Assessment of the relationship between structural and functional tests in patients with idiopathic intracranial hypertension.

PURPOSE: To assess the relationship between structural and functional tests in mild and moderate idiopathic intracranial hypertension (IIH). METHODS: Patients with mild and moderate IIH and a control group were enrolled. Best-corrected visual acuity (BCVA), macular ganglion cell layer (MGCL) thickness, peripapillary retinal nerve fiber layer (pp RNFL) thickness, perimetric mean deviation (MD), and photopic negative responses (PhNR) of the electroretinogram were recorded. The associations between structural (pp RNFL and MGCL thickness) and functional (PhNR amplitude, MD and BCVA) parameters were assessed. RESULTS: 154 eyes from 78 subjects (74 eyes from IIH patients and 80 eyes from healthy subjects) were included in this comparative observational study. The MGCL thickness, VA, pp RNFL, and PhNR base-to-trough (BT) amplitude were significantly worse in moderate IIH. The BCVA and MD were associated with MGCL thickness only in moderate IIH. The relationship between MD and MGCL thickness started when MD fell below -5.7 dB. CONCLUSIONS: The association between functional and structural parameters varies between mild and moderate IIH. The MD and MGCL thickness outperformed in assessing disease severity in mild and moderate IIH, respectively. The association between MD and MGCL thickness could be considered in IIH severity categorization.

Long-Term Results of Oral Propranolol Treatment Protocol for Periocular Infantile Hemangioma: Should There Be Any Contraindication?

PURPOSE: The authors report long-term results of the oral propranolol treatment protocol for periocular infantile hemangioma regardless of conventional indications. METHODS: This is a retrospective study (2008-2018) on children with propranolol treatment protocol for periocular infantile hemangioma and last follow-up (FU) of ≥4 months after treatment and age of >24 months. After systemic evaluation, it was started with 0.5 and increased by 0.5 every 3 days to reach 2 mg/kg/day. If there was no good response, it would be gradually increased up to 3 mg/kg/day. Tapering (0.5 mg/kg/day every 4 weeks) was started when patients were on treatment for ≥6 months and ≥12 months old and there was no change in the infantile hemangioma size for ≥3 months. Rebound growth was based on the parents' report and would be treated by increasing the dose to at least 2 mg/kg/day for 3 months. FU was either in-person or via social media. Change in periocular infantile hemangioma size on the photos was scored by 3 masked observers (visual analog scale) and presented as excellent (≥50% reduction), good (1%-49%), fair (no change), and failure (enlarged). RESULTS: Forty-three patients were included. Orbital involvement was in 49%, ptosis in 58%, and risk of amblyopia in 63%. Mean treatment, tapering, and FU duration were 37, 13, and 74 months, respectively. Mean age at presentation, start of propranolol treatment protocol, tapering, stop, and last FU were 1.5, 5, 29, 42, and 78 months, respectively. Twenty-seven patients received 2, seven 2.5, and nine 3 mg/kg/day. Mean visual analog scale significantly increased from 43% (FU1) to 92% (last FU) when 97.6% of patients showed an excellent response. The remaining skin lesions were observed in 35%. No side effect was reported. CONCLUSIONS: Long-term results of the propranolol treatment protocol for periocular infantile hemangioma showed an excellent response in 97.6% of patients with no side effects. A residual skin lesion was observed in 1/3 of the patient.

NONARTERITIC ANTERIOR ISCHEMIC OPTIC NEUROPATHY ASSOCIATED WITH IPSILATERAL HYPOPLASTIC INTERNAL CAROTID ARTERY.

BACKGROUND: Vascular insufficiency of the optic nerve head is the cause of nonarteritic ischemic optic neuropathy (NAION). Carotid artery abnormalities are now considered as a predisposing factor for developing NAION. In this report, we present a case of NAION associated with ipsilateral internal carotid artery hypoplasia. METHODS: A 69-year-old female with decreased vision in her right eye due to NAION was evaluated. the magnetic resonance imaging showed a considerably smaller left internal carotid artery than the right side. The magnetic resonance angiography confirmed the disparity and perfusion abnormalities of intracranial carotid arteries. RESULTS: The diagnosis of left internal carotid artery hypoplasia was made and verified by depicting a left side small carotid canal on the computed tomography scan. CONCLUSION: This report suggests that internal carotid artery hypoplasia could be associated with NAION.

Challenges and Pitfalls in the Management of Rhino-Orbital Mucormycosis in Ophthalmology: A Highlighted Problem in the COVID-19 Era.

