Afferent Defect Research Articles

NUT carcinoma presenting as retrobulbar optic neuropathy: A lethal masquerade!

A case of a 15-year-old girl with sudden vision loss left eye, left relative afferent pupillary defect, and normal fundus both eyes. Magnetic resonance imaging (MRI) brain and orbits showed a heterogeneous enhancing mass lesion in the left posterior ethmoid sinus with bony invasion and crowding of the optic canal. She underwent left optic nerve decompression with removal of the lesion and was started on systemic steroids. Biopsy was suggestive of NUT carcinoma (NC) and immunohistochemistry (IHC) confirmed the same. Despite chemotherapy, the tumor progressed rapidly in six months invading the left orbit, extending to right side of the midline and left anterior cranial fossa, with subsequent complete loss of vision of right eye also. She eventually underwent a globe sparing orbital exenteration with anterior cranial base resection along with postoperative radiotherapy. A month later, patient developed extensive skeletal and hepatic metastasis and succumbed to the disease; 11 months after the initial diagnosis.

VISUAL IMPROVEMENT FOLLOWING THE REMOVAL OF CHRONIC ORBITAL CAVERNOUS HEMANGIOMA

Introduction: Orbital cavernous hemangioma is a benign, well-defined vascular lesion, located mainly in the intraconal space. Surgical treatment is indicated in symptomatic cases, such as proptosis or visual disturbance. This study aims to report the visual improvement of the successfully-managed chronic orbital cavernous hemangioma. Case Report: A 51-year-old man came to Cicendo Eye Hospital with chief complaint of protrusion of the right eye for seventeen years, accompanied by blurred vision two years earlier. Ophthalmological examination revealed decreased visual acuity, together with ocular movement restriction and relative afferent pupillary defect. Computed tomography (CT) scan showed a retrobulbar mass, attached to the lateral and medial rectus muscle, and shifting the optic nerve superiorly. The tumor was removed through inferior anterior orbitotomy with a transconjunctival incision, and the histopathological finding revealed a cavernous hemangioma. Follow-up examination showed improvement in the patient's condition, measured by no protrusion remaining and the achievement of best-corrected visual acuity (BCVA) of 1.0. Discussion: In the case of a benign intraorbital tumor, the orbitotomy approach should be best selected based on its anatomical location and involvement of adjacent structures. Despite the size of the tumor, chronic duration, and disturbing manifestation, improvement of visual acuity and structural appearance could be achieved if the tumor is removed correctly and the adjacent structure has not been severely damaged. Conclusion: Cavernous hemangioma is a benign lesion in which surgical treatment is indicated in symptomatic cases. The right approach of orbitotomy is needed to give a good outcome anatomically and functionally.

Effect of Light Intensity on the Relative Afferent Pupillary Defect in Unilateral Neuro-ophthalmic Pathology.

Objective pupillometry with standardized light intensities allows a comprehensive assessment of the relative afferent pupillary defect in patients with unilateral neuro-ophthalmic pathology. This study aimed to determine the impact of varying light intensities on the grade of relative afferent pupillary defect in unilateral neuro-ophthalmic pathology vis-à-vis healthy controls. Monocular pupillary light reflexes of 20 controls (14 to 50 years) and 31 cases (12 to 72 years) with clinically diagnosed relative afferent pupillary defect were measured thrice using 1-second-long light pulses, followed by 3 seconds of darkness, at eight light intensities (6.4 to 1200 lux) using objective pupillometry. The relative afferent pupillary defect was quantified as the ratio of the percentage change in the direct light reflexes of the left and right eyes. Its change with light intensity was described using standard exponential fits. The median (25th to 75th interquartile range) defect score of 54.8% cases decreased from baseline values of 1.58 (1.25 to 1.87) for right eye pathology and 0.45 (0.39 to 0.55) for left eye pathology to saturation values of 1.18 (1.05 to 1.31) and 0.98 (0.95 to 1.06), respectively, at light intensities between 56.9 and 300.5 lux. Like controls (1.01 [1.00 to 1.06]), the defect scores of the remaining 45.2% cases were constant with light intensity at 1.23 (1.18 to 1.46) and 0.87 (0.86 to 0.89) for right and left eye pathologies, respectively. Relative afferent pupillary defects may decrease with test light intensity in a significant proportion of patients with unilateral neuro-ophthalmic pathology. This highlights the importance of objective pupillometry with standardization light intensities for clinical assessment of afferent pupillary defects.

