Visual Complaints Research Articles

Significance of Prescribing Astigmatic Correction in Young Patients having Low Astigmatism with Near Vision Complaints

Astigmatism causes increased difficulty in reading performance like book reading, mobile usage and computer work. Objective: The primary objective was to find out the significance of prescribing astigmatic correction in young patients having low astigmatism with near vision complaints and secondary objective was to find out the most common type of astigmatism affecting near vision. Methods: This was a multicentered, prospective cohort study conducted from April 2022 to Sep 2022. A total of 64 subjects of both genders were selected through non-probability convenient sampling technique. Patients with age between 15-30 years having low astigmatism (0.25-0.75D) with near vision complaints were included. Any amount of astigmatism was corrected with appropriate glasses and subjects were asked for a follow up fortnightly. Follow up improvement in symptoms were recorded and compared with earlier complaints by applying chi square test using SPSS version 23.0. Results: A total of 64 subjects were enrolled in the study. The mean age of patients was 22.44 years including 27 (42%) males and 37 (58%) females. The most common symptom was Eye Strain found in 53 (83%) of the patients. Most common type of astigmatism was Against the Rule astigmatism. 62 (96%) patients improved to 6/6 in both eyes. On follow up, improvement in symptoms was noted and compared with symptoms before the usage of glasses. Conclusions: The study concluded that the treatment for near vision complaints in young patients is prescribing them with proper cylindrical / astigmatic correction in the form of eye glasses.

Compressive Optic Neuropathy (CON) Secondary to Inflammatory Polyp Mimicking Lymphoma: A Rare Manifestation

Introduction: Compressive optic neuropathy (CON) is the impairment of optic nerve function by space-occupying lesions that mechanically compress the optic nerve or optic tract. CON can arise from either intrinsic or extrinsic compression, and determining the underlying cause is important to approach the correct management. The objective of this case report is to present a rare case of CON secondary to an inflammatory polyp that mimicking lymphoma. Case Presentation: A 68-year-old male patient came to the neuro-ophthalmology clinic with a chief complaint of blurry vision in his left eye since three months ago that was getting worse until he lost his vision accompanied by drooping of the upper left eyelid. He also felt pain in his left eye, nausea, vomiting, and headache. Visual acuity of the right eye was 5/5 and the left eye had no light perception. Ocular motility of the left eye was restricted in all gaze. The pupil was 6 mm with no light reflex, and edema in the optic nerve head in the left eye was found from the posterior segment. The patient's MRI showed soft tissue thickening on the left orbital apex – left optic canal – left anterior cavernous sinus and enlargement of left medial rectus muscle with encasement of the left optic nerve, and from post-contrast showed contrast enhancement that suggested a lymphoma. He was diagnosed with CON secondary to lymphoma and was given Methylprednisolone 32 mg three times a day orally. Conclusions: Several differential diagnoses resemble the findings of CON secondary to inflammatory polyp. Some diagnostic examination must be done to exclude the other diagnosis to give a proper treatment for the patient.

Peripheral visual field shifts after intraocular lens implantation.

To assess whether intraocular lens (IOL) implantation induces shifts in the peripheral visual field. Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands. Ray tracing study. Non-sequential ray tracing simulations were performed with phakic and pseudophakic versions of the same eye model to assess potential shifts in the visual field after IOL implantation. Two different IOL designs were evaluated and for each design 5 different axial positions and 7 different intrinsic powers were tested. The relation between the physical position of the light source and the location where the retina was illuminated was determined for each eye model. Subsequently, these relations were used to calculate whether the visual field shifts in pseudophakic eyes. The pseudophakic visual field shift was below 1 degree for central vision in all evaluated models. For peripheral vision, the light rays in the pseudophakic eyes were refracted to a more central retinal location compared to phakic eyes, resulting in a central shift of the peripheral visual field. The magnitude of the shift depended on the IOL design and its axial position, but could be as high as 5.4 degrees towards central vision. IOL implantation tends to have little effect on the central visual field but can induce an over 5 degrees shift in the peripheral visual field. Such a shift can affect the perception of peripheral visual complaints.

