Afferent Defect Research Articles

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

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

Prognosticators for Visual Outcome in Indirect Traumatic Optic Neuropathy: A Prospective Cohort Study.

Introduction Traumatic optic neuropathy (TON), with indirect TON as its more prevalent form, is a dreadful cause of severe visual dysfunctions. The condition is known to have a contentious treatment plan and poor visual sequelae; hence, the assessment of prognostic signs becomes valuable. Prospective studies evaluating important predictors of visual recovery after traumatic optic nerve injury can particularly be helpful in a longitudinal observation. The possible roles of clinical variables need to be assessed. Absent visual evoked potential (VEP) records as a crucial finding associated with TON has reportedly valuable prognostic significance. This also needs to be explored. Hence, the study sought to determine the role of prognosticators in the visual outcome of the patients, with a focus on evaluating the role of VEPs in the severity and prognosis of indirect TON. Methods A prospective observational study involving 40 patients with indirect TON was conducted. Ocular, neuro-ophthalmological, radiological, and neurophysiological variables, including flash VEP, were investigated at their initial visit and followed up until the end of six months. Final visual acuity was the primary outcome variable studied. Paired t-test was used to perform the comparison between the flash VEP variables for normal and affected eyes at the initial visit. Pearson correlation coefficient was computed for obtaining the association of initial visual acuity and flash VEP variables with the outcome variable. Relative risk was calculated and analysed for the prognosticators in univariate analysis. Statistical significance was defined as p < 0.05. Results Statistically significant variations in mean P100 latency, N75-P100, and P100-N145 amplitudes compared between normal and affected eyes in the patients at the initial visit were obtained (p < 0.0001; paired t-test). Pearson correlation coefficient for initial visual acuity and flash VEP variable as independent variables and final visual acuity as the dependent variable were statistically significant (p < 0.05). The relative risks for prognosticators with a statistically significant range of confidence intervals were poor initial visual acuity, greater relative afferent pupillary defect (RAPD) grades, deranged flash VEP variables (absent VEP, reduction in amplitude ratio (>50%), and increased interocular latency differences), loss of consciousness during injury, age greater than 40 years, and lack of improvement after 48 hours of steroid treatment. Conclusion The identified negative prognosticators may be helpful in deciding the kind of therapeutic approach and predicting the visual outcome in patients with indirect TON.

Surgical decisions in the setting of zonulopathy.

An 85-year-old man with a history of type 2 diabetes, pseudoexfoliation (PXF) in both eyes, and tamsulosin use was referred for the evaluation of a dense cataract in the right eye and a subluxated intraocular lens (IOL) in the left eye. Unfortunately, his surgery in the left eye was complicated by diffuse zonulopathy. The referring surgeon placed a 3-piece IOL in the sulcus. However, the passively fixated 3-piece IOL moved inferiorly causing monocular diplopia for over a year. Because the patient was pleased with the IOL immediately postoperatively, a refixation procedure was performed in the form of sulcus placement with iris suture fixation in the left eye. Fortunately, the iris-fixated IOL in the left eye has remained well centered and stable without cystoid macular edema (CME) or chronic inflammation for over 8 months. The patient is on no ocular medications and has no family history of glaucoma. He now needs cataract surgery in the right eye and is extremely apprehensive because of his difficult course in the left eye. The corrected distance visual acuity is 20/70 in the right eye and 20/25 in the left eye. Intraocular pressures (IOPs) measure 20 mm Hg in the right eye and 14 mm Hg in the left eye by Goldmann tonometry. Pachymetry is 536 µm in the right eye and 543 µm in the left eye. Pupils are round with minimal reactivity and without a relative afferent pupillary defect. Extraocular motility is normal in both eyes, and confrontation visual fields is full in both eyes. Gonioscopy reveals an angle open to the pigmented trabecular meshwork (PTM) in the right eye and the ciliary body in the left eye with 1+ PTM and without peripheral anterior synechia in both eyes. The retinal nerve fiber layer and macular optical coherence tomography are normal in both eyes. On slitlamp examination, pertinent findings include pseudoexfoliative changes at the pupillary margin with poor dilation of 3.5 mm in both eyes; the anterior chamber (AC) is shallow but adequate in the right eye and deep and quiet with rare pigmented cells in the left eye. There is a 5+ nuclear sclerotic cataract with pseudoexfoliative changes on the anterior capsule and no obvious phacodonesis in the right eye and a 3-piece posterior chamber IOL in the sulcus fixated to the iris with 10-0 polypropylene sutures at 6 and 12 o'clock without pseudophacodonesis in the left eye. Dilated fundus examination reveals a cup-to-disc ratio of 0.4 with healthy neuroretinal rims in both eyes, posterior vitreous detachments in both eyes, and no evidence of diabetic retinopathy in both eyes. All other findings are unremarkable. How would you counsel this patient regarding his risk factors for surgery in the right eye? What surgical maneuvers would you use to remove the cataract safely? How would you stabilize the IOL if the capsule bag becomes compromised due to zonulopathy?

