Acute Myopic Shift after a Single Dose of Acetazolamide: A Case Report and Review of the Literature.

We report the case of a 32-year-old male who presented with an acute myopic shift as a result of uveal effusion following a single administration of 250 mg acetazolamide. The drug was discontinued and following cycloplegia and topical steroid therapy, we observed progressive deepening of the anterior chamber, reopening of the iridocorneal angle, and complete resolution of the myopic shift after 5 days. A literature review since 1956 identified 23 cases, including ours, which developed a myopic shift after a median time of 24 h (3 - 24) following a median dose of 500 mg (125 - 1000) acetazolamide, with about a third complicated by angle closure ocular hypertension. This presumed idiosyncratic reaction can occur without prior drug exposure and independent of the phakic status. Treatment options include systematic drug withdrawal associated with cycloplegia, anti-glaucomatous agents, and/or corticosteroids. Full recovery is achieved within about 5 days (2 - 14). Given the widespread use of acetazolamide, awareness of this idiosyncratic reaction is crucial to avoid complications of acute angle-closure glaucoma.

Postoperative anterior uveitis in a patient submitted to combined treatment with cataract surgery and iStent inject®. How to manage? / Uveíte anterior no pós-operatório de facectomia combinada com implante de iStent inject®. Como manejar?

ABSTRACT Minimally invasive glaucoma surgeries are surgical treatment alternatives for glaucoma aimed at reducing intraocular pressure with a better safety profile compared to traditional trabeculectomy. However, in spite of less invasive techniques, complications may develop in any surgical procedure. To the best of our knowledge, this is the first case report of anterior uveitis following combined treatment with cataract surgery and iStent inject® which addresses the management of postoperative inflammation.

RESUMO As cirurgias minimamente invasivas para glaucoma consistem em uma opção de tratamento cirúrgico para glaucoma, a qual promove redução da pressão intraocular com melhor perfil de segurança do que a trabeculectomia. Todavia, complicações são inerentes à realização de procedimentos cirúrgicos, apesar do uso de técnicas menos invasivas. Este é o primeiro relato que apresenta um caso de uveíte anterior após cirurgia combinada de catarata e iStent inject®, além de orientações quanto ao manejo do quadro inflamatório.

Pediatric Intracranial Hypertension: A Spotlight on Imaging, the Idiopathic Intracranial Hypertension Treatment Trial, and COVID-19 Associated Cases.

Primary intracranial hypertension (PIH) is characterized by clinical signs of increased intracranial pressure, papilledema, elevated opening pressure, and absence of mass lesion, hydrocephalus, or meningeal enhancement on neuroimaging. Visual changes are a common presenting feature and if untreated there is risk of irreversible vision loss. There have been recent proposed changes to the criteria for PIH along with studies looking at the differences in imaging characteristics between adult and pediatric PIH. The presence of transverse sinus stenosis alone was highly sensitive and specific for pediatric PIH. The Idiopathic Intracranial Hypertension Treatment Trial was an adult, multicenter study that examined the use of acetazolamide and weight loss on the course of PIH. The study confirmed many previously held beliefs including the most common presenting symptom in PIH is headache. Most patients present with bilateral papilledema with 58.2% of patients having symmetric Frisen scale grading and within one grade in 92.8%. Although diplopia is a common reported symptom, very few have evidence of cranial nerve palsy. Male gender, high-grade papilledema, and decreased visual acuity at presentation are risk factors for treatment failure. Acetazolamide use is associated with mild metabolic acidosis. During acetazolamide treatment, monitoring for hypokalemia or aplastic anemia is not recommended. Monitoring transaminases in the titration phase of treatment should be considered due to a case of transaminitis and pancreatitis with elevated lipase. Newer case reports have also seen associations of secondary intracranial hypertension with concurrent COVID-19 infection and MIS-C.

Iris metastasis as the initial presentation of metastatic esophageal cancer diagnosed by fine needle aspiration biopsy: A case report.

