Ocular Motility Disorders Research Articles

Vision for the Future Project: Screening impact on the prevention and treatment of visual impairments in public school children in São Paulo City, Brazil

OBJECTIVES:Uncorrected refractive errors are the leading cause of visual impairment in children. In this cross-sectional retrospective study, we analyzed a social visual screening program for school children in São Paulo, Brazil, evaluated its impact on the prevention and treatment of children’s visual disabilities, and assessed its epidemiological outcomes to outline suggestions for its improvement.METHODS:First-grade children from public schools were submitted to prior visual screening by their teachers. Selected children were forwarded to the hospital’s campaigns for a second screening by ophthalmologists and treatment if needed. Data were analyzed for age, sex, visual acuity, biomicroscopy, refractive errors, ocular movement disorders, amblyopia, number of donated spectacles, and number of children forwarded to specialized care.RESULTS:A total of 1080 children were included with mean age of 6.24±0.45 years. Children with normal ophthalmological exam, 591 (54.7%; 95% confidence interval [CI]: 51.7%-57.7%) were dismissed and considered false-positives. Myopia, hyperopia, and astigmatism components were found in 164 (15.2%; CI: 13.1%-17.4%), 190 (17.6%; CI: 15.3%-20.0%), and 330 (30.5%; CI: 27.8%-33.4%) children, respectively. Amblyopia was diagnosed in 54 (5%; CI: 3.5%-6.4%) children, and 117 (10.8%; CI: 9.8%-12.8%) presented ocular movement disorders. A total of 420 glasses were donated.CONCLUSION:Epidemiological findings for amblyopia and refractive errors are consistent with those of similar studies. The expressive number of diagnoses performed and number of glasses donated to underprivileged children depict the importance of such projects. New guidelines to improve their cost-effectiveness, such as professional training and community sensitization, are imperative.

Pattern of ocular diseases among adult patients visiting ophthalmic clinics in Qassim University, Saudi Arabia 2021

Background: The World Health Organization confirmed the importance of obtaining information about the pattern of ocular diseases in the population as this is helpful to provide appropriate management and application of programs based on the priorities of the population. This study aimed to determine the most prevalent patterns of ocular diseases and to compare the patterns of ocular diseases among different age groups and genders in patients visiting ophthalmic clinics in Qassim Region, Saudi Arabia. Methods: This study was retrospective and cross-sectional in nature, and the data were collected from ophthalmic clinics in Qassim University, Qassim region, Saudi Arabia from January 1, 2020 to January 1, 2021. The data collection form consisted of basic demographic characteristics and diagnosed ocular disease. Results: A total of 384 patients were included. The most common age group was > 50 years old (35.4%) with slightly more males (53.4%) than females (46.6%). The most common anatomical region of eye abnormality was the cornea (26.8%), and its prevalence was statistically significantly higher in age group 16-30 years (p < 0.001). Refractive errors were the commonly detected corneal disease (17.7%), while cataracts (9.9%) and presbyopia (8.6%) were the most common lens diseases. Likewise, blepharitis was the most common diseases for the eyelid (7.8%), and strabismus was the common disorder of ocular motility (7.3%). Conclusion: The prevalence of refractive errors and strabismus was more common among young patients, while the prevalence of cataracts and glaucoma was more common among older patients.

A rare association of congenital fibrosis of extraocular muscles with keratoconus and bilateral sensorineural hearing loss: A co-incidence or some syndrome?

Congenital fibrosis of extraocular muscles (CFEOM) is an inherited restrictive ocular motility disorder characterized by unilateral or bilateral horizontal and/or vertical gaze impairment with ptosis. Keratoconus is a bilateral asymmetrical corneal ecstatic disease with multifactorial etiology, including complex interaction of both genetic and environmental factors. We report a case of a 29-year-old female who presented with chief complaints of bilateral diminution of vision and drooping of eyelids since early childhood with a history of seizures for 1 year. Visual acuity at presentation was hand movement close to face with accurate projection of rays in both the eyes. Contrast-enhanced magnetic resonance imaging of the brain and orbit revealed partially empty sella, neurocysticercosis, and bilateral atrophy of extraocular muscles. On detailed examination, she was found to have CFEOM type 1A (CFEOM1A, autosomal dominant inheritance) with bilateral advanced keratoconus, bilateral sensorineural hearing loss, bilateral presenile cataract, and neurocysticercosis. The association of CFEOM1A, keratoconus, and sensorineural hearing loss is not reported in the literature to date. Whether this association is co-incidental or part of some new syndrome needs to be evaluated further.

