A case of skew deviation and downbeat Nystagmus induced by Lithium.

BACKGROUND: Lithium salts have been commonly used for prophylaxis and treatment of bipolar disorder and have numerous side effects. However, there has been no report of skew deviation and downbeat nystagmus associated with lithium. Herein, we report the first case of lithium-induced skew deviation and downbeat nystagmus. CASE PRESENTATION: A 39 years-old woman presented with intermittent vertical diplopia and dizziness within 1-2 months. Ophthalmologic examination revealed downbeat nystagmus and 6 prism diopters of right hypertropia. Funduscopic examination showed mild incyclotorsion on right eye. However, ductions and versions were within normal range. Other neurological examinations were also normal. She had a history of bipolar disorder treated with daily 600-900 mg of lithium for past 6 years, and 2 months before the first visit, daily dose of lithium was increased to 1200 mg. We referred the patients to psychiatrist. Although the serum level of lithium was within the normal therapeutic range, her daily dose of lithium was reduced to 600 mg and then stopped. 6 days after cessation of lithium, down beat nystagmus and right hypertropia were completely resolved and symptoms did not recur over a year. CONCLUSION: Even within a normal therapeutic range, downbeat nystagmus and skew deviation can occur as side effect of lithium. Dehydration may contribute to the neurotoxicity of lithium.

Pediatric trochleitis associated with paranasal sinusitis: a case report.

BACKGROUND: Trochleitis is trochlear pain with evidence of inflammation in the trochlear area on radiologic examination. The etiology of trochleitis is mostly idiopathic. Secondary trochleitis is rare, and trochleitis associated with paranasal sinusitis in children has not yet been reported. CASE PRESENTATION: An 8-year-old boy presented with left periorbital pain for a week. His visual acuity and eye movement were normal. There was point tenderness on palpitation over the left trochlear region without swelling or redness. Orbital magnetic resonance imaging showed focal enhancement on the left trochlea and paranasal sinusitis on the left side. The patient's symptoms and signs were completely resolved after empirical treatment for sinusitis. There was no need to inject a local steroid. CONCLUSION: Although rare, sinusitis should be considered when diagnosing and treating trochleitis in children with periorbital pain.

Increase in esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine mixed eye drops in patients with hyperopia and esotropia.

BACKGROUD: To evaluate the manifestations of increased esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine in children with hyperopia and esotropia. METHODS: We reviewed the medical record of 34 children with hyperopia and esotropia who underwent a prism alternate cover test before and after instillation of mixed eye drops containing 0.5% tropicamide and 0.5% phenylephrine between November 2014 and October 2015. Increased angle of deviation was defined as 10 prism diopters (PD) or greater deviation after cycloplegia. The factors related to increased angle of deviation were evaluated using univariable and multivariable logistic regression analysis. RESULTS: The median age was 5.0 years (interquartile range, 3.75 to 5.0) and 12 patients (35.3%) were male. The median manifested refractive (MR) was +2.13 diopters (D) (+0.92 to +4.47) and cycloplegic refractive (CR) was +3.50 D (+1.72 to +5.66). The median difference between MR and CR was +0.88 D (+0.50 to +1.28). Thirteen patients (38.2%) showed increased esodeviation under cycloplegia and all had accommodative esotropia. A larger difference between MR and CR was the only significant factor affecting increased esodeviation in both univariable (OR = 4.72, P = 0.029) and multivariable (OR = 5.22, P = 0.047) analyses. CONCLUSION: Children with hyperopia and esotropia often showed an increased angle of deviation after instillation of 0.5% tropicamide and 0.5% phenylephrine. This phenomenon reminded the clinicians that cycloplegics can have a different effect on esodeviation and suggested that increased angle of esodeviation may help to reveal the latent deviation in some patients with hyperopia and esotropia.

Spectral domain optical coherence tomography imaging of mucopolysaccharidoses I, II, and VI A.

