Neuro-Ophthalmologic Features and Outcomes of Thalamic Infarction: A Single-Institutional 10-Year Experience.

BACKGROUND: Neuro-ophthalmologic deficit after thalamic infarction has been of great concern to ophthalmologists because of its debilitating impacts on patients' daily living. We aimed to describe the visual and oculomotor features of thalamic infarction and to delineate clinical outcomes and prognostic factors of the oculomotor deficits from an ophthalmologic point of view. METHODS: Clinical and neuroimaging data of all participants were retrospectively reviewed. Among the 12,755 patients with first-ever ischemic stroke, who were registered in our Stroke Data Bank between January 2009 and December 2018, 342 were found to have acute thalamic infarcts on MRI, from whom we identified the patients exhibiting neuro-ophthalmologic manifestations including visual, oculomotor, pupillary, and eyelid anomalies. RESULTS: Forty (11.7%) of the 342 patients with thalamic infarction demonstrated neuro-ophthalmologic manifestations, consisting of vertical gaze palsy (n = 19), skew deviation with an invariable hypotropia of the contralesional eye (n = 18), third nerve palsy (n = 11), pseudoabducens palsy (n = 9), visual field defects (n = 7), and other anomalies such as isolated ptosis and miosis (n = 7). Paramedian infarct was the most predominant lesion of neuro-ophthalmologic significance, accounting for 84.8% (n = 28) of all patients sharing the oculomotor features. Although most of the patients with oculomotor abnormalities rapidly improved without sequelae, 6 (18.2%) patients showed permanent oculomotor deficits. Common clinical features of patients with permanent oculomotor deficits included the following: no improvement within 3 months, combined upgaze and downgaze palsy, and the involvement of the paramedian tegmentum of the rostral midbrain. CONCLUSIONS: Thalamic infarction, especially in paramedian territory, can cause a wide variety of neuro-ophthalmologic manifestations, including vertical gaze palsy, skew deviation, and third nerve palsy. Although most oculomotor abnormalities resolve spontaneously within a few months, some may persist for years when the deficits remain unimproved for more than 3 months after stroke.

CENTRAL RETINAL VEIN OCCLUSION IN YOUNG PATIENTS: Clinical Characteristics and Prognostic Factors.

PURPOSE: To investigate the clinical characteristics and prognostic factors of young patients with central retinal vein occlusion (CRVO). METHODS: This retrospective cohort study involved treatment-naïve patients with CRVO. Medical records regarding basic demographics, predisposing factors, ocular characteristics, and treatments were reviewed and compared according to age at CRVO onset. RESULTS: We enrolled 263 patients, of whom 69 were younger patients. Younger patients had higher prevalence of nontraditional risk factors including physical or psychological stress (P = 0.032), hematologic abnormalities (P = 0.003), and better visual acuity at baseline and last visit (all P < 0.001) and were unlikely to undergo intravitreal injections (47.8 vs. 68.6%, P < 0.001) during follow-up. Younger patients had higher prevalence of paracentral acute middle maculopathy (28.1 vs. 4.7%, P < 0.001). Older age (odds ratio = 1.165, P = 0.028), male sex (odds ratio = 7.074, P = 0.034), coexisting renal disease (odds ratio = 7.845, P = 0.050), and poor baseline visual acuity (odds ratio = 16.069, P = 0.002) were significant risk factors for poor visual outcomes in young CRVO patients. CONCLUSION: Younger CRVO patients had a milder clinical course with fewer treatments and were more likely to have nontraditional risk factors than older patients.

Reconstruction of Large Upper Eyelid Defects Using the Reverse Hughes Flap Combined With a Sandwich Graft of an Acellular Dermal Matrix.