Impact of visual impairment following stroke (IVIS study): a prospective clinical profile of central and peripheral visual deficits, eye movement abnormalities and visual perceptual deficits

Aim This study evaluates the spectrum of visual impairment in stroke survivors. Methods The Impact of Visual Impairment after Stroke (IVIS) study is a multi-centre, acute stroke unit, prospective epidemiology study. Comprehensive visual examination was offered to all stroke survivors. Results 1500 stroke admissions were recruited. 1204 stroke survivors had visual assessment. Reduced central vision was documented in 529, visual field loss in 308, ocular motility abnormalities in 533 stroke survivors, visual perception deficits in 59 stroke survivors and visual inattention in 315 stroke survivors. About half, regardless of visual impairment type, were visually asymptomatic. Recovery, whether full or partial, was best for central vision, ocular motility abnormalities and visual perception deficits (about 70% improvement) occurring over a mean follow-up period of 2–3 months. Conclusions Incidence of impaired central vision, visual field loss, ocular motility disorders and visual inattention was 29.4%, 24.8%, 39.3% and 26.2% respectively. Visual impairment was more likely to occur in more severe stroke and older stroke survivors. Asymptomatic cases raise concerns for acute stroke units where robust specialist vision screening is not routine. Those with partial/no recovery require specialist follow-up and management whilst the wide range of abnormalities highlight the need for specialist visual assessment acutely. Implications for rehabilitation Visual impairment is a common consequence of stroke. Incidence of visual impairment is about 60%. Significant numbers of stroke survivors are visually asymptomatic, highlighting the need for standardised vision assessments. Many stroke survivors have persistent long-term visual impairment, necessitating referral and access to specialist eye care services.

Encephalitis lethargica in Peru

ABSTRACT Encephalitis lethargica first appeared during World War 1, but reported cases gradually faded over the 1920s, and in the years following, cases were only sporadically reported. The clinical presentation was heterogeneous and typically included both acute and chronic phases. The acute phase was characterized by excessive sleepiness, disorders of ocular motility, fever, and movement disorders. On the other hand, the chronic phase was characterized by Parkinsonism, oculomotor abnormalities, involuntary movements, speech and respiratory abnormalities, and psychiatric manifestations. In Peru, Espejo-Tamayo reported 47 cases of the disease between 1919 and 1924, with an average mortality of 13%. He described three waves of the epidemic in Peru: that of 1919, with a predominance of the lethargic-paralytic syndrome; that of 1920–1921, characterized by the algic-myoclonic syndrome; and the wave that began in 1922, when the disease acquired purely striatum syndromes, as well as those associated with the lethargic-paralytic and myoclonic syndromes and mental manifestations. We summarize six cases of encephalitis lethargica reported in Peru from 1920 through 1940.

Modified Y Splitting of Lateral Rectus in Treatment of Abnormal Vertical Eye Movements Combined with Globe Retraction in Duane Retraction Syndrome

Duane retraction syndrome is the most frequently seen restrictive ocular motility disorders. It is clinically presented with limitation of horizontal movement, variable amounts of upshoots or downshoots and globe retraction combined with narrowing of the palpebral aperture on attempted adduction. An 8-year-old patient presented with severe restriction of abduction, reciprocal upshots or downshoots, and globe retraction combined with the palpebral fissure narrowing of on adduction. After the modified Y splitting of LR and recession of both horizontal rectus operation, all cosmetically disfiguring clinical features disappeared. In this case report modified Y splitting procedure and its long-term efficacy is presented.

P.His16Arg of STXBP1 (MUNC18-1) Associated With Syntaxin 3B Causes Autosomal Dominant Congenital Nystagmus.

