Optic neuritis in Rosai Dorfman disease.

A 55-year-old man while being evaluated for unexplained weight loss was found to have multiple metabolically active lymph nodes on positron emission tomography-computed tomography (PET-CT) scan, and biopsy from right axillary lymph node demonstrated multiple histiocytes with emperipolesis with S100 positivity, consistent with Rosai-Dorfman disease.

Impact of weight reduction on structural and functional parameters of the optic nerve in idiopathic intracranial hypertension.

PURPOSE: To evaluate the effect of weight reduction on the structural and functional parameters of the optic nerve in established cases of papilledema in Idiopathic Intracranial Hypertension (IIH). METHODS: A prospective observational study in early and established cases of papilledema in IIH presenting from December 2019 to February 2021. Functional parameters (visual acuity, contrast sensitivity, mean deviation, VER), structural parameters (RNFL, GCL-IPL, and optic disc height), and clinical grading of papilledema were measured at baseline and every 6 weeks for 6 months. All patients underwent medical (oral acetazolamide) and diet therapy. RESULTS: Mean body mass index (BMI) at presentation was 26.32 ± 3.52 kg/m² and the mean change in BMI over 6 months was 1.27 ± 0.50 kg/m². 67% of eyes had papilledema of grades 2-3 at the presentation. At the end of 6 months, 75% of eyes had grade 1 papilledema while 13% showed complete resolution. A reduction of 5.32 ± 3.58 in mean deviation (r = 0.316; p-value 0.01) and gain in VER P100 amplitude of 4.2 ± 2.7 µV (r = 0.40; p-value 0.003) were noted over 6 months with reduction in BMI over 6 months. A statistically significant reduction in optic disc height (ODH) was noticed with BMI reduction over 6 months (p = 0.0007; r = 0.45).A reduction of 1.72 ± 0.90 kg/m² (equivalent to 6.53% weight loss) in BMI was associated with a four-grade change in clinical grading of papilledema. CONCLUSION: Reduction in BMI had a significant impact on both structural and functional parameters of the optic nerve in IIH. The involvement of a well-certified dietician should be an integral part of treatment in IIH.

Cerebrospinal fluid proteins in idiopathic intracranial hypertension: An exploratory SWATH proteomics analysis.

PURPOSE: The pathogenesis of idiopathic intracranial hypertension (IIH) is currently poorly understood. This exploratory study aimed to identify potential cerebrospinal fluid (CSF) biomarkers in IIH cases compared to controls using SWATH-MS proteomics approach. EXPERIMENTAL DESIGN: CSF samples were collected prospectively from IIH cases and control subjects which were subjected to SWATH-MS based untargeted proteomics. Proteins with fold change > 1.5 or < 0.67 and p-value < 0.05 were considered significantly differentially expressed. Data are available via ProteomeXchange with identifier PXD027751. Statistical analysis was conducted in R version 3.6.2. RESULTS: We included CSF samples from 33 subjects, consisting of 13 IIH cases and 20 controls. A total of 262 proteins were identified in Proteinpilot search. Through SWATH analysis, we quantified 232 proteins. We observed 37 differentially expressed proteins between the two groups with 24 upregulated and 13 downregulated proteins. There were two differential proteins among overweight versus non-overweight IIH cases. Network for 23 proteins was highly connected in the interaction analysis. CONCLUSIONS AND CLINICAL RELEVANCE: Neurosecretory, neuroendocrine, and inflammatory proteins were predominantly involved in causing IIH. This exploratory study served as a platform to identify 37 differentially expressed proteins in IIH and also showed significant differences between overweight and non-overweight IIH patients.

Evaluation of change in objective cyclotorsion after various inferior oblique-weakening procedures.

PURPOSE: To study the effect of four types of inferior oblique-weakening procedures on ocular torsion: inferior oblique recession (IOR), recession and antero-positioning (RAP), anterior transposition as practiced by Elliot and Nankin (EN), and anterior and nasal transposition (ANT). METHODS: The medical records of 72 consecutive patients >10 years of age undergoing inferior oblique weakening for primary or secondary inferior oblique overaction (IOOA) with or without horizontal rectus surgery were reviewed retrospectively. The 106 included eyes were assigned to one of the four groups according to the type of inferior oblique-weakening procedure. The severity of IOOA and the amount of V pattern guided the choice of procedure. IOOA, disk-fovea angle (DFA), and the amount of V pattern were recorded preoperatively. Measurements were repeated postoperatively at 1 week, 4 weeks, and 3 months. Change in the DFA was used to study the change in objective cyclotorsion in all four groups. RESULTS: A significant incyclotorsional shift was seen in all four groups at postoperative 3 months. The mean reduction in excyclotorsion 3 months postoperatively was 3.65° ± 4.84° for IOR, 5.31° ± 4.64° for RAP, 6.10° ± 3.89° for EN, and 16.62° ± 8.72° ANT; it was significantly higher in the ANT group compared with the other three groups. Reduction in DFA was also correlated with preoperative DFA overall, and for all procedures except IOR (P ≤ 0.005). CONCLUSIONS: All four inferior oblique-weakening procedures reduced excyclotorsion; the largest reductions in our study were seen in cases treated using ANT of the inferior oblique.

