Search

Thanathon Anutraungkool,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, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand, Tel +662 201 1526, Email Vanikieti.kavin@gmail.comPurpose: To report the prevalences of other non-thyroid autoimmune diseases and identify factors associated with their presence in ocular myasthenia gravis (OMG) subjects.Subjects and Methods: A total of 208 subjects with OMG diagnosis were included. Demographic data, clinical characteristics, the ice-pack test, the acetylcholine receptor (AChR) antibody test, electrophysiology tests (single-fiber electromyography and repetitive nerve stimulation), the presence of thymoma, generalized myasthenia gravis conversion, and the presence of other non-thyroid autoimmune diseases (defined as the presence of at least one other non-thyroid autoimmune disease) were retrospectively reviewed. Factors associated with the presence of other non-thyroid autoimmune diseases were analyzed by univariate and multivariate logistic regression.Results: Of the total 208 subjects, 21 (10.10%) exhibited the presence of other non-thyroid autoimmune diseases (19 subjects (9.14%) and 2 subjects (0.96%) had one and two other non-thyroid autoimmune diseases, respectively), and systemic lupus erythematosus (SLE) was diagnosed in 9 subjects, followed by Sjogren’s syndrome (7 subjects), rheumatoid arthritis (6 subjects), and ankylosing spondylitis (1 subject). Therefore, the prevalences of SLE, Sjogren’s syndrome, rheumatoid arthritis, and ankylosing spondylitis in OMG subjects were estimated to be 4.33% (95% confidence interval (CI): 2.29– 8.02%), 3.37% (95% CI: 1.64– 6.79%), 2.88% (95% CI: 1.33– 6.14%), and 0.48% (95% CI: 0.08– 2.67%), respectively. Positivity of the AChR antibody was the only significant factor associated with the presence of other non-thyroid autoimmune diseases (odds ratio 4.10, 95% CI: 1.11– 15.21, p = 0.035).Conclusions: The presence of other non-thyroid autoimmune diseases was found in approximately 10% of OMG patients, with SLE displaying the highest prevalence. We recommend screening and monitoring for other non-thyroid autoimmune diseases in OMG patients, particularly those with positivity of the AChR antibody.Keywords: ocular myasthenia gravis, autoimmune diseases, systemic lupus erythematosus, Sjogren’s syndrome, rheumatoid arthritis, ankylosing spondylitis

Sivapoj Sriwannavit,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, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand, Tel +662 201 1526, Email Vanikieti.kavin@gmail.comObjective: To evaluate the utility of peripapillary retinal nerve fiber layer thickness (pRNFLT) for the prediction of visual outcomes, including visual acuity (VA) and visual field (VF), in subjects with acute nonarteritic anterior ischemic optic neuropathy (NAION).Materials and Methods: We performed a retrospective study of data relating to 60 eyes of 60 subjects with acute NAION. Of these, reliable VF values were obtained at both the initial and at 6-month follow-up visits for 30 eyes, which were included in the VF analysis. The pRNFLT was measured globally and separately in all four quadrants (superior, inferior, nasal, and temporal) using optical coherence tomography at the initial visit. Multivariate analysis and the area under the curve (AUC) were used to evaluate the utility of pRNFLT for the prediction of visual outcomes, including favorable VA (VA better than or equal to 20/25) and favorable VF (visual field index (VFI) ≥ 90%), at the 6-month follow-up visit.Results: The median VA and mean VFI at the initial visit were 0.40 (interquartile range (IQR): 0.40, 0.54; logarithm of the minimum angle of resolution (logMAR)) and 73.07% ± 6.73%, respectively. The median VA and mean VFI at the 6-month follow-up visit were 0.30 (IQR: 0.00, 0.70) logMAR and 69.27% ± 28.94%, respectively. Thinner temporal-quadrant pRNFLT was associated with favorable VA (odds ratio 0.98; p = 0.042) with a cut-off value of 128 μm (AUC 0.839, 95% CI: 0.732– 0.947, sensitivity 77.27%, specificity 84.21%). Thinner nasal-quadrant pRNFLT was associated with favorable VF (odds ratio 0.97; p = 0.047) with a cut-off value of 105 μm (AUC 0.780, 95% CI: 0.612– 0.948, sensitivity 90.00%, specificity 70.00%).Conclusions: The pRNFLT is clinically useful for the prediction of visual outcomes in patients with acute NAION. A temporal-quadrant pRNFLT ≤ 128 μm and a nasal-quadrant pRNFLT ≤ 105 μm predict favorable VA and VF at the 6-month follow-up visit, respectively.Keywords: nonarteritic anterior ischemic optic neuropathy, peripapillary retinal nerve fiber layer thickness, optical coherence tomography, visual acuity, visual field, visual prognosis