RATIONALE: Metastasis of neoplasms to the eye is quite uncommon. In this case report, we describe a patient where primary esophageal cancer was diagnosed by fine needle aspiration biopsy (FNAB) of an iris tumor. PATIENT CONCERNS: A 70-year-old male complained of redness and discomfort in the right eye. DIAGNOSIS AND INTERVENTIONS: The patient's right eye was diagnosed as idiopathic uveitis, and a topical steroid was administered. As vitreous opacities were observed even after topical therapy, oral prednisolone was administered. On slit-lamp examination of the right eye, an iris mass with neovascularization was seen in the anterior chamber. A metastatic tumor was suspected, and FNAB was performed. Histology revealed squamous cell carcinoma. Systemic workup revealed esophageal cancer with several metastases. Best-corrected visual acuity decreased to 20/400, and intraocular pressure was 40 mmHg in the right eye. Two iris tumors with neovascularization were present extending into the anterior chamber with posterior iris synechiae and 360 degree peripheral anterior synechiae. Intraocular pressure in the right eye was medically managed with hypotensive eye drops and oral acetazolamide. Iris metastases were treated with 40 Gray of radiation therapy and concurrent chemotherapy. OUTCOMES: The tumor regressed, but intraocular pressure was refractory to treatment because of 360 degree goniosynechial closure. The right eye lost light perception six months after treatment commenced, and the patient died 9 months after the onset of therapy due to multiple systemic metastases. LESSONS: This is a rare case of masquerade syndrome without systemic symptoms in which FNAB of an iris tumor led to a diagnosis of metastatic esophageal squamous cell carcinoma. Although the patient lost his sight due to uncontrollable ocular hypertension, systemic chemotherapy, and radiation therapy were initially effective in the treatment of the metastatic iris tumor. As the prognosis of patients with metastatic iris tumors is poor, it is important for ophthalmologists to consider such diagnoses and conduct systemic investigations when necessary.

Oral acetazolamide for intraocular pressure lowering: balancing efficacy and safety in ophthalmic practice.

Introduction: Systemic acetazolamide is an efficacious adjunct to topical therapy to lower intraocular pressure (IOP) in glaucomatous eyes. This article aims to provide a comprehensive review for how best to use the agent in ophthalmic practice.Areas covered: This article will review the history, mechanism of action, methods of observing efficacy, indications for IOP lowering, side effects, allergy information including discussion of limited cross-reactivity between antimicrobial and non-antimicrobial sulfonamides, formulations, dosing and monitoring of acetazolamide. To select articles for this review, an electronic search was conducted using the PubMed database and cross-referencing was conducted for relevant literature.Expert opinion: The benefits of oral carbonic anhydrase inhibitor therapy can outweigh the risks in many circumstances. It is important that eye care practitioners work together with a patient's primary care practitioner to monitor for and mitigate risks. Greater education is needed with regard to the allergy profile of these powerful agents. Though not often a first-line option, oral carbonic anhydrase inhibitors remain pivotal and play in important role in delivery of eye care.

Assessment of cerebrovascular reserve with N-isopropyl-p-[123I]-iodoamphetamine time series analysis in patients with cerebrovascular disease.