Management of aphakia with low corneal endothelial cell count after complicated cataract surgery in a middle-age patient

Background: secondary intraocular lens implantation becomes more challenging due to pre-existing conditions. Objective: To report the outcome of retropubic iris-claw intraocular lens (RP-ICIOL) to corrects aphakia with low corneal endothelial cell count following previous complicated cataract surgery. Case: A 32-year-old male was referred to Undaan Eye Hospital with a chief complaint of blurred vision in his left eye (LE). Previously, the patient was diagnosed with a mature subluxated cataract and has undergone cataract extraction on the LE. Visual acuity of LE was 1/60 with raised intraocular pressure (31,8 mmHg with Schiotz Tonometry). On anterior segment examination, there was a clear cornea with an oval pupil and aphakia. The examination of the posterior segment was within normal limits. Specular microscopy of LE was 1140 cells/mm2. After IOP was controlled by medication, the patient then underwent retropubic iris-claw intraocular lens implantation. Post-operatively, the visual acuity of the LE was 2/10 and the IOP was 11 mmHg using non-contact tonometry. Six weeks post-op, the best visual acuity (BCVA) was 9/10 and the IOP was 15 mmHg and the CECD was 1110 cells/mm2 on the LE. Discussion: The RP-ICIOL was maintaining the physiological condition of the IOL location posteriorly, thus minimizing the risk of corneal decompensation and increased postoperative intraocular pressure, while at the same time trying to achieve a good refractive outcome. Conclusion: The implantation of RP-ICIOL is safe and effective management of aphakia with a low corneal endothelial cell coun secondary intraocular lens implantation becomes more challenging.

Neurovisual rehabilitation in multiple sclerosis: Why a close integration of low-vision rehabilitation and neuropsychological rehabilitation may be effective for visual complaints

Objective The quality of life of people with multiple sclerosis (MS) is often affected by visual complaints. A previous study suggested that visual complaints are not likely to be related to specific visual functions, but by a global decline of cognitive and visual functioning. In this study, we further explore this hypothesis, by investigating the relation between visual functions and global cognitive functioning, aiming to provide recommendations for rehabilitation for visual complaints. Design Cross-sectional study. Setting A rehabilitation centre for partially sighted and blind people and a MS centre at a university hospital. Participants 102 people with MS. Main measure Correlations between assessments of visual functions (acuity, contrast sensitivity, visual field, smooth pursuit and saccades) and composite scores of a neuropsychological assessment (tests with a visual component and without a visual component). Results All composite scores correlated with visual acuity, contrast sensitivity and the sensitivity of the monocular field, but not with smooth pursuit and saccades. Similar patterns were found in various subgroups. Results showed that visual functions that related to visual complaints correlated with a diffuse decline of global cognitive functioning and that visual and cognitive functioning may decline concurrently in people with MS. Conclusions Visual complaints may occur as a result of a diffuse decline of the integrity of a cerebral network involved in vision and cognition. People with MS with visual complaints may benefit from neurovisual rehabilitation, in which low-vision rehabilitation and neuropsychological rehabilitation are closely intertwined.

COMMUNITY-BASED EYE HEALTH SCREENING REPORT IN MALAYSIA: URBAN-RURAL REFERRAL COMPARISON

This study compared urban and rural referrals from a community-based eye health screening program named 'Jom Check Mata Malaysia (JCMM)'. The program was carried out in nine different states in Peninsular Malaysia—a total of 18 screening locations with a mix of urban and rural. Two mobile eye clinics were mobilised for community-based eye health screenings. This study involved 3,139 participants (1,158 and 1,981 participants from rural and urban, respectively). Visual complaints were collected via interviews using an ocular symptom checklist. The visual acuity was screened using a Snellen Chart. Ocular health screening, including anterior and posterior eye segments, was screened using slit-lamp bio-microscopy and fundus camera. Overall referrals were 2,139 (68%), 846 (27%) and 362 (12%) based on visual complaints, visual acuity and ocular health screening, respectively. Rural locations had significantly higher referral rates for visual complaint screening (χ2 = 422.53, p<0.05), visual acuity screening (χ2 = 20.20, p<0.05) as well as ocular health screening (χ2 = 64.70, p<0.05) compared to the urban locations. There was a consistent pattern of higher rural referrals for all types of vision screening. Information from our three-category screening analysis could help to design a vision screening for our rural and urban populations.

