Successful Management of Acute Streptococcal Meningoencephalitis Complicated by Bilateral Third-Nerve Palsies, Wall-Eyed Bilateral Internuclear Ophthalmoplegia, Blindness, and Deafness: Case Report.

Introduction: Streptococcal meningoencephalitis (SME) is a rare, and frequently lethal, acute infection, and inflammation of the central nervous system parenchyma, with associated meningeal involvement. Bacterial meningoencephalitis is generally associated with high rates of morbidity and mortality, despite available antimicrobial and corticosteroid treatments. While Streptococcus pneumoniae is well recognised to cause bacterial meningitis, direct extension into the central nervous system parenchyma is rare. Case Presentation: A previously well 49-year-old man presented with sudden onset severe headache, fevers, neck stiffness, and reduced consciousness. The manifestations of SME in this patient were bilateral pupil-involving third-nerve palsies, wall-eyed bilateral internuclear ophthalmoplegia (WEBINO), bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs in his limbs. Initially, a partial response to high dose intravenous antibiotics occurred, but with administration of intravenous corticosteroids, further substantial resolution of the patient's neurological and neuro-ophthalmological deficits occurred. Conclusion: This case highlights the benefit of multidisciplinary diagnostic and therapeutic interventions in a case of SME complicated by bilateral pupil-involving third-nerve palsies, WEBINO, bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs. It appears to be the first reported case of SME with this rare collection of neuro-ophthalmological abnormalities.

Recovery From Homonymous Hemianopia in Hyperglycemia-Induced Occipital Lobe Electroclinical Seizures Following Glycemic Control.

BACKGROUND: Visual changes due to hyperglycemia in diabetes are not uncommon. While blurred vision is a well-established sequela of chronic hyperglycemia, homonymous hemianopia with or without electroclinical seizures is much rarer and can be mistaken for migraine, temporal arteritis, or ischemia of the central nervous system. METHODS: This article analyzed case studies for 3 patients (67M, 68M, 52F) presenting with complex visual phenomena, from 3 to 42 days duration, including pathogenesis, clinical findings, management, and follow-up. RESULTS: Examinations demonstrated dense left homonymous hemianopias in 2 patients and a left inferior homonymous quadrantanopia in one, with no other abnormalities. Patients described vivid, nonstereotyped intermittent hallucinations in the affected fields. Blood glucose levels ranged from 13.5 to 35.0 mmol/L (243-630 mg/dL) without ketosis and HbA1c from 14.6% to 16.8%. Computed tomography of the brain showed no acute intracranial pathology. MRI of the brain either detected no abnormalities or demonstrated changes consistent with seizure activity. Electroencephalogram (EEG) demonstrated seizures over the right occipital region in each patient. EEG seizures coincided with patients' hallucinations, while they remained otherwise conscious. Oral hypoglycemic and antiepileptic medications were commenced with rapid and complete reversal of the seizures and visual field deficits, confirmed by repeat Automated 30-2 and MRI. CONCLUSIONS: Hyperglycemia-induced occipital lobe seizures with visual hallucinations and interictal homonymous visual field defects represent a rare but clinically important diagnosis. This article highlights the importance of prompt recognition and treatment to facilitate recovery.

Temporal arteritis presenting with facial swelling and a negative temporal artery biopsy.

A man in his 60s presented to the emergency department with marked bilateral preauricular swelling, associated with jaw claudication, temporal tenderness and blurred vision. He was immediately treated for temporal arteritis by commencing systemic corticosteroids. A temporal artery biopsy showed no evidence of vasculitis. However, positron emission tomography-CT demonstrated increased uptake in the medium-large vessels, including the left superficial temporal artery and aorta. This case illustrates that facial swelling may be an under-recognised presenting feature of temporal arteritis, and that a negative temporal artery biopsy does not always rule out a diagnosis of temporal arteritis, and should not delay treatment.

Lacrimal gland sinus generated by a retained cilium: case report and literature review.