ABSTRACT: Using N-isopropyl-p-[123I]-iodoamphetamine(123I-IMP) and single-photon emission computed tomography (SPECT), the relationship between cerebrovascular reserve and the 123I-IMP redistribution phenomenon was investigated.The 50 patients who matched the inclusion criteria were divided into control and ischemia groups, and the redistribution phenomenon was examined on resting images. The delayed images showed higher 123I-IMP accumulation in lesions in the middle cerebral artery(MCA) area and anterior cerebral artery(ACA) area, these watershed areas in the ischemia group than in the control group, confirming that the redistribution phenomenon exists with statistical significance (Wilcoxon test; control group vs ischemic group in the ACA area[P = .002], ACA-MCA watershed area(P = .014), MCA area(P = .025), and MCA-posterior cerebral artery(PCA) watershed area(P = .002). The patients were then divided into 4 types according to the Kuroda grading system, and the difference in the redistribution phenomenon was investigated between type III and the other 3 types.Compared with type I and type II, type III had a significantly lower rate of decrease in the radioisotope (RI) count, verifying the redistribution phenomenon (Student t test: type I vs type III in the ACA area(P = .008), ACA-MCA watershed area(P = .009), MCA area(P < .001), and MCA-PCA watershed area(P = .002); type II vs type III in the ACA area(P = .004), ACA-MCA watershed area(P = .2575), MCA area(P < .001), and MCA-PCA watershed area(P < .001). No significant difference between type III and type IV was observed in any area [(Student t test: type III vs type IV in the ACA area(P = .07), ACA-MCA watershed area(P = .38), MCA area(P = .05), and MCA-PCA watershed area(P = .24)].The redistribution phenomenon is associated with resting cerebral blood flow (CBF), but not necessarily with cerebral vascular reactivity (CVR).

Acetazolamida enmascara un tumor hipofisario bajo el diagnóstico de migraña vestibular / Acetazolamide conceals a pituitary macroadenoma in a patient with criteria of vestibular migraine

No disponible

An Expedited Intracranial Pressure Monitoring Protocol Following Spontaneous CSF Leak Repair.

OBJECTIVE: Spontaneous cerebrospinal fluid (CSF) leaks represent a unique subset of skull base pathology and require distinctive management. Perioperative evaluation and management of intracranial hypertension are essential in preventing further erosion of the skull base and development of recurrent leak. The objective of this study is to evaluate the safety and utility of an expedited protocol for recording and managing intracranial hypertension following endoscopic repair of spontaneous CSF leaks. METHODS: Prospectively collected data was reviewed in patients undergoing endoscopic repair of spontaneous CSF leaks between January 2017 and March 2020. A standard intracranial pressure monitoring protocol was compared to an expedited protocol (EP), and data regarding the two groups was compared for leak location, short-term success of skull base repair, complications, hospital length of stay, and cost-based analysis. RESULTS: Fifty-five patients (standard protocol, n = 28 vs. EP, n = 27) were included in the study. Leak location was similar between cohorts, with the lateral recess being the most common locations in both groups (37.9% vs. 40.6%; P = .90). Postoperative complications (3.6% vs. 7.4%; P = .53) and ventriculoperitoneal shunt rate (32.1% vs. 22.2%; P = .41) were similar among cohorts. There was no difference in lumbar drain complications (0% vs. 7.4%; P = .14) or recurrent leak (7.1% vs. 0%; P = .16). Length of stay was shorter in the EP group [median(interquartile range): 3(1) vs. 2 (1); P < .01]. Total hospital charges were similar between groups (median (USD/$1,000): 83.57 ± 49.58 vs. 83.93 ± 46.11; P = .18). CONCLUSION: An expedited monitoring protocol shortened hospital stay without increased risk of complications. LEVEL OF EVIDENCE: III Laryngoscope, 131:E408-E412, 2021.

Morbidity Among Athletes Presenting for Medical Care During 3 Iterations of an Ultratrail Race in the Himalayas.

INTRODUCTION: Although ultratrail races are increasing in popularity, there is a dearth of data regarding illnesses and medical care at these events. Data about injuries and illnesses for races taking place in the Himalayas, where the nearest medical facility can be hundreds of miles away, are even harder to find. This study aimed to describe the injuries and illnesses befalling the participants of a 7-stage 212 km (132 mi) trail race at high altitude. METHODS: Ethical approval was obtained from Nepal Research Health Council. A retrospective study of the record of medical encounters among the 100 participants competing in the Manaslu trail race in Nepal from 2014 to 2016 was performed. Diagnoses were classified into various categories. Informed consent was taken from all participants. RESULTS: Acute diarrhea was the most common ailment reported among the participants (18%), followed closely by musculoskeletal problems (17%). Altitude illness made up 6% of care provided. Approximately 35% of the athletes were using acetazolamide as prophylaxis for high altitude illnesses. The 1 case needing evacuation in the 3 iterations was high altitude pulmonary edema. CONCLUSIONS: Ultratrail races at high altitude pose a challenge in terms of provision of medical care in a remote setting with limited resources. However, most of the illnesses are minor in nature and easily managed by the race doctor. Knowledge of common illnesses among travelers to the area can help aid in preparation and provision of proper care, especially in remote settings with limited resources.

