Lymphocytic Hypophysitis Presenting as Bilateral Abducens Nerve Palsy: A Case Report.

Lymphocytic hypophysitis (LYH) is a neuroendocrine disorder characterised by autoimmune inflammation of the pituitary gland with varying degrees of pituitary dysfunction, visual field defects and ocular motility disturbance. The authors report an interesting case of a 50-year-old woman presenting with intermittent bilateral abduction deficits. Neuroimaging and histopathological findings are presented. To the authors' knowledge, this is the first report of recurrent horizontal binocular diplopia and complete bilateral internal carotid artery occlusion in association with LYH.

Floppy eyelid syndrome "plasty" procedure: Employment of a periosteal transposition flap for surgery of floppy eyelid syndrome.

IMPORTANCE: Floppy eyelid syndrome "plasty" (FESplasty) is a surgical technique that addresses underlying superior tarsal plate and lateral canthal instability in floppy eyelid syndrome (FES) and aims to restore normal anatomical and physiological function to the upper eyelid. BACKGROUND: To describe the use of FESplasty in the surgical management of FES, and to report outcomes in an initial patient cohort. DESIGN: Retrospective study. PARTICIPANTS: Seven patients (nine eyelids) with FES undergoing FESplasty. METHODS: A single surgeon (G.W.) performed all procedures. FESplasty utilizes a periosteal flap based at the inferolateral orbital rim, and applied to the anterior surface of the upper tarsal plate. It is combined with a titrated shortening procedure of the upper eyelid. Patient demographics, comorbidities and ocular symptoms and signs were recorded preoperatively. Pre- and postoperative upper eyelid distractibility were graded and documented. MAIN OUTCOME MEASURES: Postoperative improvement in upper eyelid distractibility and symptomatology, operative complications and FES recurrence. RESULTS: FES symptoms and upper eyelid laxity improved at last follow-up (average 24 weeks) in all patients, with no FES recurrences after a maximum follow-up of 36 weeks. One patient, in whom FESplasty exacerbated his pre-existing aponeurotic ptosis, required definitive ptosis surgery subsequently. There was one case of postoperative wound infection. Obstructive sleep apnoea was present in four of the seven patients. The remaining three patients were awaiting assessment. CONCLUSIONS AND RELEVANCE: FESplasty is likely to confer long-term effective stabilization of the lateral canthal tendon, lateral commissure and superior tarsal plate. Anatomical and functional results appeared to have been successfully achieved.

Intracranial Arterial Compression of the Anterior Visual Pathway.

Compression of anterior visual pathway (AVP) structures by intracranial arteries is observed not infrequently on neuroimaging. Whether or not such compression results in damage to these structures, however, remains unclear. This information is important to define as AVP compression by intracranial arteries may be a causative factor in patients with otherwise unexplained visual dysfunction. In a single centre, 37 patients with evidence of intracranial artery AVP compression demonstrated on magnetic resonance imaging were identified by retrospective review of case records over the period 2011-2017. Variables were collected, including patient demographics, visual acuity, visual fields, pupillary reactions and optic disc appearance for patients in the case series. Visual field deficits correlated with compression sites in the 37 patients examined. Internal carotid artery-optic nerve compression was the most frequent (unilateral compression n = 9, bilateral compression n = 14), followed by chiasmal compression by the anterior cerebral artery (n = 8) and a combination of optic nerve and chiasmal compression (n = 5). Visual acuity and visual fields were stable on follow-up (mean 4 years) in 24 of 26 cases (93%). We conclude that AVP compression by intracranial arteries may be a causative factor in unexplained visual dysfunction. The visual defects are largely non-progressive.

Coarsening of choriocapillaris on optical coherence tomography angiography as a sign of acute idiopathic blind spot enlargement.

Purpose: Acute idiopathic blind spot enlargement is a rare syndrome that is classified within a spectrum of primary inflammatory choriocapillaropathies with circumscribed outer retinal dysfunction. Observations: We observed coarsening of the choriocapillaris on en-face optical coherence tomography angiography when compared to the fellow eye in a patient with suspected acute idiopathic blind spot enlargement. Conclusions and Importance: Increased granularity of the choriocapillaris as imaged by optical coherence tomography angiography may assist in the diagnosis of acute idiopathic blind spot enlargement, particularly during a global pandemic when access to electrodiagnostics is limited. This finding supports the current evidence of choriocapillaris hypoperfusion in the pathogenesis of acute idiopathic blind spot enlargement.

Electrophysiological Assessment in Birdshot Chorioretinopathy: Flicker Electroretinograms Recorded With a Handheld Device.

Purpose: The flicker electroretinogram (ERG) is a sensitive indicator of retinal dysfunction in birdshot chorioretinopathy (BCR). We explored recordings from a handheld device in BCR, comparing these with conventional recordings in the same patients and with handheld ERGs from healthy individuals. Methods: Non-mydriatic flicker ERGs, using the handheld RETeval system (LKC Technologies), were recorded with skin electrodes at two centers. At one center (group 1), the stimuli (85 Td·s, 850 Td background) delivered retinal illuminance equivalent to international standards; at the other center (group 2), a different protocol was used (32 Td·s, no background). Patients also underwent international standard flicker ERG recordings with conventional electrodes following mydriasis. Portable ERGs from patients were also compared with those from healthy individuals. Results: Thirty-two patients with BCR (mean age ± SD, 56.4 ± 11.3 years) underwent recordings. Portable and standard ERG parameters correlated strongly (r > 0.75, P < 0.01) in both groups. Limits of agreement for peak times were tighter in group 1 (n = 21; -4.3 to +2.0 ms [right eyes], -3.9 to 1.5 ms [left eyes]) than in group 2 (n = 11; -3.4 to +6.9 ms [right eyes], -4.8 to +9.0 ms [left eyes]). Compared with healthy controls (n = 66 and n = 90 for groups 1 and 2, respectively), patients with BCR showed smaller mean amplitudes and longer peak times. Conclusions: Portable ERGs correlated strongly with conventional recordings, suggesting potential in rapid assessment of cone system function in office settings. Translational Relevance: Flicker ERGs, known to be useful in BCR, can be obtained rapidly with a portable device with skin electrodes and natural pupils.