Supawongwattana M, Vanikieti K, Jindahra P, Padungkiatsagul T. Clin Ophthalmol. 2023;17:649–656. Page 650, Subject Selection section, third line, the text “from January 2012 to June 2022” should be removed. Page 651, Statistical Analysis section, second sentence, the text “Independent t-test or Mann–Whitney U-test, where appropriate, were used to compare continuous variables.” should be removed. Page 651, Statistical Analysis section, fourth sentence, the text “These variables were compared using Chi-squared or exact test where appropriate.” should be removed. Page 651, Statistical Analysis section, sixth sentence, the text “For multivariate analysis, logistic regression was applied, to simultaneously regress outcomes with variables whose p-values in univariate analysis were 0.1 in univariate analysis” should read “Given the higher incidence and prevalence of autoimmune diseases in females and more evidence of thymoma producing various autoantibodies,12,13 these two factors were also included in the multivariate analysis despite their p-values of ≥ 0.05 in univariate analysis”. Table 2 on page 653, Univariate Analysis column, the OR (95% CI) and the p-value for the ≥ 8.11 nmol/L and Positive ice-pack test, n of subjects/n of subjects with available data (%) rows are incorrect. The correct Table 2 is as follows. Table 4 on page 654, Univariate Analysis column, the OR (95% CI) and the p-value for the ≥ 15.12 nmol/L and Abnormal thyroid function tests, n of subjects (%) rows are incorrect. The correct Table 4 is as follows. The authors apologize for the errors and advise they do not affect the conclusions of the study. Table 2 Factors Associated with Conversion to GMG Table 4 Factors Associated with the Presence of Thymoma

Montana Supawongwattana,1 Kavin Vanikieti,1 Panitha Jindahra,2 Tanyatuth Padungkiatsagul1 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Tanyatuth Padungkiatsagul, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand, Tel +662 201 1526, Email Blu_c16@hotmail.comObjective: To evaluate the association in acetylcholine receptor (AChR) antibody-positive ocular myasthenia gravis (OMG) subjects between AChR antibody titers and conversion to generalized myasthenia gravis (GMG), the presence of thyroid autoimmune antibodies, and the presence of thymoma.Subjects and Methods: A total of 118 subjects with AChR antibody-positive OMG were included. Demographic data, clinical characteristics, serology tests, presence of thymoma, treatment, and conversion to GMG were retrospectively reviewed. The presence of thyroid autoimmune antibodies was defined as the presence of at least one of the following: (1) thyroid peroxidase antibody; (2) thyroglobulin antibody; (3) thyroid-stimulating hormone receptor antibody. Univariate and multivariate logistic regression analyses were used as methods of evaluating association.Results: AChR antibody titers were determined in all subjects with a median of 3.33 (0.46– 141.09) nmol/L. The median follow-up period was 14.5 (3– 113) months. At the final follow-up time-point, 99 subjects (83.90%) remained with a diagnosis of pure OMG, while 19 subjects (16.10%) had converted to GMG. An AChR antibody titer ≥ 8.11 nmol/L was associated with the conversion to GMG (odds ratio (OR) 3.66, 95% CI: 1.19– 11.26; p = 0.023). Of the 79 subjects with available thyroid autoimmune antibodies data, 26 subjects (32.91%) displayed the presence of thyroid autoimmune antibodies. An AChR antibody titer ≥ 2.81 nmol/L was associated with the presence of thyroid autoimmune antibodies (OR 6.16, 95% CI: 1.79– 21.22; p = 0.004). Finally, of the 106 subjects with available thoracic computed tomography (CT) data, only 9 subjects (8.49%) demonstrated the presence of thymoma. An AChR antibody titer ≥ 15.12 nmol/L was associated with the presence of thymoma (OR 4.97, 95% CI: 1.10– 22.48; p = 0.037).Conclusion: AChR antibody titers should be considered in AChR antibody-positive OMG patients. Those with AChR antibody titers ≥ 8.11 nmol/L, who are at a greater risk of conversion to GMG, should be closely monitored and encouraged to be aware of early clinical signs of life-threatening GMG. In addition, serum thyroid autoimmune antibodies and thoracic CT screening for thymoma should be performed in AChR antibody-positive OMG patients, particularly in those with AChR antibody titers ≥ 2.81 nmol/L and ≥ 15.12 nmol/L, respectively.Keywords: ocular myasthenia gravis, acetylcholine receptor antibody levels, generalized myasthenia gravis, conversion, thymoma, thyroid autoimmune antibodies