Congenital nystagmus (CN) is an ocular movement disorder manifested as involuntary conjugated binocular oscillation and usually occurs in early infancy. The pathological mechanism underlying CN is still poorly understood. We mapped a novel genetic locus 9q33.1-q34.2 in a larger Chinese family with autosomal dominant CN and identified a variant (c.47A>G/p.His16Arg) of STXBP1 by exome sequencing, which fully co-segregated with the nystagmus phenotype in this family and was absent in 571 healthy unrelated individuals. The STXBP1 encodes syntaxin binding protein 1 (also known as MUNC18-1), which plays a pivotal role in neurotransmitter release. In unc-18 (nematode homolog of MUNC18-1) null Caenorhabditis elegans, we found that the p.His16Arg exhibits a compromised ability to rescue the locomotion defect and aldicarb sensitivity, indicating a functional defect in neurotransmitter release. In addition, we also found an enhanced binding of the p.His16Arg mutant to syntaxin 3B, which is a homolog of syntaxin 1A and specifically located in retinal ribbon synapses. We hypothesize that the variant p.His16Arg of STXBP1 is likely to affect neurotransmitter release in the retina, which may be the underlying etiology of CN in this family. Our results provide a new perspective on understanding the molecular mechanism of CN.

Visual impairment and the prevalence of ocular pathology in homeless children and adults globally: a systematic review

BackgroundHomelessness is a global issue in developing and developed countries. This article is the first systematic review to explore its impact on visual health globally. MethodsA systematic literature search was conducted on OVID MEDLINE, EMBASE, and Cochrane CENTRAL. Peer-reviewed English-language studies with a focus on homeless children or adults that reported on ocular outcomes were included. Primary outcomes and secondary endpoints were reported via weighted averages. Primary outcomes between homeless children and homeless adults were compared using the Fisher exact test. ResultsThere were 5774 individuals across 23 full-text articles included in the review. For studies reporting primary outcomes, 36.8% of homeless individuals self-reported dissatisfaction with their vision, 26.8% self-reported a previous ocular pathology, 26.3% had uncorrected refractive error, 25.6% were functionally visually impaired, 9.2% had at least one previous eye surgery or procedure, and 4.0% had nonrefractive visual impairment. Upon screening, 25.1% of homeless individuals had some type of ocular pathology, which included cornea and external eye diseases (13.4%), glaucoma (7.4%), cataracts (6.3%), retinal diseases (5.3%), ocular motility disorders (4.7%), trauma (2.3%), neuro-ophthalmological conditions (1.7%), and oculoplastic conditions (0.7%). Homeless adults had significantly more visual impairment (p < 0.001), uncorrected refractive error (p < 0.001), ocular pathology (p < 0.001), cataracts (p < 0.001), retinal pathology (p < 0.001), and neuro-ophthalmological conditions (p < 0.001) relative to children. ConclusionsVisual impairment in homeless individuals is higher than the general population. Uncorrected refractive error is a leading cause of visual impairment in this population. Additionally, homeless adults have significantly more visual impairment and ocular pathology than homeless children. Future studies should also explore if these differences are consistent in developing countries and investigate ways to increase eye care access for homeless individuals.

Tendon elongation with bovine pericardium in strabismus surgery\u2014indications beyond Graves\u2019 orbitopathy

BackgroundFor some patients with complex ocular motility disorders, conventional strabismus surgery is insufficient. Surgery with tendon elongation allows correction of larger angles and maintains a sufficient arc of contact for rectus muscles. This study reports results for tendon elongation with bovine pericardium (Tutopatch®) in indications other than Graves’ orbitopathy in which it is already widely used.MethodsWe reviewed the records of all patients who underwent surgery with Tutopatch® in our institution. Angles of squint and head postures were analyzed preoperatively, on the first postoperative day, and in the long term (median 9 weeks after the operation). Patients with Graves’ orbitopathy were excluded.ResultsFrom 2011 to 2018, the procedures on 58 eyes of 54 patients (35 females, median age 35 years (3–75)) met the inclusion criteria. Horizontal rectus muscle surgery (53 eyes) was conducted on patients with residual strabismus (13), Duane’s retraction syndrome with eso- (type I: 16)/exodeviation (type II: 2, type III: 1), 6th (7)/3rd nerve palsy (7), Möbius syndrome (2), congenital fibrosis of the extraocular muscles type 3A (CFEOM3A, TUBB3 mutation) (4), and orbital apex syndrome (1). Vertical rectus muscle surgery (5 eyes) was conducted on patients with myasthenia (1), vertical tropia after orbital floor fracture (1), CFEOM1 (2), and Parry-Romberg syndrome (1). 42 eyes had prior eye muscle surgery (1–5 procedures, median 1). Out of 45 patients with postoperative long-term data, 43 showed an angle reduction. Fifty-one percent had an angle of 10Δ (prism diopter) or less, one had a significant over-effect, and 10 had revision surgery. For the heterogeneous group of residual eso- and exotropias, the median absolute horizontal angle was reduced from 35Δ (16 to 45Δ) to 9Δ (0 to 40Δ), for Duane’s retraction syndrome from 27.5Δ (9 to 40Δ) to 7Δ (0 to 40Δ), and for sixth and third nerve palsies from 43Δ (20 to 75Δ) to 18Δ (4 to 40Δ). For 3 patients with vertical rectus muscle surgery, the median absolute vertical angle was reduced from 30Δ (20 to 45Δ) to 4Δ (1 to 22Δ). The motility range was shifted in the direction contrary to the elongated muscle in all subgroups. A considerable reduction of the excursion into the field of action of the elongated muscle had to be registered.ConclusionsStrabismus surgery with bovine pericardium introduces new surgical options for complicated revisions and for rare and complex oculomotor dysfunctions. Yet, it has to be recognized that this type of surgery aiming at maximum effects, despite preservation or restitution of the arc of contact, leads to reduction of the excursion into the field of action of the elongated muscle. Furthermore, dose finding can be difficult depending on the underlying pathology and more than one intervention might be necessary for optimal results.

