. Effects of Weight Loss on the Course of Idiopathic Intracranial Hypertension. Neurology (In Press 1997)

7. Kupersmith MJ, Warren F, Weinberg H, Moster M. Beneficial Effect Corticosteroids in Ocular Myasthenia Gravis. Arch Neurol 1996; 53:802-804

8. Kupersmith MJ, Warren FA, Newall J, and Ransohoff J: "Irradiation of Meningiomas of the Intracranial Anterior Visual Pathway". Ann Neurol 1987; 21:131-136

9. Rush SC, Kupersmith MJ, Lerch I, Cooper P, Ransohoff J, Newall J: Neuro-ophthalmological assessment of vision before and after radiation therapy alone for pituitary macroadenomas. J Neurosurg 1990; 72:594-599

10. Cohen AR, Cooper PR, Kupersmith MJ, Flamm ES, Ransohoff J: Visual Recovery After Transphenoidal Removal of Pituitary Adenomas. Neurosurgery 1985; 17:446-452

11. Vargas ME, Kupersmith MJ, Setton A, Nelson K, Berenstein A: Endovascular Treatment of Giant Aneurysms Which Cause Visual Loss. Ophthalmology 1994;101:1091-1098

12. Weiner HL, Rosenberg ME, Kupersmith MJ, Cohen H, Zagzag D, Shiminski-Maher T, Flamm ES, Epstein FJ, Miller DC: Craniopharyngiomas: A Clinicopathological Analysis of Factors Predictive of Recurrence and Functional Outcome. Neurology 1994;35:1001-1011

13. Kupersmith MJ, Rosenberg C, Kleinberg D: Visual Loss in Pregnant Women with Pituitary Adenomas. Ann Int Med 1994;121:473-477

14. Kupersmith MJ, Vargas ME, Yashar A, Madrid M, Nelson K, Setton A, Berenstein A: Occipital arteriovenous malformations: Visual disturbances and presentation. Neurology 1996; 46:953-957

15. Kupersmith MJ, Berenstein A, Flamm E, Ransohoff J. Percutaneous Transvascular Treatment of Giant Carotid Aneurysms: Neuro-ophthalmologic Findings. Neurology 1984; 34:328-335

16. Kupersmith MJ, Hurst R, Berenstein A, Choi IS, Jafar J, Ransohoff J. The Benign Course of Cavernous Carotid Aneurysms. J Neurosurg 1992;77:690-693

17. Kupersmith MJ, Berenstein A, Flamm E, and Ransohoff. J Neuro-Ophthalmologic Abnormalities and Intravascular Therapy of Carotid Cavernous Fistulas. Ophthalmology 1986;93:906-912

18. Kupersmith MJ, Vargas EM, Warren F, Berenstein A. Venous Obstruction as the Cause of Retinal/Choroidal Dysfunction Associated with Arteriovenous Shunts in the Cavernous Sinus. J Neuro-Ophthalmol 1996;16:1-6

19. Kupersmith MJ: Neurovascular Neuro-ophthalmology. Heidelberg, Springer-Verlag, 1993