Kanyarat Thammakumpee,1 Tanyatuth Padungkiatsagul,1 Bunyada Putthirangsiwong,1 Weerawan Chokthaweesak,1 Panitha Jindahra,2 Chai Kobkitsuksakul,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 Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Kavin Vanikieti, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand, Tel +662 201 1526, Email vanikieti.kavin@gmail.comPurpose: To report a case of bilateral posterior ischemic optic neuropathy (PION) due to bilateral anterior-drainage dural carotid-cavernous fistulas (CCFs).Case Description: We report on a 62-year-old woman with a history of poorly controlled hypertension who presented with sudden bilateral visual loss and headache for 5 days. She denied a history of head trauma. On examination, her visual acuities were no light perception (NLP) with fixed pupils in both eyes. The ocular motility of both eyes was limited in all directions. Both eyelids were difficult to open. Anterior segment examination revealed bilateral chemosis and episcleral corkscrew vessels. Intraocular pressures were 45 and 48 mmHg in her right and left eyes, respectively. Gonioscopy revealed blood in Schlemm’s canal at the nasal angle of the right eye. Fundus examination showed slightly dilated and tortuous retinal veins with normal-appearing optic discs in both eyes. The cup-to-disc ratios were 0.3 bilaterally. Other neurological examinations were unremarkable. Magnetic resonance imaging demonstrated dilation of the bilateral superior ophthalmic veins (SOVs), and marked orbital and periorbital congestion bilaterally. However, there was no compression or stretching of the bilateral optic nerves. Diffusion restriction on diffusion-weighted imaging, with corresponding reduced apparent diffusion coefficient, in the entire bilateral orbital segment of the optic nerves was revealed, consistent with bilateral PION. Magnetic resonance angiography revealed arterialization of the bilateral cavernous sinuses and SOVs. Cerebral angiography confirmed the diagnosis of bilateral anterior-drainage dural CCFs. Treatment with transvenous coil embolization was successful. Three months after embolization, ophthalmic examination demonstrated progressive improvement of aforementioned ophthalmic signs; however, her visual acuities remained NLP in both eyes.Conclusion: To our knowledge, this is the first reported case of bilateral PION due to bilateral anterior-drainage dural CCFs. In spite of its rarity, PION should be considered as a severe, irreversible ophthalmic complication of anterior-drainage dural CCF.Keywords: dural carotid-cavernous fistula, posterior ischemic optic neuropathy, anterior drainage, bilateral, complications

