Neurosarcoidosis Masquerading as Giant Cell Arteritis With Incidental Meningioma.

ABSTRACT: We present a case of vision loss secondary to neurosarcoidosis, which initially presented with severe bilateral vision loss, temporal headaches, and elevated erythrocyte sedimentation rate, concerning for giant cell arteritis. However, temporal artery biopsy was negative. Initial neuroimaging features were misinterpreted to represent a meningioma that did not account for his clinical presentation. Clinical course, including atypically rapid enlargement of presumed meningioma, development of skin lesions, appearance of optic nerve enhancement on MRI, and steroid response, strongly increased suspicion for sarcoidosis. Biopsy of a skin lesion demonstrated noncaseating granulomatous inflammation, consistent with sarcoidosis.

Bilateral Microphthalmia with Septo-Optic Dysplasia.

A 3-month-old boy was referred for assessment and management of apparently absent ocular globes. Ocular examination showed small orbits with apparently absent globes, small conjunctival cul-de-sac, shallow fornices, microblepharon and sunken eyelids. Magnetic resonance imaging of the orbit and brain revealed bilateral extreme microphthalmia, replacement of the optic nerves by disorganised rudimentary tissue tufts, hypoplastic orbits and extraocular muscles, an absent septum pellucidum and an absent corpus callosum. A pituitary hormonal essay showed decreased adrenocorticotropic hormone and thyroid-stimulating hormone. Septo-optic dysplasia has been rarely reported to be associated with microphthalmia. Timely treatment with hydrocortisone and levothyroxine is essential to prevent Addisonian crisis from the stress and pain that may accompany insertion of socket expanders.

The use of trypan blue to enhance intraoperative visualization during congenital lacrimal fistulectomy.

We describe the use of trypan blue stain to enhance visualization of the tract of the fistula during congenital lacrimal fistulectomy in a 9-year-old boy. This video demonstrates the surgical technique and the intraoperative finding of deep branching of the fistula in this case. We discuss alternative methods of improving delineation of the fistula's path during congenital lacrimal fistulectomy.

Pseudophakic reverse pupillary block after implantation of a single-piece foldable intraocular lens in the capsular bag: Case report and literature review.

Reverse pupillary block with intraocular pressure (IOP) elevation after cataract surgery with in-the-bag implantation of intraocular lens (IOL) is considered a very rare complication. We report the case of a 47-year-old female patient with bilateral high axial myopia and posterior staphyloma presented with left acute loss of vision and eye pain, headache, and vomiting 2 weeks after uneventful presenile cataract surgery with single-piece IOL implantation in the capsular bag 1 month and 2 weeks in the right and left eyes, respectively. Gonioscopy showed extremely wide angle in all quadrants compared to the other eye with Spaeth classification of E 60c + 2 (14). Ultrasound biomicroscopy of the left eye showed epithelial corneal edema, 4.56 mm-deep anterior chamber, abnormal iris configuration with posterior concavity, and angle opening ranging between 60° and 74°, with unremarkable posterior chamber IOL and ciliary body. We managed the patient with topical antiglaucoma medications and laser peripheral iridotomy. IOP returned to normal levels. The patient was followed for 12 consecutive months. Elevated IOP from the reverse pupillary block is a rare postoperative complication of cataract surgery. It was initially described in association with the ciliary sulcus implanted IOL. Elevated IOP from the reverse pupillary block was then reported associated with scleral sutured IOLs and Yamane technique, and most recently with in-the-bag implanted 3-piece-IOL. Herein, we report the first case of pseudophakic reverse pupillary block in association with in-the-bag implanted single-piece foldable acrylic IOL.

Medical Students' Perspectives Regarding the Use of a Slit-Lamp Smartphone Adapter for Clinical Slit-Lamp Photography.

