Ocular Exam Research Articles

PRIMARY SJÖGREN’S SYNDROME IN A MALE PATIENT

Herein we report the case of a 69-year-old male patient complaining of dry mouth and dry eyes for 8 years. Locoregional examination revealed ocular erythema, angular cheilitis, and atrophic lips. Intraoral examination revealed caries, periodontal disease, and atrophic tongue. The diagnosis hypothesis was primary Sjögren’s syndrome (pSS). Unstimulated salivary flow and minor salivary gland biopsy showed 0.05 mL/minute and chronic sialadenitis (focus score >1), respectively. The patient was referred to an ophthalmologist and the ocular exam confirmed dry eyes (Schirmer test = 5 mm/5 mm, ocular staining score with fluorescein = 4). Serological tests showed: rheumatoid factor = 27.6 IU/mL, Anti-Ro (SSA) = 144.4 U/mL and Anti-La (SSB) = 1.4 U/mL. The final diagnosis was pSS, and the treatment started with pilocarpine 2 mg during 5 months, currently with metotrexato 15 mg/week and folic acid 5 mg/week. This case demonstrated that, although pSS typically affects women, the disease can occur in men and underscores the importance of dentists in the diagnosis of pSS.

Trachomatous Scarring and Infection With Non-Chlamydia Trachomatis Bacteria in Women in Kongwa, Tanzania.

PurposeTo assess for an association between conjunctival infection with nonchlamydial bacterial species and the presence of trachomatous scarring (TS) in women in central Tanzania.MethodsCross-sectional data were collected from a random sample of women ages 18 and older in 47 trachoma-endemic communities in Kongwa, Tanzania. Each participant completed a survey, provided a conjunctival swab sample, and received an ocular exam to assess for TS. Biologic samples were cultured for bacterial growth and speciation. Contingency tables were used to assess the associations between TS and bacterial carriage.ResultsComplete data was provided by 3882 women (80.7% of invitees). Of all samples, 14% resulted in a positive bacterial isolate. There was no association between TS and nonchlamydial bacterial carriage, whether assessed by species, pathogenicity, or in aggregate. There was a significant association between increasing age and TS severity, but not between age and bacterial carriage. No Corynebacterium was found in the swabs.ConclusionsThis study found no association between TS and nonchlamydial ocular infections, although associations with Corynebacterium cannot be ruled out.

Evaluation of pentablock co-polymer (PTSsol) for sustained topical ocular drug delivery

The purpose of this study is to evaluate ocular retention, tolerability, and sustained pharmacodynamics of a clear topical formulation of brinzolamide (BRZ) in PTSsol pentablock co-polymer. To test for ocular retention, PTSsol or saline containing near infrared dye-labeled (NIR) IgG was applied to the corneal surface of mice and monitored by in vivo imaging. To evaluate pharmacodynamics, dogs were dosed for 3 consecutive days with PTSsol once daily (qd) at doses of 1% and 2.5% and compared to PTSsol qd, or commercial BRZ 1% (Azopt®) three times daily (tid). Intraocular pressure (IOP) and ocular exams were performed each treatment day and two additional days post-treatment. The NIR-IgG saline remained on the ocular surface for <3 h, while NIR-IgG in PTSsol remained for >21 h. All formulations were well tolerated in dogs and by day 3 of dosing, IOP was significantly lower in 2.5% BRZ PTSsol qd dosed eyes compared to vehicle or baseline (p < 0.014). On day 5, 48 h after dosing, IOP remained significantly lower in eyes treated with 2.5% BRZ PTSsol qd compared to those dosed with Azopt (p = 0.036). This suggests that drugs in PTSsol may allow for once a day or less frequent dosing.

