Search

Koichi Nisijima1,2 1Department of Psychiatry, Nasukougen Hospital, Nasu-machi, Tochigi, Japan; 2Department of Psychiatry, Jichi Medical University, Shimotuke City, Tochigi, JapanCorrespondence: Koichi Nisijima, Shimotuke City, Tochigi, 329-0433, Japan, Tel/Fax +81-285-44-2411, Email poppo0309@cc9.ne.jpAbstract: Anticholinergic drugs, such as biperiden, benztropine, and diphenhydramine, were used for neuroleptic malignant syndrome (NMS) in the 1980s and 1990s. However, they have not been recommended for pharmacotherapy in NMS since 2000, as they may prevent a decrease in body temperature by suppressing sweating. However, whether anticholinergic drugs actually exacerbate NMS remains unclear. This study highlights the usefulness of anticholinergic drugs, which are no longer attracting attention as current pharmacological treatments for NMS. I treated four NMS patients using anticholinergic drugs. Two patients were treated with biperiden alone, and the other two patients were treated with a combination of biperiden and other drugs, including dantrolene, amantadine, or diazepam. Intramuscular injection of biperiden improved muscle rigidity, tremors, dysphagia, and akinetic mutism. Psychiatrists are familiar with anticholinergic drugs as they are used for antipsychotic-induced akathisia and Parkinsonism. My study suggests that anticholinergic drugs, especially injectable formulations, can be a therapeutic option for NMS.Keywords: anticholinergic drug, dantrolene, intramuscular injection, Parkinsonism

Nissar Shaikh,1 Umm e-Amara,1 Athika Sajeer,1 Rohma Malik,1 Shoaib Nawaz,1 Shajahan Idayathulla,1 Abdul Gafoor M Tharayil,1 Abdulqadir J Nashwan2 1Surgical Intensive Care Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar; 2Nursing Department, Hazm Mebaireek General Hospital (HMGH), Hamad Medical Corporation (HMC), Doha, QatarCorrespondence: Abdulqadir J Nashwan, Tel +974 40240487 ; +974 66473549, Email anashwan@hamad.qaAbstract: Laparoscopic surgery is the standard of care for various abdominal pathologies due to its apparent advantages. Unintentional and accidental injuries of the intraabdominal organs and vessels caused by trocars and Veress needles are rare, but potentially fatal complications of laparoscopic surgery. Veress needle and trocar can cause major vascular, bowel, or urinary tract injuries. We report two cases of vascular laparoscopic entry injuries. Laparoscopic entry injuries are rare but life-threatening and can cause multiple organ dysfunctions. Therefore, early recognition, aggressive resuscitation, and appropriate management of laparoscopic entry injuries are vital for better outcomes.Keywords: aorta, bowel, bladder, entry injury, hemorrhage, laparoscopy

Teruumi Minezaki, Takaaki Hattori, Motoko Shibata, Hayate Nakagawa, Shigeto Kumakura, Hiroshi Goto Department of Ophthalmology, Tokyo Medical University, Tokyo, JapanCorrespondence: Takaaki Hattori, Department of Ophthalmology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan, Tel +81-3-3342-6111, Fax +81-3-3342-9170, Email ninnin@ss.iij4u.or.jpPurpose: To report seven eyes of six patients diagnosed with corneal perforation and lacrimal canaliculitis in a single facility.Methods: Clinical records of patients with corneal perforation accompanied by lacrimal canaliculitis seen by the authors were reviewed.Results: Six patients (7 eyes) with corneal perforation accompanied by lacrimal canaliculitis were identified. All patients were female, and all were treated with topical antibiotics while five were receiving topical corticosteroids. Two patients had a history of dacryocystitis and three had systemic immune diseases. The corneal lesions did not respond to topical antibiotics but were effectively treated by removal of concretions in the lacrimal canaliculi and lacrimal duct drainage together with conjunctival autograft or corneal transplantation.Conclusion: Lacrimal canaliculitis is a risk factor for corneal perforation. When corneal perforation does not respond to antibiotics, lacrimal canaliculitis should be considered.Keywords: corneal perforation, lacrimal canaliculitis, concretions

Abdulsemed Mohammed Nur,1 Zebeaman Tibebu Gorfu2 1Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; 2Department of Internal Medicine, Adera Medical Center, Addis Ababa, EthiopiaCorrespondence: Abdulsemed Mohammed Nur, Email abdulsemed.nur3@gmail.comAbstract: Upper GI bleeding secondary to a live foreign body (leech) is a very rare condition, causing diagnostic and therapeutic challenges. Aquatic leeches could infest the upper gastrointestinal (GI) mucosa, resulting in bleeding and/or anemia. A history of contact with a contaminated water source is necessary to establish the diagnosis. We, herein, present two cases of upper GI bleeding caused by leech infestation and a technique for extraction of the leech.Keywords: leech infestation, upper GI bleeding, anemia, Africa, Ethiopia