Kanyarat Thammakumpee,1,2 Jiraporn Buddawong,1 Kavin Vanikieti,1 Panitha Jindahra,3 Tanyatuth Padungkiatsagul1 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Ophthalmology, Faculty of Medicine, Burapha University, Chonburi, Thailand; 3Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Tanyatuth Padungkiatsagul, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand, Tel +662 201 1526, Email blu_c16@hotmail.comPurpose: To evaluate the prognostic ability of preoperative peripapillary retinal nerve fiber layer thickness (pRNFLT) for predicting postoperative visual functions, including the visual field index (VFI) and visual acuity (VA), of subjects with pituitary adenoma (PA) who were treated with endoscopic transsphenoidal surgery for pituitary adenoma (ETSS-PA) exclusively.Subjects and Methods: This 11-year retrospective study was performed at a single institution in Thailand. Sixty-six eyes of 33 subjects who had a PA compressing the anterior visual pathway and were treated with ETSS-PA alone were included. The pRNFLT was measured globally and in the four quadrants preoperatively, using optical coherence tomography. Multivariable analysis and area under the curve (AUC) were used to demonstrate the prognostic ability of preoperative pRNFLT for postoperative visual functions (> 1 month but < 6 months after ETSS-PA).Results: The mean postoperative VFI and median postoperative VA were 79.45% ± 24.24% and 0.14 [interquartile range: 0.02, 0.40] logarithm of the minimum angle of resolution. Among the 56 eyes with a reliable postoperative VFI, thicker preoperative temporal (odds ratio, 1.18; p = 0.024) and inferior (odds ratio, 1.07; p = 0.013) pRNFLT values were associated with a postoperative VFI > 90%. The strongest association occurred with the preoperative temporal pRNFLT (AUC = 0.821, 95% CI: 0.720– 0.923) with a cut-off value of 60 μm. Multivariable analysis for all 66 eyes showed that thicker preoperative inferior-quadrant pRNFLT (odds ratio, 1.05; p = 0.001) was associated with a postoperative VA of at least 20/25. The strongest performance was found with the preoperative inferior pRNFLT (AUC = 0.732, 95% CI: 0.615– 0.849) with a cut-off value of 105 μm.Conclusion: Preoperative pRNFLT offers clinical utility for predicting visual functions after ETSS-PA. Temporal pRNFLT ≥ 60 μm and inferior pRNFLT ≥ 105 μm predicted postoperative VFI > 90% and postoperative VA better than or equal to 20/25, respectively.Keywords: optical coherence tomography, pituitary adenoma, peripapillary retinal nerve fiber layer, visual field, visual acuity, endoscopic transsphenoidal surgery

Thongmee W, Padungkiatsagul T, Jindahra P, Khongkhatithum C, Thampratankul L, Vanikieti K. Clin Ophthalmol. 2020;14:4271–4278. Table 5 on page 4276, the 95% CI and the p-value for the Time from initial ocular symptoms (pain and/or visual loss) to IVMP in each affected eye (days) row are incorrect. Table 5 on page 4276, the 95% CI and the p-value for the BCVA at nadir better than CF row are incorrect. The correct Table 5 is shown below. Table 5 Univariate Analysis The authors apologize for these errors and advise they do not affect the conclusions of the study.

Busayanut Puangsricharoen,1 Kavin Vanikieti,1 Panitha Jindahra,2 Tanyatuth Padungkiatsagul1 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Tanyatuth Padungkiatsagul, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand, Tel +662 201 1526, Fax +662 201 2729, Email blu_c16@hotmail.comObjective: To measure serum total vitamin D or 25-hydroxyvitamin D [25(OH)D] levels and status in immune-based optic neuritis (ON) including neuromyelitis optica spectrum disorder (NMOSD)-ON, myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD)-ON, autoimmune-ON, and idiopathic-ON and compare them with age- and sex-matched healthy controls. The secondary objective was to analyze the association between serum 25(OH)D levels and ON attack severity (nadir best-corrected visual acuity; nadir BCVA).Materials and Methods: This was a single-center, case–control study. We enrolled 59 subjects (19 NMOSD-ON, 6 MOGAD-ON, 11 autoimmune-ON, 23 idiopathic-ON) diagnosed with acute immune-based ON (any ON attacks) over 11 years. Electronic medical records were reviewed and demographic data (age at sampling, sex, aquaporin-4 immunoglobulin (AQP4-IgG); myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG); other biomarkers of autoimmune disorders), ON attack severity (nadir BCVA), and serum 25(OH)D levels in the acute phase of ON were collected. Serum 25(OH)D levels of 236 age- and sex-matched healthy controls were assessed.Results: Mean serum 25(OH)D levels were significantly lower in each group of immune-based ON compared with healthy controls (p < 0.001 for each ON group). However, mean serum 25(OH)D levels were not significantly different between four ON groups (NMOSD-ON, 20.18± 5.90 ng/mL; MOGAD-ON, 23.07± 4.94 ng/mL; autoimmune-ON, 21.14± 5.29 ng/mL; idiopathic-ON, 19.56± 5.12 ng/mL; p = 0.525). All immune-based ON subjects had vitamin D insufficiency or vitamin D deficiency. The prevalences of vitamin D insufficiency and vitamin D deficiency were significantly higher than in healthy controls in each ON group (both p < 0.05 in each ON group). No associations were observed between serum 25(OH)D levels and ON attack severity (nadir BCVA).Conclusions: Thai immune-based ON subjects had lower serum 25(OH)D levels and higher prevalence of vitamin D insufficiency and vitamin D deficiency compared with age- and sex-matched healthy controls. Serum 25(OH)D levels were not associated with ON attack severity (nadir BCVA). We highly recommend that serum 25(OH)D levels be screened in all subjects with acute immune-based ON.Keywords: vitamin D insufficiency, vitamin D deficiency, optic neuritis, NMOSD, MOGAD, autoimmune-optic neuritis