Evaluation of the Levels of Low-dose Topical Atropine (0.01%) in Aqueous and Vitreous Humor in Human Eyes.

SIGNIFICANCE: This is the first human study that confirmed penetration of 0.01% topical atropine in aqueous and vitreous humor in live human eyes. This supports the possible mode of action of atropine via posterior ocular structures. This knowledge will help improve the outcomes in myopia management. PURPOSE: The purpose of this study was to evaluate penetration of low-dose atropine 0.01% in aqueous and vitreous humor. METHODS: In this cross-sectional interventional pilot study, 48 cataract cases were divided into four groups (12 each), and 30 epiretinal membrane/macular hole cases were divided into three groups (10 each). One drop of 0.01% atropine was put in the eye to be operated. Aqueous humor samples were taken from patients undergoing cataract surgery at 60 ± 15 minutes in group 1, 120 ± 15 minutes in group 2, 240 ± 15 minutes in group 3, and 360 ± 15 minutes in group 4. Vitreous humor samples were taken from patients undergoing vitreoretinal surgery for epiretinal membrane/macular hole at 120 ± 15 minutes in group 1, 240 ± 15 minutes in group 2, and 360 ± 15 minutes in group 3. The assay of atropine was performed using liquid chromatography-mass spectrometry. RESULTS: Median concentrations of atropine in aqueous samples were 1.33 ng/mL (min-max, 0.6 to 6.46 ng/mL; interquartile range [IQR], 3.05 ng/mL) at 60 minutes, 2.60 ng/mL (min-max, 0.63 to 4.62 ng/mL; IQR, 1.97 ng/mL) at 120 minutes, 1.615 ng/mL (min-max, 0.1 to 3.74 ng/mL; IQR, 1.62 ng/mL) at 240 minutes, and 1.46 ng/mL (min-max, 0.47 to 2.80 ng/mL; IQR, 1.73 ng/mL) at 360 minutes, and those in vitreous samples were 0.102 ng/mL (min-max, 0 to 0.369 ng/mL; IQR, 0.366 ng/mL) at 120 minutes, 0.1715 ng/mL (min-max, 0 to 0.795 ng/mL; IQR, 0.271 ng/mL) at 240 minutes, and 0.2495 ng/mL (min-max, 0 to 0.569 ng/mL; IQR, 0.402 ng/mL) at 360 minutes, respectively. CONCLUSIONS: Measurable concentration of low-dose topical atropine (0.01%) was noted in aqueous and vitreous humor after instillation of a single drop of low-dose atropine. Muscarinic receptors located in the posterior segment such as the choroid and retina could be the possible site of action of low-dose atropine in myopia.

Novel Inferior Oblique Muscle Y Splitting Procedure to Minimize the Anti-Elevation Syndrome: A Pilot Study.

Purpose: To describe novel Y splitting procedure of inferior oblique muscle to mitigate the anti-elevation syndrome. Methods: A pilot, prospective interventional study was undertaken to assess the effect of inferior oblique muscle Y-splitting in patients with unilateral 3+ or more overaction. To correct primary gaze hypertropia and the excyclotorsion, a Y-splitting procedure was performed (along with routine horizontal muscle surgery as per the deviation) in 14 subjects. The effect of surgery was assessed at baseline and at 6 months post-intervention. Results: The mean age of 14 subjects was 25.14±7.70 years. The mean pre-operative hypertropia, excyclotorsion and inferior oblique muscle over-action was 18.42±3.50 PD, 14.14±2.65 degrees, and +3.21±0.42 respectively. Following surgery, this was reduced to 1.57±1.74 PD of residual hypertropia (a net correction of 16.85±2.31 PD, p = 0.005), 3.85±1.46 degrees of residual excyclotorsion (a net correction of 10.28±1.72 degrees, p < 0.05), and +0.28±0.46 of residual inferior oblique over-action (a net correction ~+3) at the end of 6 months. Amongst fourteen patients, three patients still experienced residual/variable anti-elevation effect, and during the study period none of them experienced any adverse event and none of them required any additional surgeries. Conclusion: While anteriorizing the inferior oblique muscle to correct primary gaze hypertropia and the excyclotorsion, a novel "Y splitting" procedure can be followed to achieve the desired results with mitigated anti-elevation effect.

