Toxic optic neuropathy associated with lamotrigine and levetiracetam dual therapy.

We report the case of an early adolescent male on lamotrigine and levetiracetam therapy with a 1-month history of progressive, bilateral, painless visual loss which resolved on cessation of lamotrigine. To our knowledge, we present the first case of lamotrigine and levetiracetam dual therapy associated with toxic optic neuropathy, supported by electrophysiology and optical coherence tomography (OCT) changes. Electrophysiology findings were consistent with retinal ganglion cell dysfunction, with bilateral optic nerve involvement. Macula OCT showed mild retinal ganglion cell loss in all inner quadrants bilaterally. This case highlights the importance of asking patients with epilepsy treated with lamotrigine and levetiracetam about visual problems and considering early dose reduction or cessation of treatment.

Can Visual Acuity Be Reliably Measured at Home? Validation of Telemedicine Remote Computerised Visual Acuity Measurements.

PURPOSE: The recent pandemic has identified the need for telemedicine assessment of ophthalmology patients. A vital component of such assessment is visual acuity (VA) measurement. The aim of this study was to determine the feasibility and reliability of computerised 'at home' VA measurements using COMPlog software. METHODS: A Bland Altman method comparison study of worse eye 'in clinic' and 'at home' orthoptist-supervised COMPlog computerised VA measurements. Subjects underwent gold standard semi-automated computerised test and retest logMAR VA measurements on their habitually corrected worse eye both 'in clinic' and 'at home.' The orthoptist ran the test from the eye clinic with the patient viewing a secondary PC monitor either in the same clinic room or at home. A screen sharing voice and video conferencing application and standard consumer IT hardware were employed to present the test optotypes in the patient's home. RESULTS: 23 paediatric and 13 adult patients with a range of ocular diseases and worse eye visual acuities were included (range -0.14 to 1.06 logMAR). No significant bias was found between 'in clinic' and 'at home' measurements (mean -0.01 logMAR and 95% confidence interval -0.03, 0.00 logMAR). Test-retest variability of 'in clinic,' 'at home' and 'in clinic' versus 'at home' measurements were within normal reported ranges at 0.12 logMAR (6 ETDRS letters) or less. CONCLUSION: Remote home VA testing performed by an eye care professional using a semi-automated VA measurement program and video conferencing application provided unbiased measurements with acceptable test-retest reliability. Home testing was both feasible and acceptably reliable in appropriately equipped patients.

Idiopathic Hypertrophic Pachymeningitis: Does Earlier Treatment Improve Outcome?

Background/goal: Hypertrophic pachymeningitis is a rare chronic inflammatory disorder characterized by marked fibrous thickening of the cerebral and/or spinal dura mater. This condition has largely been reported in adults, but there are very few reports in children. METHODS: We describe a 14-year-old boy with idiopathic hypertrophic pachymeningitis, who presented with deteriorating vision on a background of severe headache. We evaluated pediatric cases of hypertrophic pachymeningitis and compared treatments and their relation to outcomes. RESULTS: There are only eleven pediatric cases of hypertrophic pachymeningitis reported in the literature. In the patients treated with steroids either at presentation or subsequent relapses, a good response was reported. In the cases with delayed initiation of steroid treatment, this was often related to an incomplete recovery. In our patient, this delay may have contributed to his poor visual outcome. CONCLUSIONS: Early initiation of steroid treatment in children with idiopathic hypertrophic pachymeningitis may improve outcomes.

The incidence and clinical outcome of complications in 4,000 consecutive strabismus operations.

PURPOSE: To test the validity of the British Ophthalmic Surveillance Unit (BOSU) study's incidence figure of severe complications following strabismus surgery and to determine the incidence, type, risk factors, and outcome of all strabismus surgery complications at a single institution. METHODS: A prospective audit of consecutive strabismus operations performed by consultants or trainees was carried out between 2011 and 2016 at Moorfields Eye Hospital NHS Foundation Trust. Patient diagnosis, age, sex, surgical details, complications, and outcome were recorded from hospital records. We classified complications as minor, moderate, or severe. The outcome was graded using the Bradbury and Taylor grading system (I to IV), with a poor or very poor outcome meaning loss of corrected visual acuity or unexpected primary position diplopia. RESULTS: A total of 4,076 consecutive strabismus operations were performed during the study period. There were 46 (1.13%) complications, of which 28 (0.69%) were minor, 7 (0.17%) were moderate, and 9 (0.22%) were severe. Only 1 patient (0.02%) had a poor visual outcome. Two patients had nonocular postoperative complications (0.05%). CONCLUSIONS: In this large, prospective series, we found the rate of severe complications of strabismus surgery to be 1 in 455 cases. Our results validate the findings of the BOSU study.

Using Nonechoplanar Diffusion-weighted MRI to Assess Treatment Response in Active Graves Orbitopathy: A Novel Approach with 2 Case Reports.

Two patients (68 and 71 years, both female) with sight threatening, active Graves orbitopathy but low clinical activity score underwent MRI scans before and after intravenous corticosteroid treatment. Two MRI techniques, short-term inversion recovery and nonechoplanar diffusion-weighted imaging, were used. Apparent diffusion coefficient values reduced in patient 1 who had successful medical treatment and remained elevated in patient 2 who had an inadequate treatment response. Nonechoplanar diffusion-weighted imaging provided a quantitative measure of treatment response by calculation of the apparent diffusion coefficient. The novel use of nonechoplanar diffusion-weighted imaging for monitoring treatment response in Graves orbitopathy is illustrated but requires further validation.

The psychological impact of strabismus: does the angle really matter?

INTRODUCTION: The psychological impact of strabismus is well recognized. Patients with strabismus have lower levels of psychological well being compared to normal controls. Few studies have evaluated the relationship between levels of psychological distress and the angle of deviation, age, sex, presence of diplopia, visual acuity and direction of deviation. METHODS: 50 patients with strabismus who attended the adult strabismus clinic were included in this questionnaire based prospective study. The Psychological Impact questionnaire was used to assess the psychological impact of noticeable strabismus. We measured the angle of deviation, age, sex, presence of diplopia, visual acuity and direction of deviation and correlated these with psychological impact scores. Student's t-test and Pearson's correlation coefficient (r) were used in statistical analysis. RESULTS: The average age was 48 years (range 15-84) and there were 26 females and 24 males. There was no correlation between psychological impact score and the maximum degree of horizontal deviation r = 0.02 (95% CI -0.26 to 0.29), p = 0.9, the maximum angle of vertical deviation r = 0.26 (95% CI -0.01 to 0.51), p = 0.06, age r = -0.09 (95% CI -0.36 to 0.19), p = 0.5, sex (p = 0.96), presence of diplopia (p = 0.6), visual acuity of the worse eye r = -0.01 (95% CI -0.29 to 0.27), p = 0.9 and direction of deviation (p = 0.8 for eso-deviations compared to exo-deviations, p = 0.4 for horizontal compared to vertical deviations). There was a slight negative correlation between psychological impact score and visual acuity of the better eye r = -0.28 (95% CI -0.52 to -0.01), p = 0.04. CONCLUSION: The psychological impact of strabismus does not appear to be related to the patient's angle of deviation, age, sex, presence of diplopia, visual acuity or direction of deviation. Larger studies are required using strabismus specific tools for evaluating psychological impact to further investigate these findings.