Kavin Vanikieti,1 Chaloemwong Chaiwithooanukul,1 Putipun Puataweepong,2 Panitha Jindahra,3 Tanyatuth Padungkiatsagul1 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 3Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Tanyatuth Padungkiatsagul, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand, Tel +662 201 1526, Email Blu_c16@hotmail.comObjective: To evaluate long-term visual function after fractionated stereotactic radiotherapy (FSRT) for primary optic nerve sheath meningioma (PONSM).Methods: This 22-year retrospective study included 34 subjects (34 affected eyes) with PONSM who were treated with FSRT exclusively. Subjects with a history of biopsy/resection were excluded. Visual function, including visual acuity (VA) and visual field mean deviation (VF MD), was evaluated at presentation (pre-radiotherapy; pre-RT) and at the final follow-up (post-radiotherapy; post-RT); treatment complications were also evaluated. Treatment success was defined as either stabilization or improvement of visual function.Results: The median pre-RT VA and pre-RT VF MD were 0.70 logarithm of the minimum angle of resolution (logMAR; range: 0.0– 2.9 logMAR) and − 15.4 decibels (dB) (range: − 31.4 to − 3.2 dB), respectively. The median total dose of FSRT was 50 Gy (range: 45– 54 Gy) and the median number of fractions was 25 (range: 25– 30). The median follow-up interval was 89 months (range: 6– 251 months). The median post-RT VA and post-RT VF MD were 0.48 logMAR (range: 0.0– 2.9 logMAR) (p = 0.010) and − 6.8 dB (range: − 20.6 to − 1.6 dB) (p = 0.005), respectively. Among the 34 included eyes, VA was successfully treated in 29 eyes (85.3%) and worsened in 5 eyes (14.7%). Of the 14 eyes with both VA and reliable VF MD at pre-RT and post-RT time points, VF MD was successfully treated in 13 eyes (92.8%) and worsened in one (7.2%); overall visual function was successfully treated in 13 eyes (92.8%) and worsened in 1 eye (7.2%). Complications occurred in one subject (2.9%; radiation retinopathy).Conclusion: Approximately 90% of PONSM subjects exhibited long-term treatment success in terms of VA, VF MD, and overall visual function after FSRT. Additionally, the incidence of complications was low. Therefore, FSRT is effective and safe treatment for PONSM.Keywords: primary, optic nerve sheath meningioma, fractionated stereotactic radiotherapy, visual acuity, visual field, optic nerve tumor

