Ophthalmic Division Research Articles

The trigeminal system: The meningovascular complex- A review.

Supratentorial sensory perception, including pain, is subserved by the trigeminal nerve, in particular, by the branches of its ophthalmic division, which provide an extensive innervation of the dura mater and of the major brain blood vessels. In addition, contrary to previous assumptions, studies on awake patients during surgery have demonstrated that the mechanical stimulation of the pia mater and small cerebral vessels can also produce pain. The trigeminovascular system, located at the interface between the nervous and vascular systems, is therefore perfectly positioned to detect sensory inputs and influence blood flow regulation. Despite the fact that it remains only partially understood, the trigeminovascular system is most probably involved in several pathologies, including very frequent ones such as migraine, or other severe conditions, such as subarachnoid haemorrhage. The incomplete knowledge about the exact roles of the trigeminal system in headache, blood flow regulation, blood barrier permeability and trigemino-cardiac reflex warrants for an increased investigation of the anatomy and physiology of the trigeminal system. This translational review aims at presenting comprehensive information about the dural and brain afferents of the trigeminovascular system, in order to improve the understanding of trigeminal cranial sensory perception and to spark a new field of exploration for headache and other brain diseases.

The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures?

The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is activated. Material and methods: A retrospective study included patients who developed TVR during the surgical management of mandibular, midface, and orbital fractures. The reflex was divided into type I, II, III, and IV-TVR according to the following nerves: ophthalmic, maxillary, mandibular, and non-trigeminal nerves, respectively. The magnitude of hemodynamic drops was identified at the intraoperative baseline, during reflex, and postoperatively. The needed time to elicit the reflex, frequency and duration, need for medical intervention, and sequence of the drop were also recorded. P - values < 0.05 was considered significant.Out of 260 patients’ files were reviewed, the TVR was observed in only 30 (11.55 %) patients. The ophthalmic nerve activation significantly caused the greatest intensity and magnitude of hemodynamic drop, followed by maxillary nerve, then mandibular division, and the lowest one was non-trigeminal nerves. The highest mean of drops in the mean arterial blood pressure (MABP) was 62.92 ± 2.39 with the type ITVR, whereas those of the type II, III, and IV were 75.5 ±3.98, 81.02±1.31, and 82.22±1.85, respectively. Also, the type I-TVR led to the greatest decrease in the heart rate (HR) with the mean equaled to 52.31± 3.91. The drop percentage in the MABP was -30.5, -17.5, -12, -10.08 for type I, II, III, and IV, whereas those of the HR were - 33.9, -27.13, -26.6, and -25 with type I, II, III, and IV, respectively. All results showed highly significant differences with p-values less than 0.001 when comparing between the baseline and intraoperative values of each TVR type.There is a positive correlation between the activated pathway of the TVR and the intensity of its efferent arc response due to the neural pathway of each division in the brainstem circuitry. Understanding of the pathophysiology and mechanism of the TVR, together with the rapid recognition and treatment could prevent serious negative outcomes, especially when the ophthalmic nerve is stimulated.1Introduction

Prevalence of iatrogenic trigeminal nerve injuries in routine dental practice in private, public, and educational clinics of Riyadh, Saudi Arabia

Background: The trigeminal nerve (V) is a critical nerve in the maxillofacial region relevant to dentistry. The nerve trifurcates into ophthalmic, maxillary, and mandibular nerves . The risk of having trigeminal nerve injuries (TNIs) is relatively high as dentists from various specialties perform trigeminal nerve blocks in routine dental practice. The causes of TNIs can be varied and broadly classified into iatrogenic and non-iatrogenic. The current study aimed to assess the prevalence of TNIs, mainly iatrogenic injuries, in Riyadh, Saudi Arabia, and examine the various dental factors associated with these types of nerve injuries. Methods: A cross-sectional study was carried out through a questionnaire. The questionnaire consisted of two major parts: demographic data and injury assessment and management. The participants were 349 in number and were dentists, interns, and dental students working in private, governmental, and educational sectors. The participants were approached by a simple random sampling technique. The reporting of the iatrogenic cases is mainly outlined. Results: Among the participants, 45.9% were dentists, 35.8% students, and 18.3% were interns. Most cases (93%, N = 44) were presented with neuropathy due to iatrogenic injury. Out of the 93% reported cases, 65.9% were related to extractions, 27.3% were associated with implants and restorative procedures, and 18.2% were related to endodontic procedures. Temporary injuries accounted for 82%, whereas permanent injuries were 18%. The inferior alveolar nerve is affected more often than the lingual nerve. Most of these injuries (70%) were referred to oral and maxillofacial surgeons for follow-up. Conclusion: An appropriate assessment, thorough history, and clinical examination would significantly help prevent TNI cases. Moreover, well documentation and prompt reporting and referral by the clinicians would ensure optimum patient care. Therefore, further studies covering the main Saudi regions other than Riyadh city are advocated to establish preventive and management protocols.

