Mydriasis Research Articles

Clinical characteristics and prognosis of 8 cases of severe infant botulism

Objective: To summarize the clinical characteristics and prognosis of severe infant botulism and evaluate the therapeutic effect of botulinum antitoxin in the pediatric intensive care unit (PICU). Methods: The clinical data of 8 cases diagnosed with infantile botulism were retrospectively analyzed in the PICU of Beijing Children's Hospital from October 2019 to August 2023. Data of basic demographic information, clinical manifestations, laboratory tests, treatment and prognosis of each child were collected and analyzed using descriptive statistical methods. Results: Eight laboratory-confirmed cases of infant botulism were included in this study, all of which were male infants with an age of 6.0 (3.3,6.8) months. Three of the children were from Inner Mongolia Autonomous Region, 2 of them were from Hebei, and the other 3 were from Beijing, Shandong and Xinjiang Uyghur Autonomous Region, respectively. All the patients were previously healthy. In 4 of these cases, the possible cause was the ingestion of either honey and its products or sealed pickled food by the mother or child before the onset of the disease. The first symptom was poor milk intake (4 cases), followed by shallow shortness of breath (7 cases), limb weakness (7 cases) and so on. The typical signs were bilateral dilated pupils (8 cases) and decreased limb muscle strength (8 cases). The main subtype was type B (7 cases), and only 1 case was classified as type A. Six of the children were treated with antitoxin therapy for a duration of 24 (19, 49) d. Seven of them had invasive mechanical ventilation. All the patients survived upon discharge with a follow-up period of 29 d to 3 years and 8 months. Six patients had fully recovered, and 2 recently discharged patients were gradually recovering. Conclusions: For infants with suspected contact or ingestion of botulinum and presented with bilateral pupillary paralysis, muscle weakness and clear consciousness, the stool should be collected for diagnostic testing using a mouse bioassay as soon as possible. Type B was the most common type. The antitoxin treatment was effectiveness and the prognosis was well.

Neglected Coats Disease: Determining the Most Appropriate Treatment

Introduction : Coats disease is defined as retinal telangiectasia and aneurysm with retinal exudation that typically found in unilateral eyes of young male. This condition remains a diagnostic challenge because of its varied presentation.
 Case Illustration : A 12-years-old boy presented with a chief complaints of vision loss and pain in the right eye in the last 3 months and gradually blurred vision for a year. Visual acuity was positive light perception in the right eye and 5/5 in the left eye. Intraocular pressure of the right eye was 43.4 mmHg and 15mmHg of the left eye. Slit lamp examination of the right eye revealed conjunctival hyperemia, slightly corneal oedema, iris neovascularization, xantocoria, dilated pupil. Bullous total exudative retinal detachment with telangiectasia in all quadrants was found in the ophthalmoscopy examination of the right eye and left eye is within normal limit. The patient was diagnosed with stage IV coats disease and antiglaucoma agents was given as initial treatment.
 Discussion : Coats disease is a clinical diagnosis that can be assessed by clinical triad of exudative retinal detachment, irregularly-dilated telangiectatic vessel, and peripheral nonperfusion and can be supported by the diagnostic tools such as Ultrasonography, OCT, CT-Scan and MRI. Treatment of coats disease varies depend on the stage. In stage IV coats disease, external drainage is the most appropriate treatment. The more advanced stages demonstrating poor visual acuity both at presentation and at the time of final visit
 Conclusion : Majority of coats disease cases present with advanced stage therefore cause limited treatment option and poorer prognosis.

Searching The New Culprit of Optic Neuritis: The Role of Vitamin D

Abstract
 Introduction : Low vitamin D status has long been associated in multiple sclerosis patient with higher risk of disease progression and frequent relapses. Vitamin D plays an important role in modulating the immune process responsible for demyelination. To this date, the study on vitamin D deficiency in optic neuritis case is still rare.
 Case Illustration : Female, 20 years old, presenting with bilateral sudden visual loss since 1 week prior. The patient looked relatively pale and complained of accompanying headache and myalgia. Visual acuity in both eyes were light perception with dilated pupils and posterior segment showing optic disc swelling. CBC, infection and autoimmune screening came within normal limit and brain MRI further confirmed the presence of optic neuritis. The patient was given high dose intravenous steroid but showed no improvement. Later, she was screened for nutrient deficiency and found sign of low serum 25-hydroxyvitamin D. After one week of oral supplementation and neuroprotective agents, her vision drastically improved to 6/6 in both eyes.
 Discussion : Vitamin D deficiency nowadays is getting more prevalent in high risk individuals with low dietary intake and sunlight exposure. Recent study found that mean serum vitamin D level were significantly lower in autoimmune optic neuritis (ON) and were associated with ON attack severity. Vitamin D sufficiency is associated with better inflammatory outcome and long term neurodegenerative measures in demyelinating diseases, as shown by improvement in RNFL thickness after attack.
 Conclusion : Screening for vitamin D deficiency is essential to consider in managing patient with atypical optic neuritis.

