Idiopathic Intracranial Hypertension following Levothyroxine Replacement Therapy: Systematic Review and a Case Report.

The data on the characteristics of patients with idiopathic intracranial hypertension (IIH) following levothyroxine (LT4) replacement are limited. Here, we report a case and systematically review published cases of idiopathic intracranial hypertension (IIH) following levothyroxine (LT4) replacement. The systematic review was performed as per the PRISMA guidelines. Our patient is a 46-year-old lady with hypothyroidism (thyrotropin: 319 mIU/L, free thyroxine: 0.04 ng/dl), treated with 100 µg.d of LT4 and presented a month later with headache, visual diminution, bilateral lateral rectus palsies, and papilledema. Cerebrospinal fluid (CSF) pressure was 32 cmH2O. Drainage of CSF, oral acetazolamide, and modification of LT4 dose resulted in prompt symptomatic improvement and complete reversal of IIH. In the systematic review (n = 21), the median age of patients (7 males) was 13 (IQR: 8.8- 26.5) years. The median duration of hypothyroid symptoms was 4 (n = 10, IQR: 0.44-6.25) years whereas that from initiation of LT4 replacement to the diagnosis of IIH was 2 (n = 20, IQR: 1.17-4) months. Initial median serum thyrotropin and thyroxine were 100 (n = 14, IQR: 72.5-421.6) mIU/L, and 1.13 (n = 12, IQR: 1.0-2.45) µg/dl which changed to 2.2 (n = 7; IQR: 0.23-3.40) mIU/L and 8.90 µg/dl (n = 8, IQR: 6.43-14.85 µg/dl), respectively at diagnosis of IIH after LT4 treatment with median daily LT4 doses of 0.89 (n = 8, IQR: 0.60 - 1.17) times the maximum recommended dose for age. To conclude, we report an adult woman with IIH following LT4 replacement for primary hypothyroidism, a rare entity. Pediatric age, prolonged symptom duration, and use of higher LT4 replacement dose may be associated with IIH following LT4 replacement.

An unusual cause of recurrent bloody tear.

We describe a female patient who presented with watering followed by swelling in the left infraorbital area of 5 years duration. She had previously been prescribed topical antibiotics on several occasions with no improvement. On pressure over the swelling, there was blood-tinged discharge from the left eye and nostril. Magnetic resonance imaging revealed an enhancing, well-defined mass lesion in the inferomedial aspect of the left orbit, likely of nasolacrimal origin. Computed tomography dacryocystogram with three-dimensional reconstruction showed a well-circumscribed mass with an irregular surface, originating from the lacrimal sac. Gram staining and potassium hydroxide mount from the regurgitant fluid revealed thick-walled cysts with sporangia suggestive of Rhinosporidium seeberi infection. Excision biopsy of the lesion confirmed R. seeberi as the causative agent. The patient has been put on long-term dapsone therapy to prevent a recurrence and has been asked to follow-up 6 months later.

Intraocular lens scaffold technique to prevent posterior capsule rupture in cases of Morgagnian cataract.

We describe a technique for performing safe phacoemulsification of a Morgagnian cataract using the intraocular lens (IOL) scaffold. An IOL scaffold has been used in cases in which posterior capsule rupture has occurred, leaving nonemulsified nuclear pieces. The scaffold provides a barrier that prevents the nuclear fragments from falling posteriorly into the vitreous cavity. Our technique uses the IOL as a scaffold to prevent the vulnerable posterior capsule from rupturing during nuclear emulsification in Morgagnian cataract. The technique prevents rupture of the floppy posterior capsule by providing a constant support to it. The scaffold provides stable inflation of the capsular bag and prevents inadvertent emulsification. Concurrently, it prevents dehiscence of weak zonular fibers by minimizing the stress on the zonular apparatus.