Eye Deviation Research Articles

Cortical symptoms described in emergency calls for patients with suspected large vessel occlusion: a descriptive analysis of 157 emergency calls

BackgroundEmergency medical dispatchers typically use the dispatch code for suspected stroke when the caller brings up one or more symptoms from the face-arm-speech triad. Paramedics and emergency department physicians are trained to suspect large vessel occlusion stroke when the stroke patient presents with hemiparesis and cortical symptoms: neglect, aphasia, and conjugate eye deviation (CED). We hypothesized that these symptoms could be evident in the emergency call.In this study, we aimed to describe common symptoms mentioned in the emergency calls for paramedic-suspected thrombectomy candidates. Secondly, we wanted to explore how the question about CED arises in the Finnish suspected stroke dispatch protocol. Our third aim was to find out if the symptoms brought up in suspected stroke and non-stroke dispatches differed from each other.MethodsThis was a retrospective study with a descriptive analysis of emergency calls for patients with paramedic-suspected large vessel occlusion stroke. We listened to the emergency calls for 157 patients transported to Tampere University Hospital, a Finnish comprehensive stroke centre. Two researchers listened for symptoms brought up in these calls and filled out a pre-planned case report form.ResultsSpeech disturbance was the most common symptom brought up in 125 (80%) calls. This was typically described as an inability to speak any words (n = 65, 52% of calls with speech disturbance). Other common symptoms were falling down (n = 63, 40%) and facial asymmetry (n = 41, 26%). Suspicion of stroke was mentioned by 44 (28%) callers. When the caller mentioned unconsciousness the emergency dispatcher tended to use a non-stroke dispatch code. The dispatchers adhered poorly to the protocol and asked about CED in only 57% of suspected stroke dispatches. We found CED in 12 emergency calls and ten of these patients were diagnosed with large vessel occlusion.ConclusionIn cases where paramedics suspected large vessel occlusion stroke, typical stroke symptoms were described during the emergency call. Speech disturbance was typically described as inability to say anything. It is possible to further develop suspected stroke dispatch protocols to recognize thrombectomy candidates from ischemic cortical signs such as global aphasia and CED.

Predictive value of video alone in diagnosis of epileptic vs paroxysmal nonepileptic events in children

ObjectivePrevious studies examined the use of video-based diagnosis and the predictive value of videos for differentiation of epileptic seizures (ES) from paroxysmal nonepileptic events (PNEE) in the adult population. However, there are no such published studies strictly on the pediatric population. Using video-EEG diagnosis as a gold standard, we aimed to determine the diagnostic predictive value of videos of habitual events with or without additional clinical data in differentiating the PNEE from ES in children. MethodsConsecutive admissions to our epilepsy monitoring unit between June 2020 and December 2020 were analyzed for events of interest. Four child neurologists blinded to the patient’s diagnosis formulated a diagnostic impression based upon the review of the video alone and again after having access to basic clinical information, in addition to the video. Features of the video which helped to make a diagnosis were identified by the reviewers as a part of a survey. ResultsA total of 54 patients were included (ES n = 24, PNEE n = 30). Diagnostic accuracy was calculated for each reviewer and combined across all the ratings. Diagnostic accuracy by video alone was 74.5% (sensitivity 80.8%, specificity 66.7%). Providing reviewers with basic clinical information in addition to the videos significantly improved diagnostic accuracy compared to viewing the videos alone. Inter-rater reliability between four reviewers based on the video alone showed moderate agreement (κ = 0.51) and unchanged when additional clinical data were presented (κ = 0.51). The ES group was significantly more likely to demonstrate changes in facial expression, generalized stiffening, repetitive eye blinks, and eye deviation when compared with the PNEE group, which was more likely to display bilateral myoclonic jerking. ConclusionsVideo review of habitual events by Child Neurologists may be helpful in reliably distinguishing ES from PNEE in children, even without included clinical information.