Accuracy and Feasibility of Three-Dimensional Ultrasound Testing in Eye Clinic and Emergency Department Patients with Vision Complaints

BackgroundOcular emergencies comprise 2–3% of emergency department (ED) visits, with retinal detachment requiring emergency surgery. Two-dimensional ultrasound is a rapid bedside tool but is highly operator dependent. ObjectiveWe determined three-dimensional ultrasound (3DUS) feasibility, acceptability, and usability in eye pathology detection using the ophthalmologist examination as reference standard. MethodsWe performed a prospective, blinded cohort study of a 3DUS-enabling device in 30 eye clinic and ED patients with visual symptoms and calculated 3DUS performance characteristics. Two expert readers interpreted the 3DUS images for pathology. All participants completed surveys. Results3DUS sensitivity was 0.81, specificity 0.73, positive predictive value 0.54, negative predictive value 0.91, and likelihood ratio (LR)+/LR− 3.03 and 0.26, respectively. Novice and expert sonographers had “substantial” agreement in correct diagnosis of abnormal vs. normal (κ = 0.68, 95% confidence interval 0.48–0.88). Most patients indicated that 3DUS is fast, comfortable, helps them understand their problem, and improves provider interaction/care, and all sonographers agreed; 4/5 sonographers felt confident performing ultrasound. Expert readers correctly identified an abnormal eye in 83/120 scans (76%) and correct diagnosis in 72/120 scans (65%), with no statistical difference between novice (79%; 69%) and expert (72%; 61%) sonographers (p = 0.39, p = 0.55), suggesting reduced operator dependence. Reader diagnosis confidence and image quality varied widely. Image acquisition times were fast for novice (mean 225 ± 83 s) and expert (201 ± 51) sonographers, with fast expert reader interpretation times (225 ± 136). ConclusionsA 3DUS-enabling device demonstrates a sensitivity of 0.81 and specificity of 0.73 for disease detection, fast image acquisition, and may reduce operator dependence for detecting emergent retinal pathologies. Further technological development is needed to improve diagnostic accuracy in identifying and characterizing retinal pathology.

80 Looking Beyond Visual Functioning in the Rehabilitation of Visual Complaints in People with Multiple Sclerosis: Integrating Low Vision and Neuropsychological Rehabilitation

Objective:The objective of the present study is to expand our understanding of visual complaints in people with multiple sclerosis (MS) with the aim of exploring potential rehabilitation approaches for treating visual complaints. Visual complaints are increasingly recognized as a core manifestation of MS. Up to 90% of people with MS report all kinds of visual complaints, such as blurry vision, double vision, being blinded by bright light, a reduced visual field and having trouble with depth perception. Since intact vision is quintessential to many activities of daily life, such as reading or car driving, these complaints affect independent participation to a great extent. The complaints cannot be fully explained by optical neuritis (a common symptom of MS) or other treatable visual or ophthalmological disorders. Moreover, there are no rehabilitation programs available for visual complaints in people with MS. However, the complaints are not yet understood well enough to develop effective rehabilitation strategies to reduce the impact of the visual complaints.Participants and Methods:Visual complaints were assessed using the Screening Visual Complaints questionnaire. 68 people with MS with visual complaints, and 37 with hardly any visual complaints received a standard visual function assessment and a neuropsychological assessment. Correlations between the visual complaints, visual functions and cognitive functions were calculated. In addition, correlations were calculated between several visual functions and a composite score of the neuropsychological assessment.Results:Only some specific visual measures related to visual complaints, with small to moderate effect sizes. While most specific cognitive functions did not show correlations, measures indicative of overall cognitive capacity in people with MS (such as motor speed) consistently correlated with different kinds of visual complaints. Additionally, visual functions that related to visual complaints also correlated with the composite score for cognitive functioning.Conclusions:Our study serendipitously showed that in developing or composing effective rehabilitation strategies for visual complaints, we should look beyond a person’s visual functioning: first, the overall cognitive capacity should be taken into account. Second, visual functioning and cognitive functioning are closely related. These results indicate that visual complaints may be a result of a general decline of the visual and/or cognitive system as one. When treating these complaints, low vision rehabilitation and neuropsychological rehabilitation strategies may be combined. Strategies should not focus on specific visual or cognitive functions, but at making the visual world more easily accessible, or more easily visible, to reduce the impact on the visual system and cognitive capacity. Strategies could range from applying more contrast in the environment to psycho-education. Future research should focus on developing rehabilitation programs and assessing their effectiveness in people with MS or with other types of non-acquired brain injuries.