Study of Correlation in Thermography of Ocular Surface and Dry Eye Exam

Study of Correlation in Thermography of Ocular Surface and Dry Eye Exam

Unilateral malignant optic glioma following glioblastoma multiforme in the young: a case report and literature review

BackgroundMalignant optic gliomas are rare, but they rapidly become lethal visual pathway tumors. We present the clinical course, treatment, and prognosis of a case of unilateral malignant optic glioma in a young man with a history of brain glioblastoma multiforme (GBM).Case presentationA 21-year-old man, who had GBM 7 years ago complained of a transient shadow in his vision and presented with normal visual acuity but optic disc edema and an enlarged blind spot in the right eye (oculus dexter, OD). Magnetic resonance imaging (MRI) showed a right intraorbital optic nerve tumor without a brain lesion. Chiasm involvement and severe vision deterioration occurred 3 months later. A biopsy of the right optic nerve revealed glioblastoma. Concurrent chemoradiotherapy (CCRT) prevented involvement of the fellow eye 1 year after symptom onset.ConclusionThis report demonstrated that a regular ocular exam should be recommended for several years after GBM. In young healthy patients who are able to undergo chemotherapy and radiotherapy, visual function in the fellow eye can be preserved.

Long-term complications of sulfur mustard poisoning: retinal electrophysiological assessment in 40 severely intoxicated Iranian veterans

BackgroundThe eye is one of the most sensitive organs to sulfur mustard (SM) [C4H8Cl2S], and preliminary symptoms of exposure usually become evident in the eyes. In this study we aim to evaluate the possible long-term retinal electrophysiologic complications of SM poisoning in Iranian veterans during Iran–Iraq war (1980–1988).MethodsIn a cross-sectional study forty Iranian veterans who were exposed to mustard gas during the Iran–Iraq war (1980–1988) were included. All the cases underwent complete ocular exam and retinal electrophysiological evaluation, including electroretinography (ERG) and electrooculography (EOG). Data was analyzed using SPSS software. The normal distribution was checked using the Shapiro–Wilk test. Comparison of electrophysiologic values with maximum standard levels was performed using one-sample Student t-test and test of significance was one-tailed.ResultsForeign body sensation (70%), dry eye (50%), photophobia (30%), lacrimation (20%) and pain sensation (10%) were among the common symptoms. ERG showed significant reduced amplitude in rod response, maximal combined response, oscillatory potentials, cone response and 30 Hz flicker waves compared to normal values (p < 0.05). Implicit time of b-wave rod response ERG recording was significantly decreased (p < 0.05). Implicit time of cone response b-wave was within normal limits. In EOG, Arden ratio did not decrease (total average of 2.311 and 2.48 in right and left eyes, respectively).ConclusionDelayed toxic effects of SM poisoning in the veterans were observed in the retina, but not in the retinal pigment epithelium layer. As the retina is a neural tissue, long-term effects of SM on neural tissues are presumed.

Corneal Evaluation in Healthy Brazilian Children Using a Scheimpflug Topography System

Purpose: To identify the distribution and variation in corneal topography, thickness, and elevation in healthy Brazilian children as measured by the Pentacam Scheimpflug system (Oculus Optikgerate GmbH, Wetzlar, Germany).Methods: Healthy children between 7 and 11 years of age were scanned using the Pentacam Scheimpflug corneal topography system (Oculus Optikgerate GmbH, Wetzlar, Germany). The exclusion criteria were inability to undergo the ocular exam, history of any ocular diseases (including strabismus, amblyopia, cataracts, retinal disorders, and allergic conjunctivitis), and topographic diagnosis of corneal ectasia based on the modified Rabinowitz/McDonnell criteria for keratoconus. The right eye of each subject was selected for analysis. The parameters evaluated were central corneal thickness (CCT), thinnest pachymetry (TP), average pachymetric progression index (PPIave), anterior and posterior elevation (AE and PE), anterior and posterior best fit sphere (ABFS and PBFS), pachymetric difference between the apex and the thinnest point (PDAT), Ambrosio's relational thickness (ARTMax), overall Belin/Ambrosio Enhanced Ectasia display score (BAD-D), simulated keratometry (SimK), astigmatism in SimK (SimK astig), maximum keratometry (K max), asphericity (Q value), and anterior chamber depth (ACD).Results: A total of 160 children (69 male, 91 female) were included in this study. The mean age of the children was 8.82 ± 1.23 years (ranging from 7 to 11 years). The mean CCT was 553.81 ± 32 μm, and mean TP was 547.95 ± 32.06 μm. The TP was most commonly located in the inferotemporal quadrant in 93.125% (149) eyes. The mean PPIave was 1.00 ± 0.14, similar to that of normal adults. The mean ABFS and PBFS values were 7.49 ± 3.26 and 10.54 ± 6.25, respectively. ART Max and D averaged 446.57 ± 81.20 and 0.78 ± 0.65, respectively. Mean ± SD values for SimK, SimK astig, and K max were 43.35 ± 1.31 D, 0.92 ± 0.66 D, and 44.40 ± 1.45 D respectively. The K max and SimK astig values were close to those reported by other topographic systems for children. Q value and ACD averaged -0.39 ± 0.12 and 3.065 ± 0.2745 mm.Conclusion: This study provides normative values for corneal topography, thickness, and elevation in healthy Brazilian children. These results may provide helpful information for diagnosis of corneal diseases in children. Further studies are needed to evaluate the role of tomography in identifying early forms of ectasia in this age group.