Preliminary statistical analysis of anthropometrics data in related to sitting posture among college students at east coast Malaysia

To statistically analyse sitting posture using anthropometrics data among college students in Malaysia. This study was conducted among 52 college students consisting of males and females. Data were analysed using a common statistical tool which is the Statistical Package of Sosial Science (SPSS). Preliminary analysis of data indicated that there are wider differences in standard deviation of eye sitting height compared to the previous study conducted. This study was conducted at only one higher learning institution/college located at East Cost of Malaysia. The larger value of standard deviation discovered as statistical analysis performed using combined data among male and female participants suggested that data should be segregated. Result obtained could be used as a preliminary guideline to design any related item in related to sitting posture.

Endocannabinoid dysfunction in neurological disease: neuro-ocular DAGLA-related syndrome.

The endocannabinoid system is a highly conserved and ubiquitous signalling pathway with broad-ranging effects. Despite critical pathway functions, gene variants have not previously been conclusively linked to human disease.We identified nine children from eight families with heterozygous, de novo truncating variants in the last exon of DAGLA with a neuro-ocular phenotype characterized by developmental delay, ataxia and complex oculomotor abnormality. All children displayed paroxysms of nystagmus or eye deviation accompanied by compensatory head posture and worsened incoordination most frequently after waking. RNA sequencing showed clear expression of the truncated transcript and no differences were found between mutant and wild-type DAGLA activity. Immunofluorescence staining of patient-derived fibroblasts and HEK cells expressing the mutant protein showed distinct perinuclear aggregation not detected in control samples.This report establishes truncating variants in the last DAGLA exon as the cause of a unique paediatric syndrome. Because enzymatic activity was preserved, the observed mislocalization of the truncated protein may account for the observed phenotype. Potential mechanisms include DAGLA haploinsufficiency at the plasma membrane or dominant negative effect. To our knowledge, this is the first report directly linking an endocannabinoid system component with human genetic disease and sets the stage for potential future therapeutic avenues.

Pearls & Oy-sters: Vertical Diplopia and Ocular Torsion: Peripheral vs Central Localization.

We describe a case with torsional deviation of the eyes from a brainstem lesion. Torsional eye movement refers to changes in the position of the eyes in the roll plane around the visual axis. When the head is tilted laterally (that is, rolled toward the shoulder), the eyes roll in the opposite direction as part of the torsional vestibulo-ocular reflex known as the ocular counter-roll. Pathologies that affect the otolith-ocular pathway can lead to a torsional deviation of the eyes as part of the ocular tilt reaction (OTR) that also causes vertical deviation of the eyes (skew deviation) and head tilt. Lesions caudal to the pontomedullary junction (such as the labyrinth, eighth cranial nerve, or vestibular nucleus) result in an OTR with ipsiversive torsional deviation, whereas lesions rostral to the junction result in an OTR with contraversive torsional deviation. Furthermore, torsional deviation of the eyes in the OTR is conjugate (incyclotorsion in the higher eye and excyclotorsion in the lower eye), whereas torsional deviation from ocular palsy in peripheral lesions is disconjugate (e.g., exyclotorsion only in the higher eye with superior oblique palsy). Therefore, the pattern of torsional eye deviation can be helpful in localizing the lesion. Several techniques including fundus photography, double Maddox rod testing, optical coherence tomography, and video-oculography are used to measure torsional eye position.

Altered Homotopic Connectivity in the Cerebellum Predicts Stereopsis Dysfunction in Patients With Comitant Exotropia.

PurposeComitant exotropia (CE) is a common eye disorder characterized by impaired stereoscopic vision and eye deviation. Previous neuroimaging studies demonstrated that patients with CE were accompanied by specific functional and structural abnormalities of the brain. However, the effect of impaired stereoscopic vision and eye deviation on interhemispheric homotopic connectivity remains unknown.MethodsA total of thirty-six patients with CE (25 males and 11 females) and 36 well-matched healthy controls underwent magnetic resonance imaging scanning. The voxel-mirrored homotopic connectivity (VMHC) method was applied to assess the interhemispheric homotopic connectivity changes in patients with CE. Furthermore, the support vector machine method was applied to assess to differentiate patients with CE from healthy controls (HCs) with the VMHC maps as a feature.ResultsCompared with HCs, patients with CE showed significantly increased VMHC values in the bilateral cerebelum_ 8 and cerebelum_4_5. Moreover, we found that the VMHC maps showed an accuracy of 81.94% and an area under the curve of 0.87 for distinguishing the patients with CE from HCs.ConclusionOur study demonstrates that patients with CE showed interhemispheric homotopic connectivity changes in the cerebellum, which might reflect the neurological mechanisms of impaired stereoscopic vision and eye deviation in patients with CE.