Valéria Ferreira Martinelli,1,2 Pedro Martinelli Barbosa,3 Lucila Samara Dantas de Oliveira,1 Luísa de Andrade Lima Vieira de Melo,1 João Manoel Casa Nova,1 Carlos Alexandre Antunes de Brito2,4,5 1Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil; 2Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil; 3Department of Internal Medicine, Medical Sciences Center, Pernambucana of Health College, Recife, Pernambuco, Brazil; 4Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Pernambuco, Brazil; 5Department of Immunology, Autoimune Research Institute, Recife, Pernambuco, BrazilCorrespondence: Carlos Alexandre Antunes de Brito, Department of Immunology, Autoimune Research Institute, Avenue Rui Barbosa 715, Recife, Pernambuco, 52011-040, Brazil, Tel +55 81 31480101, Email cbritoc@gmail.comBackground: Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition.Case Presentation: Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab.Conclusion: PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.Keywords: inflammatory bowel disease, pyoderma gangrenosum, Crohn’s disease, ulcerative colitis, extraintestinal manifestations

Worku Ketema,1 Kindie Woubishet,2 Sisay Tesfaye,2 Selamawit Gutema,2 Kefyalew Taye,1 Mulugeta Sitot Shibeshi,1 Negash Tagesse1 1Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Sidama, Ethiopia; 2Department of Internal Medicine, College of Health Sciences, Hawassa University, Hawassa, Sidama, EthiopiaCorrespondence: Worku Ketema, Email workuketema@gmail.comBackground: Tuberculosis is commonly detected late or not at all in HIV-positive people. Rapid and sensitive molecular tests like Gene X-pert have recently become available to replace or supplement existing conventional tests for detecting tuberculosis, and the World Health Organization (WHO) recommends that these rapid techniques be used as the initial diagnostic test for tuberculosis to avoid delays in starting appropriate treatment. The lipoarabinomannan was approved by the national ministry of health in August 2021 for the detection of active tuberculosis in specified groups.Case Summary: It is not uncommon for tuberculosis to be difficult to diagnose in this population, and we believe that our experiences with urine lipoarabinomannan for the detection of active tuberculosis will benefit other clinicians and, ultimately, patients. We discussed the experiences of two human immunodeficiency virus (HIV) patients with putative active tuberculosis, whose tuberculosis workups were negative by conventional methods, including gene expert but found to be positive by urine lipoarabinomannan and who were started on anti-tuberculosis medicines and improved. They are now in a good condition and are taking their medications regularly without any problems.Conclusion: Ending the suffering of HIV patients necessitates lobbying for more accurate tuberculosis diagnosis. The urine Lipoarabinomannan (LAM) assay will address the shortcomings of traditional sputum-based diagnostic tests including sputum Acid Fast Bacilli (AFB) and Gene X-pert, making it a credible alternative for diagnosing tuberculosis in people with HIV. The results of this case series demonstrated that TB LAM is a milestone for the difficulties in TB diagnosis in HIV patients. As of now, the national guideline only suggests urine LAM for HIV patients who fulfill the set criteria. We recommend the stakeholders to increase the availability, and extrapolate the recommendation to other populations including non-HIV patients.Keywords: urine lipoarabinomannan, diagnosis of tuberculosis, human immuno deficiency virus

Ogugua N Okonkwo,1,2 Toyin Akanbi,2 Chineze T Agweye3 1Eye Foundation Retina Institute, Lagos, Nigeria; 2Department of Ophthalmology, Eye Foundation Hospital, Abuja, Nigeria; 3Department of Ophthalmology, University of Calabar Teaching Hospital, Calabar, NigeriaCorrespondence: Ogugua N Okonkwo, Eye Foundation Retina Institute, Lagos, Nigeria, Tel +234 803 502 7308, Email o_okonkwo@yahoo.comPurpose: To report incidence, clinical presentation, and treatment outcome of full-thickness macular hole (FTMHs) diagnosed post pars plana vitrectomy.Methods: We retrospectively reviewed the demographics, best-corrected visual acuity (BCVA), indication for the primary vitrectomy, time to diagnose the secondary FTMH, optical coherence tomographic (OCT) appearance, and treatment outcome of FTMHs, occurring after vitrectomy performed between January 2019 and December 2020.Results: Six of 523 vitrectomized eyes developed FTMHs, an incidence of 1.1%. There were five females and one male, mean age of 56.5 years (range 37– 85). The indication for primary vitrectomy was rhegmatogenous retinal detachment (RRD) in three eyes, one eye each for sub internal limiting membrane hemorrhage from a ruptured macroaneurysm, vitreous hemorrhage from polypoidal choroidal vasculopathy (PCV), and pre-insertion of Ahmed glaucoma drainage device (GDD). FTMHs occurred within one week to three months after vitrectomy (time from primary vitrectomy to the identification of the secondary MH was a mean of 1.03 months). Mean BCVA in all six MH eyes was log MAR 0.9 (Snellen: 6/54). Anatomical closure was achieved after one surgery in three eyes, two surgeries in 1 eye, after photodynamic therapy (PDT) in the PCV eye, and one patient declined surgery. The mean BCVA in the four surgically closed MH eyes improved marginally from log MAR 0.82 (Snellen: 6/38) to log MAR 0.72 (Snellen: 6/30), mean follow-up 7.6 months.Conclusion: Post-vitrectomy FTMH is rare, and RRD was the commonest indication for initial vitrectomy. We observed that all secondary MHs were closed successfully using the inverted internal limiting membrane (ILM) flap technique with limited improvement in vision. The visual outcome of these secondary MHs trails behind that of idiopathic MHs.Keywords: full thickness macular hole, vitrectomy, complications of vitrectomy, epiretinal membrane, optical coherence tomogram, inverted internal limiting membrane flap