Paroxysmal Hemicrania: An Update.

Paroxysmal Hemicrania (PH) is classified under trigeminal autonomic cephalalgia (TAC) as per the International Classification of Headache Disorders (ICHD). Since the first description by 0ttar Sjaastad and Inge Dale in 1974, PH has been reported by many authors. A greater understanding of PH phenotype and pathophysiology has resulted in the evolution of its diagnostic criteria, and management. We tabulated major case series of PH to describe the epidemiology, clinical features and recent updates of PH. PH is a rare headache characterized by daily, multiple paroxysms of unilateral, short-lasting (mean duration <20 minutes), side-locked headache in the distribution of ophthalmic division of trigeminal nerve with associated profound cranial autonomic symptoms. Recent ICHD classification added "restlessness" to the criteria for PH. Pain should completely respond to indomethacin to fulfil the diagnostic criteria of PH. PH should be differentiated from cluster headache, SUNCT/SUNA, and other short-lasting side-locked headaches. Trigeminal afferents possibly produce pain in PH and trigeminal-autonomic reflex explains the occurrence of autonomic features. Recently, a "permissive" central role of the hypothalamus is unveiled based on functional imaging studies. Other Cox-2 inhibitors, topiramate, calcium-channel blockers, epicranial nerve blocks have been shown to improve headache in some patients of PH who cannot tolerate indomethacin. Hypothalamic deep brain stimulation has been used in treatment-refractory cases.

Herpes Zoster Duplex Unilateralis as a manifestation of severe lymphopenia in COVID19