Intravitreal dexamethasone implant for recurrent cystoid macular edema due to Irvine-Gass syndrome: a prospective case series.

PurposeTo determine the preliminary efficacy and safety of off-label dexamethasone implant for treatment of recurrent cystoid macular edema (CME) secondary to Irvine-Gass syndrome (IGS).Patients and methodsThis study was set in Raghudeep Eye Clinic, Ahmedabad and LV Prasad Eye Institute, Hyderabad (India). It is a Prospective Case Series. Prospective case series comprising of patients with uncomplicated pseudophakia and CME due to IGS who recurred after one course of topical steroids with NSAIDS and a sub-Tenon corticosteroid injection. A complete ocular and systemic exam, fluorescein angiography, and central subfield thickness (CST) on optical coherence tomography scans were performed. Follow-up visits were on days 1, 15, and 30 and then monthly for a year. Appropriate statistical analysis was done. The primary outcome measure was the change in CDVA at months 1, 6, and 12. Secondary outcome measures were recurrence of CME and complications if any as noted at months 1, 2, 6, and 12.ResultsAbout 27 patients (27 eyes) with 16 males were included. Median age: 63.24±5.62 years. At 1 month, the CDVA improved to 0.04±0.02 (20/25) logMAR from 0.52±0.12 logMAR (20/70) (P=0.001) with a reduction in CST from 454.2±45.3 to 218.32±38.15 microns(P=0.013). The CDVA was 0.04±0.03 logMAR(P<0.001) at month 6 and 0.05±0.02 logMAR(P<0.001) at month 12. The CST was 221±35.2 microns (P=0.013) at month 6 and 214±43.34 microns (P=0.0124) at month 12. All improvements were maintained for a year. Only one patient required a second injection. No complications were noted.ConclusionThe implant is safe and effective for the treatment of recurrent CME due to IGS.

Smartphone use is a risk factor for pediatric dry eye disease according to region and age: a case control study.

BackgroundIn 2014, the overall rate of smartphone use in Korea was 83 and 89.8 % in children and adolescents. The rate of smartphone use differs according to region (urban vs. rural) and age (younger grade vs. older grade). We investigated risk and protective factors associated with pediatric dry eye disease (DED) in relation to smartphone use rate according to region and age.MethodsWe enrolled 916 children and performed an ocular exam that included slit lamp exam and tear break-up time. A questionnaire administered to children and their families consisted of video display terminal (VDT) use, outdoor activity, learning, and modified ocular surface disease index (OSDI) score. DED was defined based on the International Dry Eye Workshop guidelines (Objective signs: punctate epithelial erosion or short tear break-up time; subjective symptoms: modified OSDI score) We performed statistical analysis of risk factors and protective factors in children divided into groups as follows: DED vs. control, urban vs. rural, younger grade (1st to 3rd) vs. older grade (4th to 6th).ResultsA total of 6.6 % of children were included in the DED group, and 8.3 % of children in the urban group were diagnosed with DED compared to 2.8 % in the rural group (P = 0.03). The rate of smartphone use was 61.3 % in the urban group and 51.0 % in the rural group (P = 0.04). In total, 9.1 % of children in the older-grade group were diagnosed with DED compared to 4 % in the younger-grade group (P = 0.03). The rate of smartphone use was 65.1 % in older-grade children and 50.9 % in younger-grade children (P < 0.001). The mean daily duration of smartphone use was longer in the DED group than controls (logistic regression analysis, P < 0.001, OR = 13.07), and the mean daily duration of outdoor activities was shorter in the DED group than controls (logistic regression analysis, P < 0.01, OR = 0.33). After cessation of smartphone use for 4 weeks in the DED group, both subjective symptoms and objective signs had improved.ConclusionsSmartphone use in children was strongly associated with pediatric DED; however, outdoor activity appeared to be protective against pediatric DED. Older-grade students in urban environments had DED risk factors (long duration of smartphone use), and a short duration of outdoor activity time. Therefore, close observation and caution are needed when older children in urban areas use smartphones.Electronic supplementary materialThe online version of this article (doi:10.1186/s12886-016-0364-4) contains supplementary material, which is available to authorized users.