Transient loss of consciousness in children: Syncope or epileptic seizure?

Background & Objective: Transient loss of consciousness (TLOC) is often benign from syncope but may be due to epileptic seizure. In this study, we aimed to evaluate the clinical differences between TLOC from epileptic seizures and syncope. Methods: The medical records of 300 children with TLOC were analyzed retrospectively. Age, sex, clinical symptoms, trigger factors, laboratory findings, ECG, ECHO, EEG and neuroimaging findings, as well as the causes of TLOC were reviewed. Results: Out of the 300 children admitted with TLOC, 288 (96%) were diagnosed as syncope. Of these patients, 231 (77%) were diagnosed as vasovagal syncope, 19 (6.3%) as orthostatic hypotension, and 38 (12.7%) as unclassifiable syncope. Twelve (4.2%) patients were diagnosed with epilepsy. Patients with epilepsy showed significantly higher rates of collapse and eye deviation during TLOC, as well as occurring in sitting and supine position (p=0.012, p=0.039, p=0.03 respectively). Conclusion: For a differential diagnosis, TLOC accompanied by collapse, eye deviation and occurrence in sitting or supine position are suggestive of epilepsy.

B.4 Spatiotemporal mapping and decoding of oculomotion in the pediatric frontal eye field

Background: The frontal eye fields (FEFs) are linked to oculomotor control and hypothesized to reside in the prefrontal cortex, where electrical stimulation reportedly evokes contraversive eye movements. The exact location and function of the FEFs in humans is controversial. Stereo-electroencephalography (SEEG) is a minimally invasive technique used to guide epilepsy surgery. It provides a unique opportunity to collect human neurophysiological data outside of the operating room and has been used by other groups to advance our understanding of specific brain functions. Methods: Two pediatric subjects undergoing non-lesional epilepsy workup were enrolled into this prospective, IRB-approved study, and received brain MRI prior to SEEG implantation. SEEG recordings were collected with video of the subjects’ eyes while performing gaze-related tasks. Results: Stimulation testing elicited contraversive head turning with or without eye deviation, and hemifacial spasm, depending on the site of stimulation. Low-threshold sites eliciting these stereotyped movements were located just deep to the inferior precentral gyrus. Stimulation of sites in the posterior middle frontal gyrus did not elicit eye movements. Conclusions: Our findings suggest that the FEFs are located more posteriorly than widely held, involving the motor cortex. Further testing in pediatric and adult subjects is warranted to confirm this hypothesis.

Bardet Biedl Syndrome-Report of three Cases and Review of Recent Articles

Purpose: To report three cases of a rare inherited familial disorder of Bardet-Biedl Syndrome (BBS). Study Design: Observational case report. Method: Two out of eight siblings presented in their second decade of life with dimness of vision in both eyes since birth. The third one is the only person of the family presented also in second decade of life with gradual blurring of vision in both eyes and outward deviation of left eye. Detail clinical history was taken. Physical, anthropometric, ophthalmic, psychological examination was done and appropriate clinical investigations were performed to exclude other systemic disorder. Review of recent literatures was done. Result: First two cases were brothers, who were mentally retarded child with delayed developmental mile stone. They were short, obese and had polydactyly, gynecomastia, hypogonadism. Their vision was poor and had retinitis pigmentosa with optic atrophy. The third one was also mentally retarded and had polydactyly, trunkal obesity, atypical retinitis pigmantosa with optic atrophy. They did not had deafness or any systemic abnormalities. Depending on clinical findings they were diagnosed as a case of BBS.