The yield of neuroimaging in patients presenting to the emergency department with isolated neuro-ophthalmological complaints: A retrospective chart review.

Neuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is based on the clinical judgment of the medical team, without defined indications. This study aims to identify presenting symptoms and physical exam findings associated with relative positive findings on neuroimaging studies. Electronic medical records of patients presenting to the emergency department (ED) with isolated neuro-ophthalmologic complaints between January 1, 2013 and September 30, 2019 were reviewed. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses. Two hundred eleven patients' charts were reviewed. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal findings. Complaining of blurry vision (P = .038) or visual field changes (P = .014) at presentation as well as having a visual field defect (P = .016), abnormal pupil reactivity (P = .028), afferent pupillary defect (P = .018), or abnormal optic disc exam (P = .009) were associated with positive findings on imaging. Neuroimaging is more likely to yield positive findings in patients presenting to the ED with visual field irregularities, afferent pupillary defects, or abnormal optic discs. These findings - when combined with the proper clinical setting - should lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making.

Proportion of Pseudoexfoliative Glaucoma Among Glaucomatous Patients Attending Makah Hospital in Aden, Yemen

Background: Pseudoexfoliative glaucoma is the most common type of secondary open-angle glaucoma. Objective: To describe the proportion and clinical features of pseudoexfoliative glaucoma among glaucomatous patients Materials and method: A retrospective chart review. The collected data were sex, age, family history, clinical features, clinical eyes examination, type of treatment and intraocular pressure outcome. SPSS version 17 was used. Data were presented as frequencies and means. The statistical significance of differences between data was evaluated using Fisher test. P &lt; 0.05 was considered to indicate statistical significance. Results: The proportion of PEXG patients among glaucoma patients was (9.1%). (Females 51.2% and males 48.8%). The mean age of the patients is 67.6 ± 9.8 years. The patients of the age group 60 – 69 years old were predominant. 65.1% had bilateral PEXG. Severe visual impairment (27.9%) found in the right eyes and (34.9%) were in the left eyes. Round regular react pupils were (60.5%) in the right eyes and (74.4%) in the left eyes, followed by relative afferent pupillary defect with (27.9%) in the right eyes and (11.6%) in the left eyes. High IOP &gt; 21 mmHg found in (60.5%) the right eyes and (53.5%) in the left eyes. The cup/disc ratio with &gt; 0.5 in the right eyes of the PEXG patients found in (60.1%). The means of cup/disc ratio in the right and the left eyes were 0.65 ± 0.26 and 0.67 ± 0.28 respectively (p &lt; 0.05). The medication treatment was given for (76.7%) patients and medication + surgical treatment was given for (23.3%). Conclusion: PEXG was more frequently observed in females. The proportion of PEXG patients was (9.1%). Severe visual impairment was predominant in both eyes. A population-based study suggests to further define the prevalence and characteristics of PEXG in Aden and the surrounding governorates. Keywords: proportion, pseudoexfoliative glaucoma, Makkah hospital, Aden.

Posterior ethmoidal mucocele with orbital apex syndrome in a young male

A 39-year-old male presented with painless diminution of vision in the right eye for 10 days, which was associated with drooping of the upper lid for 4 days. Vision was perception of light with 4 mm ptosis and mild proptosis and 3.5 mm pupil with grade 1 relative afferent pupillary defect (RAPD). Extraocular movements showed abduction and elevation limitation of -2, adduction and depression limitation of -1 in the right eye. Magnetic resonance imaging (MRI) showed right posterior ethmoidal mucocele causing optic nerve compression. Marsupialization of mucocele and optic nerve decompression were done. Post-surgery, vision, ptosis, and extraocular movements improved and pupil remained the same owing to the mechanical effect of the mucocele. Early identification and intervention of posterior ethmoidal mucocele is crucial in preventing visual compromise.

