Optic Nerve Amyloid Deposition Disguised as Optic Nerve Sheath Meningioma.

Localized orbital amyloidosis is a rare clinical entity. Periocular and orbital amyloid deposits are mainly located at the lacrimal apparatus, eyelid, conjunctiva, ocular adnexa, extraocular muscles, and levator palpebrae muscle. In this article, we report an unusual case of optic nerve amyloid deposition in an 82-year-old African American woman who presented with vertical diplopia. MRI revealed an enhancing mass from the optic nerve sheath, and CT showed foci of calcifications suggestive of optic nerve meningioma. However, an incisional biopsy demonstrated lymphoproliferative disease with focal optic nerve sheath amyloid deposition confirmed by histologic Congo red staining and immunohistochemistry.

Diminution of STING Expression in the Blood of Patients with Severe or Critical COVID-19 Pneumonia.

INTRODUCTION: Cytokine storm and critical COVID-19 pneumonia are caused in at least 10% of patients by inborn errors of or auto-Abs to type I IFNs. The pathogenesis of life-threatening COVID-19 pneumonia in other patients remains unknown. METHODS: This study was conducted at Masih Daneshvari Hospital, Tehran, Iran. In the period of study, 75 confirmed cases of COVID-19 with presentations ranging from mild upper respiratory tract infection to lower respiratory tract infection, including moderate, severe, and critical disease, were recruited. Expression of STING mRNA was measured in peripheral blood mononuclear cells (PBMCs) and compared between patients with different severity and outcome. RESULTS: There was a significant negative correlation between age and STING expression level (p value = 0.010). Patients with "severe to critical" illness had a 20-fold lower STING expression level compared to the "mild to moderate" group (p value = 0.001). Also, the results showed lower expressions of STING in the patients admitted to the ICU (p value = 0.015). Patients who finally died had lower expression of STING at the time of sampling (p value = 0.041). CONCLUSION: STING mRNA expression in PBMCs was significantly lower in older COVID-19 cases, the patients with more severe illness, who needed intensive care, and who eventually died.

Laser in situ keratomileusis versus Artisan lens implantation in correcting ametropia after penetrating keratoplasty for keratoconus.

PURPOSE: To compare the long-term safety and efficacy of laser in situ keratomileusis (LASIK) with Artisan phakic intraocular lens implantation to correct refractive errors after penetrating keratoplasty (PK) for keratoconus. METHODS: This retrospective comparative interventional case series included a total of 33 consecutive keratoconus eyes that had previous PK and received subsequent LASIK (n = 16) or Artisan lens implantation (n = 17) were included in this study. Outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive error, and complications. RESULTS: Postoperatively, the UDVA of ≥20/40 was achieved in none of the LASIK group compared to 62.5% of eyes in the Artisan group (P < 0.001); the respective values for CDVA of ≥20/40 were 87.5 and 94.1% (P = 0.51). Spherical equivalent refraction decreased from - 6.97 ± 1.50 D preoperatively to - 4.20 ± 2.05 D postoperatively in the LASIK group (P < 0.001) and from - 10.79 ± 2.15 D preoperatively to - 2.13 ± 1.23 D postoperatively in the Artisan group (P < 0.001). There was no significant change in the refractive astigmatism in LASIK group (P = 0.30) or Artisan group (P = 0.11). The efficacy and safety indices were significantly better for Artisan (0.82 ± 0.34 and 1.13 ± 0.30, respectively) than for LASIK (0.22 ± 0.17 and 0.85 ± 0.24, respectively, P ≤ 0.006 for both comparisons). While refractive error changed significantly from postoperative year 3 to the final visit in the LASIK group, it remained stable in the Artisan group through follow-up period. No significant complications were observed in any group. CONCLUSION: Artisan lens implantation provided superior and stable visual outcomes compared to LASIK for the management of post PK refractive errors in keratoconus eyes.

Evaluation of the epidemiologic, clinical, radiologic, and treatment methods of patients with subacute and chronic meningitis.