PURPOSE: The purpose of this study was to describe the spectral domain optical coherence tomography (SD-OCT) characteristics of patients with retinal manifestations of mucopolysaccharidoses (MPSs) I, II, and IV A. DESIGN: The research was a prospective, observational study. METHODS: Fourteen consecutive patients with variants of MPS and 15 healthy subjects underwent ophthalmic assessments including fundus examinations and SD-OCT. RESULTS: The fundus examinations revealed that four patients (two MPS I and two MPS II) had pigmented retinopathy in both eyes. In addition, one MPS II patient had cystoid macular edema and two MPS II patients had abnormal disc morphology. SD-OCT revealed thinning of the parafoveal photoreceptor inner segment/outer segment (IS/OS; two MPS I and one MPS II) and perifoveal photoreceptor IS/OS (two MPS I and five MPS II). All MPS I and II patients exhibited thickening of the central foveal external limiting membrane (ELM). Fundus and SD-OCT findings were normal in MPS IV A and healthy subjects. The foveal ELM was significantly thicker in MPS I and II patients than in healthy subjects (P =0 .000 and P =0 .000, respectively). The foveal IS/OS was significantly thinner in MPS I, II, and IV A patients than in healthy subjects (P = 0.000, P = 0.000, and P = 0.030, respectively). The foveal retinal pigment epithelium layer was also thinner in MPS II patients than in healthy subjects (P = 0.007) CONCLUSIONS: In MPS, accumulation of glycosaminoglycans in retinal tissue induced retinal degeneration and pigmentary retinopathy. SD-OCT was a useful tool for detecting retinal pathology, particularly changes in ELM and IS/OS.

Ocular Motor Cranial Nerve Palsies and Increased Risk of Primary Malignant Brain Tumors: South Korean National Health Insurance Data.

The aim of this study was to investigate the association between ocular motor cranial nerve palsies (OMCNP) and the occurrence of primary malignant brain tumors in a Korean population, using the national sample cohort database from Korea National Health Insurance Service (KNHIS). KNHIS data between 2010 and 2017 were analyzed. Our sample encompassed 118,686 participants, including 19,781 from a recently diagnosed OMCNP cohort and 98,905 from a matched control cohort through a 1:5 propensity score matching based on age and gender. To counteract the issue of reverse causation, we integrated a one-year time lag in our sensitivity analysis. Study participants were followed up until 31 December 2019. Cox proportional hazard regression analysis was used to compute the adjusted hazard ratio (HR) for primary malignant brain tumors according to the OMCNP diagnosis. Additionally, we performed a subgroup analysis to discern effects of various factors on the association between OMCNP and primary malignant brain tumors. HR for primary malignant brain tumors was 3.272 (95% confidence interval [CI]: 2.294 to 4.665) in the OMCNP cohort compared to the control cohort in a fully adjusted model for age, sex, socio-economic status, smoking, drinking, regular physical exercise, hypertension, diabetes, dyslipidemia, obesity, chronic kidney disease, and human immunodeficiency virus infection. Further subgroup analysis revealed that the risk of primary malignant brain tumors was significantly increased in women with OMCNP compared to men with OMCNP (HR: 5.118 in women vs. 2.441 in men, p = 0.0440), and in those aged <65 years than in those aged ≥65 years (HR: 6.951 in age < 65 years vs. 1.899 in age ≥ 65 years, p = 0.0006). Our population-based cohort study demonstrated a significantly increased risk of subsequent primary malignant brain tumors in patients with OMCNP. Particularly, OMCNP-afflicted women aged below 65 manifested a heightened probability of developing primary malignant brain tumors compared to those devoid of OMCNP.

Association between age at menarche and risk of myopia in the United States: NHANES 1999-2008.