Vitreous Seeding of Renal Cell Carcinoma in a Patient Receiving Checkpoint Inhibitors.

To describe a case of vitreous seeding with tractional retinal detachment due to metastatic renal cell carcinoma (RCC) in a patient on systemic checkpoint inhibitors. Case Report. A 44-year-old Hispanic woman with a history of RCC with metastases to the lungs, adrenal glands, hilar lymph nodes, and peritoneum presented with a complaint of severe floaters and blurry vision of the right eye for two months. She was found to have dense, web-like vitreous opacities and a peripheral tractional retinal detachment of the right eye. We performed a pars plana vitrectomy, membrane peeling, endolaser, air-fluid exchange, gas injection, and vitreous biopsy. The vitreous and membranes were sent for cytology with stains including AE1/AE3, PAX-8, CK-7, CA-IX, AMACR, and S-100. Cytology revealed crowded groups of glandular cells, some in papillary like formations. Positive stains included AE1/AE3, PAX-8, CK-7, CA-IX, and AMACR. Cytology and pathology demonstrated that vitreous seeding of metastatic RCC without an ocular mass lesion. We hypothesize that the use of checkpoint inhibitors played a role in allowing for the atypical and previously unreported seeding of RCC to the vitreous.

Cornea Classic: Bron, Evans, and Smith, "Grading of Corneal and Conjunctival Staining in the Context of Other Dry Eye Tests" (2003).

Dry eye is an increasingly common ocular condition with significant impact on quality of life due to eye discomfort and blurred vision complaints. In addition, the financial burden of dry eye on both patients and society is substantial. Although there has been a recent explosion of research in the field since 2002 with the approval of the first prescription topical treatment (Restasis, Allergan Inc, Irvine CA), dry eye lags behind other ophthalmic conditions where clinically meaningful outcome measures are closely tied with the metrics by which their therapeutics are evaluated. Unfortunately, current practice is such that physicians largely rely on patient symptoms to evaluate dry eye, and these do not always correlate with objective ocular surface and tear film parameters. In patients with severe dry eye, the patient-reported symptoms are likely dampened because of the neurotrophic state of the ocular surface, which accompanies any long-standing inflammatory ocular condition. Therefore, staining of the corneal and conjunctival surface using vital dyes is an invaluable dry eye test to provide information normally not visible during routine slit-lamp examination. The landmark article by Bron, Evans, and Smith published in Cornea in 2003 provides excellent guidance to clinicians to highlight and quantify ocular surface parameters in patients with dry eye. Validation studies correlating conjunctival or corneal staining with tangible quality-of-life parameters and metrics to measure those are needed to verify ocular surface staining as a clinically meaningful dry eye outcome to be used in clinical practice and clinical trials.

Eye & Diabetes in Morocco: Where are we from the global screening guidelines?