Shetanshu Srivastava,1 Vandana Tiwari,2 Manodeep Sen3 1Department of Pediatrics, Dr. Ram Manohar Lohia Institute of Medical Sciences Lucknow, Lucknow, UP, India; 2Department of Biochemistry, Dr. Ram Manohar Lohia Institute of Medical Sciences Lucknow, Lucknow, UP, India; 3Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences Lucknow, Lucknow, UP, IndiaCorrespondence: Shetanshu Srivastava, Department of Pediatrics, Dr RML Institute of Medical Sciences, Vibhuti Khand Gomtinagar Lucknow, 226010, Lucknow, UP, India, Email drsitanshu@yahoo.co.inBackground: Lymphatic filariasis leading to the passage of white urine or chyle is a rare manifestation in children. Filarial parasite infiltration leading to abnormal lymphatic–urinary communication occurs with prolonged infection. The incubation period ranges from 5 to 20 yrs., thus relatively infrequent in the pediatric age group. Index of suspicion should be high when a child presents with the passage of white urine because the subclinical manifestation of filarial infection is difficult to recognize. Moreover, more pathognomonic clinical manifestations such as lymphoedema or hydrocoele are present in adulthood. It should also be differentiated from non-parasitic causes like nephrotic syndrome, urates and phosphates in urine, and congenital lymphatic-urinary communication.Case Presentation: We report two pediatric cases with the intermittent passage of milky white urine since one year. Institutional ethical committee approved the study. In both patients, urine triglycerides were high, and the presence of positive filarial antigen test confirmed the diagnosis. Medical management showed remission of symptoms. Our cases highlight the rare presentation of LF in children and the use of point of care diagnostic tests, management, and outcome in them.Conclusion: LF is a rare condition in children, and the index of suspicion should be high for early management.Keywords: chyluria, filaria

Olga An,1 Lidia Mayumi Nagae,2 Steven Parrish Winesett3 1Department of Children’s Diseases, Kazakhstan’s Medical University “KSPH” - School of Public Health, Almaty, Kazakhstan; 2Department of Medical Imaging, Neuroradiology, Banner University Medical Center, Tucson, AZ, USA; 3Department of Pediatrics, Division of Pediatric Neurology, University of Florida, Gainesville, FL, USACorrespondence: Olga AnDepartment of Children’s Diseases, Kazakhstan’s Medical University “KSPH”, 19 a, Utepov st., Almaty, KazakhstanTel +7 707 101-5023Email a.olga@ksph.kzBackground: Cerebral palsy is the most frequent motor disability in childhood and is associated with a higher incidence of seizure disorders. In many instances, it is recognized that motor difficulties, as well as seizures, are from the same underlying brain lesion. However, self-limited childhood epilepsies, being a common group of epilepsy syndromes, would be expected to occur in patients with cerebral palsy merely on chance association and be unrelated to the structural brain imaging abnormality causing the motor impairment. Differential diagnosis in this case is important determining the long-term prognosis and need for anticonvulsant treatment.Case Presentation: Here, we report two patients with cerebral palsy combined with epilepsy, whose age at onset, seizure semiology and electroclinical features were similar to children with self-limited childhood-specific seizure disorders (childhood epilepsy with centrotemporal spikes and Panayiotopoulos syndrome).Conclusion: These cases highlight the importance of comprehensive differential diagnosis of seizures in cerebral palsy. Co-existence of age-dependent focal epilepsies with an underlying brain pathology as white matter injury, not affecting the cerebral cortex, might take place in the case of children with impaired motor skills. With health systems increasingly utilizing clinical pathways, it is important to consider the possibility of a self-limited childhood epilepsy and avoid aggressive and unnecessary medication treatment in children with cerebral palsy.Keywords: childhood epilepsy with centrotemporal spikes, CECTS, Panayiotopoulos syndrome, cerebral palsy, white matter injury

Salam Iriqat,1 Qusai Yousef,1 Suheir Ereqat2 1Ocular Inflammatory Disease Department, St John Eye Hospital, East Jerusalem, Palestine; 2Biochemistry and Molecular Biology Department, Faculty of Medicine, Al-Quds University, East Jerusalem, PalestineCorrespondence: Salam Iriqat Email Salam.erakat@sjeh.orgPurpose: To present the clinical features of anterior, intermediate and posterior uveitis in patients with COVID-19 and to increase the awareness of the treating physicians to refer patients with COVID-19 who have eye symptoms for ophthalmic exam, in order to diagnose as early as possible and prevent vision-threatening complications.Methods: Retrospective observational case reports.Results: We report three cases of COVID-19 patients who developed uveitis during or after the course of their sickness with COVID-19. All patients underwent a detailed eye examination, relevant history and investigations did not prove any other cause of uveitis.Conclusion: This report presents novel data on the course of subjects with uveitis during the COVID-19 pandemic. Intermediate and posterior uveitis warrant further evaluation with differential diagnosis supported by laboratory tests due to the association with systemic diseases and risk of permanent vision loss. Iridocyclitis, intermediate, and posterior uveitis treatment should be guided by ophthalmologists, particularly uveitis specialists, when possible.Keywords: SARS-CoV-2, uveitis, COVID-19

