The intersection of ophthalmology and neurology: Diagnosing acute strokes through visual symptoms.

PURPOSE: To document how acute cerebrovascular accidents (CVAs) present first to an ophthalmologist. METHODS: Retrospective, observational, unicentric hospital-based study. The electronic medical records of new patients who presented to the Neuro-ophthalmology department of a tertiary eye hospital in the month of August 2022 were reviewed. Those with symptoms suggestive of an acute stroke requiring urgent neuroimaging were chosen for further study. RESULTS: Out of the 710 new patients, 31 had a known CVA and presented with field defects (4.3%). We recognized nine new patients, subsequently diagnosed to have a CVA, initially presenting with ocular symptoms such as homonymous hemianopia in seven cases and two others as transient obscuration of vision and internuclear ophthalmoplegia. CONCLUSION: Posterior circulation strokes commonly present first to an ophthalmologist, the early recognition of which is of utmost importance.

Lethal mycotic pseudoaneurysm presenting as isolated sixth nerve palsy.

Pseudoaneurysm of the internal carotid artery caused by skull base osteomyelitis (SBO) is a lethal condition seen in immunocompromised patients, predominantly those with diabetes mellitus. Cranial nerve involvement is a common complication and generally indicates a poor prognosis. We report the case of a 62-year-old diabetic patient who presented with isolated sixth cranial nerve palsy. She had uncontrolled blood sugar levels and high erythrocyte sedimentation rate, and she suffered from pyelonephritis. Neuroimaging detected SBO with multiple secondary mycotic pseudoaneurysms prominent at the petrocavernous junction. Ischemia is the most common etiology for an isolated abducens nerve palsy, but in certain cases neuroimaging is warranted to prevent life-threatening complications. This case highlights the importance and urgency of identifying and managing such conditions.

Comparison of glaucomatous from non-glaucomatous optic neuropathy using Bruch's membrane opening minimum rim width optical coherence tomography measurements.

Purpose: To compare glaucomatous from non-glaucomatous optic atrophy using optical coherence tomography (OCT) based on the measurement values of Bruch's membrane opening minimum rim width (BMO-MRW), which is a difficult task otherwise due to their varied course of disease progression, treatment protocols, and systemic association to visual impairment. Methods: This study was conducted in 40 eyes, comprising 20 eyes with non-glaucomatous optic neuropathy (NGON) and 20 eyes with glaucomatous optic neuropathy (GON). All patients underwent a complete ophthalmic examination followed by an OCT optic disc scan to calculate the measurement of BMO-MRW. Results: The 5-fold cross-validated area under the curve for GON versus NGON from logistic regression models was 0.95 (95% confidence interval [CI]: 0.86-1.00) using BMO-MRW values from all sectors. The results revealed that the measurements were significantly lesser in GON than in NGON patients. Conclusion: Hence, OCT-based BMO-MRW values could be used as an additional test to compare glaucomatous with non-glaucomatous optic neuropathy patients, especially in cases of high clinical suspicion.

Invasive Fungal Sinusitis in Patients With Coronavirus Disease 2019 Seen in South India.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has a vast array of presentations and associations with neuro-ophthalmic diseases. There has been a recent surge in ophthalmic manifestations secondary to fungal sinus infections in India especially in diabetic patients who were given systemic steroids. We present our COVID-19-related cranial neuropathies presenting in our clinic. METHODS: This is a retrospective case series of 10 patients affected with COVID-19 disease and who presented with cranial nerve palsies at the neuro-ophthalmic department of a tertiary eye care hospital in South India. An analysis of electronic medical records data was performed, including their comorbidities, symptoms, cranial nerves involved, ocular and neuroimaging findings, site of lesion, etiology, and prognosis. RESULTS: Most of the patients (7 of 10) presented with multiple cranial nerve palsies (MCNP) with poor visual acuity. 2 of the 10 cases succumbed to death due to the intracranial involvement. All MCNP cases had uncontrolled diabetes with a history of systemic steroids, and neuroimaging of these cases showed sinusitis of varying severity most of which were suggestive of fungal invasive type. CONCLUSION: Our study emphasizes the need to screen for fungal involvement in COVID-19 cases presenting with MCNP especially on diabetic patients on systemic steroids so that an early diagnosis may reduce visual loss and mortality. Physicians treating COVID-19 cases need to be aware of this dreadful complication.

Assessment of retinal manifestations of Parkinson's disease using spectral domain optical coherence tomography: A study in Indian eyes.