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

Panitha Jindahra,1 Angsana Phuphuakrat,2 Thanapol Tangjaisanong,3 Sukanya Siriyotha,4 Tanyatuth Padungkiatsagul,5 Kavin Vanikieti,5 Pisit Preechawat,5 Anuchit Poonyathalang,5 Somnuek Sungkanuparph,6 Teeratorn Pulkes,1 Supoch Tunlayadechanont1 1Division of Neurology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; 2Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; 3Department of Medicine, Bangkhunthian Geriatric Hospital, Bangkok, 10150, Thailand; 4Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; 5Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; 6Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, ThailandCorrespondence: Panitha JindahraDivision of Neurology, Department of Medicine, Faculty of Medicine Ramathbodi Hospital, Mahidol University, Bangkok, ThailandTel/Fax +66 2201 1386Email panitha.jin@mahidol.ac.thIntroduction: Acute optic neuritis (ON) has been increasingly reported in patients infected with human immunodeficiency virus (HIV). We aimed to describe clinical characteristics of HIV-infected patients with ON.Materials and Methods: This observational retrospective study was performed from January 2008 to January 2016 in a university hospital in Bangkok, Thailand. Demographic data and clinical manifestations were retrospectively reviewed.Results: We included 10 HIV-infected patients and divided them into two groups: infectious and non-infectious ON. There were six patients in the infectious ON group (five males, mean age 33.6 years, median CD4 cell counts during ON episodes 36.5 cells/μL, high viral loads, median initial visual acuity [VA] 1.7, median VA difference [initial VA – follow-up VA] 0). Four patients developed cryptococcal meningitis and 2 developed neuro-syphilis. They were treated with amphotericin B plus fluconazole and penicillin G sodium, respectively. There were four patients in the non-infectious ON group (two males, mean age 44.3 years, median CD4 cell count during acute ON 157.5 cells/μL, undetectable viral loads, median initial VA 1.3, and median VA difference 1.2). They were given corticosteroid treatments. There were no statistically significant differences between the two groups with respect to age, sex, and initial VA. There were statistically significant differences in median VA difference and median CD4 cell counts between the two groups (p=0.02 and 0.03, respectively). There was a significant correlation between CD4 counts and duration in three non-infectious ON patients treated with antiretroviral therapy (ART, p< 0.001).Discussion: Patients with infectious ON had low initial CD4 counts and high viral loads. Patients with non-infectious ON had increasing CD4 cell counts and undetectable HIV viral load following ART. The findings are highly suggestive of immune reconstitution inflammatory syndrome. The CD4 cell counts and viral loads may help to identify the type of acute ON in HIV-infected patients and establish proper therapies.Keywords: optic neuritis, human immunodeficiency virus, acquired immune deficiency syndrome, CD4 cell count, immune reconstitution inflammatory syndrome

Chanomporn Narongkhananukul,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 Vanikieti Email Vanikieti.kavin@gmail.comPurpose: To compare demographic data, clinical and radiological characteristics, treatment, and long-term visual outcomes between myelin oligodendrocyte glycoprotein autoantibody-positive optic neuritis (MOG-IgG + ON) and aquaporin-4 autoantibody-positive optic neuritis (AQP4-IgG + ON) in Thailand.Patients and Methods: We included individuals who were diagnosed with either MOG-IgG + ON or AQP4-IgG + ON over an 11-year period. Demographic data, clinical and radiological characteristics at ON presentation, treatment, and long-term visual outcomes were retrospectively collected.Results: There were 16 patients (28 eyes) and 43 patients (59 eyes) in the MOG-IgG + ON and AQP4-IgG + ON groups, respectively. AQP4-IgG + ON occurred predominantly in female patients whereas MOG-IgG + ON-affected female patients and male patients equally (p < 0.001). Prior or concurrent non-ON demyelinating events were more often observed at AQP4-IgG + ON onset (p < 0.001). At ON presentation, bilaterality and the presence of optic disc edema were predominantly found in the MOG-IgG + ON group (bilaterality: 80% vs 8%, MOG-IgG + ON vs AQP4-IgG + ON patients, respectively (p < 0.001); presence of optic disc edema: 92.3% vs 36.6%, MOG-IgG + ON- vs AQP4-IgG + ON-affected eyes, respectively (p < 0.001)). There was no statistically significant difference in age at ON onset, nadir visual acuity (VA), presence of pain, segmental enhancement, and total enhanced segments of the anterior visual pathways. At the last follow-up, immunosuppressive drugs were used more often in the AQP4-IgG + ON group (43.7% vs 74.4%, MOG-IgG + ON vs AQP4-IgG + ON, respectively; p < 0.027). Remarkably better final VA was achieved in MOG-IgG + ON-affected eyes (median: 0.0 vs 0.4 logMAR, MOG-IgG + ON- vs AQP4-IgG + ON-affected eyes, respectively; p < 0.001).Conclusion: Compared with AQP4-IgG + ON, MOG-IgG + ON tended to present with bilaterality and optic disc edema and demonstrated better visual outcomes.Keywords: optic neuritis, myelin oligodendrocyte glycoprotein, aquaporin-4, neuromyelitis optica spectrum disorder, Thai