Defining the Clinical Role of Swept-Source Anterior Segment Optical Coherence Tomography in Eyes Undergoing Strabismus Surgery.

Purpose: To describe the clinical role of swept-source anterior segment optical coherence tomography in extraocular muscle imaging in various strabismic conditions. Study Design: Prospective observational study. Participants: A total of 1104 extraocular muscles of 150 subjects were imaged. Normal eyes (640 muscles), eyes undergoing re-operation (240 muscles), paralytic strabismic eyes (16 muscles), non-paralytic strabismic eyes (20 muscles), post-traumatic strabismic eyes (64 muscles), eyes with thyroid disease (64 muscles), and other atypical cases (60 muscles) were imaged. In all cases, up to four recti muscles were evaluated in a given eye depending on the need. Results: The mean age was 38.15 ± 16.25 years. Overall, muscle insertion was identified in over 90% of the subjects. Apart from normal muscles (n = 860, 93.68%), the location was identified in previously operated eyes (n = 54, 90%), in traumatic muscle slippage (n = 2, 11.11%), in ocular coat ectasia (n = 11, 91.66%), in thyroid muscle hypertrophy, in operated scleral fixated intraocular lens with strabismus, and other challenging cases. In all circumstances, clinically useful information was obtained from the anterior 4-14 millimetres of the rectus muscle, which in turn helped in active surgical planning and overall management. Conclusion: The SS-ASOCT with its wider and deeper scanning abilities was able to locate the extraocular muscle insertion in a variety of strabismic conditions. Therefore, this tool can be used in the preoperative periods for optimal surgical planning and management.

Optical coherence tomography features and correlation of functional and structural parameters in patients of idiopathic intracranial hypertension.

Purpose: To determine the correlation between functional parameters and optical coherence tomography (OCT) features in patients of idiopathic intracranial hypertension (IIH). Methods: A prospective observational study in early and established cases of papilledema in IIH presenting from December 2017 to February 2019. Functional parameters (visual acuity, contrast sensitivity, mean deviation, VER, and MfERG) and structural parameters (RNFL, GCL-IPL, and optic disc height) were measured at baseline and every 6 weeks for 6 months. Results: At baseline, average RNFL had a moderate negative correlation with mean deviation (r = -0.45; P = 0.0007) and a positive correlation with logMAR visual acuity (r = 0.18; P = 0.17). On the contrary, baseline GCL and logMAR visual acuity had a negative correlation (r = -0.4, P = 0.02). Optic disc height (ODH) had a negative correlation with visual field mean deviation (r = -0.046; P = 0.0005). At 6 months, ODH and GCL-IPL complex had a statistically significant correlation with functional parameters. However, RNFL values did not show any significant correlation with any of the functional parameters. Baseline GCL-IPL and optic disc height values had a moderate and significant correlation with final functional parameters. However, RNFL did not show any correlation with final functional parameters. Correlation between GCL-IPL thickness at 6 weeks and final functional parameters were stronger than that with baseline GCL values. Conclusion: In the setting of severe papilledema, RNFL can misguide the prognosis. GCL-IPL can be a valuable tool for an objective evaluation of the integrity of the optic nerve in IIH and ODH may be used as an alternative or in combination with GCL-IPL in these cases.

Simulation of complex strabismus surgical procedures on goat eyes.