СОВРЕМЕННЫЕ ПРЕДСТАВЛЕНИЯ О ФАКТОРАХ, АССОЦИИРОВАННЫХ С НЕБЛАГОПРИЯТНЫМ ФУНКЦИОНАЛЬНЫМ РЕЗУЛЬТАТОМ У ПАЦИЕНТОВ С ПРОНИКАЮЩИМ РАНЕНИЕМ ГЛАЗНОГО ЯБЛОКА И НАЛИЧИЕМ ВНУТРИГЛАЗНОГО ИНОРОДНОГО ТЕЛА

An analytical review of modern literature on the problem of penetrating ocular injuries with a retained intraocular foreign body is presented. The statistically significant relationship between the final low visual acuity and such key factors as retinal detachment, endophthalmitis, hemophthalmus and relative afferent pupillary defect in most studies was established. The association between the functional outcome of a penetrating injury of the eyeball and such factors as the length and localization of the wound of the intraocular foreign body, its final localization, volume, mass and speed of entry into the eyeball was contradictory. This indicates the need for additional comprehensive studies, taking into account heterogeneity, pathogenetic mechanisms of traumatic damage to the eyeball. Timely determination of the probability of an unfavorable outcome will make it possible to identify a risk group and improve the tactics of personalized treatment of patients with penetrating wounds of the eyeball.

Retrobulbar hemorrhage with occult globe rupture – A sinister confluence

Orbital compartment syndrome following blunt trauma is typified by an acute onset of proptosis and tight orbit, with retrobulbar hemorrhage (RBH) being the principal cause. A 9-year-old boy with blunt trauma to the left eye presented with sudden onset of pain and dramatic visual loss. Visual acuity was documented as perception of light. Examination revealed ecchymosis of eyelids, hemorrhagic chemosis, complete restriction of extraocular movements, exposure keratopathy, and relative afferent pupillary defect. A hazy view of the fundus revealed a normal optic disc. Although features favored RBH, the absence of “tight orbit” invoked suspicion. Computed tomography unveiled a hematoma in the superonasal aspect of the orbit with tenting of posterior aspect of the globe and altered globe contour, suggesting posterior globe rupture. This case highlights that an occult globe rupture should be suspected in traumatic proptosis with a “not so tight” orbit.

Extreme intraocular pressure and steroid-dependent iritis.

A 50-year-old ophthalmic technician was referred by her retina specialist for urgent consultation due to markedly elevated intraocular pressure (IOP) unresponsive to medical therapy. Her history included chronic polyarticular juvenile rheumatoid arthritis and chronic uveitis requiring ongoing topical steroid therapy. She had a sub-Tenon injection of Kenalog (triamcinolone) 18 months prior to referral. Chronic topical anti-inflammatory therapy included nepafenac (Ilevro) and prednisolone acetate 2 times a day. Attempts to discontinue topical steroid resulted in worsening inflammation. The patient was referred when the IOP measured 44 mm Hg in the left eye despite aggressive medical therapy, including acetazolamide. The IOP improved slightly when loteprednol was substituted for prednisolone acetate. Current medications in the left eye include brimonidine 3 times a day, loteprednol 2 times a day, nepafenac 2 times a day, and fixed combination latanoprost + netarsudil at bedtime. Her only medication in the right eye was travoprost. She is intolerant to dorzolamide. She was also taking acetazolamide 500 mg 2 times a day. She was not taking any anticoagulants. Past surgical history included cataract surgery in each eye. She has not had laser trabeculoplasty in either eye. Examination revealed uncorrected visual acuity of J1+ in the right eye (near) and 20/30 in the left eye (mini-monovision). There was no afferent pupillary defect. There was mild band keratopathy in each eye while the central cornea was clear in both eyes without keratic precipitates. Here angles were open to gonioscopy without peripheral anterior synechia. There was mild to moderate flare in each eye with trace cells. The IOP was 17 mm Hg in the right eye and 31 mm Hg in the left. Central corneal thickness measured 560 μm and 559 μm in the right and left eye respectively. There was a well-positioned intraocular lens within each capsule with a patent posterior capsulotomy. There was mild vitreous syneresis but no vitreous cell. The cup to disc ratio was 0.5 in each eye with a symmetrical neural rim. The retina was flat without macular edema. Visual field was normal in both eyes (Figures 1 and 2). Optical coherence tomography of retinal nerve fiber layer (RNFL) is shown in Figure 3 and retinal ganglion cell layer is shown in Supplemental Figure 1 (http://links.lww.com/JRS/A756).JOURNAL/jcrs/04.03/02158034-202301000-00020/figure1/v/2022-12-26T045736Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202301000-00020/figure2/v/2022-12-26T045736Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202301000-00020/figure3/v/2022-12-26T045736Z/r/image-tiff Please comment on your management of this patient's left eye.