Central retinal artery occlusion from Streptococcus gallolyticus endocarditis.

Central retinal artery occlusion (CRAO) is a rare but blinding disorder. We present a case of a 81-year-old woman with multiple cardiovascular comorbidities admitted to the emergency department due to sudden, painless vision loss on left eye (oculus sinister (OS)) on awakening. The patient also reported long standing fatigue associated with effort that started 4 months before admission. She presented best corrected visual acuity of counting fingers OS. Funduscopy OS revealed macular oedema with cherry red spot pattern. Blood cultures came positive for Streptococcus gallolyticus in the context of a bacteremia and native mitral valve vegetation identified on transoesophageal echocardiography. CRAO of embolic origin was admitted in the context of an infective endocarditis. CRAO can be the first manifestation of a potentially fatal systemic condition and thus multidisciplinary approach is warranted with close collaboration between ophthalmologists and internists in order to provide proper management and the best possible treatment.

Polypeptide and glycosaminoglycan polysaccharide as stabilizing polymers in nanocrystals for a safe ocular hypotensive effect.

Improved ocular delivery of a poorly soluble anti-glaucoma drug, acetazolamide (ACZ), in a stable nanosuspension (NS) was the main target of the study. The anionic polypeptide, poly-γ-glutamic acid (PG) and the glycosaminoglycan, hyaluronic acid, were used to stabilize ACZ-NS prepared using the antisolvent precipitation (AS-PT) coupled with sonication technique. To endue in site biocompatibility with high tolerability, soya lecithin (SL) phospholipid has been also combined with polyvinyl alcohol (PVA). NS with uniform PS in the range 100-300 nm, high ζ > ±20 mV, and enhanced saturation solubility were produced. Targeting solvent removal with control on future particle growth, post-production processing of NS was done using spray drying. The carriers' composition and amount relative to ACZ-NS were optimized to allow for the production of a redispersible dry crystalline powder. Particles crystallinity was confirmed using X-ray powder diffraction (XRPD) and differential scanning calorimetry (DSC) in liquid and spray dried NS. The modified Draize test proved the safety and tolerability following application to rabbit eyes accompanying an efficient ocular hypotensive activity using a steroid glaucoma model.

Antipsychotic pitfalls: idiopathic intracranial hypertension and antipsychotic-induced weight gain.

Idiopathic intracranial hypertension (IIH) is a condition associated with poor vision and headaches that can cause disability and reduced quality of life. The onset of IIH is typically associated with sudden weight gain and obesity, which may be due to first-generation or second-generation antipsychotics. This case involved the use of quetiapine in an obese, 28-year-old woman; she gained significant weight after starting the antipsychotic and later developed headaches and blurred vision. Reducing quetiapine and administering acetazolamide significantly improved her symptoms within 4 weeks. This case reminds physicians to consider IIH as a cause of headache and vision loss in patients who have gained weight after starting or increasing quetiapine.

Chemotherapy associated dural sinus thrombosis presenting as a cerebrospinal fluid leak.

Despite the well documented increased risk of thrombosis in patients with cancer and during chemotherapy, cerebral venous sinus thrombosis (CVT) remains a rare entity. We present a rare case of cerebrospinal fluid (CSF) rhinorrhoea secondary to a left transverse sinus thrombus which occurred 2 years previously during chemotherapy for breast cancer. The patient underwent a three-layer repair using Neuro-Patch, septal cartilage and middle turbinate pedicle flap and was started on acetazolamide. There was no recurrence at 1-year follow-up. Raised intracranial pressure secondary to cerebral venous occlusion can erode the base of skull and predispose to CSF leaks. Despite the theoretical risk, there have been no cases reported where CSF leaks have occurred following chemotherapy induced CVT. We describe the first case and discuss pathophysiology and management.