Genetic Testing for Eye Diseases: A Comprehensive Guide and Review of Ocular Genetic Manifestations from Anterior Segment Malformation to Retinal Dystrophy

Genetic eye diseases are a heterogeneous group that collectively involve every facet of the eye, ocular adnexa and visual system. An individual condition within this group may be rare or common, have an isolated finding or be part of a syndrome, may severely threaten survivability, significantly affect vision or may have no bearing on visual morbidity. There have been treatment successes and safety reports in clinical trials involving vector-based ocular gene therapies, and there are currently a significant number of loci and genes known to contribute to human ocular disease, many of which have been recently discovered due to recent advances in the field of molecular genetics. In addition to obtaining a medical history and performing a comprehensive ocular exam, acquiring a detailed family history, ordering and interpreting specialized vision function tests and genetic laboratory results appropriately, and having knowledge of the ocular genetic features within the diverse categories of ophthalmic genetic conditions are essential components in effectively managing the patients and their families. With the promise of treatment trials, patients’ interest and need for a molecular diagnosis will be on the rise and clinicians need to be prepared.

Grisel’s syndrome, a rare cause of anomalous head posture in children: a case report

BackgroundAnomalous head posture (AHP) or torticollis is a relatively common condition in children. Torticollis is not a diagnosis, but it is a sign of underlying disease. Grisel’s syndrome (GS) is a rare condition of uncertain etiology characterized by a nontraumatic atlanto-axial subluxation (AAS), secondary to an infection in the head and neck region. It has not been considered, in ophthalmological papers, as a possible cause of AHP.Case presentationA case of AAS secondary to an otitis media is studied. The children showed neck pain, head tilt, and reduction in neck mobility. The patient had complete remission with antibiotic and anti-inflammatory therapy and muscle relaxants. Signs of GS should always be taken into account during ophthalmological examination (recent history of upper airway infections and/or head and neck surgeries associated to a new onset of sudden, painful AHP with normal ocular exam). In such cases it is necessary to require quick execution of radiological examinations (computer tomography and/or nuclear magnetic resonance), which are essential to confirm the diagnosis.ConclusionGS is a multidisciplinary disease. We underline the importance of an accurate orthoptic and ophthalmological examination. Indeed, early detection and diagnosis are fundamental to achieve proper management, avoid neurological complications and lead to a good prognosis.

AMD Drusenoid deposits “P”, Protein‐Cellular Type: Characterization and Evolution. Multimodal imaging and OCT, OCT en Face, Evaluation and Interest