Not all orbital inflammations in the COVID-19 era are due to mucormycosis – A case of orbital pseudotumour leading to vision loss

A 57-year-old male patient with type 2 diabetes mellitus who had survived severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) disease (COVID-19) presented with loss of vision in the right eye (RE) of 20-day duration. The patient had been diagnosed elsewhere with orbital mucormycosis and had been treated for it. The patient developed vision loss in RE 1 week after the initiation of treatment. At the time of presentation in our institute, vision in RE had reduced to no perception of light. Examination showed a relative afferent pupillary defect and pale optic disc in RE. Gadolinium-enhanced contrast magnetic resonance imaging of the brain, orbit and paranasal sinuses suggested perineuritic type of idiopathic orbital inflammation. In the present COVID-19 scenario, diagnosis other than mucormycosis should be kept in mind when dealing with cases of orbital inflammation.

Open Globe Injury in a Tertiary Hospital of Northern Thailand: No Vision Survival and Ocular Trauma Score.

To determine characteristics and factors associated with no vision survival (included no light perception, enucleation, and evisceration) following open globe injury (OGI) and to correlate the proportion of final vision to predictive values of ocular trauma score (OTS). The medical records of consecutive patients diagnosed as OGI between January 2015 and December 2020 were retrospectively reviewed. Data collected included demographics, mechanisms and modes of injuries, ophthalmic presentations, managements, and visual outcomes at the final visit. Three hundred and seventy-one patients with a mean (standard deviation, SD) age of 44.0 (17.4) years were included. Male with workplace injury was the most frequent scenario. High-velocity metallic objects were the predominant causative materials. Following treatments, fifty-six eyes (14.9%) obtained no vision survival. Factors associated with no vision survival following OGI were low presenting vision, globe perforation, larger wound, presence of relative afferent pupillary defect, retinal detachment, and vitreous hemorrhage. Compared to OTS predictive values, eyes in OTS categories 1 and 2 had a lower proportion of no vision survival. This study identified the importance of workplace injuries. Overall, there were comparable final visions between OTS and this study. However, a reduced proportion of no vision survival among severely injured eyes signifies the challenges of OGI management.

Bilateral Exudative Retinal Detachment Secondary to Malignant Hypertension – A Case Report

To report a case of bilateral exudative retinal detachment secondary to malignant hypertension. Hypertension has been identified as a major cause of morbidity and mortality across the world. A 29-year-old female presented with sudden onset painless loss of vision in both eyes since a day. Known case of hypertension for 6 months on irregular medication. On examination vision of the right eye was hand movement with no pinhole improvement, and on left eye it was counting finger 2 meter with no pin hole improvement. Intraocular pressure of both eyes was normal. Anterior segment examination of right eye was normal except relative afferent pupillary defect. Anterior segment of left eye was normal. Fundus examination - Bilateral disc swelling with inferior retinal detachment extending 4 to 7 clock hours with flame shaped haemorrhages and cotton wool spots over blood vessels with AV crossings with dull foveal reflex. OCT showed bilateral exudative detachment of sensory retina. BP -150/100 mmhg. Further investigation found to have acute renal failure, requiring urgent dialysis, and patient was started on dialysis. 3weeks after blood control was acheived ,visual acquity improved to 6/18 BE with exudative retinal detachment in both eyes resolved by its own except with few residual haemorrhages. Accelerated HTN may precipitate bilateral exudative retinal detachment in patient with acute renal failure in young adults. Bilateral exudative retinal detachment is a catostropic event which results in devastating vision loss within very short time span. Timely intervention may save the vision loss and renal failure. Keywords: Hypertensive retinopathy, Exudative retinal detachment, OCT