To the editor in chief, SARS-CoV2 (severe acute respiratory syndrome coronavirus-2), a novel coronavirus was first reported in December of 2019 from Wuhan, China as an aetiological agent causing a new infectious respiratory disease (coronavirus disease 2019- COVID-19). The main clinical manifestations of COVID-19 are fever, cough, fatigue, dyspnoea and muscle aches. Herpes zoster is characterized by several groups of painful vesicles on an erythematous base with a distribution in a unilateral dermatome involving the skin and/or mucosa. Herpes zoster is caused by varicella zoster virus which remains dormant in the sensory root ganglion contained by the immune system particularly CD lymphocytes (Wollina, 2017). This characteristic presentation is seen in an immunocompetent host. Severe forms of Herpes zoster not respecting the borders of a dermatome have been described. They are (a) Disseminated Herpes zoster that is, lesions extending over three contiguous dermatomes or lesions going outside the original dermatome. (b) Herpes zoster Duplex—here the lesions involve two non-contiguous dermatomes. If the dermatome involved are unilateral then it is known as Herpes Zoster Duplex Unilateralis and if present bilaterally then—Herpes Zoster Duplex Bilateralis (Jung et al., 2000). The non-contiguous variants are rare in both immunocompetent and immunocompromised host and represent a viraemic spread of VZV due to decrease in lymphocyte count and/or function. Classical Dermatomal Herpes Zoster has been described as a marker of subclinical COVID19 infection (Tartari et al., 2020). We are presenting a case of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve (V1) and left Thoracic 10 (T10) dermatome in a patient of COVID19 with severe lymphopenia. A 62-year-old otherwise healthy male presented with highly painful vesicular lesions on an erythematous base involving the left ophthalmic division of trigeminal nerve (Day 6) and left thoracic 10 (T10) (Day 8) dermatome occurring 2 days apart. The vesicles ranged from 0.3 mm to 1 cm in size and had necrotic element at some places. Hutchinson sign was positive. A diagnosis of Herpes Zoster Duplex Unilateralis involving left ophthalmic division of trigeminal nerve and left Thoracic 10 (T10) dermatome was observed. The patient had fever (101–103°F) with malaise for preceding 5 days of appearance of vesicles. His COVID19 RT PCR test was positive (Day 8), however, evaluation for HIV status, diabetes, any immunosuppressive state and malignancy was negative. HRCT thorax showed multiple ground glass opacities in both the lungs with CT severity score being 18/30. His LDH levels were 229 units/L (normal range 135–225 U/L), D-dimer 3,422.26 (0–500 ng/ml), IL-6 levels 23 (normal range 0–7 pg/ml). Troponin-T levels determined by Card test, serum ferritin levels and liver function tests were normal. Total leucocyte count was 7,100 cells/mm3 (4000–11000 cells/mm3 normal range). However differential eucocyte count showed neutrophilia (90%) and relative lymphopenia (2.2%), whereas the normal range is 20%–40%. The patient was treated according to institutional COVID19 protocol and was given piperacillin tazobactam 4.5 mg thrice a day injection, remdesivir 200 mg slow iv infusion and dexamethasone injection 4 mg once daily , low molecular weight heparin 6 mg twice a day subcutaneously for 5 days. For VZV lesions, oral acyclovir was given at a dose of 800mg five times a day for 10 days after which he recovered with mild post herpetic neuralgia. Herpes Zoster Duplex Unilateralis represents a viraemic spread of VZV, probably due to decreased immune protection. In our patient lymphocyte percentage was 2.2% representing a severe lymphopenia. We tried to look into the possible explanations: In COVID 19 patients, the inflammatory cytokine storm is likely a key factor behind the observed lymphopenia. The serum level of pro-inflammatory cytokines, such as TNF-α and IL-6, have been closely correlated with lymphopenia, while recovered patients show close to normal levels of such cytokines (Mazzoni et al., 2020). Autopsy studies on lymphoid organs collected from several patients who succumbed to the disease revealed massive lymphocyte death, which was attributed to high levels of IL-6 as well as Fas–FasL interactions. Our patient also had high IL 6 levels and clinical features suggestive of cytokine storm. COVID-19 infection can result in exhaustion of T cells. A recent study has found both CD4+ and CD8+ T cells from COVID-19 patients had increased cell surface expression of programmed cell death protein 1 (PD-1) and T cell immunoglobulin and mucin domain 3 (Tim-3), the two markers of T cell exhaustion (Diao et al., 2020). The SARS-CoV-2 can directly infect T cells. This infection can interfere with T cell expansion. A report suggests that some genes involved in T cell activation and function, such as MAP2K7 and SOS1 are downregulated in the T cells of severe COVID-19 patients (Ouyang et al., 2020). All these mechanisms may be an explanation to the relative lymphopenia in our patient with an unusual presentation of Herpes Zoster. Nil. None declared.

Peripheral Neuromodulation for the Management of Headache.

ContextNeuromodulation is an expanding field of study for headache treatment to reduce pain by targeting structures within the nervous system that are commonly involved in headache pathophysiology, such as the vagus nerve (VNS), occipital nerves, or sphenopalatine ganglion (SPG) for stimulation. Pharmaceutical medical therapies for abortive and prophylactic treatment, such as triptans, NSAIDs, beta-blockers, TCAs, and antiepileptics, are effective for some individuals, but the role that technology plays in investigating other therapeutic modalities is essential. Peripheral neuromodulation has gained popularity and FDA approval for use in treating certain headaches and migraine headache conditions, particularly in those who are refractory to treatment. Early trials found FDA approved neurostimulatory implant devices, including Cephaly and SpringTMS, improved patient-oriented outcomes with reductions in headaches per month (frequency) and severity.Evidence AcquisitionThis was a narrative review. The sources for this review are as follows: Searching on PubMed, Google Scholar, Medline, and ScienceDirect from 1990 - 2019 using keywords: Peripheral Neuromodulation, Headache, vagus nerve, occipital nerves, sphenopalatine ganglion.ResultsThe first noninvasive neurostimulator device approved for migraine treatment was the Cefaly device, an external trigeminal nerve stimulation device (e-TNS) that transcutaneously excites the supratrochlear and supraorbital branches of the ophthalmic nerve. The second noninvasive neurostimulation device receiving FDA approval was the single-pulse transcranial magnetic stimulator, SpringTMS, positioned at the occiput to treat migraine with aura. GammaCore is a handheld transcutaneous vagal nerve stimulator applied directly to the neck at home by the patient for treatment of cluster headache (CH) and migraine. Several other devices are in development for the treatment of headaches and target headache evolution at different levels and inputs. The Scion device is a caloric vestibular stimulator (CVS) which interfaces with the user through a set of small cones resting in the ear canal on either side and held in place by modified over-ear headphones. The pulsante SPG Microstimulator is a patient-controlled device implanted in the patient’s upper jaw via an hour-long oral procedure to target the sphenopalatine ganglion. The occipital nerve stimulator (ONS) is an invasive neuromodulation device for headache treatment that consists of an implanted pulse generator on the chest wall connected to a subcutaneous lead with 4 - 8 electrodes that is tunneled the occiput.ConclusionsThe aim of this review is to provide a comprehensive overview of the efficacy, preliminary outcomes, and limitations of neurostimulatory implants available for use in the US and those pending further development.