Clinical and imaging characteristics, outcomes and prognostic factors of intraocular foreign bodies extracted by vitrectomy

To investigate the clinical and computer tomography (CT) features and visual prognostic factors of pars plana vitrectomy (PPV) for management of retained posterior segment intraocular foreign body (IOFB). Medical records of 96 patients with IOFB removed by PPV between July 2017 and June 2021 were retrieved. The medical records, including demographic data, initial and final best corrected visual acuity (BCVA) using standard Snellen chart, characteristics of IOFB, CT findings, and surgical details, were reviewed. Outcome was evaluated according to the final BCVA and prognostic factors were obtained. The mean age was 42.31 ± 12.05 years (range 13–71 years) with 94 males (97.9%) and two females (2.1%). CT was sensitive of IOFB in 93.75% (90 eyes) and the locations were consistent with that found during PPV: 20 foreign bodies were located in vitreous, 6 near ciliary body, and 70 on or in retina. Mean diameter of IOFB removed by PPV is 3.52 mm ± 3.01 mm (range 1–22; median 3), and mean area is 6.29 ± 6.48 mm2 (range 0.5–40; median 3), which was statistically associated with the initial VA < 0.1 and endophthalmitis. Endophthalmitis was found in 24 (25.0%) eyes and large wound together with scleral entry site might be related to the endophthalmitis. Visual outcome < 0.1 was associated with relative afferent pupillary defect, initial VA < 0.1, and presence of endophthalmitis. Initial VA ≥ 0.1 was independent predictive factor for a better final BCVA. Relative afferent pupillary defect, initial BCVA < 0.1, and presence of endophthalmitis are poor visual prognostic factors.

Diagnostic Yield of Investigations in Symmetric Optic Neuropathy.

Symmetric optic neuropathy (SON) is commonly seen in neuro-ophthalmic practice and is often discovered incidentally. Although multiple investigations might be performed to discover the underlying cause, they are not always indicated. The aim of this study was to report a clinically reasonable and cost-effective approach to investigating patients with SON. SON was defined as bilateral optic neuropathy with normal and/or symmetrically decreased central visual acuity, absence of relative afferent pupillary defect, presence of symmetric optic disc pallor, symmetric thinning of peripapillary retinal nerve fiber layer on optical coherence tomography, and absence of other identifiable causes of optic neuropathy. Records of all patients diagnosed with SON seen at a tertiary university-affiliated neuro-ophthalmology practice from 2016 to 2022 were reviewed to identify the yield of various investigations. Clinical data from the initial and last follow-up visit were obtained. Subgroup analysis was performed to ascertain whether diagnostic yield is higher in patients with severe visual loss (central acuity worse than 20/40) compared with those with mild visual loss (acuity 20/40 or better). One hundred thirty-six patients met inclusion criteria. Testing for OPA1 and OPA2 mutations had the highest diagnostic yield (16.0%), followed by mitochondrial genome sequencing (13.6%), serum vitamin B12 (6.1%), and serum folate (1.6%). MRI brain was performed in 54.4% of patients and had a diagnostic yield of only 5%. Both patients who had abnormal MRI had symptoms of demyelination at presentation. Patients were followed for a mean of 15.0 (SD 21.3) months. The most frequently identified etiologies of SON were Leber hereditary optic neuropathy (8.1%), alcohol/tobacco amblyopia (7.4%), vitamin B12 deficiency (5.9%), and dominant optic atrophy (2.9%). Patients with severe visual impairment were more likely to have a final diagnosis compared with those with milder visual impairment (63.9% vs 12.0%, P < 0.001). The diagnostic yield of investigating SON in patients with preserved visual function, normal diet, and absence of other neurological symptoms is very low. It is reasonable to observe patients with SON with mild visual impairment, reserving costly investigations for those with the visual acuity worse than 20/40 or progressive course.