PurposeTo study AMD drusenoid deposits “P”, Protein‐Cellular Type with multimodal imaging,to characterize their morphologic type, evolution, to consider etiopathogeny, biomarker featuresMethods148 eyes of 74 AMD patients. AMD drusenoid deposits “P”,Protein‐Cellular Type:Cuticular drusen,Drusenoid PED “P”, Subretinal drusenoid deposits (SDD),Pseudovitellifom AMD were evaluated by Autofluorescence,IR imaging,ETDRS visual acuity (VA),ophthalmic examination with Ocular Fundus,Ocular Confocal Tomography exam(spectral domain OCT, OCT en Face software). Size, characteristics, number, topography of the lesions, growth way were evaluated, also their environment above, below and evolution. Each element was studied, compared cut to cut,layer to layer,time to time.ResultsVA stabilized in 90%. Pseudovitelliform AMD are little, irregular upper limit drusenoid PED. Cuticular drusen appear, uniform, round, white, under retinal pigment epithelium (RPE). SDD deposits are white, homogeneous,quite similar in all cross‐section, FA and ICG too, nearby upper side RPE layer. Drusenoid PED “P” were dense,white, granular,different in all cross‐sections,heterogeneous PED, below RPE,with abnormal RPE above,heavily unstructured.Multimodal imaging,especially OCT en Face, let individualize “P” drusenoid deposits.Evolution was‐choriocapillaris change‐pigment epithelium involution:more dense, irregular, inhomogeneous, crumbled‐inflammation‐neovascular signs even net.Specific metabolic defect outcome, etiopathogenic pathways appear: “P” drusenoid deposit is mostly enrolled in protein‐cellular metabolic pathway dysfunction with rather evolution to neovascular complication. So it would build up its biomarker feature.ConclusionsAMD Drusenoid deposits “P”, Protein‐Cellular type study,knowledge,evolution,notably with multimodal imaging, OCT en Face contribute to and improve AMD understanding, prognosis, etiopathogic concept.

Systemic steroids as an aid to the management of Idiopathic Polypoidal Choroidal Vasculopathy (IPCV): A descriptive analysis

PurposeTo determine the role of systemic steroids in improving visual acuity, preventing recurrence and hastening pigment epithelial detachment resolution in IPCV patients. MethodsRetrospective computer assisted comparative case series of consecutive patients with documented IPCV who did and did not receive systemic steroids as part of their treatment regimen between 2007 and 2012. Patients who had systemic contraindication to steroid therapy were excluded from the steroid arm. Data collected included demographics, the best corrected visual acuity, details of the ocular and systemic exam, the treatment offered, the follow-up period and the final visual and anatomic outcomes. Outcome measures included the final BCVA, the time to resolution of the associated pigment epithelial detachment (PED, if present), the recurrence rate and the associated side effects, if any. Appropriate statistical analysis was done. Statistical significance: p<0.05. Results14 patients (14 eyes) had received systemic steroids in the stated period; these were compared with 26 consecutive patients (26 eyes) who did not. Mean age: 59.24 vs 62.38years (A vs B). Mean baseline BCVA: 1.86±1.24logMAR vs 2.12±1.48logMAR (A vs B). 8 females in Group A and 14 in Group B. 11 patients in group A and 19 in group B had associated systemic hypertension. Therapy consisted of laser photocoagulation, anti-vascular endothelial growth factor therapy, photodynamic therapy or a combination of these. Mean follow-up: 43.21±11.32months (Group A) vs 48.24±9.75months (Group B). BCVA at three months was significantly better (0.84±0.74logMAR vs 1.16±0.89 (p=0.039). Final BCVA: 0.86±0.78logMAR (Group A) vs 1.29±0.92 (Group B, p=0.042). 7 patients in group A and 12 in Group B had a recurrence (insignificant difference). 1 patient in Group A and 7 in Group B had unresolved disease (persistent PED) at the end of follow-up (OR: 4.60; 95% CI 1.7–11.10). ConclusionSteroids appear to improve visual acuity and accelerate the resolution of the PEDs in patients with IPCV and large PEDs, but do not seem to influence recurrence.

Retinal circulation and its role in macular disorders in patients without systemic disease.

To determine whether retinal circulatory changes play a role in the pathogenesis of macular disorders in patients who are otherwise healthy. Patients with macular disorders that required angiographic imaging were included in this prospective case series. After a complete ocular exam, fluorescein angiography was performed using a standardized technique on the HRA-II (Heidelberg Engineering, Heidelberg, Germany) with special focus on the posterior pole. Only patients with good quality images were included in the analysis. Circulatory parameters recorded included the arm-choroid time, choroid-retinal artery, and finally the retinal artery-vein time. Zonal asymmetry (between the upper and lower zones divided by a line passing through the centre of the fovea) in transit times, if any was also noted. Appropriate statistical analysis was done. Circulation times were compared with age matched historical controls. Changes in retinal dye transit times relative to historical age matched controls, if any, were noted and compared between various disorders. A total of 156 eyes of 156 patients (120 males) were included in the study. Mean age: 49.14±14.93y. Macular disorders studied were age related degeneration, polypoidal vasculopathy, central serous chorioretinopathy (CSCR) and parafoveal telangiectasia. Delayed circulation time was noted in CSCR patients only. CSCR patients appear to have delayed arterial filling, retinal circulatory disturbances do not seem to contribute to the pathogenesis of other macular disorders.