Isolated opsoclonus heralding neuromyelitis optica spectrum disorder

Opsoclonus is an ocular motility disorder characterized by spontaneous, arrhythmic conjugate saccades of varying amplitude occurring in all directions of gaze without normal intersaccadic interval. Etiological spectrum of opsoclonus encompasses paraneoplastic and neoplastic conditions, infectious and para-infectious encephalitis, autoimmune, metabolic and toxic encephalopathies, drugs, motor neuron diseases, multiple sclerosis and rarely neuromyelitis optica spectrum disorder (NMOSD). Opsoclonus has never been reported as a presenting manifestation heralding NMOSD. We herein report a previously healthy 37-year-old Asian Indian woman who presented with oscillopsia and opsoclonus, followed, 12 h later, by right-sided hemiparesis, right-sided appendicular ataxia, and left-sided lower motor neuron type facial palsy and dysarthria. Brain magnetic resonance imaging revealed hyperintense lesions in brainstem and thalamus in T2-weighted and fluid attenuated inversion recovery-weighted images, quite suggestive of NMOSD. Serum and cerebrospinal fluid samples were positive for anti-aquaporin-4 antibodies, which clinched the diagnosis of seropositive NMOSD. After completion of a course of intravenous methylprednisolone 1 g/day for 5 days, her opsoclonus disappeared completely. There was significant improvement in her speech and weakness within the first week of therapy and no objective deficit after day 20 of admission. After one-and-a-half-year follow-up, the patient was maintaining well on rituximab as secondary prophylaxis without any further attack. Our case highlights that isolated opsoclonus can be the presenting feature of NMOSD.

Study of clinico-etiological profile of patients with paralytic and restrictive strabismus

Incomitant strabismus typically results in intractable diplopia, blepharoptosis, ocular motility disturbance, disturbance in pupil reaction and an unacceptable compensatory head or face posture. A complete clinico etiological profile is necessary for identifying the underlying risk factors and etiology pertaining to paralytic and restrictive strabismus which is imperative in prevention , early detection, managing the etiology and timely recovery in these patients.To study the clinico-etiological profile of patients with paralytic and restrictive strabismus in a tertiary eye hospital. Patients reporting to a tertiary eye hospital in north India and diagnosed with paralytic and restrictive strabismus, over a period of one year , were enrolled in the present study . Patients were subjected to detailed ocular examination and evaluated for ocular motility or related disorders. This included detailed clinical history, ophthalmic examination, orthoptic workup , sensory evaluation, diplopia charting, Hess charting, slit lamp examination and fundus examination . In patients of suspected restricted strabismus, forced duction test was performed. Relevant systemic investigations including blood pressure , blood sugar and lipid profile were carried out . M.R.I orbit was done in every patient. Neuroimaging was advised in those patients where indicated. 48 patients were diagnosed with incomitant strabismus and enrolled in the study. 81.3%were of paralytic strabismus while 18.8 % were of restrictive strabismus. In the group of paralytic strabismus, 43.8 % patients had sixth nerve palsy , 27.1% patients had third nerve palsy , 6.3% patients had fourth nerve palsy and combined nerve palsy patients were 4.2%. Analysing the etiology, out of total patients of paralytic strabismus, 48.7% of cases were idiopathic, 25.6% were post traumatic, 15.4% were due to microvascular causes , 5.1% of cases were due to intracranial anomalies and rest 5.1% were due to inflammatory causes. In restrictive strabismus group, 66.7% were congenital and rest 33.3% were acquired. Our study has reflected the prevalence, distribution , etiological and clinical profile of patients presenting with incomitant strabismus . It is helpful for ophthalmologists and other physicians in guiding diagnosis and evaluation and is useful for proper and timely intervention and timely recovery in these patients.