Inadvertent intraocular injection of methylprednisolone in a patient with prior superior oblique tuck surgery

Summary Background To report inadvertent intraocular methylprednisolone injection into an eye that had previously undergone superior oblique tuck surgery. Material and methods An observational case report. Results An inadvertent intraocular penetration occurred following periorbital methylprednisolone injection, which was performed via the superonasal quadrant to relieve trochlear pain in an eye that had undergone previous superior oblique tuck procedure. There was immediate loss of vision, afferent pupillary defect, and raised intraocular pressure. Fundoscopy revealed intravitreal and subretinal methylprednisolone with retinal detachment. Immediate removal of intravitreal and subretinal methylprednisolone was performed with a retinal reattachment procedure. Postoperatively, retinal necrosis was noted in the area that was in contact with methylprednisolone. Conclusions This case highlights the risk of inadvertent intraocular penetration while injecting through a limited periorbital space that has been previously operated on.

Burkholderia pseudomallei – The malicious invader causing orbital cellulitis !!!

This case report represents an unusual presentation of Melioidosis presenting as orbital cellulitis. Orbital cellulitis is an acute infection of the eye, commonly caused by Staphylococcal, Streptococcal species and also by fungi. Here we report a case of a 57 year old male who was a diabetic and hypertensive presented with fever, protrusion of right eyeball with sudden onset of defective vision. On examination right eye visual acuity was light perception with relative afferent pupillary defect. Proptosis, chemosis and total ophthalmoplegia were present. Routine investigation revealed leucocytosis. Conjunctival swab culture was negative whereas blood culture revealed Burkholderia pseudomallei. On further work up ultrasound abdomen showed splenic abscess. Even with effective treatment with IV antibiotics patient didn’t improve and succumbed to this disease. Ocular involvement in melioidosis is rare but can lead to devastating outcomes. This case represents the highly virulent nature of this organism which rarely presents with ocular involvement as primary presentation.

Subperiosteal and Orbital Abscesses: A Comparison of Clinical Features, Management, and Outcomes.

To compare the clinical features, management, and outcomes between orbital cellulitis patients with subperiosteal abscess (SPA) and those with orbital abscess (OA). A retrospective study was conducted at a tertiary care center through medical record search to identify patients with orbital cellulitis from January 1, 2000 to December 31, 2022. Charts were screened for those with radiographic evidence of SPA or OA. Demographic data and presenting clinical features were compared between the 2 cohorts. Primary outcomes compared included rates of surgical intervention, reoperation, and readmission; and length of hospital stay and final vision. A total of 189 patients, 162 with SPA and 27 with OA, met the criteria. The OA group (mean 46.5 ± 18.6 years) was older than the SPA group (mean 19.1 ± 21.4 years). Comorbid sinusitis was significantly more common in the SPA cohort (95.7% SPA; 70.4% OA; p < 0.001), while OA was more likely to occur with orbital trauma (29.6% vs. 8.0%; p = 0.003), implanted hardware (11.1% vs. 0.6%; p = 0.005), and comorbid diabetes (22.2% vs. 4.3%; p = 0.001). OA patients more often presented with a relative afferent pupillary defect (21.7% vs. 3.9%; p = 0.005), vision worse than 20 of 50 (42.3% vs. 16.2%; p = 0.005), and methicillin-resistant Staphylococcus aureus infection (20.8% vs. 5.8%; p = 0.036). OA was associated with a higher reoperation rate (47.8% vs. 21.3%; p = 0.019), readmission rate (18.5% vs. 5.6%, p = 0.047), and limited extraocular motility at follow-up (4.3% vs. 25%; p = 0.013); while mean length of hospital stay and final visual acuity were similar. OA may affect an older population with a divergent risk factor profile compared with SPA. OA may cause more severe functional impairment on presentation, warranting more aggressive management to achieve visual outcomes similar to SPA.