Secondary infections in hospitalized and ill patients with coronavirus disease 2019 (COVID-19) are common. One of these life-threatening infectious diseases is rhino-orbital mucormycosis, which made an outbreak recently. This outbreak was mainly caused by the administration of high-dose corticosteroids in patients with COVID-19, especially those with diabetes mellitus. The increased incidence of rhino-orbital mucormycosis in the COVID-19 era presents different challenges for healthcare providers including ophthalmologists who are directly involved in disease management. We summarized the main challenges and recommendations for ophthalmologists on the management of rhino-orbital mucormycosis.

Anterior and posterior ischemic optic neuropathy following liposuction surgery in a previously healthy young woman.

A previously healthy 28-year-old female developed bilateral painless vision loss, more prominent in the right eye than in the left, following abdominoplasty and liposuction surgery. Laboratory studies showed severe peri- and post-operative anemia. Over a 5-month follow-up, visual function remained decreased but stable in the right eye and improved in the left eye. This is the second reported case of anterior ischemic optic neuropathy in one eye and posterior ischemic optic neuropathy in the other eye after liposuction.Level of evidence: Level VI, case report study.

Superior ophthalmic vein thrombosis following coil embolization of posterior communicating artery aneurysm: Report of two cases.

INTRODUCTION: The purpose was to present two patients with superior ophthalmic vein thrombosis following coil embolization of posterior communicating artery aneurysm, that have not been reported after this particular procedure yet. METHODS: We present two patients with subarachnoid hemorrhage due to posterior communicating artery aneurysms, who were treated with stent-assisted coil embolization. Shortly after the procedure, both cases demonstrated painful proptosis, ophthalmoplegia, increased intraocular pressure, intraretinal hemorrhage and macular edema on the ipsilateral side, with congestion of intraorbital tissues and thickened and dilated superior ophthalmic vein in neuroimaging investigation. The occlusion was confirmed by digital subtraction angiography. RESULTS: Patients were treated with anticoagulant agents and systemic corticosteroids immediately and then received medical treatment by an ophthalmologist for ocular complications of superior ophthalmic vein thrombosis. CONCLUSION: Isolated superior ophthalmic vein thrombosis (SOVT) is rare, but may be associated with sight-threatening complications. After intracranial interventions on cerebral vessels, clinical features of SOVT including choroidal effusion syndrome should be investigated, and the patients should receive prompt and proper care including ophthalmic medications and systemic anticoagulants to restrict the ocular and systemic complications.

Necrosis of the optic nerve and chiasm with safe radiation doses: Report of two rare cases.

INTRODUCTION: Radiation-induced optic neuropathy (RION) is still a devastating complication of brain and skull base radiation that has no effective treatment up until today, thus uttermost caution must be taken in treating patients that brain radiotherapy is needed. We present two cases of RION that happened in seemingly safe radiation doses. CASE DESCRIPTION: A 48-year-old female with a history of pleomorphic pituitary adenoma developed bilateral and painless loss of vision 10 months after radiation to the brain; the total radiation dose was 45 Gy in 25 fractions and no other risk factors of RION were found. Magnetic resonance imaging of the brain depicted bilateral prechiasmatic optic nerve enhancement with involvement of the optic chiasm. Treatment with high doses of corticosteroids was unsuccessful. A 62-year-old female with a history of lung adenocarcinoma and brain metastases presented with a 1-month history of decreased vision in both eyes. He had undergone whole-brain radiotherapy with a total dose of 30 Gy over 10 fractions and concurrent chemotherapy with cisplatin and pemetrexed. Brain magnetic resonance imaging (MRI) with contrast showed bilateral intracranial optic nerve enhancement. CONCLUSIONS: This is the second case report of RION in a patient with a history of brain radiotherapy and concurrent chemotherapy with pemetrexed. History of chiasmal compression, concurrent use of chemotherapeutic agents, and high fraction size (despite the safety of total radiation dose) were possible contributing risk factors to develop RION in our cases. Hence, adjusting the radiation dose according to the presence of these risk factors is recommended.

Conversion Rate of Web-based Versus Non-web-based Patient Referral Sources in a Facial Plastic Surgery Practice.