Influence on intraocular pressure of anti-inflammatory treatments after selective laser trabeculoplasty

Selective laser trabeculoplasty (SLT) is an effective and safe procedure to lower intraocular pressure (IOP) in the management of open-angle glaucoma. The post-laser inflammatory reaction could be positively implicated in SLT efficacy and the relevance of postoperative use of topical anti-inflammatory remains controversial. The goal of this study is to determine the effect of various anti-inflammatory treatments on intraocular pressure and on side effects following SLT. A prospective, randomized, double-blind study with a control group was conducted. Ninety-six eyes of 67 patients with primary open-angle glaucoma who underwent SLT were enrolled in this study between March 2009 and March 2012. Eyes recruited in the study were randomized to receive either prednisolone acetate 1%, diclofenac 0.1% or a placebo. The 3 treatments were administered 4 times a day for 5 days following SLT. The intraocular pressures were measured at regular intervals during the 6-months follow-up period. Side effects were also evaluated with a questionnaire as well as with the ocular exam. The analysis of the relative IOP decrease over the 6-months period revealed a significant difference between the time points of follow-up (P<0.0001), but no group effect (P=0.2980). No significant difference regarding anterior chamber inflammation and discomfort was observed between the 3 groups. There was no difference in intraocular pressure reduction, intraocular inflammation or ocular discomfort post-SLT when comparing the 3 treatment modalities.

663. Safety and Biodistribution Study of rAAV2tYF-CB-hRS1 in Nonhuman Primates

Background: AGTC is developing a recombinant AAV vector expressing retinoschisin (RS1) for treatment of humans with X-linked retinoschisis (XLRS). Here we report results of a toxicology and biodistribution study of this vector administered by intravitreal injection in cynomolgus macaques.Methods: Three groups of male cynomolgus macaques (n=3 per group) received an intravitreal injection in one eye of vehicle or rAAV2tYF-CB-hRS1 at one of two dose levels (4 × 10^10 or 4 × 10^11 vg/eye). Half of the animals were sacrificed 14 days after vector administration and the remaining animals were sacrificed 91 or 115 days after vector administration. At each sacrifice time point blood and tissue samples were collected for evaluation of safety and biodistribution.Results: There were no test article-related effects on intraocular pressure, electroretinography, visual evoked potentials, and clinical pathology parameters. Ocular exams demonstrated a dose-related ocular inflammatory response that improved over time. In the vehicle control group, aqueous cells ranged from trace to 4+ at 1 week after injection and resolved by Week 2. Vitreous cells ranged from trace to 2+ at 2 to 3 weeks, resolved by Week 4 in four animals and in the other two animals were resolved or resolving at Week 12. None of the animals in this group had vitreous haze. Ocular inflammation was greater in the vector-treated animals and was more pronounced at the higher dose. Aqueous cells ranged from 1+ to 4+ at Week 1 in all animals, resolved by Week 2, recurred at Week 2 to 4 in two animals in the low dose and three animals in the high dose group, and then resolved over the next several weeks. Vitreous cells developed in 5 of 6 animals in the low dose and all animals in the high dose group, and persisted at 2+ or greater for more than 4 weeks in two animals in the low dose and three animals in the high dose group. Vitreous haze developed at Week 4 in one animal in the low dose and three animals in the high dose group and resolved over the next several weeks. Microscopic pathology results demonstrated mononuclear infiltrates at the optic disc and/or around blood vessels in the ganglion cell layer, iris, and ciliary body of the injected eye was observed in 2 of 6 animals in the lower dose group and 4 of 6 animals in the higher dose group. Immunohistochemistry studies showed RS1 labelling of the ganglion cell layer at the foveal slope. At terminal sacrifice there was limited vector biodistribution outside the injected eye.Conclusions: Intravitreal administration of rAAV2tYF-CB-hRS1 in normal cynomolgus macaques was associated with dose-related anterior and posterior segment inflammatory response that improved over time. Histological examination showed mononuclear cell infiltrates that were more prevalent at the higher dose level and RS1 expression in the retinal ganglion cell ring was demonstrated by immunohistochemistry. Results from this study support the use of rAAV2tYF-CB-hRS1 in clinical studies in patients with XLRS.