Ana Maria Cunha,1 Rodrigo Vilares-Morgado,1 Ana Filipa Moleiro,1 Fernando Falcão-Reis,1,2 Olinda Faria1,2 1Department of Ophthalmology, Centro Hospitalar Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, PortugalCorrespondence: Ana Maria CunhaDepartment of Ophthalmology, Centro Hospitalar Universitário de São João, Avenida Prof. Hernâni Monteiro, Porto, 4202 – 451, PortugalTel +35 1225512100Fax +35 1225513669Email ana.cunha.18@gmail.comBackground: Leber hereditary optic neuropathy (LHON) is an optic neuropathy of mitochondrial inheritance. Childhood-onset disease is relatively rare and there are limited data on this important patient subgroup.Case Presentation: We present 3 particular presentations of LHON. Patient 1 was an 8-year-old boy admitted to the emergency department reporting a progressive bilateral visual loss and intermittent headaches. Neuro-ophthalmological examination revealed a bilateral pseudopapilledema. Lumbar puncture identified intracranial hypertension and the brain and orbits magnetic resonance imaging showed T2 hyperintensity in the posterior region of the left optic nerve and the optic chiasm. Patient 2 was a 12-year-old boy admitted to the emergency department reporting painless, progressive central vision loss in the right eye. Fundus examination revealed a hyperemic disc and vascular network papillary and peripapillary vascular microdilations. Three months later, the left eye presented visual loss. Patient 3 was a 6-year-old female child referred to the neuro-ophthalmology specialist due to painless central visual loss in both eyes. Her BCVA was 1/10 and counting fingers in right and left eye, respectively, and fundus examination revealed a pallor optic disc in the temporal sector.Discussion: The phenotype of childhood-onset disease may present itself distinct from classical adult-onset LHON. The absence of classical clinical features could lead to initial misdiagnosis. There should exist a high index of suspicion in children presenting unexplained subnormal vision in order to avoid potential diagnostic delays.Keywords: Leber hereditary optic neuropathy, childhood-onset disease, mitochondrial inheritance

Jessica El-Khazen Dupuis, Michael Marchand, Simon Javidi, Tuan Quynh Tram Nguyen Department of Ophthalmology, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC H2X 3E4, CanadaCorrespondence: Michael MarchandDepartment of Ophthalmology, Centre Hospitalier de l’Université de Montréal, 1051 Rue Sanguinet, Montréal, QC H2X 3E4, CanadaTel +1 (514) 890-8000Email mic9@sympatico.caPurpose: To report on the importance of detecting and investigating non-traumatic enophthalmos, which occurred as the first presenting sign of an undiagnosed metastatic breast carcinoma in two patients with no prior history of neoplasia.Design: Case series.Observations: The first case consists of a 74-year-old woman with no significant past medical history, who presented with a non-traumatic enophthalmos and ptosis of her left eye, and horizontal diplopia on right-gaze. Imaging revealed an intraconal lesion of her left orbit, with orbital fat atrophy. Transcutaneous anterior orbitotomy was performed for tumor biopsy, and the histopathology study concluded on a diagnosis of orbital metastasis consistent with infiltrative breast carcinoma. Thorough breast imaging and multiple breast biopsies were not able to localize the primary tumor. The second case consists of a 76-year-old woman, with no prior relevant medical history, who presented for progressive enophthalmos and ptosis of her right eye. Imaging revealed an osteolytic lesion of her right frontal bone, and multiple infiltrative lesions implicating both orbits. A biopsy was performed through a transcutaneous anterior orbitotomy and histopathology study lead to a diagnosis of metastatic lobular breast carcinoma. The primary breast tumor was localized using positron emission tomography, and further biopsy confirmed the diagnosis.Conclusion: Although uncommon, non-traumatic enophthalmos has a broad differential diagnosis. In some rare instances, it may be the initial presentation of orbital metastases in patients with no prior history of cancer, and in the absence of other systemic symptoms. Clinicians must be thorough when assessing and investigating this clinical entity. A comprehensive eye exam, systemic evaluation, orbit imaging, biopsy and immunohistochemistry analysis are essential to promptly diagnose orbital metastases and plan the appropriate treatment.Keywords: enophthalmos, breast carcinoma, breast cancer, orbitotomy biopsy