Abstract In Morocco, the prevalence of diabetes in the adult population is 12.4% (WHO). Diabetic Retinopathy (DR) is the 2nd cause of blindness. Nearly 1 million people worldwide are blind due to diabetes. The aim of our work is to study the epidemiological profile of patients with diabetes in ophthalmology and to determine the observance of the follow-up guidelines. This is a descriptive study carried out at the Vision Clinic of Tetouan-Morocco, including all diabetic patients who presented to the ophthalmology consultation of the same doctor, between June 2022 and December 2022. The study involved 500 patients, including 217 men and 283 women, with an average age of 62 years. The average duration of diabetes was 11.5 years. 1 out of 3 diabetic patients was unaware that diabetes was a blinding disease and 3 out of 4 patients did not follow a specific diet. 1 out of 8 patients has an annual ophthalmological check-up. 55% of the patients have a screening every 2-5 years, when 7% haven't had their eyes checked in the last 10 years. Visual complaints accounted for 58% of the motivations for all consultations, while diabetes only accounted for 30%. Depending on the duration of the condition, diabetes represents 60% of the reasons for consultation among new diabetics (1 year) whereas it represents only 20% among diabetics over 10 years old. Eye examinations revealed a proliferative DR in 24% of the cases and a non proliferative DR in 22%. In 31%, there was no sign of DR and in 23%, the fundus was inaccessible due to cataract. The prevalence of proliferative DR increases with years of diabetes, reaching 40% in diabetics over 20 years old. The results of this work prove that diabetes is still underestimated by the Moroccan population. This is probably related to a lack of information of the target population. Thus, health professionals should strengthen their education in order to establish a better monitoring and screening policy aimed to reduce the occurrence of an avoidable blindness. Key messages • Less than one Diabetic out of 3 consults an ophthalmologist for their diabetes & Only one diabetic out of 8 consults annually in ophthalmology. • The older the diabetes, the less regular is the consultation in ophthalmology & One out of 4 diabetics will already have proliferative diabetic retinopathy at their ophthalmological consultation.

Pituitary Adenoma Hidden by Comorbid Cataract

Background: Background: A pituitary adenoma is an abnormal growth in the pituitary gland. Pituitary adenomas are the most common cause of sellar masses accounting for approximately 10% of all intracranial neoplasms. Early visual symptom of pituitary adenoma can be hidden by comorbid cataract in elderly patients. Case Case Report: Report: A 74 y.o. male presented to the eye clinic with blurry vision at all distances and has trouble with glare from lights. His best corrected visual acuity (BCVA) was 20/20-1 OD, 20/25-2 OS, but subjectively of poor quality. Slit lamp exam confirmed mild nuclear sclerotic cataract OU and normal fundus exam. Patient underwent uncomplicated cataract extraction with intraocular implant, OS first then OD. Post-op course was unremarkable until one month later when patient stated that his vision OS was blurry to the left. BCVA was 20/25 OD, 20/25-2 OS. Post-op exam was still normal including FCF. Humphrey visual field (HVF) however showed a bitemporal hemianopia. Patient was referred for a brain imaging. Brain MRI confirmed a 24 x 22 x 28 mm T2 isointense enhancing mass of the sella with suprasellar extension consistent with a pituitary macroadenoma. Patient underwent endonasal transphenoidal craniectomy for debulking of the tumor subsequently by an ENT specialist. Conclusion Conclusion: Clinicians need to be sure the cataract matches the visual complaint. When in doubt further ancillary testing such as comprehensive HVF is crucial to detect visual pathway disorder and brain tumors. Co-management with corresponding specialist is essential to preserve vision and save life.

Effective optical zone following small incision lenticule extraction: a review.