A Randomized Controlled Trial of the Lowest Effective Dose of Acetazolamide for Acute Mountain Sickness Prevention.

BACKGROUND: Acetazolamide is the most common medication used for acute mountain sickness prevention, with speculation that a reduced dose may be as efficacious as standard dosing with fewer side effects. METHODS: This double-blind, randomized, controlled noninferiority trial compared acetazolamide 62.5 mg twice daily to the standard dose acetazolamide 125 mg twice daily starting the evening prior to ascent from 1240 m (4100 ft) to 3810 m (12,570 ft) over 4 hours. The primary outcome was acute mountain sickness incidence (ie, headache, Lake Louise Questionnaire ≥3, and another symptom). RESULTS: A total of 106 participants were analyzed, with 51 (48%) randomized to 125 mg and 55 (52%) to 62.5 mg, with a combined acute mountain sickness incidence of 53 (50%) and mean severity of 3 (± 2.1). The 62.5-mg group failed to fall within the prespecified 26% noninferiority margin for acute mountain sickness incidence (62.5 mg = 30 [55%] vs 125 mg = 23 [45%], 95% confidence interval [CI] -11% to 30%). Participants in the 62.5-mg group had a higher risk of acute mountain sickness (odds ratio = 1.5, 95% CI 0.7-3.2) and moderate acute mountain sickness (odds ratio = 1.8, 95% CI 0.6-5.9), with a number needed to harm (NNH) of 9, with a number needed to treat (NNT) in the 125-mg group of 4.8. Increased acute mountain sickness incidence and symptom severity corresponded to lower weight-based and body mass index dosing, with similar side effects between groups. CONCLUSION: Acetazolamide 62.5 mg twice daily failed to demonstrate equal effectiveness to 125 mg twice daily for prevention of acute mountain sickness. With increased risk and no demonstrable symptomatic or physiologic benefits, acetazolamide 62.5 mg twice daily should not be recommended for acute mountain sickness prevention.

Unusual presentation of idiopathic intracranial hypertension.

Idiopathic intracranial hypertension typically presents with holocephalic headache associated with nausea, vomiting and bilateral papilledema. Involvement of the sixth cranial nerve is relatively common. The involvement of other cranial nerves, however, is rare in this disorder. We describe a patient with idiopathic intracranial hypertension who presented with episodic unilateral retro-orbital pain and multiple cranial nerve abnormalities without papilledema. Imaging studies excluded alternate diagnoses, and the immediate resolution of symptoms after lumbar puncture confirmed that these symptoms were due to intracranial hypertension. Atypical presentations of such a disabling yet treatable disorder is very important to recognise and address.

The regional pattern of abnormal cerebrovascular reactivity in HIV-infected, virally suppressed women.

The purpose of this study was to assess whole brain and regional patterns of cerebrovascular reactivity (CVR) abnormalities in HIV-infected women using quantitative whole brain arterial spin labeling (ASL). We hypothesized that HIV-infected women would demonstrate decreased regional brain CVR despite viral suppression. This cross-sectional study recruited subjects from the Bay Area Women's Interagency Health Study (WIHS)-a cohort study designed to investigate the progression of HIV disease in women. In addition to conventional noncontrast cerebral MRI sequences, perfusion imaging was performed before and after the administration of intravenous acetazolamide. CVR was measured by comparing quantitative ASL brain perfusion before and after administration of intravenous acetazolamide. In order to validate and corroborate ASL-based whole brain and regional perfusion, phase-contrast (PC) imaging was also performed through the major neck vessels. FLAIR and susceptibility weighted sequences were performed to assess for white matter injury and microbleeds, respectively. Ten HIV-infected women and seven uninfected, age-matched controls were evaluated. Significant group differences were present in whole brain and regional CVR between HIV-infected and uninfected women. These regional differences were significant in the frontal lobe and basal ganglia. CVR measurements were not significantly impacted by the degree of white matter signal abnormality or presence of microbleeds. Despite complete viral suppression, dysfunction of the neurovascular unit persists in the HIV population. Given the lack of association between CVR and traditional imaging markers of small vessel disease, CVR quantification may provide an early biomarker of pre-morbid vascular disease.