Posteriorly Displaced Orbital Implant Causing Intractable Anophthalmic Socket Pain.

Anophthalmic socket pain is a rare complication of enucleation. The authors present a patient presenting with intractable anophthalmic socket pain due to a posteriorly displaced orbital implant. The patient's pain localized to the V1 and V2 orbitofacial dermatomes, and we suspect compression of the frontal and zygomatic branches of the ophthalmic and maxillary nerves, respectively, as the underlying etiology of the patient's pain. Removal of the implant and placement of a dermis fat graft was effective at alleviating the patient's symptoms.

Herpes zoster of the trigeminal nerve with multi-dermatomal involvement: a case report of an unusual presentation

BackgroundHerpes zoster, also known as shingles, results from reactivation of the varicella-zoster virus. It commonly presents with burning pain and vesicular lesions with unilateral distribution and affects the thoracic and cervical sites in up to 60 and 20% of cases, respectively. The branches of the trigeminal nerves are affected in up to 20% of cases. Multidermatomal involvement of the trigeminal nerves has been only anecdotally described in immunocompetent subjects.Case presentationA 71-year-old previously healthy male presented with grouped vesicular and impetiginized lesions with crusts on the left half of the face of two-weeks duration. The lesions first developed on the left nasal tip and progressively worsened with unilateral appearance of vesicular lesions on the left forehead, face, ala nasi, nasal vestibulum and columella, as well as on the left side of hard and soft palate. The affected edematous erythematous areas corresponded to the distribution of the left ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve, including the infraorbital and nasopalatine nerves of the maxillary branch responsible for the oral cavity involvement. Viral DNA amplification by polymerase chain reaction confirmed the presence of Varicella zoster virus. The patient was started on oral valaciclovir with rapid recovery.ConclusionsAmong immunocompetent patients, herpes zoster is considered a self-limited localized infection. Our observation provides a rare but paradigmatic example of herpes zoster with involvement of both the ophthalmic and maxillary divisions of the trigeminal nerve in an immunocompetent patient. Immunocompetence status and age-specific screening should be warranted in case of atypical involvement and according to the patient’s history, while treatment with antiviral drugs should be rapidily initiated in patients at risk.

Radioanatomic Characteristics of the Posteromedial Intraconal Space: Implications for Endoscopic Resection of Orbital Lesions.

Imaging is essential in the diagnostic work-up of patients with orbital lesions. The position of an orbital lesion relative to the inferomedial muscular trunk of the ophthalmic artery determines endoscopic resectability, anticipated technical difficulty, and patient morbidity. Although the inferomedial muscular trunk is not readily identifiable on preoperative imaging, we hypothesize that it is spatially approximate to the location where the ophthalmic artery crosses the optic nerve. Our aim was to determine whether the ophthalmic artery-optic nerve crosspoint anatomically approximates the inferomedial muscular trunk in a cadaver study and can be appreciated on imaging of known posteromedial orbital lesions. Dissection was performed on 17 fresh-frozen cadaver orbits to assess the relationship between the inferomedial muscular trunk and ophthalmic artery-optic nerve crosspoint. Retrospective review of imaging in 9 patients with posteromedial orbital lesions assessed posteromedial orbital compartment characteristics and the ability to locate the ophthalmic artery-optic nerve crosspoint. In our cadaver study, the mean distance between the ophthalmic artery-optic nerve crosspoint and the inferomedial muscular trunk was 1.21 ± 0.64 mm. Retrospectively, the ophthalmic artery-optic nerve crosspoint was identifiable in 9/9 patients, whereas the inferomedial muscular trunk was not identifiable in any patient. Total or partial effacement of the posteromedial intraconal fat triangle was observed in 9/9 patients. This study of neurovascular relationships within the posteromedial orbit demonstrates that the ophthalmic artery-optic nerve crosspoint closely approximates the inferomedial muscular trunk and can be seen in patients with posteromedial orbital lesions. Posteromedial intraconal fat effacement may help to localize these lesions. These findings may facilitate multidisciplinary communication and help predict lesion resectability and patient outcomes.