PURPOSE: To compare the conversion rate (number of procedures/referrals) of web-based and non-web-based referrals to a facial plastic surgery practice (2012-2019). METHOD: Data on demographics, referral source, patient's concern, and their facial procedures were recorded. Web-based referral sources include website and Instagram. Non-web-based counterparts were the word-of-mouth, medical professionals, and others (TV, radio, printed media). Patient concerns were either cosmetic or noncosmetic (functional). Patients who underwent facial cosmetic surgery and injections (botulinum toxin A, filler, fat) were categorized in the cosmetic procedure group. Patients with functional procedures with or without facial injections were categorized in the noncosmetic procedure group. The conversion rate was defined as the ratio of the number of referrals with different facial procedures to the total number of referrals. RESULTS: Included were 19,965 patients, majority of whom (63.3%) had cosmetic concern. Total, cosmetic, and noncosmetic conversion rates were 30.1%, 27.7%, and 2.4% for the web-based and 24.1%, 19.8%, and 4.3% for the non-web-based referrals, respectively (0.3 < p < 0.4). Cosmetic conversion rate grew from 6.7% in referrals ≤20 to more than 23% in >20 years of age (p = 0.03). It was also significantly (p < 0.001) higher in the referrals with cosmetic (28.3%) than noncosmetic (12.1%) concern. Gender and year of practice did not have a significant effect on the conversion rates. CONCLUSION: Conversion rates were not significantly different between the web-based and non-web-based referrals. A significantly higher cosmetic conversion rate was observed for the referrals with cosmetic concern and older than 20 years.

Anterior Ischaemic Optic Neuropathy following Liposuction in a Patient with Optic Disc Drusen.

Ischaemic optic neuropathy (ION) following non-ocular surgeries is a rare but devastating complication. Spine and cardiovascular surgical procedures are well known to be accompanied by this complication. ION after liposuction surgery is gaining attention during the past decades due to the escalating demand for this procedure. We report a case of unilateral anterior ION (AION) after abdominoplasty and liposuction in an eye with optic disc drusen (ODD), which has not been reported previously. The presence of ODD is not only an independent risk factor for AION in young patients, but could also be the underlying cause of the ischaemic insult to the optic nerve head in haemodynamically unstable patients.

Unilateral and Spontaneous Complete Anterior Dislocation of the Crystalline Lens in a Patient With Homocystinuria.

Homocystinuria is a metabolic disorder caused by a deficiency of cystathionine beta-synthase with autosomal recessive inheritance. Clinically it is characterized by lens subluxation, skeletal abnormalities, and thromboembolic accidents. We present a 6-year-old boy who was a known case of homocystinuria. The patient had a previous history of thrombotic cerebrovascular infarction at the age of 3. He had mild and vague pain in the left eye two weeks before presentation without being exposed to trauma. Ophthalmic examination revealed the dislocation of the crystalline lens into the anterior chamber with diffuse corneal stromal edema in the affected eye. The patient was treated with topical atropine and betamethasone eye drops, but due to the corneo-lenticular contact and corneal edema, he underwent lens extraction and placement of iris-fixated intraocular lens after 48 hours. Corneal edema exhibited improvement at follow-up visits. Early age onset and unilateral complete lens dislocation to the anterior chamber in the absence of a history of trauma is a less common presentation of homocystinuria. In patients with systemic diseases including homocystinuria that cause zonulysis, lens dislocation is usually symmetric and bilateral. Nevertheless, in unilateral cases especially in those who did not have any history of trauma, evaluation for systemic diseases like homocystinuria is necessary for early diagnosis and prevention from other systemic involvements.

Overminus Lens Therapy in the Management of Children with Intermittent Exotropia.

PURPOSE: To evaluate the results of overminus lens therapy in the management of children with intermittent exotropia or X(T). METHODS: In this retrospective study, 163 consecutive patients with X(T) who were treated with overminus spectacles with at least 12 months of follow-up were included in the study. The outcome measures were the level of X(T) control evaluated using the Jampolsky's qualitative assessment method and refractive error changes under overminus lens treatment. RESULTS: The mean angle of deviation at the initial visit was 24.7 ± 15.1 prism diopters (PD) that improved to 10.6 ± 4.2 PD with overminus glasses with a median follow-up of 38 months (P = 0.02). One hundred and nine patients (66.8%) achieved good controlled X(T) or orthotropia by overminus lens therapy after 1 year. Three patients progressed to esotropia, which disappeared after discontinuing overminus lens therapy. Overminus lens therapy did not have a statistically significant effect on the mean spherical equivalent of cycloplegic refraction in each eye (right eye: P = 0.13; left eye: P = 0.15). CONCLUSIONS: Overminus lens therapy can be effective for improving the control of X(T) in young children. It can defer the requirement for surgery or decrease the rate of surgical intervention.

Optical Coherence Tomography Angiography and Structural Analyses of the Pale Optic Discs: Is It Possible to Differentiate the Cause?

