An Unusual Presentation of Neurosarcoidosis.

BACKGROUND Sarcoidosis is a systemic granulomatous disease of unknown cause, often affecting the lungs and lymphatic system. Neurologic manifestations of sarcoidosis, called "neurosarcoidosis", can present as cranial neuropathies and occur in an isolated fashion or alongside other systemic findings. These findings occur in about 5% to 15% of individuals, and mainly in women between the ages of 30 and 40 years. Within those subsets of patients who develop neurologic manifestations, ocular manifestations occur 13% to 79% of the time. Less common presentations include secondary glaucoma, intermediate or posterior inflammation, or other neuro-ophthalmic findings. CASE REPORT A 63-year-old White man initially presented with blurry vision, acute glaucoma, and other symptoms closely simulating hypertensive retinopathy. He later developed diplopia and was not accurately diagnosed by general ophthalmologists and a retina specialist. Due to the unusual presentation, hypertensive retinopathy was the incorrect initial working diagnosis and the patient continued to develop more severe symptoms. A multidisciplinary approach to patient care through a nephrology referral led to the final diagnosis of neurosarcoidosis. Prompt treatment improved renal function and ocular disturbances. CONCLUSIONS Retinal cotton-wool spots, glaucoma, and optic nerve swelling are rare presentations of neurosarcoidosis. Unusual vascular symptoms warrant consideration of all vascular diseases and prompts for collaboration through a multidisciplinary team. This case serves to highlight the importance of sarcoidosis as a differential, even in patients with no previous signs of granulomatous disease, and how a team-based approach between multiple specialties improves accuracy, timeliness, and treatment regimen.

Rasch-calibrated Intermittent Exotropia Symptom Questionnaire for Children.

SIGNIFICANCE: A rigorously designed and calibrated symptom questionnaire for childhood intermittent exotropia would be useful for clinical care and for research. PURPOSE: The aim of this study was to Rasch-calibrate and evaluate the previously developed Child Intermittent Exotropia Symptom Questionnaire using data gathered as part of a randomized clinical trial. METHODS: The questionnaire was administered to 386 children aged 3 to 10 years with intermittent exotropia who were enrolled in a randomized clinical trial comparing overminus with nonoverminus spectacles. Participants were followed at 6 and 12 months while on treatment and at 18 months off treatment. Factor analysis determined dimensionality, and Rasch analysis evaluated questionnaire performance. Logit values were converted to 0 (best) to 100 (worst). We evaluated differences in questionnaire scores between treatment groups and time points, and correlations with control scores. RESULTS: The Child Intermittent Exotropia Symptom Questionnaire was unidimensional. Rasch analysis indicated that there was no notable local dependence and no significant differential item functioning for sex or age. There was suboptimal targeting (mean logit, -1.62), and person separation was somewhat poor (0.95). There were no significant differences in the Child Intermittent Exotropia Symptom score between overminus spectacles and nonoverminus spectacles at 6, 12, and 18 months. Combining data from both treatment groups, there was significant improvement from baseline at all follow-up visits (e.g., mean change from baseline to 12 months, -6.6 points; 95% confidence interval, -8.6 to -4.6). Child Intermittent Exotropia Symptom scores were not correlated with distance or near control scores at 12 months. CONCLUSIONS: The seven-item Rasch-scored Child Intermittent Exotropia Symptom Questionnaire is limited by suboptimal performance. Future study is needed to determine whether it may be useful for clinical practice and for research.

A Rare Case of Tubulointerstitial Nephritis and Uveitis Syndrome Treated with a Multi-Specialty Approach.

BACKGROUND It is important for an ophthalmologist and nephrologist to look for hidden causes of uveitis and nephritis, respectively. Delay in diagnosis leads to increased morbidity and failure to systemically manage the patient results in future recurrence of disease. It is likely that TINU remains underdiagnosed and could potentially account for some of the cases of idiopathic uveitis, especially when greater than 50% of uveitis cases have no identifiable cause. Fewer than 300 cases of tubulointerstitial nephritis and uveitis (TINU) syndrome have been reported. In TINU syndrome, inflammation affects the renal tubules, interstitial tissue, and uveal tract. Its pathogenesis remains poorly understood. CASE REPORT We report a rare case of TINU syndrome in a 23-year-old female who was treated using a multispecialty approach. Her primary care physician diagnosed her with proteinuria and acute kidney injury and referred her to the nephrologist, who later referred her to the ophthalmologist. A left kidney biopsy confirmed acute interstitial nephritis. Following the discovery of a "pink eye", the patient was referred to ophthalmology and diagnosed with anterior uveitis, confirming TINU syndrome. Without the additional findings of uveitis, the diagnosis would have been missed. Resolution was obtained through steroid therapy. CONCLUSIONS Correctly diagnosing TINU syndrome requires a multispecialty approach and may not be obvious upon initial presentation. Therefore, the ophthalmologist needs to consider TINU in the differential diagnosis for a patient with bilateral uveitis and evaluate a urinalysis for proteinuria as part of the work up.

Effect of strabismus surgery on the reading ability of school-age children.

AIM: To evaluate if strabismus surgery on children between the ages 5 and 14 years leads to an improvement in reading ability by comparing reading performance of patients before and after surgery. METHODS: Pre- and postoperatively, the visual acuity, ocular alignment, and stereoacuity of 15 children with horizontal strabismus was recorded. The "3-Minute Reading Assessments: Word Recognition, Fluency, and Comprehension" for the appropriate age-group were used to assess children between the ages of 5 and 14 years. Thirteen of the 15 children presented with esotropic deviation, and the remaining 2 were exotropic. RESULTS: Postoperatively, 12 patients were orthophoric and 3 had significant residual esotropia. The 15 patients had an average improvement in reading speed (10.3 words per minute), accuracy (4%), and fluency (2 points). For the 12 orthophoric patients, reading speed increased by 12.2 (P = .003), accuracy by 3% (P = .064), and fluency by 1.33 (P = .006). CONCLUSION: Corrective strabismus surgery in school-age children showed an early improvement in reading ability that could translate into better academic performance. Our results suggest that reading ability could be an important factor when considering corrective surgery for children with strabismus.