Atypical Posterior Reversible Encephalopathy Syndrome Following COVID-19 Vaccination

Purpose: This report describes a visual field defect associated with atypical posterior reversible encephalopathy syndrome (PRES) after coronavirus disease 2019 (COVID-19) vaccination.Case summary: A 25-year-old man presented with visual field defects in both eyes 1 week after COVID-19 vaccination. He had brief chest discomfort following the vaccination. His best-corrected visual acuity was 20/25 in both eyes without relative afferent pupillary defects. The color vision test was normal. The Humphrey visual field test showed a bitemporal visual field defect respecting the vertical midline. A slit-lamp examination revealed no abnormality in the anterior eyes. Funduscopic examination revealed no abnormalities in the posterior parts of the eyes, including the optic discs. Orbital and brain magnetic resonance imaging were normal. Hematological tests, including two auto-antibodies related to optic neuritis (myelin oligodendrocyte glycoprotein and aquaporin-4 antibodies) were normal. Two months after the initial symptoms, the visual field defects had improved. At the 6-month follow-up, there was more improvement. Atypical PRES was diagnosed.Conclusions: Patients may develop visual field defects due to encephalopathy following COVID-19 vaccination. A detailed history and proper imaging studies are needed to diagnose PRES.

Unilateral Papilledema as a Rare Manifestation of Cerebral Neurotoxoplasmosis in HIV Patient: Case Report

Introduction: Cerebral toxoplasmosis is one of the opportunistic diseases that present in patients with HIV/AIDS. One of the rare symptoms is unilateral papilledema due to cerebral toxoplasmosis. Case report: A 26-year-old male patient came with complaints blurred vision for 2 months. The patient had a history of pouting lips, and weakness face, arm, and legs on the left side of the body. The patient has been diagnosed with the observation of space occupying lesion Cerebri in November 2020. Patient with HIV stage IV (WHO) infection and CD4 14 cells/uL and viral load 5.43 x 105 copies /mL. Visual acuity left eye 6/18 PH 6/12, contrast sensitivity examination in both eyes 1.65, and the results of FD-15 are within normal limits, but the results of perimetry was enlargement of blind spot, relative afferent pupillary defect in the left eye, with optic nerve head swelling in the left eye. An MRI showed the presence of intracerebral neurotoxoplasmosis. Discussion: Papilledema is the manifestation of optic nerve abnormality due to an increase in intracranial pressure. Cerebral toxoplasmosis leads to asymmetric target lesion present with ring enhancement image on MRI with contrast which causes SOL and manifests as papilledema. Bilateral papilledema is a hallmark of increasing cerebrospinal fluid pressure, but unilateral papilledema is a rare case with a 2% of prevalence among papilledema cases. Two proposed mechanisms of atypical papilledema were anatomical nerve sheath anomalies and unilateral axoplasmic blockage of the lamina cribrosa. Conclusion: Early diagnosis and appropriate treatment have a very important role in determining the prognosis of patients with cerebral toxoplasmosis.

Orbital Complications of Acute Invasive Fungal Rhinosinusitis: A New Challenge in the COVID-19 Convalescent Patients.