Asima Bajwa,1 Travis Peck,1 Ashvini K Reddy,2 Peter A Netland,1 Yevgeniy Shildkrot1 1Department of Ophthalmology, University of Virginia, Charlottesville, VA, USA; 2Johns Hopkins Wilmer Eye Institute, Baltimore, MD, USA Purpose: To evaluate the long-term efficacy of the 0.70 mg dexamethasone (DEX) intravitreal implant in patients with birdshot chorioretinopathy (BSCR).Methods: Retrospective descriptive case series of BSCR patients treated with DEX implant (DEX implant 0.70 mg, DEX). Patients receiving treatment between September 2013 and November 2016 with a minimum follow-up (FU) of 12 months were included. The outcomes of primary interest were vision-related functioning, Snellen visual acuity, ocular inflammation status, presence or absence of vasculitis, change in central macular thickness, and development of glaucoma and/or cataract. Change in vision-related functioning was evaluated by comparing the National Eye Institute Visual Function Questionnaire-25. The outcomes were assessed at baseline, after DEX implant, at time of relapse, and at last FU.Results: Three patients (six eyes) were included in the study and were followed for 1–3 years. They received 1–4 DEX implants OU. All patients demonstrated improvement in National Eye Institute Visual Function Questionnaire-25 scores. Mean Snellen visual acuity better than or equal to 20/40 was seen in three eyes at baseline and five eyes at last FU. At induction, all of the patients (six eyes) had active vitritis and two (four eyes) had retinal vasculitis. All three patients (six eyes) were quiet at last FU. One patient (two eyes) developed bilateral ocular hypertension requiring topical therapy and discontinuation of DEX implants. Two patients (three eyes) developed posterior subcapsular cataract during therapy. Two patients (four eyes) showed progression of disease while on DEX therapy. All patients were eventually transitioned to systemic immunosuppressive drug therapy.Conclusion: BSCR patients receiving DEX implant experienced clinically meaningful improvements in patient-reported visual function as well as ocular inflammation. However, patients in this study required repeat implantation and were unable to be maintained on DEX implant long term due to development of adverse effects or progression of disease. Eventually, it was necessary to transition to systemic immunosuppressive therapy in all patients. Keywords: birdshot chorioretinopathy, dexamethasone implant, inflammation, uveitis&nbsp

Lensen R, Netea MG, Rosendaal FR. Int Med Case Rep J. 2021;14:573–576. Page 574, Results, third paragraph, Blood test on day 5, Leucocytes row, the text “109” should read “108”. The authors apologize for this error. Read the original article

Abdurrahman Kaya,1 Sibel Yıldız Kaya2 1Department of Infectious Disease, Istanbul Training and Research Hospital, Istanbul, Turkey; 2Department of Infectious Disease, Sungurlu State Hospital, Istanbul, TurkeyCorrespondence: Abdurrahman KayaDepartment of Infectious Disease, Istanbul Training and Research Hospital, Istanbul, TurkeyTel +90 506 6113328Email dr.abdkaya@hotmail.com View the original paper by Dr Lensen and colleagues

Masatoshi Haruta, Hiroyuki Ohshima, Ryoji Yamakawa Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan Purpose: This study aimed to demonstrate the clinical usefulness of measuring the macular ganglion cell complex (GCC) for the early detection of axonal loss in eyes with bilateral ­retrobulbar optic neuropathies.Patients and methods: We retrospectively reviewed the medical records of three patients with bilateral toxic, ischemic, or infiltrative retrobulbar optic neuropathy.Results: No relative afferent pupillary defect was detected in any patients. The results of the fundus examinations were unremarkable at the initial presentation except for slight optic disk pallor in the right eye of Case 3. Magnetic resonance imaging showed no abnormal findings in Cases 1 and 2. Measurement of the macular GCC clarified the presence of axonal loss in all three cases with diagnostic uncertainty. Although reduction in the macular GCC thickness was not observed initially in Case 2, it became evident later when both optic disks still appeared normal.Conclusion: A reduction in the macular GCC thickness seemed to precede the appearance of optic disk pallor and occurs regardless of toxic, ischemic, or infiltrative retrobulbar optic neuropathy. The current case series suggested that measurement of the macular GCC facilitated early differentiation between bilateral retrobulbar optic neuropathy and nonorganic visual loss, which can otherwise be challenging in some cases. Keywords: infiltrative optic neuropathy, ischemic optic neuropathy, magnetic resonance imaging, optic disk pallor, optical coherence tomography, toxic optic neuropathy

Tunji S Oluleye,1 Adekunle O Rotimi-Samuel,2 Adetunji Adenekan,2 Olubanke T Ilo,2 Folashade B Akinsola,2 Adeola O Onakoya,2 Olufisayo T Aribaba,2 Adebukunola Adefule-Ositelu,2 Kareem O Musa,2 Yele Oyefeso2 1Retina and Vitreous Unit, Department of Ophthalmology, University College Hospital, Ibadan, 2Department of Ophthalmology, Guinness Eye Center, Lagos University Teaching Hospital, Lagos, Nigeria Abstract: Vogt–Koyanagi–Harada’s (VKH) disease has been reported to be rare in sub-Saharan Africa. Two Nigerians with the disease are presented in this report. The first patient, a 32-year-old pregnant Nigerian woman presented with a 1-month history of bilateral blurring of vision, persistent headache, and alopecia. Presenting visual acuity was 1 m counting fingers in both eyes. Examination revealed vitiligo and poliosis with bilateral panuveitis as well as bilateral exudative retinal detachment. A clinical assessment of complete VKH disease was made. The patient commenced systemic and topical steroids that resulted in remarkable recovery of vision and control of inflammation. The second patient, a 56-year-old Nigerian woman presented with severe headache, tinnitus, and visual loss in both eyes of 2 weeks duration. There was associated redness of both eyes and photophobia. Examination showed visual acuity of Hand motion (HM) and counting fingers at 1 meter (CF). in the right and left eye, respectively, with bilateral panuveitis and bilateral exudative retinal detachment. Subsequent follow-up showed poliosis, vitiligo, and sunsetting fundus appearance. The patient improved with systemic and topical corticosteroids. Developing a high index of suspicion is necessary in diagnosing VKH disease, even in sub-Saharan Africa. Prompt institution of appropriate treatment prevents blindness. Keywords: Vogt–Koyanagi–Harada’s disease, exudative retinal detachment, vitiligo, ­sub-Saharan Africa