Steroid Induced Glaucoma and Primary Angle Closure Glaucoma: A Case Report of Mixed Mechanism Glaucoma

Introduction : Steroid induced glaucoma is a form of secondary open angle glaucoma (OAG) caused by adverse effects of steroid usage. Primary angle closure glaucoma (PACG) is characterized by shallow anterior chamber accompanied by peripheral anterior synechiae (PAS), elevated IOP and glaucomatous optic neuropathy (GON).
 Case Illustration : A 58 year-old woman presented with red eye, blurry vision, pain in her right eye radiating to the head, watery eye and halo. History of experiencing recurrent red eye, improving after taking steroid topical drug for about 3 months. Visual acuity 6/20 ph 6/20, IOP 39 mmHg, mixed conjunctival injection, shallow anterior chamber Van Herick 1-2, dilated pupil and iris pigment on anterior capsule of lens. Posterior segment showed glaucomatous optic neuropathy with cup disc ratio 0.8-0.9, anterior chamber depth 2.58, and thinning of optic nerve head layer. Patient was diagnosed with steroid induced glaucoma and mixed mechanism PACG. The patient underwent trabeculectomy procedure after mannitol injection was given to reduce IOP.
 Discussion : We diagnosed the patient with steroid induced glaucoma and mixed mechanism PACG based on history, clinical findings, and diagnostics. Steroid raised IOP by accumulating polymerized glycosaminoglycans (GAGs) in the trabecular meshwork, producing "biologic edema" thus increased outflow resistance. PACG was determined based on Van Herick and anterior chamber depth. Trabeculectomy remains an effective treatment in this case where medications were failed to control IOP.
 Conclusion : Steroid induced glaucoma commonly found in OAG, definitive treatment includes halting steroid drugs and trabeculectomy. Further follow-up is needed to evaluate angle closure mechanism.

BILATERAL CONGENITAL MYDRIASIS WITH ACCOMPANYING MIXED DEVELOPMENTAL DELAY

Introduction: Congenital bilateral mydriasis is a rare condition characterized by fixed dilated pupils unresponsive to light. It may occur associated with cardiovascular syndrome, gastrointestinal malformation, or developmental delay. Referred causes in comprehensive differential diagnosis for congenital mydriasis include alterations in ocular structures, ocular innervation alterations and others secondary to trauma, infection, or topical medication. Case Illustration: A 10 months-old boy presented to the hospital with large pupils in both eyes since birth. He has a persistent pupillary membrane with 9 mm diameter of pupil and unable to respond to light in both eyes. The pupillary response test using pilocarpine solution 0.1% showed no difference in diameter of pupils. Comprehensive pediatric examination revealed developmental delay. Computed tomography and laboratory result (laboratory blood count, toxoplasmosis, and cytomegalovirus) within normal limit. After eight months follow up, no significant change in pupil size or light responsiveness was found. Discussion: Comprehensive examination of anterior to posterior segments of the eyes is imperative on the lookout for underdiagnosed diseases. Clinical assessment remains vital for guiding investigations. Observation is required to detect the presence of certain systemic abnormalities that frequently do not manifest at birth. Conclusion: Congenital mydriasis can be diagnosed quickly in ordinary conditions, but it can be quite challenging when it presents as a coincidental finding of other spectrum diseases. It is important to perform a comprehensive general and eye examination to rule out any serious condition related to it. Keyword: Bilateral congenital mydriasis, dilated pupil, mixed developmental delay, pediatric ophthalmology

Serotonin syndrome: An often-neglected medical emergency.