Increased incidence of acute invasive fungal rhinosinusitis (AIFR) in the setting of COVID-19 is undeniable. This can be attributed to its effect on innate immunity and extensive use of corticosteroids. The goal of our study was to assess the orbital complications of AIFR and its management in the COVID-19 convalescent patients. Our longitudinal prospective study included 45 patients with orbital complications of AIFR in recently recovered COVID-19 patients. We performed otorhinolaryngological, ophthalmological, and neurological examinations to monitor the manifestations of the disease. Computed tomography and contrast enhanced magnetic resonance imaging were performed to detect the extent of infection. Antifungal medications, surgical intervention, and general condition management were all provided to all the patients. We reported pre-septal cellulitis, orbital cellulitis, and orbital apex syndrome in 18, 13, and 10 patients, respectively. Four patients had cavernous sinus thrombosis. Mucormycosis and Aspergillus species were detected in 80% and 11.11% of our patients, respectively, while the mixed infection was found in 8.88% of our patients. Diabetes mellitus was the most common cause of immunocompromise (95.55% of our patients). Orbital pain and ophthalmoplegia were the most common ocular manifestations, followed by proptosis and relative afferent pupillary defect. All patients underwent surgical intervention, except for one patient who was unfit for surgery. One patient had orbital exenteration. The ophthalmological manifestations were reversible in cases of orbital and pre-septal cellulitis. The overall survival rate was 66.67%. Early diagnosis and treatment of AIFR can decrease the morbidity and mortality rate of affected patients.

Intermediate uveitis associated with Cogan's syndrome

AbstractPurpose: To describe a case of intermediate uveitis and optic neuritis associated with Cogan's syndrome.Methods: A case report.Results: A 29‐year‐old white Caucasian female was referred to our department for decreased vision in her left eye (LE). Previous medical history revealed relapsing intermediate uveitis and optic neuritis in the LE for 5 years and a sensio‐neural hearing loss a year earlier. On presentation, her ophthalmological examination revealed best corrected visual acuity in the LE of 6/60 with a relative afferent pupillary defect. Slit lamp examination revealed a clear cornea, 0.5+ cells in the anterior chamber and 3+ cells in the vitreous. Fundus examination showed an optic disc atrophy. Examination of the right eye was unremarkable. Examination by the internist revealed palmar erythematous lesions. Laboratory work‐up was negative for infectious diseases. Testing for antinuclear antibodies, antineutrophil cytoplasmic antibodies and rheumatoid factor were negative. The diagnosis of atypical Cogan's syndrome was made based on the association of atypical ophthalmological manifestations and typical audio‐vestibular manifestations. The patient was treated with oral prednisone and azathioprine.Conclusions: Optic neuritis may rarely be an ocular manifestation of Cogan's syndrome.

Orbital Fractures and Risk Factors for Ocular Injury.

To identify factors predictive of serious ocular injury requiring urgent consultation by ophthalmology in patients presenting with blunt trauma orbital fractures. This is a retrospective study of adult patients diagnosed with orbital fractures after blunt trauma at a university medical center emergency room. Patient records were examined over a three-year period. Data including mechanism of injury, fracture location, ocular symptoms, and examination findings were recorded. Ocular injuries were divided into three levels of severity: mild, moderate, and severe. Fracture characteristics, patient demographics, and examination findings were analyzed using multinomial regression to identify risk factors for more severe injury. One hundred and eighty-six patients met inclusion criteria. For 29.6% of patients, urgent ophthalmologic consultation was required. Ruptured globes occurred in 2.2% of injuries. There was a statistically significant association between severe ocular injury and three examination findings: poor vision (OR 14.5; p < 0.001), afferent pupillary defect (OR 44.8; p < 0.001), and abnormal pupillary reaction (OR 28.0; p < 0.001). Likewise, blurry vision (OR 3.6; p = 0.018), ocular pain (OR 3.7; p = 0.011), and facial pain (OR 4.4; p = 0.031) were also associated with an increased risk of severe ocular injury. Abnormal pupillary reaction was associated with moderate injury (OR 4.5; p = 0.041). Demographic factors, mechanism of injury, anti-coagulant use, fracture location, diplopia, no documented vision, subconjunctival hemorrhage, chemosis, and motility restriction were not associated with injury severity. Most patients who presented to the emergency room with an orbital fracture did not require urgent ophthalmologic consultation. The presence of blurry vision, ocular pain, facial pain, poor vision, and afferent pupillary defect significantly increased the odds of severe injury. Abnormal pupillary reaction was associated with both moderate and severe injury.