We evaluate the effect of menarche on myopia in women in the United States (US). A cross-sectional survey and examination were conducted using data from the 1999-2008 US National Health and Nutrition Examination Survey (NHANES), and 8,706 women aged ≥20 years (95% confidence interval [CI], 44.23 to 45.37) were enrolled. Characteristics were compared between nonmyopic and myopic participants. Univariable and multivariable logistic regression analysis was performed to evaluate the risk factors for myopia. A minimum p-value approach was used to estimate the cut-off point for age at menarche. The prevalence of myopia was 32.96%. Mean spherical equivalent (SE) were -0.81 diopters (95% CI, -0.89 to -0.73) and the mean age of menarche was 12.67 years (95% CI, 12.62 to 12.72). In the crude logistic regression model, age (odd ratio [OR] 0.98), height (OR, 1.02), astigmatism (OR, 1.57) (all p < 0.0001), age at menarche (OR, 0.95; p = 0.0005), white ethnicity, being born in the US, higher level of education, and higher annual household income (all p trend <0.0001) were significantly associated with myopia. 1-year increments in age at menarche was associated with a 4% decrease in the risk of myopia after adjusting for age, height, body mass index (BMI), ethnicity, and astigmatism (OR, 0.96; 95% CI, 0.93 to 0.99, p = 0.0288). The cut-off value for age at menarche was 15 years by the maximum chi-square test (p < 0.0001). Age at menarche may attribute to myopia progression, along with other environmental and individual risk factors.

Long-term results of augmented unilateral lateral rectus muscle recession for dissociated horizontal deviation.

We report the long-term surgical results of augmented lateral rectus muscle (LR) recession for dissociated horizontal deviation (DHD) without concomitant exotropia (XT) or esotropia (ET). This retrospective review included patients with DHD without XT or ET who underwent augmented LR recession and were followed-up for ≥12 months. Each patient's medical records were evaluated to identify their demographics, preoperative angle of deviation, surgical procedure, success rate, and reoperation rate. A total of 11 patients with DHD were included (median patient age at surgery, 6 years; interquartile range [IQR], 5 to 10 years). Four patients (36.4%) had a history of infantile ET while three patients (27.3%) had a history of unilateral cataract surgery for congenital cataract. The median preoperative angle of DHD in the unilateral eye was 20 prism diopters (PD) (IQR, 15 to 25 PD). The median amount of LR recession was 8.0 mm (IQR, 7.5 to 8.0 mm). Three patients (27.3%) underwent simultaneous surgery for dissociated vertical deviation. At the final examination after a median follow-up period of 32 months (IQR, 24 to 58 months), 10 patients (91%) showed successful alignment. The long-term successful alignment rate after augmented LR recession for DHD was good; thus, application of this technique is appropriate in patients with DHD.

Association between myopia and peripapillary hyperreflective ovoid mass-like structures in children.

We investigated the characteristics of children with peripapillary hyperreflective ovoid mass-like structures (PHOMS) and evaluated the associated risk factors. This cross-sectional study included 132 eyes of 66 children with PHOMS and 92 eyes of 46 children without PHOMS (controls) who were assessed by disc enhanced-depth image spectral-domain (SD) optical coherence tomography (OCT). Univariable and multivariable logistic analyses were performed to evaluate risk factors associated with presence of PHOMS. Among the 66 children with PHOMS, 53 (80.3%) had bilateral and 13 (19.7%) had unilateral PHOMS. The mean age of the PHOMS group was 11.7 ± 2.6 years, and that of the control group was 11.4 ± 3.1 years. The mean spherical equivalent (SE) as determined by cycloplegic refraction was -3.13 ± 1.87 diopters (D) in the PHOMS group and -0.95 ± 2.65 D in the control group. Additionally, mean astigmatism was 0.67 ± 0.89 D and 0.88 ± 1.02 D in the PHOMS group and the control group, respectively. Mean disc size was 1,735 ± 153 µm in the PHOMS group and 1,741 ± 190 µm in the control group, while mean optic nerve head (ONH) tilt angle was 9.84 ± 5.38 degrees in the PHOMS group and 3.71 ± 4.41 degrees in the control group. SE and ONH tilt angle were significantly associated with PHOMS according to both univariable [odds ratio (OR): 1.59; p < 0.001 and OR: 1.35; p < 0.001, respectively] and multivariable (OR: 1.71; p = 0.001 and OR: 1.29; p = 0.001, respectively) logistic regression analyses. There was a significant correlation between SE and ONH tilt (r = -0.46; p < 0.001). In conclusion, PHOMS is associated with myopic shift in children, and optic disc tilt may be a mediator between myopia and PHOMS.