Side effects of acetazolamide: a systematic review and meta-analysis assessing overall risk and dose dependence.

INTRODUCTION: Acetazolamide (AZM) is used for various conditions (eg, altitude sickness, sleep apnoea, glaucoma), but therapy is often limited by its side effect profile. Our objective was to estimate the risk of commonly reported side effects based on meta-analyses. We hypothesised that these risks are dose-dependent. METHODS: We queried MEDLINE/EMBASE (Medical Literature Analysis and Retrieval System Online/Excerpta Medica dataBASE) up until 04/10/2019, including any randomised placebo-controlled trial in which adults received oral AZM versus placebo reporting side effects. Eligibility assessment was performed by two independent reviewers. Data were abstracted by one reviewer who verified key entries at a second time point. For side effects reported by >3 studies a pooled effect estimate was calculated, and heterogeneity assessed via I2; for outcomes reported by >5 studies effect modification by total daily dose (EMbyTDD; <400 mg/d, 400-600 mg/d, >600 mg/d) was assessed via meta-regression. For pre-specified, primary outcomes (paraesthesias, taste disturbances, polyuria and fatigue) additional subgroup analyses were performed using demographics, intervention details, laboratory changes and risk of bias. RESULTS: We included 42 studies in the meta-analyses (Nsubjects=1274/1211 in AZM/placebo groups). AZM increased the risk of all primary outcomes (p<0.01, I2 ≤16% and low-to-moderate quality of evidence for all)-the numbers needed to harm (95% CI; nStudies) for each were: paraesthesias 2.3 (95% CI 2 to 2.7; n=39), dysgeusia 18 (95% CI 10 to 38, n=22), polyuria 17 (95% CI 9 to 49; n=22), fatigue 11 (95% CI 6 to 24; n=14). The risk for paraesthesias (beta=1.8 (95% CI 1.1 to 2.9); PEMbyTDD=0.01) and dysgeusia (beta=3.1 (95% CI 1.2 to 8.2); PEMbyTDD=0.02) increased with higher AZM doses; the risk of fatigue also increased with higher dose but non-significantly (beta=2.6 (95% CI 0.7 to 9.4); PEMbyTDD=0.14). DISCUSSION: This comprehensive meta-analysis of low-to-moderate quality evidence defines risk of common AZM side effects and corroborates dose dependence of some side effects. These results may inform clinical decision making and support efforts to establish the lowest effective dose of AZM for various conditions.

Infusión de furosemida intravenosa domiciliaria, continua y prolongada en insuficiencia cardiaca refractaria por pericarditis constrictive / Long-term home-administered continuous intravenous furosemide infusion in refractory heart failure from constrictive pericarditis

Presentamos dos casos clínicos de pacientes con pericarditis constrictiva en insuficiencia cardiaca refractaria a tratamiento diurético combinado y dosis elevadas de furosemida, con disnea de pequeños-mínimos esfuerzos y grandes dificultades para abandonar el hospital por dependencia al tratamiento parenteral. Fueron tratados con infusión continua intravenosa de furosemida mediante infusores elastoméricos. La técnica se mantuvo a largo plazo en domicilio de forma eficaz, con muy buena tolerancia y sin efectos secundarios reseñables

We present two clinical cases about constrictive pericarditis in advanced heart failure refractory to combined diuretic therapy and high dose of furosemide. Patients had small-minimum efforts dyspnea and difficulties to be discharged because of parenteral treatment dependency. They were treated with intravenous continuous furosemide infusion administered by elastomeric pumps. Long-term use at home was effective, well-tolerated and without remarkable secondary effect