Optimum serotonin level in the serotonergic synapses of the central nervous system (CNS) is related to mood, behavior, and sleep. Serotonin syndrome (SS) is a rare yet very dangerous adverse effect resulting from increased serotonin in CNS. The diagnosis of SS is based on the presence of clinical symptoms, which can include agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle rigidity, tremors, sweating, and diarrhea. SS is invariably caused by inadvertent use of serotonergic medicines. There is an ever-growing list of medicines that are associated with the risk of SS. Some of the common classes of drugs that can contribute to the development of SS include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, stimulants (e.g., amphetamines and cocaine), lithium, opioids, drugs used for recreational purposes like ecstasy Methylenedioxymethamphetamine (MDMA), and some herbal supplements (e.g., St. John's Wort). SS can occur when these medications are taken alone or in combination, especially when a new medication is added, or the dose of an existing medication is changed. The management of SS typically involves discontinuing the use of the substance that caused the excess serotonin levels and providing supportive care, such as intravenous fluids and electrolytes. In severe cases, benzodiazepines may be used to control agitation and muscle rigidity, while serotonin antagonists, such as cyproheptadine, may be used to reduce serotonin levels. The literature review points to a general unawareness among physicians about the condition or drugs associated with it. Consequently, this potentially fatal condition is overlooked. There is a need for regular information updates and reminders to all those who prescribe medications to the patients.

Study of peripheral blur in retinal electrical activity

Aims/Purpose: The aim of this study was to evaluate changes in peripheral refraction by the use of a contact lens to control the progression of myopia. In addition, the response of electrophysiological activity in different areas of the retina with and without contact lens was also determined.Methods: We recruited 7 myopic individuals (23.71 ± 5.41 years) with refraction up to −4.50D (spherical equivalent), without eye pathologies and surgeries. Visual acuity was recorded, high and low contrast, with the updated refraction and with the Misight 1 Day contact lens. Peripheral refraction measurements were obtained using an open‐field autorefractometer. Multifocal electrophysiology measurements were performed binocularly with and without contact lens, with dilated pupil. Topography and aberrometry values were also recorded.Results: lens, peripheral refractions become significantly more myopic. The change in peripheral refraction induced at 30° Nasal is −0.66D. High Contrast Visual Acuity was always superior to Low Contrast VA in both conditions. The Misight 1 Day contact lens manifests a different behaviour along the anterior surface of the cornea. LC induces a significant increase in high‐order aberrations, especially in comatic aberrations, which increase three times their initial value.Conclusions: Regarding the electrophysiological response of the retina, with the use of the LC Misight 1 Day, it presented a greater implicit time and amplitude of the P1 component, in the superior temporal retina, these differences being statistically significant. The implicit time of the P2 component increased in the temporal retina and in the retinal area delimited by Rings 3, 4 and 5.

Low‐cost fundoscopy simulation for everyone? Evaluation of knowledge gain and student satisfaction with the Kyoto Kagaku model

Purpose: To evaluate the influence of a relatively low‐cost fundoscopy simulator, the Kyoto Kagaku Model, on the subjective learning experience and an objective knowledge gain of medical students at Saarland University Medical Center, Homburg, Germany.Methods: Medical students at the Saarland University Medical Center were enrolled in a clinical course about fundoscopic examination and pathologies. The course consisted of a theoretical part, an introduction to the practical basics of ophthalmoscopy with the Kyoto Kagaku fundoscopy simulator, and a clinical practice with dilated pupils on each other (the classical ophthalmoscopy course). They then completed two questionnaires. The first one was about the subjective learning experience and was filled out shortly after the course, the second one about the objective clinical knowledge gain in ophthalmoscopy and was filled out before the start of ophthalmoscopy training and 1 week thereafter.Results: The medical students showed a significant (p < 0.001) gain in knowledge of the fundoscopic examination and pathologies after the course with the Kyoto Kaguka Fundoscopy Simulator. Specific anatomical structures in the fundus were identified significantly (p < 0.001) more often during the simulator training compared to the classical ophthalmoscopy course. 47% of the medical students preferred a simulator‐based course, 23% a classical ophthalmoscopy course and 30% a combination of both.Conclusion: Simulator‐based training is a valuable tool for teaching medical students (and aspiring resident physicians) various skills, including those related to ophthalmology. Hands‐on courses using the Kyoto Kagaku fundoscopy simulator have been successful in increasing medical students' interest in medical simulation and ophthalmology. This model, known for its relatively low cost, is a good immersive tool for teaching the basics of direct and indirect fundoscopic examination and various retinal pathologies. Although there are still challenges to overcome, such as accessibility and cost, the future of simulator‐based training in ophthalmology looks promising.