Internuclear Ophthalmoplegia with Ipsilateral Abduction Deficit : Half and Half Syndrome

Introduction: Head trauma can often result in the complaint of diplopia. Internuclear ophthalmoplegia (INO) coexists with abduction deficit, introduced as half and half syndrome, is rarely reported. This article presents an INO case with ipsilateral abduction deficit after a head trauma. Methods: A 17-year-old male came with binocular diplopia on horizontal gaze 2 days after a head trauma. Best corrected visual acuity on both eyes was 6/6. Adduction deficit of contralateral gaze appeared in the right eye associated with an abducting dissociated horizontal nystagmus in the left eye. He also had a moderate under-action of abduction on ipsilateral gaze in the right eye. On up gaze, both eyes were found to have vertical nystagmus. Anterior and posterior segments revealed normal, except minimal chemosis on the right eye, no relative afferent pupillary defect. Brain imaging showed lesions in pons mainly on the right side. Results: Improvement of ocular movement was observed in 2 weeks. Diplopia and mild ocular movement limitation were still found after 6 months. Conclusion: Based on ophthalmologic and systemic examinations the patient had internuclear ophthalmoplegia (half) with ipsilateral abduction deficit (half): half and half syndrome. Head trauma is one of the risk factors of ocular motility disorders.

Optical coherence tomography angiography for the measurement of optic disc: Macular relationship.

Fundus photography is the gold standard for assessing ocular torsion over the last 30 years. However, it is not a precise and reproducible tool during clinical practice. Optical coherence tomography angiography is characterized by precise identification of the macula and the optic disc, and it could be an effective method to easily calculate the angle of ocular torsion, compared to fundus photography. The aim of this study was to show whether any difference in the measurement and the accuracy of the angle of torsion between the head of the optic nerve and the fovea was present. This is a prospective single-, referral-center study conducted at the San Giuseppe Hospital in Milan on 80 eyes of 40 adult patients, included in a random-sample way. Exclusion criteria were non-cooperation, higher refractive errors of ±3 diopters, retinal and optic disc pathologies, and ocular movement disorders. Patients' mean age was 54.3 ± 16.3 (range: 22-83) years. The angle measured by the fundus camera was 7.78° ± 3.04°, while the angle measured by the angiography was 7.09° ± 3.08° (p = .035). The mean interocular difference was 1.54° ± 3.42° for fundus photography and 0.5° ± 4.71° for angiography (p = .013). Optical coherence tomography angiography is a very useful, fast, precise, reproducible, and reliable technique in cooperative subjects, not inferior to the fundus camera and less prone to human error.

Characteristics of Ocular Motility Disorders with Anti-ganglioside Antibodies

Characteristics of Ocular Motility Disorders with Anti-ganglioside Antibodies

Severe Acquired Restrictive Strabismus Fixus in Patients with Trisomy 21

ABSTRACTAcquired strabismus fixus is a rare form of severe esotropia described most frequently in patients with high axial myopia and infrequently associated with other conditions. Refractive errors, cataracts, and ocular motility disorders are common in patients with trisomy 21. We report two unusual cases of patients with trisomy 21 who developed severe acquired restrictive strabismus fixus. Both patients were successfully treated with medial rectus recession followed by lateral rectus and superior rectus myopexy combined with additional medial rectus weakening, including free tenotomy in one case.

Ocular motility disorders with special emphasis on multiple sclerosis

Ocular motility disorders with special emphasis on multiple sclerosis

Use of Unsintered Hydroxyapatite and Poly-L-lactic Acid Composite Sheets for Management of Orbital Wall Fracture.