Probable Posterior Ischemic Optic Neuropathy Associated with Acute Fungal Sinusitis

Purpose: We report a case of probable posterior ischemic optic neuropathy in a patient with acute fungal sinusitis.Case Summary: An 81-year-old male patient presented with sudden-onset visual loss in his left eye 3 weeks prior to presentation. His best corrected visual acuity was 0.6 in his right eye and light perception in his left eye. Pupillary size was 3 mm in both eyes, and a relative afferent pupillary defect was detected in his left eye. In fundus examination, diabetic retinopathy was found, and cup/disc ratios were increased in both eyes, but disc swelling and hemorrhage were not observed. Fluorescein angiography did not indicate filling delay, defects, or leakage of discs in either eye. Magnetic resonance imaging of the brain revealed multi-sinusitis in the sphenoid, ethmoid, and frontal sinuses. No bony defects or erosion were found around the optic canal or orbital apex during endoscopic surgery; however, histological examination revealed aspergillosis. The patient was diagnosed with posterior ischemic optic neuropathy caused by acute fungal sinusitis.Conclusions: When elderly patients with uncontrolled diabetes experience sudden visual disturbances without ocular pain, posterior ischemic optic neuropathy with fungal sinusitis should be considered as a differential diagnosis. Immediate imaging studies and appropriate treatment should be performed.

Case Report: Multimode Imaging of Chronic Syphilitic Chorioretinitis.

The clinical manifestations of ocular syphilis may mimic those of other diseases, which may result in a missed diagnosis and delayed treatment. We describe multimodal imaging findings and treatment outcomes of a patient with chronic syphilitic chorioretinitis. A 40-year-old male patient complained of progressive decreased visual acuity of his left eye for over one year. The best-corrected visual acuity (BCVA) was 20/20 in the right eye and 3/50 in the left eye. Relative afferent pupillary defect and 1+ vitreous cells were detected in the left eye. The authors performed fundus examination, fluorescence angiography, ultra-widefield fundus autofluorescence, structure optical coherence tomography, widefield montage optical coherence tomography angiography and visual field. Laboratory tests including a toluidine red unheated serum test (TRUST; 1:32) and the Treponema pallidum antibody (9.01S/CO) were positive. The diagnosis of chronic syphilitic chorioretinitis was diagnosed in both eyes. The patient was admitted for administration of intravenous penicillin G for 14 days, followed by intramuscular benzathine penicillin G weekly for three doses. Six months after treatment, the TRUST ratio had decreased to 1:2 (positive). BCVA was 20/20 in the right eye and 6/20 in the left eye. The re-examination results showed the ocular structure and capillaris flow partially recovered. Chronic syphilitic chorioretinitis profoundly affects the structure of the retina and choroid; however, eyes may partially recover after effective treatment. Ultra-widefield imaging technology has several advantages, such as broader imaging field and more details provided, in determining syphilis induced ocular disorders.

Sinonasal Orbital Apex Syndrome, Horner Syndrome and Pterygopalatine Fossa Infection: A Case Report and Mini-Review.

This paper presents a literature review and a case of an 83-year-old otherwise healthy female patient with a history of recent syncope, a sudden-onset right-sided temporal headache, diplopia, and vision loss. An exam revealed right-sided upper eyelid ptosis, myosis, vision loss, ophthalmoplegia, and a positive relative afferent pupillary defect on the right eye. CT showed sphenoid sinus opacification, eroded lateral sinus wall, Vidian canal, disease extension to the posterior ethmoid air cells, orbital apex, medial orbital wall, and pterygopalatine fossa. An orbital apex syndrome (Jacod's syndrome), Horner syndrome, and pterygopalatine fossa infection were diagnosed due to the acute invasive fungal sinusitis developed from a sphenoid sinus fungal ball. The patient was treated with antimicrobial therapy and transnasal endoscopic surgery twice to decompress the orbital apex, drain the abscess and obtain specimens for analysis. The right-sided ptosis, visual loss, ophthalmoplegia, and headache resolved entirely. No immune or comorbid diseases were identified, microbiological and histopathological analyses were negative, and MRI could not be performed on the presented patient. For that reason, the diagnostic procedure was non-standard. Nevertheless, the treatment outcome of this vision and life-threatening disease was satisfactory. Treating the fungal ball in an older or immunocompromised patient is essential to prevent invasive fungal rhinosinusitis and fatal complications.

Maculopathies Referred to Neuro-Ophthalmology Clinic as Optic Neuropathies: A Case Series.