Musleh Algarni,1,2 Pejman J Maralani,3 Arun NE Sundaram1 1Department of Ophthalmology and Vision Sciences, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada; 2Department of Medicine, Al Thagher General Hospital, Jeddah, Saudi Arabia; 3Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada Abstract: Optic nerve sheath meningocele, also called dural ectasia of the optic nerve, is a benign dilation of the optic nerve sheath. We report two interesting cases of primary optic nerve sheath meningocele. Etiology, clinical features, and management options are discussed. Keywords: optic nerve sheath meningocele, dural ectasia of the optic nerve sheath, optic disc edema

Pramendra Prasad Gupta,1 Rabin Bhandari,1 Deebya Raj Mishra,2 Krishna Kumar Agrawal,3 Rupak Bhandari,1 Sunil Jirel,1 Gyanendra Malla1 1Department of General Practice and Emergency Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal; 2Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal; 3Department of Internal Medicine, Nepal Medical College and Teaching Hospital, Kathmandu, Nepal Background: Drug-induced hypersensitivity reaction is of great clinical significance in therapeutics. The objective of this reporting of two cases is to show that anaphylaxis reaction can occur with pantoprazole. Case summaries: A 38-year-old female reported to the emergency ward in a critical condition, with a history of periorbital edema, edema of the skin, pruritus, nausea, vomiting, and difficulty breathing 20 minutes after ingestion of a pantoprazole 40 mg tablet. A 32-year-old female reported to the emergency ward in a critical condition, with complaints of rashes all over the body, itching on the whole body, and swollen lips and eyes after ingestion of a pantoprazole 40 mg tablet. Conclusion: It is necessary for all health care providers to know that pantoprazole can cause anaphylaxis, which is a life-threatening reaction, and to be cautious while prescribing it. Keywords: anaphylactic reactions, pantoprazole, proton pump inhibitors

Sergio A Sara,Andrew S McAllister Department of Ophthalmology, Gold Coast University Hospital (GCUH), Southport, QLD, Australia Abstract: The past few years has seen a resurgence of syphilis. It is predominantly associated within men who have sex with men and also within heterosexual Indigenous Australians. Possessing the ability to mimic a variety of ocular diseases, it typically manifests as uveitis, although it can affect any structure within the eye. Thus, a high degree of clinical suspicion by ophthalmologists is required to prevent disease progression and ocular morbidity. Patients require prolonged antibiotic treatment with intravenous benzylpenicillin and outpatient monitoring to successfully resolve the infection. We describe a case series of ocular syphilis presentations in Queensland, Australia. Keywords: ocular syphilis, Indigenous Australians, men who have sex with men

Tsai TH, Peng KL, Lin CJ. International Medical Case Reports Journal. 2017;10:143–148On page 144, right column, last paragraph, “Informed consent was obtained from the patient for publication of this case report and accompanying images. The ethics committee of ....... did not require written informed consent be obtained from the patient because .....” should have read “Written informed consent was obtained from the patient for publication of this Case Report and accompanying images”.Read the original article

Nowadays, dislocated intraocular lenses (IOLs) and inadequate capsular support are becoming a challenge for every ophthalmic surgeon. Explantation of dislocated IOL and iris claw IOL (ICIOL) are the techniques that have been used in our ophthalmic department. The aim of this study is to report our technique for retropupillar ICIOL.This study is a retrospective case series. A total of 105 eyes with dislocated IOL from the patients at the Department of Ophthalmology in Santa Maria Hospital, a tertiary reference hospital in Lisbon, Portugal, from January 2012 until January 2016, had been analyzed. Of these 105 eyes, 66 eyes had dislocated one-piece IOL and 39 eyes had dislocated three-piece IOL. The latter underwent iris suture of the same IOL and were excluded from this study. The remaining 66 eyes with dislocated one-piece IOL underwent pars plana vitrectomy, that is, explantation of dislocated IOL through corneal incision and an implantation of retropupillary ICIOL. Operative data and postoperative outcomes included best corrected visual acuity, IOL position, intraocular pressure, pigment dispersion, clinical signs of endothelial cell loss, and anterior chamber depth.The mean follow-up was 23 months (range: 6-48 months). The mean preoperative best corrected visual acuity was 1.260±0.771 logMAR, and postoperative best corrected visual acuity was 0.352±0.400 logMAR units. Mean vision gain was 0.909 logMar units. The patients had the following complications: 1) retinal detachment was found in one patient, 2) corneal edema was found in three patients, 3) high intraocular pressure was observed in twelve patients, 4) subluxation of the IOL was observed in one patient, and 5) macular edema was found in three eyes.The results demonstrate that retropupillary ICIOL is an easy and effective method for the correction of aphakia in patients not receiving capsule support. The safety of this procedure must be interpreted in the context of a surgery usually indicated in complicated cases.