Background This study aimed to investigate medical students' perspectives regarding the ease and utility of smartphone slit-lamp photography. Methodology In this prospective experimental study, fourth and fifth-year medical students who were in or had finished ophthalmology rotation were included to attempt slit-lamp smartphone anterior segment photography on adult patients after a brief hands-on instruction course. Each medical student attempted to record five supervised slit-lamp videos of the anterior segment of five patients using the described adapter and their own smartphone. The time taken until photography was calculated for each attempt. After the fifth attempt, each medical student rated the ease of the use of this method of slit-lamp photography as well as their perspective regarding its utility as a potential means of medical education and telemedical consultations on a five-point Likert scale. Results A total of 33 medical students participated, with each successfully recording five slit-lamp examinations using their smartphones. The time used for the application of the adapter until the image capture ranged from 6 to 278 seconds (average = 39.51 ± 34.7 seconds) and markedly improved by the fifth attempt (30.5 ± 25.7 seconds) compared to the first attempt (67.3 ± 49.3 seconds). Learning this skill was perceived to be relatively easy (2.2 ± 1), with high potential in clinical education (4.6 ± 0.75) and teleconsultations (4.7 ± 0.65). Conclusions Smartphone slit-lamp photography is a relatively easy process. It can be quickly acquired by medical students and has the potential to enhance their medical education and telemedical consultation capabilities.

The Use of Infrared Auto Refractometer for Meibomian Gland Imaging.

Introduction This study proposes the utility of an infrared auto refractometer for meibography and compares miebographs obtained by an auto refractometer to meibographs obtained by a designated meibography machine. Methods A prospective observational comparative study of meibographs of patients with clinical signs of meibomian gland dysfunction (MGD) using a designated meibography machine and an infrared auto refractometer. Five masked, experienced interpreters graded the images of the two machines. The Kappa test was used to calculate Intra-rater and inter-rater agreements between the meibography machine and automated refractor grading of meibomian gland dysfunction. Results High-quality photos of all 30 eyes delineating the meibomian glands (MG) were successfully obtained with both the meibography machine and the autorefractor. Both methods had a good intra-rater agreement (κ= 0.667 to 0.784, average 0.738). Poor to fair interrater agreement was noticed in the grading of autorefractor images (k= -0.030 to 0.343, average 0.092) and poor to moderate agreements between investigators for meibography machine images (K= -0.016 to 0.420, average 0.173). Conclusion A commercially available auto refractometer could capture high-quality non-contact IR digital meibographs.

A Comparative Study of Ocular Surface Disease in Childhood Glaucoma.

PURPOSE: To evaluate ocular surface disease (OSD) in patients with childhood glaucoma (CG). METHODS: A multicenter, comparative, cross-sectional study of 41 eyes of 27 patients with CG and 42 eyes of 42 healthy age- and sex-matched controls was conducted between 2021 and 2022. Developmentally delayed children and those having a coexisting systemic illness that might affect the ocular surface were not enrolled. Data collected included glaucoma type, glaucoma medications and surgeries, anterior segment examination, symptom frequency and severity, and tear break-up time (TBUT). Dry eye disease (DED) symptoms were evaluated using an Arabic-language SPEED questionnaire. RESULTS: The average number of glaucoma medications and surgeries among the 27 patients with CG was 1.17 and 1.4, respectively. TBUT was shorter in patients with CG compared with controls and even shorter when glaucoma medication usage was accounted for. Punctate epithelial erosions were more prevalent in patients with CG and of a higher grade. The severity of all DED parameters, and the prevalence of all DED parameters except for eye fatigue, were greater in patients with CG on the day of questionnaire intake. In addition, each additional glaucoma drop was associated with worse TBUT and ocular surface dryness. All analyses mentioned above were statistically significant (P < 0.05). CONCLUSIONS: In this first study to comprehensively evaluate OSD in patients with CG, a significantly greater incidence of OSD signs and symptoms was found in patients with CG compared with a healthy population. Additional study by CG subtype is needed.

A Novel Snake-chain Metal Probed Silicon Intubation Set for Nasolacrimal Duct Intubation: A Cadaveric Feasibility Study.

PURPOSE: A fresh-frozen human cadaveric feasibility study to investigate the feasibility of probing and stenting the nasolacrimal ducts (NLDs) of human cadavers with a novel flexible bicanalicular nasolacrimal stent. METHODS: A custom-designed bicanalicular nasolacrimal stent was made by connecting a 250 mm long, 0.9 mm diameter silicone tube to a 200 mm long stainless-steel, snake-chain probe at each end. The punctum was dilated, and the snake-chain stent fed into the nasolacrimal drainage system. The emergence of the stents from the terminal end of the NLD and retrieval with a ball probe was conducted under endoscopic guidance. RESULTS: Bicanalicular nasolacrimal stenting with intranasal retrieval under endoscopic guidance was successfully achieved in six NLDs of three adult cadaveric nasolacrimal drainage systems. CONCLUSION: Despite being soft and flexible, the snake-chain silicon stent passes smoothly and freely through cadaveric human NLD and is easily retrieved from the nasal cavity. This novel NLD stent design may make stenting of the NLD easier and less traumatic.