Small incision lenticule extraction (SMILE) is a "flapless" keratorefractive surgery with excellent safety, efficacy, stability, and predictability for myopia correction. A recent global multicenter study also reported good refractive outcomes for hyperopic SMILE. SMILE has shown advantages including improved biomechanical strength, fewer dry eye symptoms, less corneal denervation, and fewer surgery-induced higher-order aberrations over laser in situ keratomileusis (LASIK). However, night vision complaints, including glare, halos, and starbursts, could still occur after SMILE. These symptoms have been proven to be closely related to the effective optical zone (EOZ), which is defined as the achieved area of corneal ablation. A larger postoperative EOZ may indicate better visual quality, making EOZ an important safety parameter for keratorefractive surgeries. As SMILE has gained wider application globally, the EOZ following SMILE has also been increasingly studied in the field of refractive surgery. This review provides an update on topics related to the EOZ after SMILE, including its measurement and influencing factors, aiming to benefit the personalization of the surgical algorithm and ultimately improve the visual quality after the SMILE procedure.

Dynamics of retinal perfusion parameters in patients with post-COVID syndrome

BACKGROUND: A major current health issue is the rehabilitation of patients who previously had a coronavirus infection (COVID-19), as well as the treatment of patients with post-COVID syndrome. For a long time after COVID-19, patients may have complaints, including vision-related ones. One of the theories is that this may be due to long-term persistent microcirculatory retinal changes.
 AIM: To assess the long-term dynamics of retinal microcirculation changes in patients with post-COVID syndrome and to evaluate the relationship of these parameters with visual functions.
 MATERIALS AND METHODS: The main group consisting of 41 patients (82 eyes) was divided into groups depending on the severity of COVID-19: mild, moderate and severe. The control group included 13 people (26 eyes) who did not have COVID-19 to the time of the examination. All patients underwent an ophthalmological examination, including low-contrast visual acuity testing and optical coherence tomography-angiography. Vessel density (VD) was examined within the superficial capillary plexus (SCP), deep capillary plexus (DCP), and radial peripapillary capillaries (RPC). The following structural indicators were also measured: the retinal thickness, the retinal nerve fiber layer thickness and the ganglion cell complex. All patients were examined twice: 6 weeks after COVID-19 and in 27 weeks (6 months after the first visit).
 RESULTS: Patients who went through moderately severe and severe COVID-19 showed a significant decrease in low-contrast visual acuity in comparison to the control group at Visit 1 (p .001 in both cases), which totally recovered to the Visit 2. In the same group of patients, there was a significant decrease in VD SCP (p .001) and VD DCP (p .001) in comparison to the control group, and these parameters significantly decreased at visit 2 (p .001 in both cases). In the group of patients with moderate COVID-19, there was also a decrease in VD SCP and VD DCP in comparison to the control group (p .001 in both cases), while the indicators remained stable during 6 months of follow-up (p = .082). There were no significant changes in VD RPC and main morphometric parameters during 6 months of follow-up.
 CONCLUSIONS: In patients with COVID-19 from moderate severity to severe, there is a significant decrease in contrast sensitivity, which is temporary and fully recovers after 6 months. In patients with severe COVID-19, there was a negative dynamic of retinal perfusion during 6 months, both in deep and superficial capillary plexuses. Patients with post-COVID syndrome, or those who have had COVID-19 and present with visual complaints, need a deep ophthalmological examination including optical coherence tomography-angiography, with a possible involvement of related specialists.

A novel Finding in the Diagnosis of Primary Vitreoretinal Lymphoma: A Case Report.

Introduce a unique case of primary vitreoretinal lymphoma with a new optical coherence tomography finding. A case report. A 67-year-old healthy man with complaints of blurry vision in his right eye. The patient's visual acuity was 20/60 and 20/20 in the right and left eyes, respectively. Anterior segment exam of the right eye demonstrated mild inflammation. Dilated fundoscopy revealed 2+ vitreous haze and 4+ disc edema. Optical coherence tomography of the macula in the right eye revealed optic nerve head swelling and thickening of the retina. Fluorescein angiography demonstrated mild leakage and staining of vessels along the inferotemporal arcade in the right eye. Labs were within normal limits except positive Herpes simplex virus 1 IgG. Initially, the patient was treated for herpetic panuveitis for three weeks with a favorable response. However, the clinical condition deteriorated as a new abnormality was identified in the macular region of the right eye through optical coherence tomography. Considering intraocular lymphoma as a potential diagnosis, the patient underwent a diagnostic vitrectomy. The vitreous sample analysis confirmed PVRL through immunohistochemistry and flow cytometry. The patient exhibited a rapid response following the initiation of intravenous and intravitreal methotrexate treatment. The presence of subretinal fluid accompanied by suspended hyperreflective lesions originating from the roof of the subretinal fluid pocket on the OCT of macula "stalactite sign" might serve as a characteristic sign indicative of primary vitreoretinal lymphoma; however, further investigation using robust studies is necessary to examine this hypothesis.