Lung cancer screening by nodule volume in Lung-RADS v1.1: negative baseline CT yields potential for increased screening interval

ObjectivesThe 2019 Lung CT Screening Reporting & Data System version 1.1 (Lung-RADS v1.1) introduced volumetric categories for nodule management. The aims of this study were to report the distribution of Lung-RADS v1.1 volumetric categories and to analyse lung cancer (LC) outcomes within 3 years for exploring personalized algorithm for lung cancer screening (LCS).MethodsSubjects from the Multicentric Italian Lung Detection (MILD) trial were retrospectively selected by National Lung Screening Trial (NLST) criteria. Baseline characteristics included selected pre-test metrics and nodule characterization according to the volume-based categories of Lung-RADS v1.1. Nodule volume was obtained by segmentation with dedicated semi-automatic software. Primary outcome was diagnosis of LC, tested by univariate and multivariable models. Secondary outcome was stage of LC. Increased interval algorithms were simulated for testing rate of delayed diagnosis (RDD) and reduction of low-dose computed tomography (LDCT) burden.ResultsIn 1248 NLST-eligible subjects, LC frequency was 1.2% at 1 year, 1.8% at 2 years and 2.6% at 3 years. Nodule volume in Lung-RADS v1.1 was a strong predictor of LC: positive LDCT showed an odds ratio (OR) of 75.60 at 1 year (p < 0.0001), and indeterminate LDCT showed an OR of 9.16 at 2 years (p = 0.0068) and an OR of 6.35 at 3 years (p = 0.0042). In the first 2 years after negative LDCT, 100% of resected LC was stage I. The simulations of low-frequency screening showed a RDD of 13.6–21.9% and a potential reduction of LDCT burden of 25.5–41%.ConclusionsNodule volume by semi-automatic software allowed stratification of LC risk across Lung-RADS v1.1 categories. Personalized screening algorithm by increased interval seems feasible in 80% of NLST eligible.Key Points• Using semi-automatic segmentation of nodule volume, Lung-RADS v1.1 selected 10.8% of subjects with positive CT and 96.87 relative risk of lung cancer at 1 year, compared to negative CT.• Negative low-dose CT by Lung-RADS v1.1 was found in 80.6% of NLST eligible and yielded 40 times lower relative risk of lung cancer at 2 years, compared to positive low-dose CT; annual screening could be preference sensitive in this group.• Semi-automatic segmentation of nodule volume and increased screening interval by volumetric Lung-RADS v1.1 could retrospectively suggest a 25.5–41% reduction of LDCT burden, at the cost of 13.6–21.9% rate of delayed diagnosis.

Gunshot wounds of the head in peacetime, with the formation of a delayed carotid-cavernous fistula (case report)

The objective of the article is to present the clinical observation of a gunshot wounds of the head in peacetime, with the formation of a delayed carotid-cavernous fistula.Clinical case. A patient aged 26 years received a penetrating parabasal single gunshot wound to the head. After transfer to the N.V. Sklifosovsky Research Institute of Emergency Medicine from a local hospital, intima dissection and occlusion of the left internal carotid artery (ICA) were diagnosed. Supraclinoid section of the left ICA, left anterior cerebral and middle cerebral arteries were filled from the right ICA through the anterior communicating artery. For prevention of suppurative-septic complications as well as decubitus of the left ICA and development of life-threatening hemorrhages, repeat surgery was performed. Acute subdural hematoma and brain detritus were removed. Using pterional approach, the chiasm and sellar region was accessed. Sequentially the ophthalmic, interpenducular, penducular cisterns, cisterna laminae terminalis and left carotid cistern were dissected. Sequentially the left ophthalmic nerve, left ICA, left choroid arteries were isolated. A metallic foreign object (bullet) located in the medial regions of the larger wing of the sphenoid bone and lateral wall of the cavernous sinus was found and removed. On day 14 after the second surgery, headache became worse, pulsing noise developed in the left part of the head, as well as moderate exophthalmos on the left. Left-hand type A (per the Barrow classification) carotid-cavernous anastomosis with retrograde inflow due to occlusion of the left ICA was diagnosed. Endovascular intervention was performed: separation of the carotid-cavernous anastomosis through retrograde occlusion of the supraclinoid segment of the left ICA with microcoils through contralateral ICA and anterior communicating artery. The patient was discharged at day 30 after hospitalization. Cerebral and meningeal symptoms regressed. Ptosis grade decreased, the left eye started to move.Conclusion. This abovementioned observation is of interest due to the rarity of such pathology and the possibilities of modern multidisciplinary centers for the diagnosis and treatment of such patients as of this date.