PURPOSE: To assess the retinal manifestations of Parkinson's disease using optical coherence tomography. METHODS: A prospective case-control study comparing 30 eyes from 15 patients with Parkinson's disease and 22 eyes from 11 healthy age-matched controls. Total macular subfield thickness and the thickness of the ganglion cell layer, nerve fiber layer, and peripapillary retinal nerve fiber layer were measured with spectral-domain optical coherence tomography (SD-OCT). RESULTS: The mean age of PD patients was 68.4 years ± 10.64 (range: 46-82) and in the control group was 66.36 ± 5.22 (range: 64-68). The average disease duration in patients with PD was 6.7 ± 2.8 years (range: 2-10 years). The mean best-corrected visual acuity in PD was 20/26 and 20/20 in controls, with P = 0.0059, which was significant. Significant difference was also found in the contrast sensitivity between both groups. Structural differences in the central macular thickness (P = 0.0001), subfield thicknesses in the superior (P = 0.003), inferior (P = 0.001), nasal (P = 0.004), and temporal subfields (P = 0.017) was seen. Severe thinning of the ganglion cell layer was seen in PD patients (P = 0.000) as well as of the nerve fiber layer (P = 0.004). Peripapillary retinal nerve fiber thickness measured showed significant thinning in superotemporal (P = 0.000), superonasal (P = 0.04), inferonasal (P = 0.000), inferotemporal (P = 0.000), nasal (P = 0.000), and temporal quadrants (P = 0.000). CONCLUSION: Visual dysfunction was observed in patients with PD along with structural alterations on OCT, which included macular volumes, ganglion cell layer, and peripapillary retinal nerve fiber layer.

Isolated Compressive Sixth Nerve Palsy due to Multiple Intracranial Cavernomas.

Cavernomas or cavernous malformations are the most common clinically significant vascular anomalies, accounting for 8-15% of all brain and spinal vascular malformations. While there are several articles in the literature on cavernomas, most cases report haemorrhage from these lesions as the cause of cranial nerve palsies. We report a rare case of multiple intracranial cavernomas in the brain and pons causing an isolated compressive sixth nerve palsy.

Optic Neuritis During Lactation: A Case Series.

BACKGROUND: Optic neuritis is a rare condition that can lead to sudden blindness and also could be a precursor to multiple sclerosis. When it occurs postpartum during lactation, it is called lactation optic neuritis. MAIN ISSUE: We present four cases of optic neuritis in lactating mothers, two of which had additional features of demyelinating disease upon neurological imaging. MANAGEMENT: All participants were treated with high dose intravenous steroids followed by 11 days of oral steroids, per the optic neuritis treatment trial, which led to complete recovery of vision. Two participants with demyelinating disease on magnetic resonance imaging scans were advised to wean, because of a need for immunosuppressive therapy later. CONCLUSION: Optic neuritis during lactation should be suspected following acute loss of vision. Prompt referral to an ophthalmologist is mandated for early diagnosis and treatment to prevent long-term co-morbidities.

Diplopia as the presenting feature of acute lymphoblastic leukemia.

PURPOSE: To report a rare case of acute lymphoblastic leukemia presenting with diplopia to an ophthalmologist. OBSERVATIONS: A 29-year-old male patient presented to ophthalmology department with sudden onset of binocular diplopia in left gaze. Magnetic resonance imaging of brain and orbits revealed a thickened left medial rectus, with enhancement of right sixth nerve, bilateral third and fifth nerves. Bone marrow biopsy revealed acute lymphoblastic leukemia (ALL) with a Burkitt-type chromosomal translocation-t(8; 14) and the patient was started on chemotherapy. CONCLUSION AND IMPORTANCE: This was a case of incomitant esotropia worse with left gaze due to left medial rectus infiltration mimicking a left sixth cranial nerve paresis. Diplopia can be the only presenting symptom of ALL and it can involve either an extraocular muscle or a cranial nerve.

Bilateral vertical gaze palsy due to midbrain infarct associated with iron deficiency anemia in a young boy.

An 8-year-old boy presented with complaints of sudden-onset binocular vertical diplopia of one day duration. Ophthalmic examination showed restricted up- and downgaze movement with rotatory nystagmus. Systemic investigations revealed iron-deficiency anemia and localized acute infarct in the left paramedian rostral and dorsal part of the upper midbrain at the level of the red nucleus on magnetic resonance imaging. The patient was started on oral iron supplement, which resulted in symptomatic as well as clinical improvement after 2 weeks.