THU444 A Case Of Zoledronic-Acid Induced Acute Anterior Uveitis, Episcleritis, And Synovitis

Abstract Disclosure: X. Au: None. R.I. Dorin: None. L.E. Aguirre: None. Introduction: IV zoledronic acid infusion (ZAI) may result in acute phase reaction associated with self-limited symptoms of pyrexia, myalgia, headache, arthralgia, and pain in extremities. Eye inflammation and joint swelling are less common manifestations of post-ZAI acute phase reaction, but are important to recognize and treat owing to the potential for long-term sequelae. Clinical Case: A 66-year-old female was diagnosed with osteoporosis by DXA. She received her first ZAI (5 mg) and within 24 hours noted onset of moderate-to-severe diffuse musculoskeletal pain and fever up to 102°F. Two days later, the patient noted swelling of her left wrist and bilateral knee and ankle joints. Clinical assessment led to a diagnosis of post-ZAI synovitis, which improved somewhat with IV ketorolac followed and outpatient po acetaminophen and ibuprofen. Six days after ZAI she developed left eye (OS) redness. Ophthalmologic evaluation identified acute episcleritis and acute anterior uveitis with normal visual acuity and intraocular pressures. The patient was managed with a transient (5 day) course of prednisone (40 mg daily) and a 14-day course of topical prednisone, cyclosporine, and lubrication. Posterior synechiae of OS resolved on follow-up exam and topical medications were successfully tapered over three weeks with resolution of visual complaints. Discussion: Acute phase reaction is a common side effect of ZAI, with an incidence of fever (17.2%) and diffuse musculoskeletal pain (15.7%) reported in one study [1]. Eye inflammation and joint swelling have also been reported after ZAI, but at a lower incidence (0.4% each) [1]. Patients with acute episcleritis and uveitis may require systemic steroids. While the prognosis of appropriately treated acute anterior uveitis is good, it may be associated with concomitant orbital inflammation that could lead to permanent vision loss. Risk factors for development of severe acute-phase reactions after ZA infusion have not been identified, though acute phase reactions are more commonly observed after the first dose of ZAI [2]. Conclusion: Physicians should be aware of rare ophthalmic complications of ZAI, as their prompt recognition and treatment may be important in prevention of long-term ocular sequelae.

How to manage the cataract with nystagmus under topical anesthesia: A case report

In the case, we aim to point out the way to manage the cataract with nystagmus under topical anesthesia in phacoemulsification surgery. A 62-year-old female patient came to department of ophthalmology in January 2020 with a complaint of blurry vision in her right eye for a year. The observed visual acuity of the subject's right eye was measured to be 0.15. During the biomicroscopic examination, the presence of bilateral nystagmus and cortical cataract was observed. The iris and retina were found to be undamaged. No lens subluxation was seen. Under topical anesthesia in phacoemulsification surgery, globe stabilization was provided by holding the conjunctival pouch. With one hand and with the other hand, capsulorhexis, the most critical part of the operation was achieved. The case we present is close to point out the easy method to explain to manage this kind of cataracts. How to cite this article: Alaçamlı G. How to manage the cataract with nystagmus under topical anesthesia: A case report. J Med Dent Invest 2023;4:e230329. https://doi.org/10.5577/jomdi.e230329 Linguistic Revision: The English in this manuscript has been checked by at least two professional editors, both native speakers of English.

