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Sirin Lueangaram,1 Oranan Tritanon,2 Sukanya Siriyotha,3 Kavin Vanikieti,1 Tanyatuth Padungkiatsagul,1 Pisit Preechawat,1 Anuchit Poonyathalang,1 Charungthai Dejthevaporn,4 Teeratorn Pulkes,4 Supoch Tunlayadechanont,4 Panitha Jindahra4 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 3Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 4Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, ThailandCorrespondence: Panitha JindahraDivision of Neurology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchatewi, Bangkok, 10400, ThailandTel +6622011386Email panitha.jin@mahidol.ac.thPurpose: To analyze radiological characteristics of the extraocular muscles (EOMs) in myasthenia gravis (MG) patients with ocular manifestations.Patients and Methods: This retrospective case–control study included all MG cases with ocular manifestations, who attended a neuro-ophthalmology clinic at a university hospital, Bangkok, from April 2009 to June 2018. They experienced double vision and ophthalmoplegia. Control participants had normal eye movements. Orbital scans were thoroughly reviewed. We measured muscle thickness (MT) of the superior rectus, inferior rectus, medial rectus and lateral rectus muscles in both eyes using magnetic resonance imaging or computed tomography scan. The sum of the muscle thickness at all sites was calculated (MTsum). Comparisons of the mean MT of each muscle type and the mean MTsum between the MG and control groups were performed by using Student’s t-test. MRI signal intensities of the EOMs were also recorded.Results: Twenty MG cases and 20 controls were included in the study. The mean MTsum was 23.7 (standard deviation 4.8) mm in the MG group and 32.6 (3.5) mm in the controls. There were statistically significant differences between the two groups with respect to the mean MT and mean MTsum (p < 0.001). In the MG group, there was a negative correlation between the MTsum and disease duration (p= 0.03). By using coronal T2-weighted orbital MRI with fat suppression (T2W/FS), the most frequent finding was isointensity with central hypointensity of the EOMs in the MG group.Conclusion: Atrophic EOMs were frequently found in the MG group, particularly in chronic cases. Isointensity with central hypointensity of EOMs on T2W/FS was also common in the MG group. These findings highlight the importance of muscle involvement in MG and may be helpful for clinical decision-making.Keywords: myasthenia gravis, acetylcholine receptor antibodies, extraocular muscles, extraocular muscle atrophy, central hypodensity

Watcharaporn Thongmee,1 Chanomporn Narongkhananukul,1 Tanyatuth Padungkiatsagul,1 Panitha Jindahra,2 Kavin Vanikieti1 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Kavin Vanikieti Email Vanikieti.kavin@gmail.comObjective: To compare demographic data, clinical and radiological characteristics, treatments, and long-term visual outcomes between patients with late-onset neuromyelitis optica spectrum disorder-related optic neuritis (LO-NMOSD-ON) (age at onset ≥ 50 years) and patients with early-onset neuromyelitis optica spectrum disorder-related optic neuritis (EO-NMOSD-ON) (age at onset < 50 years).Patients and Methods: This retrospective study included 47 patients (69 eyes) who were diagnosed with neuromyelitis optica spectrum disorder-related optic neuritis (NMOSD-ON) over a 12-year period. There were 14 patients (21 eyes) and 33 patients (48 eyes) in the LO-NMOSD-ON and EO-NMOSD-ON groups, respectively.Results: LO-NMOSD-ON–affected eyes exhibited significantly worse median nadir visual acuity (VA) at optic neuritis (ON) onset, compared with EO-NMOSD-ON–affected eyes (2.7 logMAR (range 2.6– 2.9 logMAR) vs 1.95 logMAR (range 0.4– 2.9 logMAR); p = 0.03). Similarly, 100% of LO-NMOSD-ON–affected eyes demonstrated a nadir VA of worse than or equal to 1.0 logMAR, compared with 62.5% of EO-NMOSD-ON–affected eyes (p = 0.03). LO-NMOSD-ON–affected eyes had a worse median final VA, compared with EO-NMOSD-ON–affected eyes (1.3 logMAR (range 0– 2.9 logMAR) vs 0.3 logMAR (range 0– 2.9 logMAR); adjusted p = 0.037). LO-NMOSD-ON–affected eyes more frequently exhibited a final VA of worse than or equal to 1.0 logMAR, compared with EO-NMOSD-ON–affected eyes (57.1% vs 27.0%; adjusted p = 0.039). A positive correlation was observed between age at ON onset of each eye and the final VA (logMAR) (Spearman r = 0.34, p = 0.0075). The remaining parameters did not significantly differ between the two groups.Conclusion: Patients with LO-NMOSD-ON had significantly worse nadir VA at ON onset and significantly worse final VA, relative to patients with EO-NMOSD-ON. Age at ON onset of each eye was positively correlated with final VA (logMAR). Despite the difference in common age at onset, NMOSD-ON should be included in the differential diagnosis of late-onset acute to subacute optic neuropathy, along with ischemic optic neuropathy.Keywords: late-onset, optic neuritis, neuromyelitis optica spectrum disorder, Thai