Lacrimal gland stone(s) (LGSs) are rare and usually asymptomatic. LGSs should be distinguished from dacryoliths, as the former arise in the lacrimal gland. The aetiology of LGSs in many cases is likely related to a reaction to a hair within the palpebral lobe of lacrimal gland. Eye rubbing may contribute to the migration of the hair into the lacrimal gland. This case report describes the rare occurrence of an LGS with a central hair shaft (cilium) and associated sinus formation in a 39-year-old male presenting with persistent redness of, and discharge from the right eye for 4 weeks. Examination revealed a sinus opening onto the inferonasal surface of the palpebral lobe of the right lacrimal gland. The patient was treated with surgical excision of the sinus, with rapid and complete resolution of his symptoms.

Acute angle closure glaucoma misdiagnosed as sinusitis.

A 69-year-old woman developed severe right suprabulbar pain with blurred right-sided vision. There were no haloes around lights, photophobia, nausea or vomiting. Investigations in the emergency department excluded a posterior communicating/internal carotid artery aneurysm. However, she did not have an ophthalmological assessment and the initial diagnosis was of sinusitis-related headache. An urgent ear, nose and throat assessment found no abnormality, but a local ophthalmologist subsequently diagnosed and managed the patient's acute angle closure crisis. Periocular pain always deserves detailed assessment with an accurate history, visual acuity assessment and intraocular pressure measurement.

Spontaneous Extrusion of a Conjunctivolith Containing Herpes Virus Confirmed by Electron Microscopy and Energy Dispersive Spectroscopy.

: This report describes the spontaneous extrusion from between the eyelids of a presumed conjunctivolith in a patient with resolving severe herpes zoster ophthalmicus. A 57-year-old man presented for ophthalmologic assessment and management due to severe left herpes zoster ophthalmicus. At one subsequent ophthalmologic assessment, a conjunctivolith spontaneously egressed the lateral commissure of the OS when the lateral fornix was inspected. The conjunctivolith was retrieved from the floor of the consulting room. Electron microscopic analysis and energy dispersive spectroscopy was undertaken to determine its composition. Scanning electron microscopy showed that the conjunctivolith was composed of carbon, calcium, and oxygen. Transmission electron microscopy diagnosed Herpes virus within the conjunctivolith. Conjunctivoliths, or possible lacrimal gland stones, are a very rare phenomenon, and their etiology is currently unclear. In this case, there was likely to have been an association between herpes zoster ophthalmicus and the conjunctivolith.

Efficacy of patient-sided breath shields for slit-lamp examination.

OBJECTIVE: To evaluate the efficacy of patient-sided breath shields in preventing oronasal droplet transmission during slit-lamp examination. DESIGN: Experimental study testing the efficacy of patient-sided breath shields on a slit lamp. METHODS: Two commercially available patient-sided breath shields and a 3-dimensional (3D)-printed shield designed by the authors were attached to a slit-lamp chin rest for testing. Each shield was exposed to 3 standardized sprays of coloured dye from a spray gun with its nozzle adjusted to simulate the angular dispersion of a human sneeze. Any overspray not blocked by the shields was recorded and compared with spray with no shield (control). Image-processing software was used to ascertain the surface area of overspray not blocked by the tested shield compared with the control of no shield. RESULTS: With typical use, both commercially available patient-sided shields and the 3D-printed shield blocked 100% of forward-travelling measurable droplets from a simulated sneeze spray. Even when set to the furthest distance setting to simulate the worst-case scenario, shield 1 and the 3D-printed shield blocked 99.96% and 99.65% of overspray, respectively. However, slow-motion footage did reveal that a considerable amount of spray rebounded off the shields and extended peripherally past its borders. CONCLUSIONS: With typical use, all tested shields prevented 100% of oronasal transmission. To encourage accessibility, the authors offer a free 3D model and instructions for creating the tested patient-sided breath shield. Patient-sided shields should be combined with other infection-control measures to minimize transmission.

Practising refraction in ophthalmology: instructive or outdated? A prospective study and literature review.