Teaching Video NeuroImage: Oculogyric Crises in a 12-Year-Old Girl With Rapid-Onset Dystonia Parkinsonism.

A 12-year-old girl presented to the emergency department for forced upward eye deviation for 2 hours with craniocervical dystonia and intact consciousness. During the half-year, she experienced several emotionally triggered attacks (Video 1). Sudden-onset dystonic gait occurred 1 month before the first attack and progressively deteriorated with subsequent attacks. All limbs showed bradykinesia and rigidity without ataxia. Normal EEG and consciousness suggested oculogyric crises rather than epilepsy. A de novo pathogenic variant in ATP1A3 (c. 2767 G > A) confirmed rapid-onset dystonia parkinsonism (Figure), which is not generally dopa-responsive.1 However, since her oculogyric crises might correlate with a hypodopaminergic state,2 levodopa was beneficial. Adding flunarizine improved her condition.

Looking out or Looking Away?—Exploring the Impact of Driving With a Passenger on Young Drivers’ Eye Glance Behavior

Objective To explore how passenger presence and the degree of association between young driver and passenger influences young drivers’ eye glance behavior when they are subjected to distraction. Background Young drivers (18–20 years old) are at an elevated crash risk when subjected to distraction. They are likely to be distracted even further when they drive with passengers. However, the eye glance behavior of these drivers when driving with passengers has not been explored. Method Eye glance data of 34 young drivers between the ages of 18 and 20 years were collected. Participants drove with and without a passenger while subjected to three distracting tasks (visual-manual, cognitive, or visual-cognitive) and driving scenarios that required driver attention. Results Visual-cognitive as well as visual-manual states of distraction result in higher mean and standard deviation of glance duration, along with higher number of glances away from road. Passenger presence is found to negatively influence young drivers’ eye glance behavior. The degree of association between the young driver and the passenger may help reduce the deviation of eye glances towards the task-related objects. Conclusion In addition to distraction, passengers have a negative influence on the eye glance behavior of young drivers. However, a high degree of association between driver and passenger may mitigate the negative impact of distraction on the eye glance behavior of young drivers. Application (non-theoretical works) This research may aid in the design of interventions that improve young drivers’ eye glance behavior when they drive with their peers.

Study of Geometric Illusory Visual Perception - A New Perspective in the Functional Evaluation of Children With Strabismus.

Despite the various perceptual-motor deficits documented in strabismus, there is a paucity of studies evaluating visual illusions in patients with strabismus. The aim of this study was to examine how the illusionary perception occurs in children/adolescents (10–15 years old) with strabismus with referral for surgery to correct ocular deviations. A controlled cross-sectional study was carried out in which 45 participants with strabismus and 62 healthy volunteers aged 10–15 years were evaluated. The behavioral response to three geometric illusions [Vertical-Horizontal illusion, Müller-Lyer illusion (Bretano version) and Ponzo illusion] and respective neutral stimuli (non-illusory images) regarding the estimation of image size and response time were measured using the Method of Adjustment. To analyze the influence of secondary factors: type of ocular deviation (convergent, divergent or associated with vertical deviation); amount of eye deviation; presence of amblyopia and stereopsis, a one-way ANOVA was performed. Among the tested illusions, children with strabismus showed greater susceptibility (p = 0.006) and response time (p = 0.004) to Ponzo’s illusory images. Children with strabismus and preserved stereopsis, on the other hand, showed similar susceptibility and response time to control group patients to the Ponzo illusion (p < 0.005). Patients with amblyopia showed overcorrection in the estimate of non-illusory Ponzo images (p = 0.046). Children with horizontal ocular deviation (esotropia or exotropia) associated with vertical deviation (hypertropia, DVD and/or alphabetical anisotropy) showed higher susceptibility to vertical adjustment images for the Müller-Lyer illusion (Brentano version) (p = 0.017). Individuals with strabismus tended to overcorrect the length of the straight-line segment adjusted for non-illusory images when testing non-illusory images in the Müller-Lyer test (Brentano version) (p = 0.009), as well as for the neutral images in the Vertical-Horizontal test (p = 0.000). The findings indicated impairment in the perception of geometric illusions and neutral figures, especially for the Ponzo illusion test by children with strabismus. As the behavioral response to illusory images may indirectly reflect the visual and morphofunctional alterations present in these individuals, we suggest that the investigation of visual illusory perception can be used as a new research strategy in the field of investigating the visual function in strabismus.