A Life-Threatening Neurotoxicity in Bungarus Candidus Snake Bite: A Case Report

Background: Bungarus Candidus, a snake inducing severe neurotoxic symptoms. Case: A 31-year-old female presented to the emergency department with complaints of pain in the whole body, limb weakness, shortness of breath after being bitten by a snake. Neurological examination, ptosis of both eyelids was found with normal movement of the eyeballs. Muscle strength in all extremities is 4 followed by decreased physiological reflexes. There are fang marks in the form of 2 slightly swollen and reddened black dots on the left foot. During observation, the patient had decreased consciousness, severe shortness of breath with desaturation without any signs of shock. Other clinical revealed bilateral dilated pupils, dysphonia, dysarthria, and muscle strength that was difficult to assess. The patient was intubated and subsequently admitted to the ICU. The patient regained consciousness but still had difficulty opening his eyes and weak muscle strength on the 2nd of ICU. The patient's condition improved on the 5th of ICU, extubating was performed and transferred to the non-ICU. The treatment obtained included 17 vials of SABU, analgesics, antibiotics, anticholinesterase, and anticholinergic. The patient was discharged after 11 days of hospitalization. Discussion: The neurotoxicity of snake venom is related to mechanisms of neuromuscular transmission blockade, pre-synaptic and post-synaptic. Bungarus Candidus has a peculiar type of toxin, candoxin that acts by inhibiting nicotinic acetylcholine receptors at the postsynaptic site. Recognition of symptoms and management interventions in snakebite cases are critical to patient outcomes and survival.

Ketamine in DUID cases in the greater Cologne area

IntroductionKetamine is primarily used as an anaesthetic or for analgesics in medical treatment, but due to its dissociative and hallucinogenic effects, abuse has increased in the past years leading to several drug impaired driving cases. MethodsEight DUID (driving under the influence of drugs) cases involving ketamine from two institutes of legal medicine over a period from January 2021 to January 2023 were evaluated. The cases were compared with regard to psychomotor impairments, adverse effects on driving performance and co-consumption of drugs. Analyses of ketamine were carried out by high performance liquid chromatography with diode array detection (HPLC-DAD). Other drugs of abuse were either detected via liquid chromatography with tandem mass spectromety (LC–MS/MS) and/or gas chromatography with (tandem) mass spectrometry (GC–MS(/MS)). ResultsKetamine plasma concentrations in a range of approx. 100–1200 ng/mL (mean: 510 ng/mL, median: 370 ng/mL) were detected. Co-consumption of at least one substance was ascertained in all cases. Besides driving impairments, recorded psychomotor impairments of the drivers comprised e.g. dilated pupils, missing or delayed pupil reactions, a slurred or decelerated speech, delayed reaction, lack of concentration, vertigo or agitation. DiscussionThe observed peculiarities were in-line with literature data. However, the assessment and differentiation of ketamine-induced impairments was aggravated due to co-consumption of other drugs of abuse or pharmaceuticals in the herein investigated cases. Nevertheless, in two cases impairments can be attributed mainly to ketamine consumption since the co-consumed substances were only detected in low concentrations. ConclusionThe presented cases provide additional data on psychomotor impairments observed in ketamine-related DUID cases. Limiting factors are co-consumption of substances, unknown habituation to drugs and the limited case number. Nevertheless, the results of this study are comparable with existing literature data. Since the abuse of ketamine has increased in the past years, these data will support forensic casework.