PURPOSE: To describe the possibility of complex strabismus surgical simulation on goat eyes. METHODS: The goat eyes were procured from local slaughterhouse with retained extra ocular muscle tissues. The obtained eyes were inspected for globe integrity, muscle quality, muscle length, and the surrounding teno-conjunctival layers. The included eyes were then segregated for surgical simulation based on their insertion and orientation (as oblique or recti), and they were mounted on a mannequin head, with a fixation suture at free end to simulate the resting tension. Additionally, as per necessary, extra muscles were also transplanted along desired sites to simulate human extra ocular muscle anatomy. RESULTS: The inferior oblique, superior oblique, and all other four recti were successfully simulated in varying proportions in more than 50 eyes. Primarily, by simulating the lateral rectus, inferior rectus, and the inferior oblique muscle, staged weakening procedures of inferior oblique were successfully practiced (Fink's recession, Park's recession, Elliot and Nankin procedure, total anterior positioning, and antero-nasal trans-position or Stager's procedure). Similarly, by simulating superior rectus, inferior rectus, lateral rectus, and the medial rectus muscles, half width transposition, full width transposition, and other complex procedures were practiced (Knapp's procedure, augmented Knapp's, Nishida's procedure, Faden operation, and Y splitting procedure). Furthermore, by simulating superior oblique and the superior rectus muscles, superior oblique tuck, posterior tenectomy, loop tenotomy, and Harada Ito procedures were successfully practiced. CONCLUSIONS: On goat eyes, the complex strabismus surgical procedures can be successfully simulated and practiced after re-organizing the existing muscles in different patterns.

Clinical Role of Swept Source Anterior Segment Optical Coherence Tomography in Strabismus Re-Operation with Lost Surgical Details.

BACKGROUND: To characterize the diagnostic role of swept source anterior segment optical coherence tomography (SS-ASOCT) in strabismus re-operations with lost surgical details. METHODS: Patients presenting to our outpatient services for strabismus care from February 2020 to March 15th 2021 were systematically evaluated. Those willing to undergo re-operation were included in the study. A total of 30 patients were identified and out of this a total of 10 eyes of 10 patients with lost surgical details were finally included in the study. Demographic details, preoperative deviation, ocular findings, orthoptic measurements, detailed SS-ASOCT findings, intraoperative measurements, and post-operative outcomes were recorded. RESULTS: The mean age of 10 patients was 23.7±5.75 years. Seven were male and three were female. The mean pre-operative SS-ASOCT measured distance from angle to insertion was 8.90±1.85 mm and the mean intraoperative distance was 9.12±2.14 mm. A mean difference of 0.21±1.31 mm was noted, and this difference was statistically insignificant (paired t test, p = 0.57). In addition, SS-ASOCT unraveled novel signs to differentiate operated eyes from the un-operated eyes, and recessed muscle from the resected muscle. CONCLUSION: In strabismus re-operation with lost surgical details, the pre-operative SS-ASOCT can provide reliable muscle details with respect to its type of surgery and amount surgery.

Effect of induced anisometropia on stereopsis and surgical tasks in a simulated environment.

Purpose: To quantitatively correlate the loss of stereopsis by induced anisometropia with its effect on tasks that require binocular vision and stereopsis, such as ophthalmic surgery in a simulated environment. Methods: Thirty-nine ophthalmic residents with best-corrected visual acuity of 20/20 or better OU, with normal binocular vision and stereopsis, were recruited for the study. Anisometropia was induced using spherical and cylindrical trial lenses from +1D to +5D in a trial frame. The residents performed an anterior chamber navigation exercise on the EYESi simulator and the surgical score at baseline and for each level of induced anisometropia was noted. Near stereopsis was assessed by the Randot test and TNO test at baseline and for each level of induced anisometropia. Results: Stereoacuity on the Randot test and TNO test were 30 (95% CI, 25.9-34.1) and 44.4 (95% CI, 28.5-60.3) arcseconds, respectively which reduced to 65.5 (95% CI, 48.7-82.3) and 75.9 (95% CI, 15.5-136.3) arcseconds at anisometropia of +1D Sph (P < 0.001) and 380 (95% CI, 309.9-450.1) and 1922.1 (95% CI, 1582.5-2261.7) arcseconds for +5D Sph, respectively for the two tests, (P < 0.001). The corresponding surgical score reduced from 93.8 (95% CI, 91.1-96.7) to 87.5 (95% CI, 79.2-95.8, P < 0.001) for 1 DSph and 55.97 (95% CI, 38.3-73.7, P < 0.001) for 5DSph. There was a strong negative correlation between stereopsis scores and surgical task scores (Spearman's rho -0.86, P value <0.001) Similar changes were seen for anisometropia induced with cylindrical powers. Conclusion: Induced anisometropia is associated with a significant diminution in surgical task scores in a simulated environment and this is correlated with the deterioration in stereoacuity. Assessment of stereopsis may be included as a regular part of the screening procedure for ophthalmic trainee residents.

Optical coherence tomography angiography in neuro-ophthalmology: Current clinical role and future perspectives.