Comprehensive analysis of differentially expressed microRNAs and mRNAs involved in diabetic corneal neuropathy

AimsCorneal nerve fibers are derived from the ophthalmic division of the trigeminal ganglion (TG). Here, by sequencing of microRNAs (miRNAs) and messenger RNAs (mRNAs) from diabetic and normal TG tissues, we aimed to uncover potential miRNAs, mRNAs, and the network of their interactions involved in the pathogenesis of diabetic corneal neuropathy. Main methodsWe performed RNA sequencing to systematically screen out differentially expressed miRNAs and mRNAs in TG tissues from diabetic and normal mice. Functional enrichment analyses were performed to illustrate the biological functions of differentially expressed mRNAs (DEmRNAs). Following this, miRNA-mRNA regulatory networks were built by means of bioinformatics methods to suggest regulatory role for miRNAs in the pathogenesis of diabetic corneal neuropathy. Finally, the credibility of the sequencing-based results was validated using qRT-PCR. Key findingsSequencing analyses disclosed that 68 miRNAs and 114 mRNAs were differentially expressed in diabetic TG tissues compared with normal TG samples. The functional analyses showed that DEmRNAs participated in diabetes-related biological processes. After applying an optimized approach to predict miRNA–mRNA pairs, a miRNA-mRNA interacting network was inferred. Subsequently, the expression and correlation of miR-350-5p and Mup20, miR-592-5p and Angptl7 as well as miR-351-5p and Elovl6 were preliminarily validated. SignificanceOur study provides a systematic characterization of miRNA and mRNA expression in the TG during diabetic corneal neuropathy and will contribute to the development of clinical diagnostic and therapeutic strategies for diabetic corneal neuropathy.

A Rare Case of Atypical Pleomorphic Neoplasm of Pineal Region in a Child: A Case Report

A 10-year-old boy with no past medical history presented with complaints of nausea and vomiting associated with morning headache for the last month. Ophthalmic nerve and eye exam showed diplopia and strabismus with no other significant findings on physical and neurological examination. Magnetic resonance imaging (MRI) of the brain revealed a homogenous hyperdense and enhancing mass in the pineal region. The endoscopic biopsy of the pineal region demonstrated the cells with highly pleomorphic and hyperchromatic nuclei with an increase in mitotic activity. There were many vessels but no area of vascular proliferation and necrosis. Granular bodies with eosinophilia were identified. Immunohistochemistry was positive for class III b-tubulin with epidermal growth factor receptor (EGFR) staining and glial fibrillary acidic protein (GFAP). Immunostaining was positive for p53, Phosphatase and Tensin homolog (PTEN), and oligodendrocyte transcription factor (OLIG2), while staining for cluster of differentiation (CD)34, cytokeratin (CK), human melanoma black (HMB)45, and isocitrate dehydrogenase (IDH)-R132H mutation was negative, consistent with atypical pleomorphic neoplasm of the pineal region. The patient underwent tumor resection via a sub-occipital trans-tentorial approach, followed by one dose of chemotherapy. The patient experienced a resolution of the symptom and was doing well on his bi-monthly follow up.

COVID‐19 and herpes zoster co‐infection presenting with trigeminal neuropathy

BackgroundVaricella‐zoster virus (VZV) is a human neurotropic virus that remains in a latent state within ganglionic neurons throughout the entire neuroaxis after the primary infection. When herpes zoster (HZ) leads to trigeminal involvement, the ophthalmic division is the most implicated. COVID‐19 has emerged as a viral cause of severe acute respiratory syndrome that has spread all over the world in the last months. Co‐infection with COVID‐19 and other viruses has been reported, but sparsely, and involving the respiratory viruses.MethodsThe case of a co‐infection of COVID‐19 with VZV is reported, and the literature reviewed.ResultsA 39‐year‐old immunocompetent man presented with oligosymptomatic infection with COVID‐19, which evolved to left facial HZ, affecting the three divisions of the trigeminal nerve. The co‐infection was remotely registered, being the respiratory viruses, especially influenza, the most commonly cited association. However, the present case illustrates the emergence of a latent virus infection, which might be favored by the inflammatory response to the former agent (COVID‐19). This reaction ascended from the nasal cavity, where trigeminal branches are also placed.ConclusionsThe emergence of latent VZV infection in this rare presentation might illustrate an effect, at least locally, of COVID‐19. This virus possibly induced a retrograde reactivation of VZV in a young immunocompetent patient.