The clinical features of maculopathies and optic neuropathies often overlap: Both present with decreased visual acuity and variable loss of color vision; thus, maculopathy can be misdiagnosed as optic neuropathy, leading to patient harm. We aimed to determine what findings and/or tests were most helpful in differentiating between optic neuropathy and maculopathy. A retrospective chart review of consecutive patients over 4.5 years who were referred to neuro-ophthalmology clinics with the diagnosis of optic neuropathy but whose final diagnosis was maculopathy. Patient demographics, mode of presentation, clinical profile, complete ophthalmological examination, results of all ancillary testing, and final diagnosis were recorded. A total of 47 patients (27 women) were included. The median age was 55 years (range, 18-85). Most referrals were by ophthalmologists (72.3%) and optometrists (12.8%). The diagnosis of maculopathy was made in 51.1% of patients at the time of first neuro-ophthalmic consultation. Only 6.4% patients (3) had relative afferent pupillary defect. Benign disc anomalies (tilted, myopic, small, or anomalous discs) were present in 34.0%, and 21.3% had pathologic disc changes unrelated or secondary to maculopathy. Macular ocular coherence tomography (OCT) was abnormal in 84.4% (with outer retinal pathology in 42.2% and inner retina pathology in 17.8%). Retinal nerve fiber layer (RNFL) thickness was normal in 82.6% of patients. Macular OCT is a high-yield test in differentiating between optic neuropathy and maculopathy and should be obtained in patients with suspected optic neuropathies who have normal RNFL thickness. Macular dystrophies, particularly cone dystrophies, unspecified retinal disorders, and macular degeneration were the most common mimics of optic neuropathy. The diagnosis was often present on OCT of the macula. The presence of coexistent benign and pathological disc anomalies may lead to maculopathy being misdiagnosed as optic neuropathy.

Intravenous Thrombolysis for Central Retinal Artery Occlusion: A Look at the Literature for the Emergency Medicine Physician.

Central retinal artery occlusion (CRAO) is a subtype of ischemic stroke and true ocular emergency presenting with acute, painless, monocular vision loss. Typical findings include poor visual acuity (VA), impaired color vision, relative afferent pupillary defect, and on fundoscopic evaluation, retinal edema, cherry red spot, and occasionally visualization of retinal artery emboli. While there are no proven treatments for CRAO, options include orbital massage, hyperbaric oxygen therapy, and intra-arterial or intravenous thrombolysis (IVT). This study reviews the current literature on the efficacy of IVT for patients affected by acute, symptomatic CRAO and provides an up-to-date, evidence-based background for emergency physicians (EPs) who evaluate and manage these patients.

Apical idiopathic orbital inflammatory disease presenting with disc edema - A case report

Idiopathic orbital inflammatory disease (IOID) is an inflammatory pathology of the orbital contents like muscles, lacrimal glands, and periorbital fat. This report presents a case of a 24-year-old female with axial proptosis, defective vision, and lid edema in the left eye. Her best-corrected visual acuity (BCVA) was 6/36 N8 with grade 1 relative afferent pupillary defect (RAPD) and impaired color vision in the left eye. Magnetic resonance imaging (MRI) of the left orbit showed infiltration of the retro-orbital fat with thickening of the optic nerve sheath. She was diagnosed with apical IOID with optic perineuritis and was treated successfully with intravenous and oral steroids.

Pituitary apoplexy following cataract surgery: A novel complication

A 54-year-old female underwent uneventful phacoemulsification cataract surgery in the left eye. On postoperative day 1, she developed sudden visual loss. The examination was unremarkable except for a relative afferent pupillary defect. Neuroimaging revealed features suggestive of pituitary macroadenoma complicated by pituitary apoplexy (PA) causing optic chiasmal compression. Surgical intervention was done and the other eye vision was salvaged. This is the first case report documenting cataract surgery as a precipitant of PA, resulting in sudden visual loss.

Binocular head-mounted chromatic pupillometry can detect structural and functional loss in glaucoma.