Optical coherence tomography angiography (OCTA) is a noninvasive, depth-resolved imaging tool for the appraisement of retinal vascular changes. Since its introduction, the understanding of diabetic retinopathy, age-related macular degeneration, central serous retinopathy, and other diseases has been enriched on many fronts. Its dyeless imaging property maps retinal as well as deeper choroidal vasculature in quick succession with good reproducibility. Hence, it can play an important role in the diagnosis and management of optic nerve-related diseases as well. A detailed literature review for its role in nonarteritic anterior ischemic optic neuropathy, papilledema, optic disc drusen, papillitis, hereditary optic neuropathies, central nervous system diseases, and others highlights its role. The whole spectrum of neuro-ophthalmological diseases shows consistent peripapillary and macular capillary changes with structural and functional correlation. The superficial and deeper retinal and choroidal vasculatures are affected depending on the nature of the disease process. Hence, OCTA positions itself as a useful, noninvasive tool in the armamentarium of a neuro-ophthalmologist in future; however, there are several limitations of the OCTA with respect to its technical abilities in challenging neuro-ophthalmic cases. Therefore, future research should be directed to enhance the technical capabilities of OCTA and to determine the more precise role of it in the prognosis of neuro-ophthalmic diseases.

Perineuritis or infiltration of optic nerve sheath? A presentation of diffuse large B cell Gastric lymphoma.

Optic perineuritis is an inflammatory disorder involving the optic nerve sheath. It is currently considered as a part of idiopathic orbital inflammatory disease which also includes dacryoadenitis, orbital myositis, superior orbital fissure, and cavernous sinus syndrome (Tolosa hunt syndrome). As it is idiopathic, it is considered a diagnosis of exclusion. Another important differential is optic nerve lymphoma. Isolated optic nerve lymphoma associated with systemic involvement has been described in literature. We report a case that presented as third nerve palsy but later on developed central retinal vein occlusion and was ultimately diagnosed as primary gastric lymphoma of diffuse large B cell type.

Sympathetic ophthalmitis after scleral perforation during strabismus surgery.

We report the case of a 24-year-old woman who experienced sympathetic ophthalmitis after scleral perforation during strabismus surgery. She presented postoperatively with distorted vision and was successfully treated with intravenous and oral steroids.

Vertical rectus transposition procedures for lateral rectus palsy: A systematic review.

Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy," "vertical rectus transposition for abducens palsy," "superior rectus transposition," "inferior rectus transposition," and "Hummelsheim procedure." References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.

Extraocular muscle surgery on goats' eye: An inexpensive technique to enhance residents' surgical skills.

Hands-on resident surgical training for various ocular procedures is essential to impart good surgical skills to the budding ophthalmologists. Here in this report, we demonstrate a simple and inexpensive technique of performing extraocular muscle surgery on goats' eye. These animal eyes possess soft tissue resemblance to that of human eyes to a greater extent in terms of scleral rigidity, muscle elasticity, its width, thickness, and its insertion onto the sclera. Therefore, rectus muscle recession, resection, and plication surgeries can be performed repeatedly to improve an individual's orientation and practical experience before performing the procedure on human eyes.

Pulled into two syndrome (PITS) in a case of congenital fibrosis of the extraocular muscle.

A four-year-old child with a clinical diagnosis of unilateral congenital fibrosis of extraocular muscles (CFEOM) was planned for inferior and medial rectus muscle recession surgery, adjusted with the status of forced duction test. Due to pathological changes within the muscles subsequent to innervational abnormality, intraoperatively the inferior rectus muscle was pulled into two following the insertion of muscle hook. Moreover, the snapped muscle fibers could not be identified, thus further surgery was abandoned and an observation was commenced. At the end of 6 weeks, there was a significant reduction in the amount of hypotropia but clinically significant perverted convergence with esotropia necessitated further surgical intervention. A second surgical intervention consisting of medial rectus transposition to superior rectus with 3 mm recession was performed to achieve acceptable results in the primary gaze.

Cervical carcinoma leading to orbital apex syndrome and blindness.

Orbit is an unusual and rare site for metastases from cancer. The most frequent site of a primary malignancy to metastasise to the orbit is the breast, followed by the lung. The malignant mixed mullerian tumour is a rare uterine and cervical carcinoma and accounts for <5% of uterine cancers. It is the primary tumour of the uterus, and de novo involvement of the cervix itself is extremely rare. We report the first case of cervical carcinoma with mixed mullerian aetiology to be associated with orbital metastasis and eventually leading to blindness and death.