PURPOSE: To investigate the usefulness of the reverse Hughes flap procedure combined with a sandwich graft of an acellular dermal matrix for reconstruction of large full-thickness defects of upper eyelids after cancer excision. METHODS: Clinical data were obtained from patients who underwent upper eyelid reconstruction using a reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix (AlloDerm) as a tarsal substitute. The tarsoconjunctival flap of the donor lower eyelid was mobilized to reconstruct the posterior lamella, and acellular dermal matrix was grafted onto the tarsoconjunctival flap. A skin-orbicularis muscle flap superior to the defect was advanced to cover the acellular dermal matrix graft, followed by application of lid crease formation sutures to prevent postoperative entropion. The tarsoconjunctival pedicle was divided 3-8 weeks after the surgery. RESULTS: Six patients with sebaceous carcinoma were included, and all had ≥70% full-thickness upper eyelid defects after tumor excision. After a median follow-up of 40 months (range 6-62 months), all 6 showed satisfactory functional and cosmetic outcomes. Tumor recurrence, exposure keratopathy, upper eyelid entropion, persistent use of bandage contact lenses, lower eyelid deformity, and dermal matrix-related complications were not observed by the last follow-up. CONCLUSIONS: Reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix as a tarsal substitute was successful in reconstructing large upper eyelid defects. Acellular dermal matrix graft and lid crease formation sutures enhance marginal stability and prevent postoperative entropion of the reconstructed upper eyelid.

Relationship Between Optical Coherence Tomography Angiography Peripapillary Vessel Density and Lamina Cribrosa Depth.

PRéCIS:: Peripapillary vessel density (pVD) assessed by optical coherence tomography angiography (OCT-A) has poor global and regional correlations with lamina cribrosa depth (LCD), except for the inferotemporal area. PURPOSE: To investigate the global and regional relationship between the pVD assessed by OCT-A and LCD assessed by enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT). METHODS: A total of 38 eyes of 38 healthy subjects and 38 eyes of 38 glaucoma patients were included. Peripapillary microvasculature and lamina cribrosa were imaged by OCT-A and enhanced depth imaging SD-OCT, respectively. The pVD and LCD were measured at temporal, superotemporal, superonasal, nasal, inferonasal, and inferotemporal sectors. Global and regional correlations between pVD and LCD were evaluated in all subjects. RESULTS: The pVD (59.0±2.6 vs. 54.4±5.4%) and LCD (318.5±76.4 vs. 404.6±92.5 µm) were significantly different between healthy and glaucoma subjects. The average pVD assessed by OCT-A was not significantly correlated with average LCD assessed by SD-OCT (r=-0.160, P=0.167). Regional correlation between pVD and LCD was statistically significant only in the inferotemporal sector (r=-0.301 and P=0.008). In the linear regression analysis, reduced pVD was independently associated with decreased visual field mean deviation and peripapillary retinal nerve fiber layer thickness but not with increased LCD. CONCLUSIONS: Global and regional correlations between pVD and LCD were poor except for the inferotemporal sector. This finding suggests that peripapillary microvascular impairment may not result directly from posterior lamina cribrosa displacement.

Deep Anterior Lamellar Keratoplasty in a Case of Hurler-Scheie Syndrome Undergoing Enzyme Replacement Therapy.

PURPOSE: To report successful management of corneal clouding associated with Hurler-Scheie syndrome with deep anterior lamellar keratoplasty (DALK) undergoing concurrent enzyme replacement therapy (ERT). METHODS: A 13-year-old boy with Hurler-Scheie syndrome (MPS I-HS) presented with corneal clouding in both eyes. He was on ERT with laronidase (Aldurazyme; Genzyme, Cambridge, MA) and had a visual acuity of 20/32 in both eyes. Seven years later, visual acuity in his left eye decreased to counting fingers and DALK was performed for vision recovery. Two years later, visual acuity in his right eye decreased to 20/100 and DALK was performed. RESULTS: At his last visit, which was 3 years after right eye DALK and 5 years after left eye DALK, the grafts were clear and the corrected visual acuity in his right and left eyes was 20/30 and 20/25, respectively. CONCLUSIONS: The present case highlights the possible effectiveness of DALK in patients with mucopolysaccharidosis (MPS)-related corneal stromal opacification, treated with ERT.