The aim of this study is to evaluate the utility of binocular chromatic pupillometry in detecting impaired pupillary light response (PLR) in patients with primary open-angle glaucoma (POAG) and to assess the feasibility of using binocular chromatic pupillometer in opportunistic POAG diagnosis in community-based or telemedicine-based services. In this prospective, cross-sectional study, 74 patients with POAG and 23 healthy controls were enrolled. All participants underwent comprehensive ophthalmologic examinations including optical coherence tomography (OCT) and standard automated perimetry (SAP). The PLR tests included sequential tests of full-field chromatic stimuli weighted by rods, intrinsically photosensitive retinal ganglion cells (ipRGCs), and cones (Experiment 1), as well as alternating chromatic light flash-induced relative afferent pupillary defect (RAPD) test (Experiment 2). In Experiment 1, the constricting amplitude, velocity, and time to maximum constriction/dilation were calculated in three cell type-weighted responses, and the post-illumination response of ipRGC-weighted response was evaluated. In Experiment 2, infrared pupillary asymmetry (IPA) amplitude and anisocoria duration induced by intermittent blue or red light flashes were calculated. In Experiment 1, the PLR of POAG patients was significantly reduced in all conditions, reflecting the defect in photoreception through rods, cones, and ipRGCs. The variable with the highest area under the receiver operating characteristic curve (AUC) was time to max dilation under ipRGC-weighted stimulus, followed by the constriction amplitude under cone-weighted stimulus and the constriction amplitude response to ipRGC-weighted stimuli. The impaired PLR features were associated with greater visual field loss, thinner retinal nerve fiber layer (RNFL) thickness, and cupping of the optic disk. In Experiment 2, IPA and anisocoria duration induced by intermittent blue or red light flashes were significantly greater in participants with POAG than in controls. IPA and anisocoria duration had good diagnostic value, correlating with the inter-eye asymmetry of visual field loss. We demonstrate that binocular chromatic pupillometry could potentially serve as an objective clinical tool for opportunistic glaucoma diagnosis in community-based or telemedicine-based services. Binocular chromatic pupillometry allows an accurate, objective, and rapid assessment of retinal structural impairment and functional loss in glaucomatous eyes of different severity levels.

Detection of Relative Afferent Pupillary Defects Using Eye Tracking and a VR Headset.

The purpose of this study was to assess the feasibility of detecting relative afferent pupillary defects (RAPDs) using a commercial virtual reality headset equipped with an eye tracker. This is a cross-sectional study in which we compare the new computerized RAPD test with the traditional clinical standard using the swinging flashlight test. Eighty-two participants including 20 healthy volunteers aged 10 to 88years were enrolled in this study. We present a bright/dark stimulus alternating between the eyes every 3seconds using a virtual reality headset, and we simultaneously record changes in pupil size. To determine the presence of an RAPD, we developed an algorithm analyzing the pupil size differences. For the assessment of the performance of the automated and the manual measurement a post hoc impression based on all available data is created. The accuracy of the manual clinical evaluation and the computerized method is compared using confusion matrices and the gold standard of the post hoc impression. The latter is based on all available clinical information. We found that the computerized method detected RAPD with a sensitivity of 90.2% and an accuracy of 84.4%, as compared to the post hoc impression. This was not significantly different from the clinical evaluation with a sensitivity of 89.1% and an accuracy of 88.3%. The presented method offers an accurate, easy to use, and fast method to measure an RAPD. In contrast to today's clinical practice, the measures are quantitative and objective. Computerized testing of Relative Afferent Pupillary Defects (RAPD) using a VR-headset and eye-tracking reaches non-inferior performance compared with senior neuro-ophthalmologists.

Inflammatory Sinonasal Polyposis-Causing Globe Perforation-With Response to Dupilumab Therapy.