CLINICAL RELEVANCE: Many ophthalmologists preform clinical refactions, although little is known of the perceptions and practise of refraction by ophthalmologists and key barriers preventing this aspect of ophthalmic practice. BACKGROUND: Although there are numerous studies on visual acuity in ophthalmology, there is no study to date on the practice of refraction by ophthalmologists. This study evaluates the practice patterns of ophthalmologists in current practice. It specifically addresses perceptions of ophthalmologists about (a) the importance of refraction in clinical practice, and (b) barriers to performing refraction. The methodology and frequency of performing refraction by ophthalmologists is also assessed. METHODS: This cross-sectional study was conducted at the Annual Scientific Congress of the Royal Australian and New Zealand College of ophthalmologists in 2017, held in Perth, Australia. All attending ophthalmologists and ophthalmology trainees were invited to participate. Participants completed a 17-variable questionnaire on the perceptions of practitioners about refraction and their practice of it. Data were analysed using Microsoft Excel and IBM SPSS Version 24. RESULTS: At this Congress, 213 attendees completed the survey, with most being consultant general ophthalmologists (85%). Twenty-six percent of participants either 'really loved' or 'liked' refracting patients. Those who reported feeling competent with refraction were more likely to perform it themselves (p = 0.001). Individuals most commonly reported taking 3-5 minutes to refract a patient (38%). Participants under the age of 65, and participants practising paediatric ophthalmology, were more likely to perform a refraction. CONCLUSIONS: The literature indicates that this is the first study to describe the practice patterns of refraction by ophthalmologists. Although ophthalmologists found refraction important, the majority preferred patients to be refracted by others. Key barriers to ophthalmologists performing refraction included the time required to perform the refraction, a busy clinic, and the availability of alternative providers.

Apparent Defective Abduction Without Diplopia.

Sixth nerve palsies present with horizontal diplopia and typically have a neurological or neurovascular aetiology. They can be confirmed by clinically evaluating the velocity of the abducting saccade, which is slowed. Three cases are presented in which the patients had apparent defective abduction of one eye, resulting from not only neurological causes but also orbital causes. Clinicians should have a high index of suspicion in patients with defective abduction without diplopia and should include apparent defective abduction without diplopia (ADAD) in the list of potential differential diagnoses, considering not only neurological involvement but also orbital involvement.

5-Fluorouracil in primary, impending recurrent and recurrent pterygium: Systematic review of the efficacy and safety of a surgical adjuvant and intralesional antimetabolite.

Pterygium is an ultraviolet-related disease characterized by an aberrant, wing-shaped and active wound-healing process. There is nothing quite as disheartening for the surgeon or patient as the recurrence of pterygium, and various adjuvants have been studied to ameliorate this. This systematic review provides a comprehensive summary of the efficacy and safety of 5-Fluorouracil (5-FU) as an antimetabolite agent for pterygium management. An appraisal of electronic searches of six databases identified 34 clinical studies reporting recurrence outcomes of 5-FU use in primary, impending recurrent and recurrent pterygia. In vitro and in vivo studies of 5-FU showed dose- and duration-dependent cytostatic and cytotoxic effects in human cells. 5-FU is relatively inexpensive, available, and easy to administer, making it attractive for resource-limited scenarios. However, the published evidence demonstrates a recurrence rate of 11.4-60% with the bare scleral technique, 3.5-35.8% with conjunctival rotational flaps, 3.7-9.6% with conjunctival autografts for intraoperative topical 5-FU, and 14-35.8% for preoperative and intraoperative injections. This suboptimal efficacy brings the role of 5-FU as an adjuvant for pterygium surgery into question and the authors do not recommend its use. In contrast, postoperative intralesional injections of 5-FU to arrest progression in impending recurrent pterygium and true recurrent pterygia were more promising, with success rates of 87.2-100% and 75-100%, respectively. Furthermore, 5-FU as a treatment modality, without surgery, effectively arrested progression in 81.3-96% of primary and recurrent pterygia. Other treatments such as topical and intralesional corticosteroids, cyclosporine and anti-VEGF agents are discussed. Complications of 5-FU increase with higher doses and range from transient and reversible to severe and sight-threatening. For pterygium, 5-FU has a predilection for causing scleral thinning, corneal toxicity, and graft-related complications. Additional study with extended follow-up is needed to elucidate the optimal dose, frequency, duration, and long-term safety of 5-FU injections. If 5-FU is used in the management of pterygium, it should be with caution, in selected patients and with vigilant long-term monitoring.