The use of the built-in macro mode of smartphone cameras for pediatric external and anterior segment digital photography.

We describe a novel method for clinical ophthalmic photography that uses the inherent macro-photography mode available in most recent smartphones, without additional attachments. This method facilitates acquisition of high-quality external and anterior segment clinical photography in children who may have difficulty remaining still enough for anterior segment photography at the slit lamp. We describe this technique and discuss its advantages and limitations.

Eyelid Blink Lagophthalmos and Blinking Velocity Changes After External Transcutaneous Dacrocystorhinostomy: A Prospective Study.

PURPOSE: To investigate the changes in eyelid blinking dynamics after external dacryocystorhinostomy (DCR). DESIGN: Prospective before-and-after study with follow-up. METHODS: Patients undergoing external DCR surgery for primary acquired nasolacrimal duct obstruction were observed using high-speed videography that recorded eyelid blinking of both eyes for a total duration of 4 minutes at a rate of 120 frames per second. These recordings were taken before the surgical procedure, on postoperative day 3, and then at 1 week, 1 month, and 3 months after the DCR surgery. A total of 3 random blinks were selected and isolated from each video recording for data analysis. For each blink, lagophthalmos and eyelid blinking velocity were calculated for the operated eye, and their values were then compared with those calculated for the contralateral, nonoperated eye. RESULTS: Data were obtained for 22 patients. Operated eyes showed large postoperative lagophthalmos on postoperative day 3, with a mean of 56.58% ± 52.63% of the palpebral fissure height. Gradual improvement of the lagophthalmos occurred over the next follow-up visits, and reached a mean of 31.24% ± 36.71% at follow-up visit 3 months postoperatively. The velocity of eyelid blinking showed a significant reduction for the operated eyes, with gradual improvement over 3 months. CONCLUSIONS: Postexternal DCR eyelid blinking changes included significant blink lagophthalmos with decreased velocity of eyelid blinking which gradually improved over the 3-month follow-up period. A longer follow-up period may be required to confirm if eyelid blinking lagophthalmos and velocity will return to baseline levels.

Supernumerary lacrimal puncta: case series and review of the literature.

We report a case series of supernumerary puncta-canaliculi, a very rare congenital anomaly, and describe different clinical presentations and new treatment options. This is a retrospective chart review of patients diagnosed with supernumerary lacrimal puncta during the time between June 2015 and December 2021 at the Research Institute of Ophthalmology, Giza, Egypt. Four patients (two females and two males) with a mean presenting age of 54 ± 14 years had unilateral double puncta. Of those four patients, three had double puncta on the right lower eyelid whereas one had double puncta on the left upper and lower eyelid. In one of the three patients, the double puncta anomaly was an incidental finding, and the patient was asymptomatic. The other three patients had associated epiphora. All four patients were found to have patent double puncta with no mechanical obstruction. No surgical interventions were necessary for all four patients as one resolved after discontinuing the topical eye drops. Another patient resolved after the diagnostic probing of the puncta, and the third asymptomatic patient required no interventions. Epiphora in the fourth patient resolved with botulinum toxin injection in the lacrimal gland. Accessory lacrimal puncta can present in patients as an incidental asymptomatic finding or patients may present with epiphora. Patients who present with unilateral epiphora, dry eye, or canaliculitis should be carefully evaluated with a detailed slit-lamp examination using lid eversion to appreciate potentially easily missed supernumerary lacrimal puncta.

A smartphone-based portable fundus camera for retinal photography in infants with suspected nonaccidental trauma.

We describe a novel, do-it-yourself smartphone-based fundus camera to help with documentation of retinal hemorrhages in infant patients with suspected nonaccidental trauma. This device can be easily assembled from commercially available and inexpensive materials. We discuss the advantages and limitations of our described fundus camera and provide representative images.

Investigating the light emitting diode (LED) flashlight characteristics of a sample of smartphones for its safety in indirect retinal photography.