Adie’s tonic pupil: Significance in aviators and aeromedical disposal

Adie’s tonic pupil is a benign, usually unilateral, pupillary syndrome, in which a larger than normal pupil responds minimally, if at all, to light, but constricts slowly and tonically to a near stimulus (light-near dissociation) and has cholinergic super-sensitivity. It induces impaired near vision, glare, photophobia, and difficulty with dark adaptation, which may not be conducive in a flying environment. A Weapon System Operator of a fighter aircraft with an isolated dilated pupil was assessed over approximately 3 years – right from the beginning until his condition became stable. His condition was not considered an absolutely disabling condition for aviation and he was finally retained in flying in the restricted medical category. The important aspects considered in the aeromedical assessment were – neurological assessment; ophthalmic issues such as tolerance to glare and visual acuity; anisocoria and the executive report on flying concerning visual response to bright sunlight, ability to read maps and MFDs, and ability to identify ground features and spot another ac in bright light conditions. The aviator did not have any neurological, traumatic, or systemic condition/Adie’s syndrome. The tonic pupil stabilized at 4 mm and there was an anisocoria of 2 mm. Light-near dissociation persisted. His executive report was uncomplimentary concerning spotting another aircraft in bright sunlight in the air-superiority fighter (which flies at a max speed of 2120 kmph) as his eyes were getting shut by the glare. However, he could read MFDs, maps, and pick up ground features comfortably and satisfactorily. Hence, considering that Navigation in a transport ac was his parent branch (max speed 452 kmph), he was advised a trial on that ac to assess his capabilities in performing Flt Nav duties. If successful, the organization could revert him back to his parent branch and original ac, thereby avoiding attrition of a valuable human resource. This case demonstrates that Adie’s tonic pupil is not always a disabling condition for military flying. Nevertheless, it has to be analyzed on a case to case basis. Aeromedical disposal of a potentially disqualifying case, having no reference in the available aeromedical guidelines.

Quantitative analysis of optic disc changes in school-age children with ametropia based on artificial intelligence.

To explore changes in the optic disc and peripapillary atrophy (PPA) in school-age children with ametropia using color fundus photography combined with artificial intelligence (AI) technology. Based on the retrospective case-controlled study, 226 eyes of 113 children aged aged 6-12y were enrolled from October 2021 to May 2022. According to the results of spherical equivalent (SE), the children were divided into four groups: low myopia group (66 eyes), moderate myopia group (60 eyes), high myopia group (50 eyes) and emmetropia control group (50 eyes). All subjects underwent un-aided visual acuity, dilated pupil optometry, best-corrected visual acuity (BCVA), intraocular pressure, ocular axis measurement and color fundus photography. The width of PPA, horizontal diameter ratio of PPA to the optic disc and area ratio of PPA to the optic disc were significantly different among the four groups (P<0.05). The width of the nasal and temporal neuroretinal rim, the roundness of the optic disc, the height of PPA, the vertical diameter ratio of PPA to the optic disc, and the average density of PPA in the high myopia group were significantly different compared with the other three groups (P<0.05). There were strong negative correlations between SE and area ratio of PPA to the optic disc (r=-0.812, P<0.001) and strong positive correlation between axial length (AL) and area ratio of PPA to the optic disc (r=0.736, P<0.001). In school-age children with high myopia, the nasal and temporal neuroretinal rims are narrowed and even lost, which have high sensitivity. The area ratio of the PPA to the optic disc could be used as an early predictor of myopia progression, which is of great significance for the development prevention and management of myopia.

Role of Decompressive Craniectomy in the Treatment of Malignant Cerebral Venous Sinus Thrombosis: A Single Center Consecutive Case Series Study in China

ObjectivePatients with cerebral venous sinus thrombosis (CVST) may die during the acute phase due to increased intracranial pressure and cerebral herniation. The purpose of this study was to assess the role of decompressive craniectomy in the treatment of patients with malignant CVST. Patients and MethodsPatients who underwent decompressive craniectomy and were consequently admitted to the Critical Care Unit, Department of Neurosurgery, at Capital Medical University Xuanwu Hospital from March 2010 to January 2021 were retrospectively examined with follow-up data at 12 months. ResultsIn total, 14 cases were reviewed, including 9 female and 5 male patients, aged 23–63 years (42.7±12.3 years). Prior to surgery, all patients had a GCS score < 9. Six patients had a unilateral dilated pupil, while 4 patients had bilateral dilated pupils. According to the head computed tomography (CT), all patients had hemorrhagic infarction, and the median midline shift was 9.5 mm before surgery. Thirteen patients underwent unilateral decompressive craniectomy, and 1 patient underwent bilateral decompressive craniectomy, among whom, 9 patients underwent hematoma evacuation. Within three weeks of surgery, 3 cases (21.43%) resulted in death, with 2 patients dying from progressive intracranial hypertension and 1 from acute respiratory distress syndrome (ARDS). Eleven patients (78.57%) survived after surgery, of whom 4 (28.57%) patients recovered without disability at 12-month follow-up (mRS 0-1), 2 (14.29%) patients had moderate disability (mRS 2-3), and 5 (35.71%) patients had severe disability (mRS 4-5). ConclusionEmergent decompressive craniectomy may provide a chance for survival and enable patients with malignant CVST to achieve an acceptable quality of life.