BACKGROUND: Meningitis is known as a meningeal inflammation accompanied by pleocytosis in the cerebrospinal fluid (CSF), and can be classified into acute, subacute, and chronic meningitis based on symptoms duration of ≤ 5 days, ≥ 5 days and ≥ 4 weeks, respectively. Subacute and chronic meningitis are caused mainly by indolent infectious agents and noninfectious causes such as autoimmune, and neoplastic. In this study, we investigated the characteristics, diagnosis, and treatment of subacute and chronic meningitis. METHODS: We extracted the medical records of patients with chronic and subacute meningitis who were referred to three tertiary centers from Jun 2011 to Jun 2021. Initially, 2050 cases of meningitis were screened, and then 79 patients were included in the study. RESULTS: Headache (87.3%), nausea and vomiting (74.7%), fever (56.4%), and visual impairments (55.7%) were the most prevalent symptoms. The most common signs were nuchal rigidity (45.3%), altered mental status (26.9%), and papillary edema (37.5%). Brain computed tomography (CT) was normal in 68.6% of the patients while 22.9% of the cases had hydrocephalus. Brain magnetic resonance imaging (MRI) was normal in 60.0% of the patients. The most common abnormal MRI findings were leptomeningeal enhancement (16.0%) and hydrocephalus (16.0%). We had a 44.3% definite diagnosis with bacterial (n:25, 31.6%) and neoplastic (n:8, 10.1%) being the most prevalent etiologies. Mycobacterium tuberculosis (60%) and Brucella spp. (12%) were the most prevalent bacterial pathogens. CONCLUSIONS: The most common etiologies include infectious, neoplastic, and immunologic. Due to insidious presentation and uncommon etiologies, establishing a proper diagnosis, and providing timely targeted treatment for patients with subacute and chronic meningitis remains a challenge for clinicians.

The effect of preoperative biliary drainage on postoperative complications of pancreaticoduodenectomy: a triple center retrospective study.

BACKGROUND: Biliary obstruction which is a major complication of pancreas and periampullary tumors could result in cholangitis, coagulopathies, gastrointestinal symptoms, and impaired wound healing. Pancreaticoduodenectomy (PD) is still the standard approach for pancreas resection and imposes high risk of morbidity and mortality to patients. To reduce the high risk of PD and address the biliary obstruction, the use of preoperative biliary stenting was increased. However, available literature doubts its efficiency. METHODS: A total of 147 patients who underwent PD between September 2012, and February 2022, at three medical centers were identified. Patients were grouped based on biliary stent placement. Non-jaundiced patients with and without preoperative biliary drainage (PBD) were compared. RESULTS: The incidence of overall complications (34.2% versus 45.8%) and mortality (17.8% versus 24.3%) did not differ in the PBD group compared to the no PBD group. There was no difference in complications and mortality in non-jaundiced patients with and without PBD. Patients with drainage duration of > 30 days experienced more overall complications compared to patients with less than 30 days drainage duration (12 (50.0%) and three (15.8%) patients, respectively, p-value = 0.019). CONCLUSIONS: PBD does not significantly increase the post-operative burden on patients who undergo PD. However, we cannot overlook the financial burden that PBD places on the patient and the healthcare system, as well as the difficulties related to endoscopic retrograde cholangiopancreatography (ERCP). Therefore, biliary stenting should not be routinely practiced in the absence of a valid indication, such as severe jaundice, pruritus, cholangitis, delayed surgery for neoadjuvant treatment, or referral to a tertiary facility.

Burn-Induced Cicatricial Eyelid Retraction: A Challenging Case and Review of Management Principles.

Thermal and chemical burns can result in cicatricial eyelid retraction, characterized by an abnormal resting position of the eyelid margin and increased palpebral fissure height. Eyelid retraction often leads to exposure keratopathy, which can cause complications ranging from mild dry eye to globe-threatening ulceration and perforation. Prompt intervention includes aggressive lubrication, moisture chambers, eyelid tarsorrhaphy, and retraction repair surgery. Discussed here is a burn patient that developed severe cicatricial eyelid retraction and ectropion, leading to severe exposure keratopathy and infectious corneal ulceration with perforation. The patient required aggressive medical intervention, as well as 2 surgeries to restore the normal eyelid anatomy to protect the globe.

The Relationship between the Clinical Course of SARS-CoV-2 Infections and Expression of Bruton's Tyrosine Kinase.