Toshiyuki Oshitari, Sakiko Nonomura, Miyuki Arai, Yoko Takatsuna, Eiju Sato, Takayuki Baba, Shuichi Yamamoto Department of Ophthalmology and Visual Science, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan Purpose: To compare the effects of sub-Tenon's capsule triamcinolone acetonide (STTA) injection to that of STTA injection combined with microaneurysm photocoagulation (MAPC; STTA + MAPC) on eyes with diabetic macular edema (DME). Patients and methods: The medical records of 138 eyes of 138 patients with DME treated by either STTA or STTA + MAPC were reviewed. The degree of DME was determined by the optical coherence tomographic features: patients with serous retinal detachment (SRD+; 38 eyes) and patients without SRD (non-SRD; 100 eyes). The central macular thickness (CMT) and the best-corrected visual acuity (BCVA) were measured periodically for 6 months after the treatments. Results: The BCVA was significantly improved in the non-SRD group after STTA + MAPC. The CMT was significantly improved in all groups and improved considerably more in the non-SRD group than in the SRD+ group after STTA + MAPC. Conclusion: Our findings indicate that MAPC has an additive effect in the non-SRD type. Keywords: diabetic macular edema, sub-Tenon's triamcinolone acetonide injection, microaneurysm photocoagulation, best-corrected visual acuity, central macular thickness

Masumi G Asahi, Gabriela L Bobarnac Dogaru, Spencer M Onishi, Ron P GallemoreRetina Macula Institute, Torrance, CA, USA Purpose: To report the combination cocktail of strong steroid, non-steroidal anti-inflammatory drug (NSAID), and carbonic anhydrase inhibitor drops for treatment of cystoid macular edema. Methods: This is a retrospective case series of patients with cystoid macular edema managed with a topical combination of strong steroid (difluprednate), NSAID, and carbonic anhydrase inhibitor drops. The patients were followed with optical coherence tomography and fluorescein angiography. Results: In our six cases, resolution of the cystic edema with improvement in visual acuity was achieved with the use of a combination cocktail of drops. Leakage on fluorescein angiography and cystic edema on optical coherence tomography both responded to treatment with the topical cocktail of drops. Conclusion: A topical cocktail of strong steroid, NSAID, and carbonic anhydrase inhibitor drops are effective for managing cystoid macular edema. Further studies comparing this combination with more invasive treatments should be undertaken to determine the efficacy of this cocktail over other treatment options. Keywords: birdshot chorioretinopathy, diabetic macular edema, retinal vein occlusion

Basil K Williams Jr, Jonathan S Chang, Harry W Flynn Jr Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA Abstract: Chorioretinal folds may occur as a consequence of hypotony and can be a cause of vision loss when associated with macular involvement. In this report, the spectral domain ocular coherence tomography imaging of three patients with chorioretinal folds before and after management are presented. The cases had unique presentations and each underwent different management approaches, but the results included improved visual acuities and lessened chorioretinal folds. Keywords: hypotony, chorioretinal folds, ocular coherence tomography

Nana Furuya, Toshiyuki Oshitari, Jiro Yotsukura, Takayuki Baba, Shuichi Yamamoto Department of Ophthalmology and Visual Science, Chiba University, Graduate School of Medicine, Chuo-ku, Chiba, Japan Abstract: We were presented with two cases of relapsing polychondritis (RP) associated with different types of ocular inflammation. The first case was a 35-year-old man who had bilateral hyperemic conjunctiva and ocular pain, and was referred to Chiba University Hospital with a diagnosis of episcleritis refractory. He was treated with dexamethasone eye drops. He developed tinnitus, deafness in both ears, and left auriculitis. A left auricular biopsy showed an infiltration of lymphocytes surrounding the cartilage. He was diagnosed with RP and treated with 30 mg/day oral prednisolone. After tapering the prednisolone, the scleritis in both eyes improved. The second case was a 71-year-old man who was deaf in both ears and had bilateral scleritis. At the first visit to our hospital, his left eyelid and right auricula were reddish and swollen, and he reported some pain. He was treated with intravenous antibiotics, and the left orbital cellulitis quickly improved. However, he developed right scleritis and left gonitis. Magnetic resonance imaging showed bilateral posterior scleritis and right auricular perichondritis. Auricular biopsy showed an infiltration of lymphocytes into the periauricular tissue. He was diagnosed with RP, and 40 mg/day oral prednisolone was given and his symptoms improved. Although RP is rare, it is a life-threatening disease. Thus, ophthalmologists should consider RP in patients with both ocular and auricular inflammation. Keywords: relapsing polychondritis, scleritis, oral prednisolone, ocular cellulitis

Kavin Vanikieti, Pisit Preechawat, Anuchit Poonyathalang Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Abstract: Primary optic nerve sheath meningioma (PONSM) is extremely rare among children. We report two cases of pediatric PONSM. The first case was a 12-year-old boy who presented with gradual visual loss of his right eye and was found to be associated with neurofibromatosis type 2. The second case was a 10-year-old boy who presented with gradual proptosis of his left eye with normal visual acuity. Severe visual loss is a common clinical manifestation of pediatric PONSM. Although the visual acuity in the second case was normal, his vision rapidly deteriorated to 20/200. In both cases, the diagnosis of PONSM was confirmed by magnetic resonance imaging, and a successful tumor growth control was achieved after stereotactic radiotherapy was implemented. Keywords: meningioma, optic nerve, children, pediatric, sheath, orbit