Cone-driven strong flash electroretinograms in healthy adults: Prevalence of negative waveforms

PurposeBoth rod and cone-driven signals contribute to the electroretinogram (ERG) elicited by a standard strong flash in the dark. Negative ERGs usually reflect inner retinal dysfunction. However, in diseases where rod photoreceptor function is selectively lost, a negative waveform might represent the response of the dark-adapted cone system. To investigate the dark-adapted cone-driven waveform in healthy individuals, we delivered flashes on a dim blue background, designed to saturate the rods, but minimally adapt the cones.MethodsERGs were recorded, using conductive fibre electrodes, in adults from the TwinsUK cohort. Responses to 13 cd m−2 s white xenon flashes (similar to the standard DA 10 flash), delivered on a blue background, were analysed. Photopic and scotopic strengths of the background were 1.3 and 30 cd m−2, respectively; through a dilated pupil, this is expected to largely saturate the rods, but adapt the cones much less than the standard ISCEV background. ResultsMean (SD) participant age was 62.5 (11.3) years (93% female). ERGs from 203 right and 204 left eyes were included, with mean (SD) b/a ratios of 1.22 (0.28) and 1.18 (0.28), respectively (medians, 1.19 and 1.17). Proportions with negative waveforms were 23 and 26%, respectively. Right and left eye b/a ratios were strongly correlated (correlation coefficient 0.74, p < 0.0001). We found no significant correlation of b/a ratio with age.ConclusionsOver 20% of eyes showed b/a ratios less than 1, consistent with the notion that dark-adapted cone-driven responses to standard bright flashes can have negative waveforms. The majority had ratios greater than 1. Thus, whilst selective loss of rod function can yield a negative waveform (with reduced a-wave) in some, our findings also suggest that loss of rod function can occur without necessarily yielding a negative ERG. One potential limitation is possible mild cone system adaptation by the background.

Ureaplasma-Induced Hyperammonemia Syndrome - an Acute Complication Post Allogeneic Stem Cell Transplant

Hyperammonemia syndrome is characterized by elevated serum ammonia levels and neurological dysfunction due to cerebral encephalopathy, andcauses lethargy, confusion, hyperventilation, seizures, death. In solid organ transplantation, hyperammonemia syndrome has been reported as a potentially fatal complication secondary to Ureaplasma infection ( Ureaplasma urealyticum or parvum). We present a patient with acute lymphoblastic leukemia (ALL) who underwent allogeneic stem cell transplant (HSCT) and developed hyperammonemia syndrome during systemic infection with Ureaplasma urealyticum. A 32-year-old female with B-ALL received a haploidentical HSCT complicated by stage II acute GvHD of the gut and skin. During her hospital course, on Day +43, cellulitis of the right arm was diagnosed and treated empirically with amoxicillin-clavulanate on discharge. She presented back to the hospital on Day +53 with bilateral elbow pain and cellulitis. She had no focal neurological deficits initially but became increasing drowsy with dilated pupils. She had no episodes of sustained fever throughout her hospitalization. Empiric antimicrobial coverage with Meropenem and Vancomycin was given, and she was intubated and admitted to the ICU all on the same day. CT head was normal, and blood cultures and lumbar puncture were negative. She developed status epilepticus and her ammonia level increased to &amp;gt;1500 μmol/L on Day +57. Liver function, renal function and extended electrolytes remained within normal limits. MRI was consistent with hyperammonemic encephalopathy, prompting initiation of intermittent hemodialysis, lactulose, Rifaximin, and L-carnitine. EEG revealed no discernible rhythms, and intensive life support was discontinued on Day +61. PCR testing of preserved lung tissue confirmed Ureaplasma urealyticum as the likely cause. Ureaplasma infections can be a serious complication of HSCT. The hydrolysis of urea by U reaplasma leads to elevated serum ammonia levels when systemic infections occur in immunocompromised patients. HSCT patients often have hypogammaglobulinemia due to conditioning and immunosuppressive therapies with a reduced ability to neutralize Ureaplasma. The role of neutrophil in controlling Ureaplasma is limited, as antibody-mediated defence is the sole mechanism of protection. Other contributing factors that can exacerbate hyperammonemia include Valproic acid, severe liver disease, and TPN. Ureaplasma is challenging to diagnose due to limited growth on standard culture medium PCR testing is required for diagnosis and was the method of detection in our reported case. Numerous cases in non-HSCT immunocompromised populations have reported soft tissue infections involving Ureaplasma species, indicating a possible source for infection in the current case. Although there are no other reported cases of cellulitis and Ureaplasma infection in HSCT, a previous case with polyarthritic involvement may be mechanistically similar. A literature review was completed with results presented in Table 1 outlining details of reported cases with confirmed Ureaplasma infection post-HSCT. The cases were quite heterogenous although two of the cases were treated for Non-Hodgkin's Lymphoma where they were heavily pretreated with agents targeting B-Cells and immunoglobulin production. Empirical doxycycline should be considered first line due to the Ureaplasma resistance to other agents such as Azathioprine. Beta-lactam antibiotics and vancomycin have limited efficacy as Ureaplasma's does not have a cell wall. Adjunct therapies to reduce ammonia production and increase elimination should also be considered. Ureaplasma should be considered in immunocompromised patients in the context of fever of unknown origin and altered level of consciousness, especially if rising serum ammonia levels and soft tissue infections is present. The overall 50% mortality associated with the six cases presented demonstrates the significant risk associated with the infection.