Introduction: the off-label use of smartphones for indirect retinal photography and videography made it a popular ophthalmic clinical practice for its ubiquity and simplicity which enhanced telemedical care. Smartphone indirect retinal photography involves focusing the bright flashlight from the light emitting diode (LED) source on the rear side of the phone on the patient´s retina. Phototoxic hazards of the bright light on the already compromised patients´ retina raise concerns that require safety studies. The aim of this work is to study the characteristics of LED flashlights of a sample of smartphone types currently in use by ophthalmologists in Egypt to evaluate for potential photobiological implications when used in conjunction with + 20-diopter indirect ophthalmoscopy condensing lens for indirect photography of the retina. Methods: the spectral profile, weighted irradiance, and thermal exposure rates produced by a variety of smartphones´ LED flashlights currently used by ophthalmology specialists and trainees at the Comprehensive Outpatient Clinic of the Research Institute of Ophthalmology, Giza, Egypt, were tested in this study when collimated by a +20-diopter indirect ophthalmoscopy lens in a setup similar to actual indirect smartphone retinal photography. Results: the spectrum of the LED flashlights of all tested smartphones fell entirely in the optically safe visible spectrum between 400-750 nm with no significant infrared or ultraviolet components. Two regions of main spectral distribution were noticed in all tested smartphones with a peak at 450 nm and the other ranging between 520 to 585 nm. Weighted irradiance was within the safe limits for ocular examination and ranged from 0.58 to 2.30 mW/cm2 (safe limit is up to 706 mW/cm2) without a measurable thermal effect. Conclusion: the LED flashlight of the tested smartphones appeared to be within safe limits when used for indirect smartphone retinal photography. However, the high composition of the short wavelength blue light spectrum may be a concern particularly with prolonged and repeated examinations.

An All-Digital, Binocular, Indirect Virtual Video Ophthalmoscope: A Novel Approach to Retinal Examination and Photography.

Purpose: We describe a novel method of digital, virtual-reality based binocular indirect ophthalmoscopy which allows for simultaneous stereoscopic recording of the examination with the potential of real-time anatomic correction of the retinal view. Materials and Methods: A provisional prototype of the all-digital, binocular, indirect virtual stereo video ophthalmoscope was designed consisting of a generic LED light source and two synchronized closely spaced side-by-side minicameras which are connected to a processor, storage media (a Samsung note-9 android smartphone in the current provisional prototype), and a virtual reality set (VISIONHMD Bigeyes H1 3D Video Glasses, in the current prototype). A custom designed android application was developed to capture the examination media and allow optional real-time anatomical correction of the examination view. Binocular stereoscopic indirect ophthalmoscopy was attempted on 15 eyes of 15 patients without and with digital real-time anatomic correction of the examination view. Results: Binocular, video, stereo ophthalmoscopic media could be successfully obtained in all 15 patients. Anatomic correction of the examination view as well as a collateral observer's view could be achieved in all 15 patients. Conclusion: An all-digital, binocular, stereo, video indirect ophthalmoscopy is a feasible alternative for conventional binocular indirect ophthalmoscopy and provides stereoscopic video documentation identical to what the examiner sees. The examination video can be streamed in the real-time of the examination for educational or telemedicine purposes.

Pilot Study of Smartphone Infrared Pupillography and Pupillometry.

PURPOSE: To describe and validate a novel portable smartphone-based infrared pupillographer. MATERIALS AND METHODS: A prototype infrared smartphone pupillographer device was custom designed for this project. Infrared video and photo pupillography were attempted on 12 patients with different clinical pupillary examination findings. Captured pupillography media files were assessed by three masked investigators, and the agreement between their qualitative clinical evaluation was tested against the evaluation of the neuro-ophthalmologist who performed the real-time examination and pupillography. Quantitative measurements of the pupillary diameter were performed by three investigators using a custom designed smartphone application on three different smartphones and on a personal computer. Measurements obtained by the three investigators using the smartphone and the desktop computer were compared. RESULTS: Infrared video pupillography of high quality was successfully captured for light and near pupillary reflexes, and infrared still photographs were obtained in light and dark conditions in 23 eyes of the 12 patients. Examination findings included relative afferent pupillary defect (n = 5), normal pupillary examination (n = 4), anisocoria (n = 2), and relative afferent pupillary reflex by reverse (n = 1). There was 100% agreement in the qualitative pupillary evaluation of the masked investigators compared with real time clinical examination. Quantitative measurements of pupillary size obtained on the smartphone and desktop computer showed excellent agreement among the three investigators with intraclass correlation (ICC) coefficient ranging from 0.982-0.986 (P<0.001) and 0.995 (P<0.001) for the smartphone and the desktop computer groups, respectively. Level of agreement ranged between -0.27 and 0.32. Mean pupil diameter errors were 0.03 ± 0.15 mm between groups (P = 0.248). CONCLUSION: This pilot study demonstrates the feasibility of smartphone-based infrared pupillography for high quality photo and video documentation of pupillary examination at the bedside and in the clinic with accurate and reproducible measurements of the pupillary size in light and dark conditions.