Effects of orthoptic therapy in children with intermittent exotropia after surgery: study protocol for a randomized controlled trial

BackgroundIntermittent exotropia (IXT) is the most common type of exotropia in China. Surgery is usually required to align the eye deviation to maintain or obtain better binocular visual function. However, there is a high rate of exodrift or recurrence in surgically treated patients. Orthoptic therapy is sometimes recommended for IXT patients after surgery. However, there is a lack of high-quality randomized controlled trials to prove that orthoptic therapy could be an effective supplement to surgical treatment for IXT patients. The main purpose of this study is to test the clinical effectiveness of orthoptic therapy in long-term stabilization of postoperative IXT patient. This report describes the design and methodology of the Intermittent Exotropia Postoperative Treatment Clinical Trial, which is the first large-sample, blank-controlled, randomized clinical trial.MethodsA total of 136 IXT patients (aged 7 to 17 years) will be enrolled and assigned to the orthoptic therapy group or blank control group according to a simple randomization scheme. Patients in the orthoptic therapy group will receive at least 2 months of orthoptic therapy, such as anti-suppression, vergence, and accommodation training. Patients in the blank control group will receive only refractive correction. All enrolled patients will need regular follow-up observation until 24 months after surgery. The primary outcome will be the proportion of participants meeting suboptimal surgical outcomes in this 24-month follow-up, which is defined as (1) exodeviation of 10 prism diopters (PD) at distance or near using the simultaneous prism and cover test (SPCT) or (2) loss of 2 or more octaves of stereoacuity from baseline, at any masked follow-up visit examination. The secondary outcomes will be the exodeviation at distance and near using the simultaneous prism and alternate cover test (PACT), magnitude of fusional convergence, stereoacuity, and accommodation. Measurements will be taken at baseline and at the 6-, 12-, 18-, and 24-month follow-ups.DiscussionTo the best of our knowledge, this will be the first prospective, randomized controlled study of orthoptic training in IXT patients after surgery. The aim of this work is to confirm the efficacy of orthoptic therapy in reducing the proportion of recurrence among IXT patients after surgery and improving binocular vision function.Trial registrationChinese Clinical Trial Registry ChiCTR1900026891. Registered on 25 October 2019.

A descriptive study of eye and head movements in versive seizures

BackgroundVersive seizures, consisting of forced, involuntary, sustained and unnatural turning of eyes and head toward one side, lateralize to the hemisphere contralateral to the direction of the eye and head turn. The characteristics of eye and head movements in version have been rarely and incompletely studied in spontaneous epileptic seizures as opposed to direct cortical stimulation studies. MethodsWe performed a single center retrospective analysis of a cohort of 28 patients with 43 seizures, who had been admitted to the adult epilepsy monitoring unit at University Hospitals Cleveland Medical Center between January 2009 and August 2020. We only included patients with clear, high-resolution seizure videos and interpretable EEG. ResultsThe eye movements were conjugate and contralateral to the hemisphere of seizure onset in 100% of the focal-onset seizures. The eye movements were saccadic in 89.3% with a predominant vector in oblique upward direction in 86.8% of the seizures. Head deviation was present in 100% of the seizures and the eyes and head deviated in the same direction in 97.6% of the seizures. In addition to deviation along the horizontal meridian, there was a vertical component to the head deviation as well, as evidenced by movement of the chin upward along the vertical axis in 93% of the seizures, thus indicating strong activation of the sternocleidomastoid muscle ipsilateral to the hemisphere of seizure onset. Concomitant facial motor activity ipsilateral to the direction of version was seen in 93% of the seizures. The most common pattern was a clonic superimposed on tonic facial contraction. DiscussionVersion remains a reliable and highly lateralizing sign. The majority of the eye movements during version occur in a saccadic fashion rather than one smooth movement, mostly in an oblique upward direction. Head deviation is very closely associated with eye deviation, thus indicating a common symptomatogenic zone for both, which is most likely the frontal eye field. A high concurrence of ipsilateral facial motor activity with version is likely because of close proximity of the frontal eye field to the face area in the primary motor cortex.