Isolated sixth nerve palsy as an initial manifestation of systemic lupus erythematosus – A rare case report

A 35-year-old female presented to our neuro-ophthalmology OPD with chief complaints of binocular double vision for the past 4 days, which increased in right lateral horizontal gaze. On ocular examination, the patient had restriction of abduction in the right eye, suggestive of right sixth nerve palsy. Investigations revealed antinuclear antibodies positive with titer 1:1000 speckled homogenous pattern suggestive of systemic lupus erythematosus (SLE). Neuroimaging revealed no evidence of an aneurysm in the brain, after which the patient was treated with intravenous methylprednisolone 1 gm once daily pulse steroids for 3 days followed by oral steroids 1 mg/kg was given. The patient improved clinically after 1 month. Although most patients demonstrate the classic diagnostic signs of skin rash and arthritis, the case reported here of an isolated sixth cranial nerve palsy suggests that such an uncharacteristic presentation of SLE is possible.

Diplopia in a patient presenting with “blurred vision”: a case report

BackgroundMyasthenia gravis is an autoimmune condition affecting the neuromuscular junction and causing muscle weakness along with fatigue (myasthenia). When the clinical manifestations of myasthenia gravis are isolated to the eye muscles, only causing weak eye movements, it is referred to as ocular myasthenia gravis, which can mimic a 1 and ½ syndrome.Case presentationAn African-American female in her fifties with past medical history of hypertension presented to our outpatient clinic with complaints of blurred vision for two weeks. Her symptoms were associated with facial discomfort and a generalized headache. On physical examination upon her initial presentation, there was demonstratable swelling of the left upper eyelid with drooping. Her extraocular movements revealed defects with the abduction and adduction of the right eye, and the left eye would not adduct, although the outward movement was normal. The left eye failed to lift/elevate completely when looking upwards, a pseudo 1 and ½ syndrome. A positive Cogan lid twitch was also noticed. Imaging of the brain and orbit ruled out central causes. Diagnosis of ocular myasthenia gravis was made in accordance with positive anti-acetylcholine receptor antibodies. With 120 mg pyridostigmine oral dose, the patient experienced improvement subjectively and objectively, and the patient was discharged on oral pyridostigmine and prednisone. Six months later, with prednisone having been tapered off, the patient developed a myasthenic crisis and was treated with plasmapheresis and intravenous immunoglobulins. After recovering from the myasthenic crisis, efgartigimod infusions were instituted, which helped our patient restore normal life.ConclusionOur patient who presented with “blurred vision” was discovered to have binocular diplopia due to significant dysconjugate eye movements. After diligently ruling out central etiologies, we concluded that her presentation was due to a peripheral etiology. Her serologies and her presentation helped confirm a diagnosis of ocular myasthenia gravis. Also, as in most cases, our patient also progressed to develop generalized myasthenia gravis while on pyridostigmine. Efgartigimod infusions instituted after our patient recovered from a myasthenic crisis have helped her restore a normal life.

How a Subclinical Unilateral Vestibular Signal Improves Binocular Vision.

The present study aimed to determine if an infra-liminal asymmetric vestibular signal could account for some of the visual complaints commonly encountered in chronic vestibular patients. We used infra-liminal galvanic vestibular stimulation (GVS) to investigate its potential effects on visuo-oculomotor behavior. A total of 78 healthy volunteers, 34 aged from 20 to 25 years old and 44 aged from 40 to 60 years old, were included in a crossover study to assess the impact of infra-liminal stimulation on convergence, divergence, proximal convergence point, and stereopsis. Under GVS stimulation, a repeated measures ANOVA showed a significant variation in near convergence (p < 0.001), far convergence (p < 0.001), and far divergence (p = 0.052). We also observed an unexpected effect of instantaneous blocking of the retest effect on the far divergence measurement. Further investigations are necessary to establish causal relationships, but GVS could be considered a behavioral modulator in non-pharmacological vestibular therapies.