THU100 Case Of A Large Suprasellar-clival Mass: Prolactinoma Vs Paraganglioma

Abstract Disclosure: L.N. Madera Marin: None. Y. Rivera-Nieves: None. M.A. Ortiz-Rivera: None. A. Rosado-Burgos: None. L. El Musa Penna: None. W. Medina-Torres: None. L. Sepulveda-Garcia: None. M. Ramirez: None. L.A. Gonzalez-Rodriguez: None. M. Alvarado: None. N. Canales: None. Introduction Prolactin secreting adenomas comprise 30-40% of all pituitary adenomas. Generally, serum prolactin levels correlate with tumor size. Giant prolactinomas measure &amp;gt;4 cm, most have mass related clinical effects. Even large masses respond to cabergoline. Some may require surgical intervention. We present a case of a large pituitary mass associated with elevated prolactin levels, but with an interesting histopathologic analysis. Patient Description 30 y/o male patient with new onset decreased peripheral vision. Retinologist evaluation showed no abnormalities. Laboratories done by PCP found with altered thyroid function tests, but no treatment offered at the time. Two months later, the patient complained of worsening peripheral vision and was found with a left dilated pupil. A head CT scan was performed that showed a large brain mass. Admitted for urgent neurosurgery evaluation and high dose dexamethasone was initiated. ROS was remarkable for weight gain over the past year, and decreased morning erections, although denied decreased libido or erectile dysfunction. MRI showed an infiltrative skull base tumor extending from the clivus to the parasellar area encasing the left cavernous segment of the internal carotid artery with expansion of the sella obliterating the pituitary gland, and extension into the left optic canal. Pre-operative laboratories: Prolactin &amp;gt;877 ng/ml (2-17ng/ml), Cortisol 1.80 mcg/dL (4-22 mcg/dL), TSH 1.45 uIU/ml (0.4-4.0 uIU/ml), Sodium 142mMol/L (135-145mMol/L). Patient underwent left pterional craniotomy. Initial intra-operative pathology: “Positive for Neoplasia”. Post-operative laboratories: Prolactin &amp;gt;877 ng/ml, TSH 0.229 uIU/ml, FSH &amp;lt;0.30 mIU/ml (1.2-7.8 mIU/ml), and LH 0.16 mIU/ml (1.5-9.3 mIU/ml). Case Outcomes/Discussion Central hypothyroidism and hypogonadism confirmed, secondary hypocortisolism could not be assessed due to emergent corticosteroid infusion upon admission. A presumptive diagnosis of a giant prolactinoma was made for which cabergoline therapy was initiated. Final pathologic diagnosis revealed a paraganglioma. Urine fractionated metanephrines and catecholamines were normal. Immunostaining for prolactin requested. Paragangliomas arise from neuroendocrine cells, from either sympathetic or parasympathetic ganglia and can be solitary or multiple. Skull base and neck paragangliomas are usually benign while ∼20% of abdominal paragangliomas (sympathetic) are malignant. Anterior skull base paragangliomas are predominantly located in the sella and are rare but have been described in the literature. Very rare cases of pheochromocytomas or paragangliomas associated to pituitary adenomas have been reported. It has been named as the three P association, thought to be related to succinate dehydrogenase B and D mutations. Moreover, there are no cases in the literature of paragangliomas secreting prolactin. Presentation: Thursday, June 15, 2023