A 75-year-old male patient with asthma presented with left eye vision loss for 1 year and progressive nasal obstruction, anosmia, and purulent eyelid and nasal discharge for several months. There was no light perception vision with an afferent pupillary defect in the left eye. Examination demonstrated nasal dorsum widening, sino-cutaneous fistulae, bilateral proptosis, and left eye chemosis with corneal keratinization in the setting of prior perforation (Fig. 1A). Nasal endoscopy showed severe, bilateral polyposis (Fig. 1B). MRI revealed an extensive sinonasal process with left globe disfigurement and severe, postobstructive, sinus mucocele formation (Fig. 2, top). The patient underwent bilateral functional endoscopic sinus surgery. Intraoperatively extensive sinonasal polyposis and inspissated mucinous debris were encountered. Histopathology demonstrated nasal polyps with dense eosinophilic infiltration and cultures grew polymicrobial bacteria. He underwent left eye evisceration, left lower eyelid ectropion repair, and second-stage sinus surgery. Postoperatively, there were improvements in pain, breathing, and smell. Nasal endoscopy displayed improved sinus patency, although with rapid polyp recurrence. Given concern for mucocele formation and potential impact on the right eye, bimonthly subcutaneous dupilumab was initiated. Following 5 doses, there was dramatic improvement, with symptom resolution, nasal bridge narrowing, sinonasal polyposis reduction, and fistulae closure (Fig. 1C). Subsequent CT showed dramatic polyposis involution and sinus clearing (Fig. 2, bottom). Severe chronic sinusitis with polyposis may exert mass effect on local structures including the brain, optic nerves, and globes. Among patients with severe, refractory, or recurrent polyposis, subcutaneous dupilumab may provide a dramatic clinical response.FIG. 1FIG. 2

Lens-induced Glaucoma, a Collateral Damage during COVID-19 Pandemic

Cataract if left untreated, can lead to complications such as lens induced glaucoma and permanent visual loss. The COVID-19 outbreak resulted in movement control orders causing closure and reduction of non-COVID hospital services resulting delayed appointment dates. This study described the side effects of delayed patient appointments due to COVID-19 pandemic. A 70-year-old man presented with right eye (RE) pain and redness. There was gradual reduction in RE vision over the last year but treatment was delayed due to pandemic. In examination, visual acuity on his RE was hand movement and left eye (LE) was 6/12 (ph6/12) and near vision of N5. The right pupil was mid-dilated, reacting sluggishly with presence of relative afferent pupillary defect. Intraocular pressure (IOP) on the RE was 54 mmHg and LE was 16 mmHg. Circumciliary injection of right conjunctiva with central corneal haziness was seen. The anterior chamber was deep with the presence of 3+ cells with whitish lens material at the pupillary axis. A Morgagnian cataract with phacodonesis was present. A diagnosis of lens induced glaucoma was made. Immediate reduction of IOP included topical and systemic medication and pain relief were instituted. Intracapsular cataract extraction with anterior vitrectomy and surgical peripheral iridectomy was performed. This highlights the late presentation of a patient with mature cataract during the COVID-19 pandemic. Patient awareness and education are essential in recognising the complications of mature cataract if it is presented later. A reminder of signs and symptoms of lens induced glaucoma should be conveyed to patient when appointment is delayed.

Detection of Relative Afferent Pupillary Defect and Its Correlation with Structural and Functional Asymmetry in Patients with Glaucoma Using Hitomiru, a Novel Hand-Held Pupillometer.

Patients with asymmetric glaucomatous optic neuropathy (GON) present a relative afferent pupillary defect (RAPD) in the eye with more advanced damage. Although useful, pupillometric RAPD quantification is not widely used as it is not portable. Whether asymmetry of the peripapillary capillary perfusion density (CPD) detected using optical coherence tomography angiography correlates with the severity of RAPD remains unknown. This study assessed RAPD in 81 patients with GON using Hitomiru, a novel hand-held infrared binocular pupillometer. The correlation and ability to detect clinical RAPD based on the swinging flash light test of two independent RAPD parameters (the maximum pupil constriction ratio and the constriction maintenance capacity ratio) were assessed. The coefficient of determination (R2) was calculated between each of the two RAPD parameters and asymmetry of the circumpapillary retinal nerve fiber layer thickness (cpRNFLT), ganglion cell layer/inner plexiform layer thickness (GCL/IPLT), and CPD. The two RAPD parameters showed a correlation coefficient of 0.86 and areas under the receiver operating characteristic (ROC) curve of 0.85-0.88, with R2 being 0.63-0.67 for the visual field, 0.35-0.45 for cpRNFLT, 0.45-0.49 for GCL/IPLT, and 0.53-0.59 for CPD asymmetry. Hitomiru has high discriminatory performance in detecting RAPD in patients with asymmetric GON. CPD asymmetry may better correlate with RAPD than cpRNFLT and GCL/IPLT asymmetry.