Long-term surgical outcomes and factors for recurrence after unilateral lateral rectus muscle recession.

AIM: To evaluate long-term surgical outcomes and risk factors for recurrence after unilateral lateral rectus muscle recession (ULR) in children with small to moderate angle intermittent exotropia (IXT). METHODS: 214 patients with basic type IXT of 15-24 prism dioptres (PD) who underwent ULR were included. The main outcome measure was success rate at 2 years after surgery and at final follow-up. The risk factors related to recurrence were evaluated using univariable and multivariable logistic regression analyses. RESULTS: Success rate at postoperative 2 years was 92.5% and at final examination after a mean follow-up of 3.9 years was 83.2%. No overcorrection was observed. Preoperative exodeviation of 20-24 PD was the significant risk factor for recurrence according to both univariable (OR=3.577, p=0.022) and multivariable analysis (OR=3.265, p=0.034). CONCLUSIONS: The overall long-term successful alignment rate of ULR for 15-24 PD of IXT was good. However, patients with 20-24 PD of IXT showed worse prognosis compared with 15-19 PD of IXT.

Correlation between Extraocular Muscle Size Measured by Computed Tomography and the Vertical Angle of Deviation in Thyroid Eye Disease.

The aim of this study was to investigate extraocular muscle (EOM) volume and cross-sectional area using computed tomography (CT), and to determine the relationship between EOM size and the vertical angle of deviation in thyroid eye disease (TED). Twenty-nine TED patients (58 orbits) with vertical strabismus were enrolled in the study. All patients underwent complete ophthalmic examination including prism, alternate cover, and Krimsky tests. Orbital CT scans were also performed on each patient. Digital image analysis was used to quantify superior rectus (SR) and inferior rectus (IR) muscle cross-sectional areas and volumes. Measurements were compared with those of controls. The correlation between muscle size and degree of vertical angle deviation was evaluated. The mean vertical angle of deviation was 26.2 ± 4.1 prism diopters. The TED group had a greater maximum cross-sectional area and EOM volume in the SR and IR than the control group (all p<0.001). Area and volume of the IR were correlated with the angle of deviation, but the SR alone did not show a significant correlation. The maximum cross-sectional area and volume of [Right IR + Left SR - Right SR - Left IR] was strongly correlated with the vertical angle of deviation (P<0.001). Quantitative CT of the orbit with evaluation of the area and volume of EOMs may be helpful in anticipating and monitoring vertical strabismus in TED patients.

Surgical Responses of Medial Rectus Muscle Recession in Thyroid Eye Disease-Related Esotropia.

We evaluate the surgical outcomes and surgical responses of medial rectus muscle (MR) recession patients with thyroid eye disease (TED)-related esotropia (ET). The surgical dose-response curves 1 week postoperatively and at the final visit were analyzed. Univariable and multivariable linear regression analyses were applied to investigate factors influencing surgical dose-response. A total of 43 patients with TED-related ET that underwent MR recession were included. The final success rate was 86.0% and the rate of undercorrection was 14.0%. The surgical dose-response curves of TED-related ET showed a gentle slope compared with those of standard surgical tables. In the univariable model, simultaneous vertical rectus muscle recession was the only significant factor influencing surgical dose-response of MR recession in TED-related ET (ß = -0.397, P = 0.044). In a model adjusted for age, sex, type of surgery, and preoperative horizontal angle of deviation, simultaneous vertical rectus muscle recession showed marginal significance (ß = -0.389, P = 0.064). The surgical dose-response curve of TED-related ET was unique. Simultaneous vertical rectus muscle recession was associated with increased surgical dose-response in TED-related ET.

The Association Between Menarche and Myopia: Findings From the Korean National Health and Nutrition Examination, 2008-2012.