Introduction: To compare the optic nerve head (ONH) structure and microvasculature in patients with optic atrophy due to non-arteritic anterior ischemic optic neuropathy (NAION), compressive optic neuropathy (CON), methanol-induced optic neuropathy (MION), and traumatic optic neuropathy (TON) using optical coherence tomography angiography.Methods: In this comparative, cross-sectional study, 32 eyes with NAION, 18 eyes with CON, 32 eyes with MION, 23 eyes with TON, and 55 normal eyes were enrolled. Radial peripapillary capillary (RPC) vessel density, peripapillary retinal nerve fiber layer (RNFL) thickness, disc area, cup volume, and cup/disc area ratio were obtained using the RTVue XR Avanti system (Optovue Inc., Fremont, CA, USA).Results: RPC vessel density and peripapillary RNFL thickness in all patients were significantly lower than normal subjects. A positive correlation was found between the RPC vessel density and peripapillary RNFL thickness in normal subjects and all study groups. The positive correlation between the inside and outside disc RPC vessel density was only found in the NAION (r = 0.36, P = .042) and MION (r = 0.42, P = .018) groups. No significant difference was found among the groups in terms of peripapillary and inside disc vascular densities (all P > .05). Disc area and cup volume in patients with MION was larger than the values in patients with NAION (P = .018) and TON (P = .044) and normal subjects (P = .015). The discriminating features among the study groups were the larger cup volume and cup/disc area ratio in patients with MION, and lower RNFL thickness in patients with TON.Conclusions: There was a positive correlation between the RNFL thickness and peripapillary RPC vessel density regardless of the cause of optic disc pallor. Structural evaluation of the ONH seems to be a better way to differentiate the cause of optic nerve head atrophy than the microangiographic changes.

The Impacts of Episcleral Plaque Brachytherapy on Ocular Motility.

Background: To investigate the effect of various factors on ocular motility disturbance after episcleral plaque brachytherapy with Ruthenium 106 (106Ru).Methods: Twenty consecutive patients who underwent plaque brachytherapy for all types of intraocular tumors were included in this interventional prospective case series. Ruthenium-106 was used with a mean total dose of 93.2 ± 21.2 Gy toward the tumor apex. Full orthoptic examinations were performed before and after the surgery.Results: The average follow-up time was 6 months (range: 4-9 months). Two (10%) out of 20 patients developed exotropia. The mean age of patients without strabismus was higher than the patients with strabismus (49.8 ± 10.7 years compared to 23 ± 4.2 years, respectively) (p = .011). Strabismus was observed in the patients who had tumors with larger apical diameters (7.6 ± 2 mm compared to 4.1 ± 0.9 mm, respectively) (p = .021). The mean radiation dose to the tumor base in the group with strabismus was higher than the group without motility disturbance (1046.5 ± 604.1 Gy compared to 384.3 ± 175.3, respectively) (p = .021). Most tumors were located in the inferotemporal fundus (30%), followed by supratemporal location (25%), supranasal (10%), and macular region (10%). A higher percentage of patients with postoperative strabismus underwent muscle manipulation compared to the patients who did not develop this complication (100% compared to 38.9%).Conclusion: Manipulation of the extraocular muscles, high doses of radiation, and low vision could cause strabismus after episcleral plaque brachytherapy.

Intravitreal Injection Of The Granulocyte-Colony Stimulating Factor For The Treatment Of Non-Arteritic Anterior Ischemic Optic Neuropathy: A Pilot Study.

Purpose To investigate the efficacy of intravitreal injection of granulocyte colony-stimulating factor (G-CSF) for the treatment of non-arteritic anterior ischemic optic neuropathy (NAION).Methods: Patients with acute NAION were enrolled in this prospective interventional case series. They received an intravitreal injection of 60 micrograms in 0.1 ml of G-CSF within 2 weeks of the onset of the disease. Visual acuity, visual field, intraocular pressure (IOP), corneal endothelial cell density, and peripapillary retinal nerve fiber layer (RNFL) thickness were recorded before injections and 1 week, 1 month, 3 months, 6 months, and one year after the injections. Full-field electroretinography (ERG) was obtained at the baseline, 1 month, and 12 months post- injections.Results: Fourteen eyes of 14 patients entered the study. Best-corrected visual acuity (BCVA) significantly improved in the first month following injections (p = .007), decreased subsequently, and the final BCVA showed no significant improvement (p = .278) compared to the baseline measurements. A significant decrease in RNFL thickness was observed in all quadrants compared to the baseline measurements. Also, no improvement in the visual field parameters was observed. From the toxicity aspect, no significant changes in the corneal endothelial cell density, IOP, and ERG recordings were observed.Conclusion: Intravitreal injection of G-CSF seems to be safe. The effect may last for one month and then decline.