Ocular Complications Following Vaccination for COVID-19: A One-Year Retrospective.

Vaccination efforts as a mitigation strategy in the corona virus disease 2019 (COVID-19) pandemic are fully underway. A vital component of understanding the optimal clinical use of these vaccines is a thorough investigation of adverse events following vaccination. To date, some limited reports and reviews have discussed ocular adverse events following COVID-19 vaccination, but a systematic review detailing these reports with manifestations and clinical courses as well as proposed mechanisms has yet to be published. This comprehensive review one-year into vaccination efforts against COVID-19 is meant to furnish sound understanding for ophthalmologists and primary care physicians based on the existing body of clinical data. We discuss manifestations categorized into one of the following: eyelid, orbit, uveitis, retina, vascular, neuro-ophthalmology, ocular motility disorders, and other.

COVID-19 Vaccine-Associated Optic Neuropathy: A Systematic Review of 45 Patients.

We provide a systematic review of published cases of optic neuropathy following COVID-19 vaccination. We used Ovid MEDLINE, PubMed, and Google Scholar. Search terms included: "COVID-19 vaccination", "optic neuropathy", "optic neuritis", and "ischemic optic neuropathy". The titles and abstracts were screened, then the full texts were reviewed. Sixty eyes from forty-five patients (28 females) were included. Eighteen eyes from fourteen patients (31.1%) were diagnosed with anterior ischemic optic neuropathy (AION), while 34 eyes from 26 patients (57.8%) were diagnosed with optic neuritis (ON). Other conditions included autoimmune optic neuropathy and Leber hereditary optic neuropathy. Fifteen patients (33.3%) had bilateral involvement. The mean age of all patients was 47.4 ± 17.1 years. The mean age of AION patients was 62.9 ± 12.2 years and of ON patients was 39.7 ± 12.8 years (p < 0.001). The mean time from vaccination to ophthalmic symptoms was 9.6 ± 8.7 days. The mean presenting visual acuity (VA) was logMAR 0.990 ± 0.924. For 41 eyes with available follow-up, the mean presenting VA was logMAR 0.842 ± 0.885, which improved to logMAR 0.523 ± 0.860 at final follow-up (p < 0.001). COVID-19 vaccination may be associated with different forms of optic neuropathy. Patients diagnosed with ON were more likely to be younger and to experience visual improvement. More studies are needed to further characterize optic neuropathies associated with COVID-19 vaccination.

A Novel Cost-Effective Simulation Model for Continuous Curvilinear Capsulorhexis.

Introduction: We describe and validate a low-cost simulation model for practicing anterior lens capsule continuous curvilinear capsulorhexis (CCC). Methods: A simulation model for CCC was developed from widely available low-cost materials. Ophthalmologists attending the annual scientific meeting of the Research Institute of Ophthalmology, Giza, Egypt, were asked to perform a five CCC model task and then anonymously answer a questionnaire that assessed the realism and training utility of the model using a five-point Likert scale (1 = unacceptable, 2 = poor, 3 = acceptable, 4 = favorable and 5 = excellent). Results: Twenty-seven ophthalmologists completed the task and the anonymous questionnaire. Overall, participants felt that the model simulated CCC step in cataract surgery well (mean: 3.5) and was comparable to other kinds of CCC simulation models (mean: 3.3). The model scored highly for its overall educational value (mean: 4.00) and for enlarging a small CCC (mean:3.7), while the feasibility of this model in practicing the management of a runaway leading edge of CCC scored 2.9. Conclusion: This model may provide an alternative method for training for CCC and other anterior lens capsule-related maneuvers. This option may be particularly helpful for residency training programs with limited access to virtual reality simulators or commercially available synthetic eye models.