Human Vaccines and Herpes Zoster Ophthalmicus: Clinical Manifestation, Treatment, and Prevention

Herpes zoster ophthalmicus (HZO) is a reactivation of HZ virus that is latent in ophthalmic division of trigeminal ganglion. Patients over 50 years old, premature infant, pregnancy woman, receiving immunosuppressive agents, and malignancies are at risk of having HZO. Ocular manifestations of HZ are ectropion, entropion, ectopic eyelash, keratitis, conjunctivitis, symblepharon, hypoesthesia, episcleritis, scleritis, scleral atrophy and thinning, uveitis, iris atrophy, posterior synechiae, acute retinal necrosis, progressive outer retinal necrosis, retinal detachment, retina atrophy, optic neuritis, optic atrophy, and strabismus. Polymerase chain reaction, antigen detection, and antibody detection can help to confirm diagnosis. Pharmacology treatments for HZ ophthalmicus are antiviral drugs, corticosteroids, analgesics, tricyclic antidepressants, and antiepileptic drug. Non-pharmacology therapies are scleral contact lens, phototherapeutic keratectomy, photorefractive keratectomy, and penetrating keratoplasty. There are two kinds of vaccination which can be given to patients: Live-attenuated varicella zoster vaccine and recombinant zoster vaccine. It is recommended by Centers for Disease Control and Prevention and Food and Drugs Administration to use recombinant zoster vaccine by 50 years old.

Factors Associated With Long-Term Risk of Recurrence After Percutaneous Radiofrequency Thermocoagulation of the Gasserian Ganglion for Patients With Trigeminal Neuralgia Involving the Ophthalmic Division: A Retrospective Study.

To evaluate risk factors associated with recurrence after radiofrequency thermocoagulation (RFT) of the gasserian ganglion among patients with ophthalmic trigeminal neuralgia (TN) and prognostic factors in terms of recurrence-free survival (RFS) during a long-term follow-up. From January 2005 to December 2017, 300 patients with ophthalmic TN underwent RFT. A retrospective analysis of 14-year outcomes was performed. Kaplan-Meier analysis was used for RFS after the procedure. Univariate and multivariate Cox regression analyses were performed to identify risk factors for pain recurrence. The initial effective rate of RFT for ophthalmic TN was 92%. The mean follow-up time was 77.38±43.24months. The cumulative probability of RFS was 86.94% at 1year, 80.03% at 2 years, 77.27% at 3 years, 74.01% at 5 years, and 59.92% at 10 years after RFT. The mean duration of RFS was 114.67 months (95% confidence interval [CI] 106.27 to 123.06 months). In multivariate analysis, atypical pain (hazard ratio [HR]=2.831, 95% CI 1.759 to 4.554, P<0.001) and mild facial hypesthesia (HR=2.540, 95% CI 1.309 to 4.931, P=0.006) before RFT were independently associated with pain recurrence. Patients with a prognostic index (PI) >1.27 were at high risk for pain recurrence. Major complications included troublesome dysesthesia (0.7%), keratitis (10.9%), diplopia (0.4%), facial paresthesia (6.2%), and masseter weakness (12.7%). Masseter weakness was more common in patients with V3 branch involvement. Three patients lost their sight due to keratitis. Our study investigated long-term outcomes and complications of RFT for ophthalmic TN. Patients at high risk for pain recurrence were identified, which might provide a basis for clinical decision making before RFT.

Ultrasound detection of iatrogenic injury during peribulbar eye block: a cadaveric study

BackgroundOphthalmic eye blocks, such as retrobulbar, peribulbar and sub-Tenon’s, are traditionally conducted “blind”. Complications are rare but potentially devastating. Life-threatening complications include brain stem anesthesia and local anesthetic toxicity, whereas...