Abdul-Rahim Haslinda, Yaakub Azhany, Rasid Noor-Khairul, Embong Zunaina, Ahmad-Tajudin Liza-Sharmini Department of Ophthalmology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia Abstract: We demonstrated a noninvasive management of early bleb leak following trabeculectomy using cyanoacrylate tissue glue (CATG). Three patients who underwent augmented trabeculectomy with mitomycin C with early bleb leak between January 2009 and June 2010 were reviewed. Case 1 and Case 2 exhibited bleb leak on postoperative Day 1 and Case 3 showed leak on follow-up at postoperative Day 7. Case 1 was successfully sealed with CATG at postoperative Day 3, after failed pressure padding and bandage contact lens. Case 2 was successfully sealed with CATG at postoperative Day 3, after failed pressure padding and conjunctiva flap resuturing. In Case 3, the leaking conjunctival flap was managed with combined techniques of resuturing and applying CATG at postoperative Day 9, after failed pressure padding. During leakage, the intraocular pressure was low (6–8 mmHg) in all three cases, with shallow anterior chamber depth and absence of other complications such as choroidal detachment, hypotony maculopathy, or endophthalmitis. Foreign body sensation was the main complaint following the procedure. No clinical allergy reaction was documented. CATG may serve as a potential adjunctive and effective method in the management of posttrabeculectomy early bleb leak. Keywords: cyanoacrylate tissue glue, bleb leak, trabeculectomy, mitomycin C

Asima Bajwa,1 Gitanjali Khurana,2 Donald Kimpel,2 Ashvini K Reddy1 1Department of Ophthalmology, University of Virginia, Charlottesville, VA, USA; 2Division of Clinical Rheumatology, Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA Objective: The proportion of patients with systemic lupus erythematosus (SLE) who manifest retinal involvement increases many fold in patients with active systemic disease. The objective of this report is to stress upon the significance of comprehensive ophthalmic assessment of all SLE patients to prevent and manage blinding ocular manifestations of the disease. Methods: Retrospective case review. Results: Incidental retinal vascular complications seen in patients undergoing baseline hydroxychloroquine screening. Conclusion: The purpose of comprehensive ophthalmic screening in SLE patients is twofold. It will aid in the diagnosis and treatment of blinding ocular complications of the disease and monitor hydroxychloroquine macular toxicity. Keywords: systemic lupus erythematosus, hydroxychloroquine, retinal vein occlusion, retinal artery occlusion

Wayne L Harper,1 William K Schmidt,2 Nicole J Kubat,3 Richard A Isenberg41Tarheel Clinical Research, LLC, Raleigh, NC, USA; 2NorthStar Consulting, LLC, Davis, CA, USA; 3Nicole Kubat Consulting, Pasadena, CA, USA; 4Regenesis Biomedical, Inc., Scottsdale, AZ, USAAbstract: Persistent pain following back surgery remains a major treatment challenge. The primary objective of this open-label exploratory study was to investigate the analgesic effectiveness of pulsed electromagnetic field therapy administered twice daily over a 45-day period in 34 subjects (68% female) with persistent or recurrent pain following back surgery. A secondary goal was to guide the design of future randomized controlled trials that could target responsive subpopulations. All predefined primary and secondary outcomes, including change in pain intensity (PI), physical function (Oswestry Disability Index), analgesic consumption, and overall well-being (Patient Global Impression of Change), are reported. A responder analysis (≥30% reduction in PI versus baseline) was added as a post hoc evaluation. Safety outcomes, as well as results of a cost-avoidance survey, are also summarized. Of the 30 per-protocol subjects who completed the study, 33% reported a clinically meaningful (≥30%) reduction in PI. A higher response rate (60%) was reported for subjects who had undergone discectomy prior to the trial compared to subjects who had undergone other types of surgical interventions (decompression or fusion) without discectomy. Improvements in PI were paralleled by improvements in secondary outcomes. Relative to baseline, responders reported an average 44% and 55% reduction in back PI and leg PI (respectively), and an average 13% improvement in Oswestry Disability Index scores. In the per-protocol population, 50% of responders and 12% of nonresponders reported less analgesia consumption at the end of treatment versus baseline. Sixty-seven percent of per-protocol responders and 0% of nonresponders reported clinically meaningful improvement in overall well-being on the Patient Global Impression of Change scale.Keywords: failed back surgery syndrome, pain management, pulsed electromagnetic field therapy, PEMF

Akira Sugamata, Naoki Yoshizawa, Takahiro OkadaDepartment of Plastic and Reconstructive Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, JapanAbstract: Gloydius blomhoffii, commonly known as Japanese mamushi, is a venomous viper species found widely in Japan. The most frequently bitten regions are the fingers and toes, and severe swelling causes compression of peripheral arteries and/or compartment syndrome of the extremities. We experienced four cases of mamushi bites to the hand, and undertook relaxation incision in the hands of three of these patients. As a result, the patients who underwent relaxation incision did not show any skin necrosis or permanent sensory disturbance in the affected fingers. Relaxation incision can be useful to not only decompress subcutaneous and compartment pressure of the hand, but also to wash out the venom from the bitten region by improving venous and lymphatic drainage.Keywords: mamushi, snakebite, viper, relaxation incision