A novel decision tree approach to predict the probability of conversion to multiple sclerosis in Iranian patients with optic neuritis.

BACKGROUND: assessing the risk of conversion to multiple sclerosis (MS) in patients with optic neuritis (ON) has been the topic of numerous studies. However, since the risk factors differ from population to population, the extension of conclusions is a matter of debate. This study focused on the Iranian patients with optic neuritis and assessed the probability of conversion to multiple sclerosis by using a machine-based learning decision tree. METHODS: in this retrospective, observational study the medical records of patients with optic neuritis from 2008 to 2018 were reviewed. Baseline vision, the treatment modality, magnetic resonance imaging (MRI) findings, and patients' demographics were gathered to evaluate the odds of each factor for conversion to MS. The decision tree was then obtained from these data based on their specificity and sensitivity to predict the probability of conversion to MS. RESULTS: the overall conversion rate to MS was 42.2% (117/277). 63.1 percent of patients had abnormal MRIs at baseline. The presence of white matter plaque had the highest odds for the conversion followed by the positive history of optic neuritis attack and gender. The regression tree showed that the presence of plaque was the most important predicting factor that increased the probability of conversion from 16 to 51 percent. CONCLUSION: the decision tree could predict the probability of conversion to MS by considering multiple risk factors with acceptable precision.

Choroidal thickness after phacoemulsification: nonrandomized comparison of postoperative topical ketorolac vs dexamethasone vs combination of ketorolac-dexamethasone eyedrops.

PURPOSE: To compare the effect of topical dexamethasone vs ketorolac vs combined dexamethasone-ketorolac after phacoemulsification on choroidal thickness (CT). SETTING: Tertiary university-based hospital. DESIGN: Prospective nonrandomized comparative case series. METHODS: Ninety-two eyes of 92 patients were assigned to the 3 groups after uneventful phacoemulsification: Group 1, dexamethasone; Group 2, ketorolac; Group 3, combined dexamethasone-ketorolac applied topically. CT at subfoveal (SFCT), nasal, and temporal as primary and central retinal thickness (CRT) as secondary outcomes were measured preoperatively and at 1 month, 3 months, and 6 months postoperatively using enhanced depth-imaging optical coherence tomography. RESULTS: Preoperative CT was similar between the groups (all P > .05). The groups differed in pattern of changes in nasal and temporal CT (both P < .001) although their changes of CRT (P = .13) and SFCT (P = .55) over time were similar. The mean of SFCT at 1 month, 3 months, and 6 months was significantly higher than baseline in dexamethasone (P < .001 for all follow-ups) and combined (P < .001 for both 1 month and 3 months and P = .03 for 6 months) groups, whereas it was not statistically significant in the ketorolac group (P = .07). There was an increase in the nasal and temporal CT in 3 groups, persisted at 6 months in dexamethasone (both P < .001) and ketorolac (both P < .001) groups, whereas the change was not statistically significant at 6 months in the combined group. Choroidal thickness measurements were performed in 31 eyes of 31 patients in group 1, 29 eyes of 29 patients in group 2, and 32 eyes of 32 patients in group 3. CONCLUSIONS: Dexamethasone and combined groups had statistically significant changes of SFCT after phacoemulsification; however, the ketorolac group did not. The pattern of SFCT changes was similar between 3 groups.

Bilateral Optic Disc Edema in a Patient with Lead Poisoning.

PURPOSE: Heavy metals, such as lead can cause optic neuropathy. Optic disc neuropathy due to lead intoxication has previously been reported. We report a rare case of lead toxicity-induced optic neuropathy presenting with bilateral hemorrhagic optic disc swelling. CASE REPORT: The patient was a 42-year-old man with a history of chronic oral opium use, who had a gradually progressing blurred vision in both eyes over 40 days, with ataxia, paresthesia, and a toxic level of serum lead. He had been treated with lead chelators for lead poisoning. His color vision was impaired in both eyes. Humphrey's visual field test revealed double arcuate scotoma with enlargement of the blind spot. Funduscopy revealed bilateral optic disc swelling, which was confirmed on optical coherence tomography and fluorescein angiography. CONCLUSION: In cases of optic disc edema, a comprehensive history should be taken to detect the cause. Further, in cases of chronic oral opium use, lead toxicity should be considered.