Although unsintered hydroxyapatite and poly-L-lactic acid (u-HA/PLLA) composite sheets have various applications, such as in craniomaxillofacial fractures, orthognathic surgery, and orthopedic surgery, and have been proven to be safe and effective, no studies have reported the use of u-HA/PLLA composite sheets for orbital wall reconstruction with long-term follow-up. This study reports our preliminary results using the u-HA/PLLA composite sheet for orbital wall fractures. The SuperFIXSORB MX sheet (u-HA/PLLA composite sheet; Takiron, Tokyo, Japan), with size of 30 × 50 mm and thickness of 0.5 mm, was used in all cases of hard reconstruction of the orbital bone defect. Seventy-two patients with acute orbital wall fractures (within 2 weeks after sustaining the injury) treated at the Jikei University between January 2014 and August 2016 were included. The authors evaluated the postoperative complications and the operability of the material. The authors did not observe any postoperative complications, such as infection, postoperative diplopia, or enophthalmos, due to the use of the u-HA/PLLA composite sheet. In pure orbital fractures (orbital fractures only), the mean (±standard deviation) operation time was significantly longer with combined inferior and medial wall fractures (201.1 ± 36.6 minutes; n = 11) than with inferior wall or medial wall fractures only (135.0 ± 54.4 minutes; n = 51) (Mann-Whitney U test, P < 0.001). The U-HA/PLLA composite sheet is safe and can be used for orbital wall fracture reconstruction. Further long-term functional and aesthetic assessments for infection, ocular movement disorder, enophthalmos, and any other complication are necessary.

Medial transposition of a split lateral rectus muscle in synergistic divergence

Synergistic divergence is a rare congenital ocular motility disorder characterized by paradoxical abduction during attempted horizontal gaze to the contralateral side. It is generally unilateral and associated with limited adduction of the affected eye and large-angle exotropia in primary position. Various surgical techniques have been used to manage this condition, with limited success. We describe our experience using splitting and medial transposition of the lateral rectus muscle on the affected side to treat an 18-month-old girl with synergistic divergence. Postoperative improved motor alignment remained stable through 6months' follow-up.

Usefulness of the anterior transpetrosal approach for pontine cavernous malformations.

Surgical resection of pontine cavernous malformation remains a particularly formidable challenge. We report the surgical outcome of eight cases with pontine cavernous malformations operated using the anterior transpetrosal approach. All cases presented with neurological deficits caused by hemorrhage before surgery. Gross-total removal was achieved in all cases without any postoperative complication such as worsening of facial nerve palsy, ocular movement disorder, or hemiplegia. A small incision of the pons with multidirectional dissection is the most important factor for minimizing postoperative neurological deficits, so resection of a pontine cavernous malformation via this approach can be an alternative better option.The video can be found here: https://youtu.be/2Q2CUhBbo28.

A Case Report of an Internuclear Ophthalmoplegia Patient caused by Pontine Infarction Treated by Korean Medicine Treatment Including &lt;italic&gt;Yukmijihwang-tang&lt;/italic&gt;

Internuclear Ophthalmoplegia (INO) is characterized by lesion side eye’s adduction limitation in lateral horizontal gaze and nystagmus in the abducting eye due to lesions in the Medial Longitudinal Fasciculus (MLF). Brainstem infarction is one of the causes of INO, but related issues have seldom been reported in the Korean medical literature. The present case was a pontine infarction patient with INO who complained of diplopia and eye movement disorder. The patient was treated with Korean medicine treatment, including herbal medicine, acupuncture, cupping, and moxibustion for 30 days. Her changes in clinical symptoms were measured with a Numeric Rating Scale (NRS) and a length of External Ocular Movement (EOM), in which the patient’s right eyeball moved to the left from the midline in the left gaze. After treatment, her clinical symptoms were improved. Diplopia decreased from NRS 10 to NRS 2, and eye movement disorder was improved such that EOM increased from 1mm to 5 mm. Therefore, integrative Korean medicine treatment may be effective in the treatment of INO patients caused by pontine infarction. Keywords: diplopia, ocular motility disorders, internuclear ophthalmoplegia, pontine infarction, Yukmijihwang-tang-gami (Liuwei-Dihuang-tang), case report