PURPOSE: The purpose of this study was to analyze the relationship between age at menarche and myopia in Korean adult females. METHODS: A total of 8398 women of at least 19 years of age, who participated in the Korean National Health and Nutrition Examination Survey from 2008 to 2012, underwent a refractive examination using an autorefractor. The association between age at menarche and the severity of myopia was evaluated using a four-level multinomial logistic regression analysis. RESULTS: The prevalence of myopia was 61.77% (95% confidence interval [CI], 60.46-63.08), including 40.02% with low, 15.46% with moderate, and 6.29% with high myopia. The mean age at menarche was 14.09 ± 0.03 years. Age at menarche was inversely associated with the severity of myopia. In fully adjusted models, older age at menarche decreased the risk of moderate myopia (odds ratio [OR], 0.93; 95% CI, 0.86-0.99; P = 0.0261), and high myopia (OR, 0.85; 95% CI, 0.77-0.95; P = 0.0012). CONCLUSIONS: Later age at menarche is associated with a decreased risk of moderate and high myopia. The effects of female sex hormones on ocular structures and growth spurts may mediate this relationship between age at menarche and myopia.

Risk factors associated with night vision disturbances after phakic intraocular lens implantation.

PURPOSE: To investigate the incidence and severity of night vision disturbances after implantable collamer lens surgery and to analyze the risk factors. DESIGN: Retrospective, noncomparative study. METHODS: Medical charts from 50 eyes of 25 patients who underwent implantable collamer lens implantation were retrospectively reviewed. The incidence and severity of night vision disturbances were evaluated using questionnaires administered 6 months after surgery. Univariate simple and multiple logistic regression analyses were used to detect risk factors associated with postoperative night vision disturbances. Potential risk factors included in the analysis were keratometric value, anterior chamber depth, postoperative residual refractive error, higher-order aberrations, preoperative and postoperative mesopic pupil size, the difference between preoperative and postoperative mesopic pupil size, the difference between mesopic pupil size and implantable collamer lens optic zone diameter, white-to-white diameter, sulcus-to-sulcus diameter, and postoperative implantable collamer lens vaulting. The power, size, optic zone diameter, and toricity of the implantable collamer lens were also included as variables. RESULTS: The incidence of night vision disturbances was 34.0% for halos and 26.0% for glare. Halos were found to be significantly related to the difference between mesopic pupil size and implantable collamer lens optic zone diameter (P = .013), white-to-white diameter of the cornea (P = .028), and implantable collamer lens optic zone diameter (P = .030). For glare, toricity of the implantable collamer lens was revealed as a significant risk factor (P = .047). CONCLUSIONS: Although not severe, the incidence of night vision disturbances after implantable collamer lens implantation was not negligible. Possible risk factors for night vision disturbances include implantable collamer lens optic zone diameter, the difference between mesopic pupil size and implantable collamer lens optic zone diameter, and white-to-white diameter of the cornea for causing halos, and the toricity of the implantable collamer lens for causing glare.

Conjunctival hypertrophic scar following cryotherapy for retinopathy of prematurity.

A 6-year-old boy was referred to our hospital with symblepharon and lateral canthal deformity in both eyes, which developed 6 years ago. The patient was born at 27 weeks gestation. He had received cryotherapy for retinopathy of prematurity. One month after cryotherapy, he developed a conjunctival scar with symblepharon in both eyes and underwent symblepharon lysis at another hospital 5 years prior. Ocular examination revealed an extensive conjunctival hypertrophic scar with symblepharon and limitation of extraocular movements. An excisional biopsy, lateral canthoplasty, and symblepharon lysis with conjunctival autograft from the contralateral eye were performed in the left eye. Histopathologic examination revealed diffuse proliferation and infiltration of collagenous tissue.

Phaco windmill: nondividing, nonchopping phacoemulsification technique.

We describe a nondividing, nonchopping phacoemulsification technique for nucleus removal with minimal zonular stress. It can be applied in any type of cataract surgery, regardless of nuclear color or density, as long as the anterior chamber is stabilized and properly maintained and there is sufficient followability using torsional modality. This technique uses less phacoemulsification energy, thereby avoiding zonular stress, and does not require an initial division of the nucleus, which is another advantage for beginners. The procedure is safe and easy to learn and is most advisable for beginners as it can prevent complications.