Adie pupil. Literature review

Anisocoria (unequal pupil size) is a condition described as various lacerations in iris sphincter or dilator muscles, innervation abnormalities, or conditions caused by external pharmacological agents. Adie pupil is one of the causes of anisocoria. Adie pupil is a rare neurological disorder which represents itself with unilateral or bilateral mydriasis, unresponsiveness to bright or dim light, and constriction on accommodation. This condition is idiopathic, affecting 25-45-year-old adults, more frequently women. The symptoms are a unilateral or bilateral dilated pupil, photophobia, and blurred vision. The diagnosis is based on patients’ symptoms, clinical examination findings, and a dilute pilocarpine test can also be performed. Most patients do not need treatment. In this article, we review the epidemiology, pathogenesis, etiology, clinical evaluation, diagnostic features, treatment of Adie pupil, its relationship with COVID-19, and other conditions that cause anisocoria.

One case of acute poisoning with stramonium

This paper reported 1 case of poisoning caused by stramonium. Cases of Datura poisoning have been reported nationwide, Its effect on the central nervous system of patients is characterized by first excitation and then inhibition, clinical manifestations include decreased gland secretion, dilated pupils, and tachycardia, etc. Its poisoning mechanism is anticholinergic effect, the effect on Peripheral nervous system is to inhibit Parasympathetic nervous system. Hemoperfusion combined with neostigmine anticholinergic therapy at the early stage of poisoning can effectively improve the clinical symptoms of patients in a short time.

Outcomes of three-piece rigid scleral fixated intraocular lens implantation in subjects with deficient posterior capsule following complications in manual small incision cataract surgery

ObjectiveTo evaluate the surgical visual outcomes of three-piece rigid scleral fixated intraocular lens (SFIOL) implantation in subjects with deficient posterior capsule following complications of cataract extraction. DesignRetrospective 4-year cohort study. ParticipantsData from 174 eyes that underwent SFIOL combined with pars plana vitrectomy (PPV) between January 2018 and March 2022 and follow-up exams were included. MethodsDemographic characteristics including primary indications for surgery, history of trauma, laterality, baseline and best-corrected visual acuity (BCVA), refraction as spherical equivalent (SE), intraocular pressure (IOP), duration of follow-up, and complications were analyzed. ResultsThe mean preoperative BCVA was 1.38 ± 0.46 logarithm of the minimum angle of resolution (logMAR), which improved significantly to 0.37 ± 0.22 logMAR. The baseline refractive status measured in spherical equivalent (SE) was 4.1 ± 6.2 Diopters (D), and the postoperative status was −0.4 ± 0.97 D. Early postoperative complications included hypotony (n = 1; 0.57%, vitreous hemorrhage (n = 3; 1.72%), elevated IOP (n = 8; 4.59%), mild dilated pupil (n = 1; 0.57%) and corneal edema (n = 16; 9.19%). Late complications included in this study were retinal detachment (n = 1; 0.57%), cystoid macular edema (CME) (n = 1; 0.57%), primary glaucoma (n = 1; 0.57%), secondary glaucoma (n = 13; 7.47%), zonular dehiscence (n = 3; 1.72%), retinal pigment epithelium (RPE) changes (n = 3; 1.72%), choroidal coloboma (n = 2; 1.14%), posterior dislocation of posterior chamber IOL (PCIOL) (n = 1; 0.57%), corneal decompensation (n = 1; 0.57%), retinal hemorrhage (n = 1; 0.57%), macular hole (n = 1; 0.57%), chronic uveitis (n = 1; 0.57%), mild non-proliferative diabetic retinopathy (NPDR) (n = 3; 1.72%), and mild NPDR with diabetic macular edema (DME) (n = 1; 0.57%). ConclusionIntegrating IOL implantation with vitrectomy various posterior segment complications were resolved in the same setting without attempting a second surgery.

Unilateral Oculomotor Nerve Palsy as a Rare Manifestation of Isolated Pre-Communicating Segment of Posterior Cerebral Artery Thrombosis.

Ipsilateral mydriasis (IM) is usually not acute. However, the acute occurrence of unilateral dilated pupil may result in acute ischemic stroke. Herein, we present 3 patients with IM, lateral eye deviation, ptosis, and contralateral hemiparesis due to isolated occlusion of the pre-communicating segment of the posterior cerebral artery with preservation of the posterior communicating artery, which was successfully treated by emergent mechanical thrombectomy. In a 3-month follow-up, all patients were independent without any neurological deficits.