Watcharaporn Thongmee,1 Tanyatuth Padungkiatsagul,1 Panitha Jindahra,2 Chaiyos Khongkhatithum,3 Lunliya Thampratankul,3 Kavin Vanikieti1 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 3Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Kavin VanikietiDepartment of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok 10400, ThailandTel +662 201 1526Fax +662 201 2729Email Vanikieti.kavin@gmail.comObjective: We aim to identify prognostic factors for visual outcomes following a first episode of neuromyelitis optica spectrum disorder-related optic neuritis (NMOSD-ON) in affected eyes.Materials and Methods: This was a single-center, retrospective study. The study included 50 individuals who were diagnosed with NMOSD-ON (63 affected eyes) in a tertiary institution over a 12-year period. Data regarding any second, or higher, episodes of NMOSD-ON in each eye were not taken into consideration. Medical records of included individuals were reviewed. Demographic data, clinical and magnetic resonance imaging characteristics, and treatment outcomes were collected. Main outcome measures of the study were prognostic factors for good visual outcome (best-corrected visual acuity (BCVA) ≥ 20/200) following an initial episode of NMOSD-ON in affected eyes.Results: Sixty-three affected eyes of 50 individuals (3 men and 47 women) were included. BCVA at nadir that was better than counting fingers (CF) (odds ratio 10.43, 95% confidence interval 1.04, 104.45, p = 0.046) and time from NMOSD-ON onset to intravenous methylprednisolone (IVMP), less than 21 days (odds ratio 10.73, 95% confidence interval 1.91, 60.01, p = 0.007), were significantly associated with good visual outcomes.Conclusion: BCVA at nadir that was better than CF and treatment with IVMP within 21 days of symptom onset were important prognostic factors of good visual outcomes following a first episode of NMOSD-ON in affected eyes.Keywords: optic neuritis, neuromyelitis optica spectrum disorder, prognostic factors, visual outcomes, Thai

Kavin Vanikieti,1 Piyaphon Cheecharoen,2 Panitha Jindahra,3 Sirin Lueangaram,4 Tanyatuth Padungkiatsagul1 1Department of Ophthalmology, 2Department of Radiology, 3Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 4Department of Ophthalmology, Queen Sirikit National Institute of Child Health, Bangkok, Thailand Abstract: Vertebrobasilar dolichoectasia (VBD) is a rare dilative arteriopathy defined as elongation or widening of the intracranial vertebral and/or basilar arteries. The prevalence ranges from 0.06% to 5.8%. The majority of VBDs are asymptomatic. Downbeat nystagmus has been reported as a component of an infrequent ocular movement disorder in VBD. Nevertheless, oculopalatal tremor (OPT), delayed sequelae of a brainstem lesion, has never been demonstrated in VBD cases. Synchronized rhythmic involuntary contractions of the soft palate with an ocular pendular nystagmus, predominantly vertical pendular nystagmus, are the hallmark presentation. Our case demonstrated a 50-year-old female who presented with 3-month history of oscillopsia. Examination showed binocular conjugate torsional jerk nystagmus simultaneous with a contraction of the soft palate, defined as an atypical OPT, resulting from dolichoectatic left vertebral artery compressing on medulla, demonstrated by magnetic resonance imaging. Bilateral conjugate torsional jerk nystagmus simultaneous with palatal tremor, considering as an atypical OPT, should be included as one of the symptomatic presentations of vertebral artery dolichoectasia in spite of its rarity. Keywords: vertebral artery dolichoectasia, oculopalatal tremor, torsional nystagmus