OBJECTIVES: The Bruton tyrosine kinase (BTK), an important element for the production of several inflammatory cytokines, may play a role in the pathogenesis of COVID-19. The aim of this study was to investigate the level of BTK gene expression in COVID-19 cases based on the severity and the outcome of the disease. METHODS: In this study, 33 hospitalized patients with COVID-19 were recruited and were divided into two groups based on the severity of the disease: "mild to moderate" and "severe to critical". A blood sample was taken from each patient, peripheral blood mononuclear cells (PBMCs) were extracted, and BTK gene expression was measured. The level of BTK gene expression was compared based on the demographic data, laboratory results, and the severity and outcome of the disease. RESULTS: Among 33 patients, 22 (66.7%) were male. Nearly half of the cases had at least one underlying disease. According to the severity of the disease, 12 patients were in the "mild to moderate" group, and 21 were in the "severe to critical" group; eight (24.2%) eventually died. Age, weight, and BMI had no significant relationship with BTK expression. BTK expression was significantly lower in "severe to critical" and ICU-admitted cases and in subjects with low O2 saturation. There was no significant difference in BTK expression between cured and dead patients (p=0.117). CONCLUSION: BTK gene expression in PBMCs had an inverse relationship with the severity of the disease of COVID-19. However, no correlation between BTK expression and disease outcome was observed.

Management of post-keratoplasty ametropia.

Even after a successful corneal transplant, patients experience severe refractive errors, impeding their rehabilitation and satisfaction. Refractive errors can be caused by recipient pathology and corneal thickness, as well as intraoperative factors such as donor-host discrepancy, recipient's eccentric trephination, vitreous length, wound apposition, technique of suturing, and suture material. Also, wound healing and the interim between keratoplasty and suture removal contribute to astigmatism. Lamellar keratoplasty outperforms penetrating keratoplasty in terms of endothelial cell loss and endothelial graft rejection, yet the risk of developing refractive errors is comparable. Nonsurgical interventions such as spectacles and lenses fail to provide desirable vision in cases with high astigmatism and corneal irregularity. When these limitations are encountered, surgical interventions including incisional keratotomy, wedge resection, laser refractive surgeries, intracorneal segments, and intraocular lens implantation are employed. However, occasionally, none of these approaches deliver the desired effects, leading to the need for a repeat keratoplasty.

Penetrating Keratoplasty Versus Deep Anterior Lamellar Keratoplasty for Advanced Stage of Keratoconus.

PURPOSE: To compare visual acuity, refractive error, and complications after penetrating keratoplasty (PK) vs deep anterior lamellar keratoplasty (DALK) in the management of advanced stage of keratoconus. DESIGN: Retrospective, comparative, interventional study. METHODS: This study enrolled 411 consecutive keratoconus eyes with preoperative mean keratometry ≥60 diopters (D) that received either PK (218 eyes) or DALK (193 eyes). The outcome measures were postoperative visual acuity, refraction, complications, and further surgical interventions. RESULTS: The mean follow-up duration was 77.9±46.5 and 72.9±47.8 months in the PK and DALK groups, respectively (P = .28). Compared with baseline values, postoperative visual acuity and refraction significantly improved in both groups. Postoperative corrected distance visual acuity was 0.18±0.13 and 0.26±0.19 logMAR in the PK and DALK groups, respectively (P < .001). Postoperative spherical equivalent refraction was -2.89±2.89 D after PK and -4.58±3.62 D after DALK (P < .001). Final keratometric astigmatism was comparable between the 2 groups (P = .82). Suture-related complications were observed in 48.6% of the PK eyes and 72.0% of the DALK eyes (P < .001). The incidence of graft rejection was 33.5% after PK and 19.7% after DALK (P = .002). At the last visit, 98.2% of PK grafts and 94.8% of DALK grafts remained clear (P = .06). CONCLUSION: Both techniques of corneal transplantation led to a significant improvement in the visual and refractive variables in eyes with advanced keratoconus. PK resulted in a better visual acuity and refraction with less suture-related complications compared to DALK. However, PK was associated with a higher rate of graft rejection. The 2 techniques were comparable in terms of graft survival.

Acute Pancreatitis as a Possible Unusual Manifestation of COVID-19 in Children.

Coronavirus disease-2019 (COVID-19) which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread throughout the world causing problems for millions of people. Symptoms of COVID-19 in pediatric patients include both respiratory and gastrointestinal symptoms. The most common symptoms are fever, cough, and fatigue. In this report, we describe a case of a previously well 14-year-old boy, who presented to our emergency department with a complaint of abdominal pain, nausea, and vomiting without fever or respiratory symptoms. He was diagnosed with acute pancreatitis based on an abnormal amylase level and abdomen computed tomography (CT) and later found to be infected by SARS-CoV-2, by a positive reverse transcriptase-polymerase chain reaction (RT-PCR) test.