Trigeminal activation patterns evoked by chemical stimulation of the dura mater in rats

BackgroundAlthough migraine is one of the most common primary headaches, its therapy is still limited in many cases. The use of animal models is crucial in the development of novel therapeutic strategies, but unfortunately, none of them show all aspects of the disease, therefore, there is a constant need for further improvement in this field. The application of inflammatory agents on the dura mater is a widely accepted method to mimic neurogenic inflammation in rodents, which plays a key role in the pathomechanism of migraine. Complete Freund’s Adjuvant (CFA), and a mixture of inflammatory mediators, called inflammatory soup (IS) are often used for this purpose.MethodsTo examine the activation pattern that is caused by chemical stimulation of dura mater, we applied CFA or IS over the right parietal lobe. After 2 h and 4 h (CFA groups), or 2.5 h and 4 h (IS groups), animals were perfused, and c-Fos immunoreactive cells were counted in the caudal trigeminal nucleus. To explore every pitfall, we examined whether our surgical procedure (anesthetic drug, stereotaxic apparatus, local lidocaine) can alter the results under the same experimental settings. c-Fos labeled cells were counted in the second-order neuron area based on the somatotopic organization of the trigeminal nerve branches.ResultsWe could not find any difference between the CFA and physiological saline group neither 2 h, nor 4 h after dural stimulation. IS caused significant difference after both time points between IS treated and control group, and between treated (right) and control (left) side. Stereotaxic frame usage had a substantial effect on the obtained results.ConclusionsCounting c-Fos immunoreactive cells based on somatotopic organization of the trigeminal nerve helped to examine the effect of chemical stimulation of dura in a more specific way. As a result, the use of IS over the parietal lobe caused activation in the area of the ophthalmic nerve. To see this effect, the use of lidocaine anesthesia is indispensable.In conclusion, application of IS on the dura mater induces short-term, more robust c-Fos activation than CFA, therefore it might offer a better approach to model acute migraine headache in rodents.

Corneal Confocal Microscopy Demonstrates Corneal Nerve Loss in Patients With Trigeminal Neuralgia.

Background: The diagnosis of trigeminal neuralgia (TN) is challenging due to the lack of objective diagnostics. Corneal confocal microscopy (CCM) is a non-invasive ophthalmic imaging technique, which allows quantification of corneal nerve fibers arising from the trigeminal ganglion and may allow the assessment of neurodegeneration in TN.Methods: CCM was undertaken in 11 patients with TN and 11 age-matched healthy controls. Corneal nerve fiber density (CNFD), corneal nerve branch density, corneal nerve fiber length (CNFL), corneal nerve fiber width, corneal nerve fiber area, and dendritic cell and non-dendritic cell density with or without nerve fiber contact were quantified.Results: Patients with TN had significantly lower CNFD and CNFL but no difference for any other corneal nerve or dendritic cell parameter in the ipsilateral and the contralateral cornea compared to the control group. There was no significant difference in corneal nerve and cell parameters between patients with TN with and without involvement of the ophthalmic nerve (V1) or with nerve vessel conflict.Conclusion: Corneal confocal microscopy is a rapid non-invasive imaging technique that identifies symmetrical corneal nerve loss in patients with TN.

Man with facial rash.

A 43-year-old male presented to the emergency department (ED) with a rash to his right cheek 4 days after hyaluronic acid filler injections by a non-credentialed beautician. Examination was notable for serpiginous, violaceous erythema with overlying yellow crusting to the right mid-face and involvement of the nasal tip. Patient did not have vision complaints at this time. Accidental facial arterial cannulation with dermal filler injections can cause occlusion and embolization. Risks of embolization may depend on practitioner experience, injection pressure, rate of filler injection, and location of injection.1 On ED presentation, emergent dermatology and/or plastic surgery consult is required. There are serious adverse effects including tissue necrosis, blindness, or neurologic deficits.2, 3 Of all blood vessels affected, the ophthalmic artery was significantly associated with irreversible blindness. There are 2 common fillers used, autologous fat injections and hyaluronic acid. Autologous fat injection is more associated with vascular complications than is hyaluronic acid and has been reported to have more severe outcomes with higher rates of permanent blindness. Ophthalmology consult is required if the patient endorses vision changes or there are signs of skin involvement in the V1 distribution. Neurology consult is required if the patient endorses neurologic complaints. Treatment involves direct injection of hyaluronidase within and around the affected vessel, with multiple injections diffusely across the affected skin. Additional treatments include nitroglycerin paste and oral aspirin.4 Oral antibiotics should be considered if fat necrosis is present. Once blindness occurs, rates of full recovery are low so initial precautions during filler placement, including slow injection rates with low pressure, are crucial. The patient received hyaluronidase injections and nitroglycerin paste and started on oral aspirin and antibiotics. After a 3-month follow-up in plastic surgery clinic, the patient reported full recovery of the rash with no other sequelae.