J.L. Prévost, Eye Deviation, and Early Steps in Space Lateralization: "Looking At or Away".

Conjugate deviation of the eyes toward side of lesion was recognized over a century ago as a manifestation accompanying hemiplegia, usually of apoplectic origin. While working on the services of Alfred Vulpian and Jean-Martin Charcot, Jean-Louis Prévost sparked international interest in the neurologic sign later named after him. His 1868 thesis represents the first systematic case series of patients with this ocular sign, observed in conjunction with head rotation toward the nonparalyzed side, which he called conjugate deviation (CD) of the eyes. Within a decade, it was uniformly reported in both French and English medical literature. Ipsilesional deviation was the rule for cortical or subcortical paralytic lesions. Contralesional deviation, more rarely seen, signaled lesions of lower brain regions, particularly pontine, or indicated irritative, excitatory effects (as in Jacksonian epilepsy). The sign was recognized to be a valuable diagnostic aid in unilateral cerebral lesions. Centralized control of CD by specific cerebral sites, such as frontal, or occipital, or oculomotor centers, was explored, along with the complex relationship with hemineglect, which interestingly was reported only several decades later. The discovery of intricate oculomotor interconnections and self-space relationships, which play an essential role in CD, owes much to Prévost and his followers.

Ocular Dominance in Open-angle Glaucoma: The Shifting Trend Depending on Stage of the Disease.

PurposeTo investigate the characteristics and distribution of ocular dominance in primary open-angle glaucoma eyes. In addition, we tried to catch any trend of ocular dominance according to the stage of disease.MethodsTwo hundred participants with bilateral open-angle glaucoma underwent ocular dominant testing by “the hole-in-a-card” test. Using optical coherence tomography, macular ganglion cell-inner plexiform layer, as well as circumpapillary retinal nerve fiber layer thickness were measured and compared according to ocular dominance. Of the two eyes of one subject, the eye with less glaucomatous damage based on mean deviation was considered to be the “better eye” in our study.ResultsOcular dominance was in the right eye in 66% of the population and ocular dominance was positioned in the better eye in 70% of the population (p = 0.001 and p = 0.002, respectively). In conditional logistic regression analyses, right eye and better mean deviation were significantly associated with ocular dominance (p = 0.001 and p = 0.002, respectively). Ocular dominance tends to be present in the better eye and this trend was more apparent as the severity of glaucoma increased. Intereye comparison of visual field indices and retinal nerve fiber layer thickness between dominant versus nondominant eye become apparent in moderate and advanced glaucoma whereas it was not as apparent in early glaucoma.ConclusionsIn glaucomatous eyes, laterality and severity of glaucoma determined ocular dominance. Intereye difference between nondominant and dominant eyes increased with the severity of glaucoma. Our findings suggest the existence of potential reciprocal interactions between ocular dominance and glaucoma.