Successful outcome of paediatric cytomegalovirus optic neuritis treated with combined steroid and valganciclovir: A case report

AbstractPurpose: To report the clinical approach for diagnosis and management of paediatric optic neuritis.Methods: A 13 years old girl patient came to the emergency room with complaints of sudden blurred vision in both eyes and pain with eye movement. On Ophthalmic examination, the visual acuity in the right eye was 6/30 and the left eye was no light perception. There was a positive relative afferent pupillary defect in the left eye. Both the optic disc was swollen. The colour vision was abnormal and there was inferior visual field defect. Laboratory examination showed an increase leukocyte, increase in cytomegalovirus (CMV) immunoglobulin G (IgG) antibody, and decrease in cluster of differentiation 4 (CD4) cell. The head and orbital MRI did not show any intracranial pathological lesion. The patient was diagnosed with optic neuritis caused by CMV and treated with intravenous methylprednisolone 250 mg every 6 h for 3 days followed by oral prednisone 1 mg/kg daily and valganciclovir 16 mg/kg daily for 3 weeks.Results: After 3 days of only intravenous steroid treatment, her visual acuity improved to 6/9 in right eye and 1/300 in left eye. The vision increase significantly to 6/6 in the right eye and 6/7.5 in the left eye after 1 month treated with combined steroid and valganciclovir.Conclusions: A comprehensive examination, includes history taking, optic nerve examination, laboratory and serology tests related to infection, also head and orbital MRI to rule out other causes is important in the management of paediatric optic neuritis. Appropriate treatment with IV methylprednisolone and valganciclovir provide a better visual prognosis for paediatric CMV optic neuritis.

Retinal nerve fiber layer and ganglion cell complex thickness analysis in patients having relative afferent pupillary defect.

To determine the retinal nerve fiber layer (RNFL) thickness and ganglion cell complex (GCC) thickness in patients having relative afferent pupillary defect (RAPD) measured by optical coherence tomography (OCT). This cross-sectional study was conducted on 30 patients with posterior segment disease and glaucoma presenting with RAPD. The control group comprised 30 patients with the aforementioned diseases without RAPD. RAPD was graded using neutral density filters placed over the unaffected eye. Peripapillary RNFL thickness and macular GCC were measured using the Cirrus HD-OCT machine. There were 45 males and 15 females. There was a statistically significant (P < 0.05) difference in the mean of average RNFL thickness in patients having RAPD (64.73 ± 15.16 μm in the affected eyes) as compared to sick control (82.73 ± 11.33 μm in the affected eyes). It was further observed that there was a decrease in RNFL thickness with advancing grades of RAPD. There was a statistically significant (P < 0.05) difference in the mean of average GCC thickness in patients having RAPD (51.57 ± 14.96 μm in the affected eyes) as compared to sick control (76.36 ± 8.06 μm in the affected eyes). Our study suggests that there is a significant reduction in RNFL thickness and GCC thickness in RAPD patients as compared to the sick control group.

Oculomotor and trochlear nerve neuritis following botulinum toxin injection for masseter hypertrophy - a case report with literature review.

To report a rare complication of oculomotor and trochlear nerve neuritis following botulinum toxin injection for masseter hypertrophy. A previously healthy 31-year-old man presented with a two-week history of left eye (OS) ptosis and diplopia, following botulinum toxin injection over the masseter area for masseter hypertrophy at an aesthetic centre. He had no proptosis or facial asymmetry. Visual acuity was 6/6 in the right eye (OD) and 6/9 in the OS. There was anisocoria, with pupils measuring 3 mm in the OD and 5 mm in the OS but no relative afferent pupillary defect. OS appeared hypertropic in primary gaze with impaired intorsion. Extraocular movement of the OS was restricted in all gazes, except for laevoversion; that of the OD was normal. This was associated with diplopia in all gazes except on laevoversion. Both eyes' anterior and posterior segment examinations were otherwise unremarkable. Besides the oculomotor and trochlear nerve, the other cranial nerves and neurological examinations were normal. Investigations including blood and cerebrospinal fluid, magnetic resonance imaging and angiography of the brain, were normal. Our impression was left oculomotor and trochlear nerve neuritis secondary to botulinum toxin injection. He was started on oral prednisolone 1 mg/kg daily and tapered by 5 mg per week. His condition improved gradually with no residual ptosis or anisocoria after three months. Extraocular movements normalised except for minimal residual restriction on depression. Oculomotor and trochlear nerve neuritis can occur following botulinum toxin injection over the masseter area. Healthcare professionals should be aware of this potential complication before offering the injection.