Seasonal Variation in Dry Eye

Seasonal Variation in Dry Eye

Isolated Medial Rectus Nuclear Palsy as a Rare Presentation of Midbrain Infarction

Diplopia is a common subjective complaint that can be the first manifestation of a serious pathology. Here, we report a rare case of midbrain infarction involving the lateral subnucleus of the oculomotor nuclear complex presenting as diplopia, with no other stroke manifestations. An 83-year-old right-handed white man with past medical history of diabetes mellitus, hypertension, dyslipidemia, and coronary artery disease presented to the emergency department (ED) with diplopia and unsteadiness. Two days prior to admission, the patient woke up with constant horizontal diplopia and unsteadiness, which limited his daily activities and led to a fall at home. He denied any weakness, clumsiness, nausea, vomiting, photophobia, fever, or chills. Ocular exam showed a disconjugate gaze at rest, weakness of the left medial rectus muscle, impaired convergence test, and bilateral 3-mm reactive pupils. The diplopia resolved by closing either eye. The remaining extraocular muscles and other cranial nerves were normal. There was no nystagmus, ptosis, or visual field deficit. Sensation, muscle tone, and strength were normal in all extremities. Magnetic resonance imaging (MRI) of the brain revealed a tiny focus of restricted diffusion in the left posterior lateral midbrain. A thorough history and physical examination is essential to diagnose and manage diplopia. Isolated extraocular palsy is usually thought to be caused by orbital lesions or muscular diseases. Here, we report a case of midbrain infarction manifested as isolated medial rectus palsy.

Diplopia as first symptom of multiple sclerosis

Purpose: To determine the frequency and clinical features of the extrinsic ocular motility changes in patients with multiple sclerosis living in the state of Sao Paulo (Brazil), consecutive cases series from 1996 to 2011. Methods: Eighty-three consecutive multiple sclerosis subjects were enrolled, aged from 17 to 59 years. All patients had a history taking and a comprehensive ocular exam. Results: Extrinsic ocular motility changes was detected in 17 (20,48%) out of 83 individuals. Diplopia as the first symptom of the [...]

Retrospective hospital-based analysis of age-related macular degeneration patterns in India: 5-year follow-up.

Purpose:To provide a detailed analysis of age-related macular degeneration (AMD) with a 5-year follow-up at a Tertiary Eye Care Center in India.Methods:In this retrospective institutional study, 408 eyes of 204 subjects (100 males) with a diagnosis of AMD with minimum 5-year follow-up were included. Data collected included demographics, details of the ocular exam, special investigations performed, treatment offered, complications, and systemic diseases, if any.Results:The median age was 74.24 ± 8.23 years. Median follow-up was 5.77 years. The visual acuity (VA) at baseline and last visit was 0.74 ± 0.12 (Snellen's equivalent 20/100) and 0.54 ± 0.12 logarithm of the minimum angle of resolution (Snellen's equivalent 20/50; P = 0.032) in patients with choroidal neovascular membrane (CNVM). The most common complaint was decreased vision (94.5%). AMD (any stage) was found to be bilateral in 93% of patients at baseline and 197 patients (96.56%) at 5 years. Seventeen eyes had active CNVM (12 of these were occult) at presentation. At baseline, 43 eyes had a disciform scar. Three hundred twenty-one eyes had dry AMD at baseline (geographic atrophy - 12 [3.7%] eyes). Five-year conversion rate into wet AMD and geographic atrophy was 2.87% and 3.12%. Median number of anti-vascular endothelial growth factor injections administered per patient was 2.8 ± 1.2. CNVM bilaterality was low (7.5%).Conclusion:Patients with AMD in India presented later in the course of the disease. Bilateral advanced AMD and geographic atrophy were uncommon. Five-year conversion rate into wet AMD and geographic atrophy was 2.87% and 3.12%.