Panayiotopoulos syndrome: Unusual clinical manifestations

PurposeWe retrospectively analyzed the electroclinical features, treatment, and outcome of patients with Panayiotopoulos syndrome (PS) who presented with unusual clinical manifestations. MethodA retrospective, descriptive, multicenter study was conducted evaluating 44 patients with PS who had seizures with an unusual semiology. Data from patients with PS seen at eight Argentine centers between April 2000 and April 2019 were collected. ResultsTwelve patients (29.2%) had ictal syncope or syncope-like epileptic seizures. Three children (7.3%) had recurrent episodes of vomiting. Four patients (9.7%) presented with urinary incontinence associated with autonomic signs and consciousness impairment. One child had hiccups with autonomic manifestations followed by eye deviation. One boy had episodes of laughter with autonomic symptoms followed by loss of consciousness. Six patients (14.6%) had hyperthermia without acute febrile illness with autonomic symptoms as the first manifestation. Six others (14.6%) had focal motor seizures characterized by eye and head deviation in four and eyelid blinking in two. Four patients (9.7%) had ictal headache as the initial manifestation followed by nausea and vomiting. Two children (4.8%) had their first seizure while asleep associated with cardiorespiratory arrest. Two children (4.8%) had oral automatisms, such as sucking and chewing. In two children (4.8%) coughing was the initial manifestation followed by emetic symptoms. One patient (2.3%) had vertigo with a sensation of fear, with eye deviation and unresponsiveness. One child started with continuous spikes and waves during slow sleep, behavior disturbances, and emetic symptoms. ConclusionIn this study, evidence of the existence of unusual clinical cases of PS with typical EEG patterns was found. Outcome was excellent.

Myelinated retinal nerve fiber layer: an extensive presentation.

Myelinated retinal nerve fiber layer is rare. It is estimated to occur in 0.5% to 1% of the population and is often detected on routine examination without symptoms. It consists of white or gray-white well-demarcated patches on the outermost surface of the retina that obscure the underlying retinal vessels. It can be associated with axial myopia, amblyopia, and strabismus. A 12-year-old girl with normal development presented with ocular deviation of the right eye. There was no past medical or ocular history. Automatic refraction found in the right eye -9 DP and -1 DP in the left eye. The best Visual acuity was 20/600 in the right eye and 20/20 in the left one. Slit lamp examination of the right eye (A) revealed two vast whitish zones extending from the papilla towards the temporal sector sparing the posterior pole. These lesions covered the temporal vessels with fuzzy and scalloped boundaries. Fundus examination of the left eye was without abnormalities (B). Scan of Optical coherence tomography showed isolated hyper reflectivity of the fiber optic layer, an abnormality of the vitreoretinal interface with posterior shadow cone effect (C).

Tacrolimus-associated posterior reversible encephalopathy syndrome after kidney transplantation

Calcineurin inhibitors are essential immunosuppressive agents for kidney transplant patients. Posterior reversible leukoencephalopathy syndrome is a rare complication of treatment with calcineurin inhibitors. Herein, we report three cases of tacrolimus-associated posterior reversible leukoencephalopathy syndrome after kidney transplantation and their unique clinical courses. Patients in Cases 1 and 2 presented with headache and visual field disturbance on the fourth day after transplantation. Both patients were successfully treated with antihypertensive therapy and a change in medications from tacrolimus to cyclosporine and everolimus. Case 3 was a kidney transplant patient at 12 years post-transplant who developed fever and conjugate eye deviation to the right. The patient was initially treated with antihypertensive medication and a reduction in tacrolimus dose, but she experienced prolonged disturbance of consciousness, which eventually improved. These cases highlight the importance of considering the possibility of posterior reversible leukoencephalopathy syndrome in kidney transplant recipients taking calcineurin inhibitors who present with acute neurological dysfunction. They also demonstrate the need to perform appropriate imaging to confirm the diagnosis and initiate treatment, even if a significant amount of time has passed since transplantation. The introduction of an mTOR inhibitor may be practical when changing or discontinuing calcineurin inhibitors.

Assessment of pattern of refractive errors in infantile esotropia- A single-center cross-sectional study

This was a cross-sectional study conducted to explore the patterns of refractive errors found in infantile esotropia patients from newborns to the age of 15 years, attending the Pediatric clinic of Al-Ibrahim Eye Hospital, Karachi, Sindh, Pakistan. Data was collected on a pre-designed proforma. A total of 79 patients (total of 158 eyes) including 44 males (55%) and 36 females (45%) were recruited. All these patients had infantile esotropia. The study showed out of 79 patients (158 eyes), 89 eyes had hyperopia, 15 eyes had myopic astigmatism, 44 eyes had hyperopic astigmatism, while 4 eyes had mixed astigmatism, and 6 eyes had myopia. The hypermatropia was found to be the most commonly occurring refractive error in infantile esotropia resulting in inward eye deviation.