Panitha Jindahra,1 Nitchanan Hengsiri,1 Pirada Witoonpanich,1 Anuchit Poonyathalang,2 Teeratorn Pulkes,1 Supoch Tunlayadechanont,1 Kunlawat Thadanipon,3 Kavin Vanikieti2 1Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 3Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Kavin Vanikieti Department of Ophthalmology, Faculty of Medicine Ramathibodi HospitalMahidol University, 270 Rama VI Road, Bangkok 10400, ThailandTel +662 201 1526Fax +662 201 2729Email Vanikieti.kavin@gmail.comObjective: To evaluate the feasibility of using optical coherence tomography (OCT) for the detection of Alzheimer’s disease (AD), by measuring the thickness of the retinal nerve fiber layer (RNFL) and the ganglion cell layer and inner plexiform layer (GCL-IPL).Material and Methods: This was a single-center, cross-sectional study. The study included 29 patients with AD (mean age ± standard deviation: 75.61 ± 6.24 years) and 29 healthy age- and sex-matched controls. All participants underwent cognitive evaluations using the Montreal Cognitive Assessment test. Measurements of the RNFL thickness, as well as GCL-IPL thickness, were obtained for all participants using OCT. Both RNFL and GCL-IPL parameters were adjusted for best-corrected visual acuity, hypertension, diabetes and dyslipidemia.Results: The mean RNFL thickness was significantly thinner in the AD group than in the control group (85.24 and 90.68 μm, respectively, adjusted P=0.014). The superior quadrant was thinner in the AD group (adjusted P=0.033). The thicknesses did not differ significantly between groups for the other quadrants. The mean GCL-IPL thickness in the AD (68.81 μm) was significantly thinner than that in the controls (76.42 μm) (adjusted P=0.014). Overall, there was a negative correlation between age and mean RNFL; and between age and GCL-IPL thickness (r=− 0.338, P=0.010 and r=− 0.346, P=0.008, respectively).Conclusion: The mean RNFL and GCL-IPL thicknesses were thinner in the AD group than in the control group. These findings suggest that RNFL and GCL-IPL thickness may be biological markers for AD.Keywords: Alzheimer’s disease, optical coherence tomography, retinal nerve fiber layer, ganglion cell layer, dementia

Kavin Vanikieti,1 Pavarut Janyaprasert,1 Sirin Lueangram,1 Jirat Nimworaphan,1 Natthapon Rattanathamsakul,1 Nanida Tiraset,1 Wimonwan Chokthaweesak,1 Narong Samipak,1 Tanyatuth Padungkiatsagul,1 Pisit Preechawat,1 Anuchit Poonyathalang,1 Teeratorn Pulkes,2 Supoch Tunlayadechanont,2 Sukanya Siriyotha,3 Panitha Jindahra2 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; 2Division of Neurology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; 3Department of Clinical Epidemiology and Biostatistics, 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 Phaya Thai, Ratchathewi, Bangkok 10400, ThailandTel +6622011386Email panitha.jin@mahidol.ac.thPurpose: To analyze the demographic patterns, clinical characteristics and etiologies of acute optic neuritis (ON).Methods: This retrospective observational study included patients with acute ON who presented to a university hospital in Bangkok, Thailand, between January 2010 and March 2020. The demographic details, clinical characteristics and etiologies of acute ON were evaluated.Results: A total of 171 patients were included in the study (78.4% [n=134] female; mean age 45 years [standard deviation 15.4 years]; 32.2% [n=55] bilateral involvement). The most common type of acute ON was idiopathic (51.5%), followed by neuromyelitis optica spectrum disorder (NMOSD, 30.9%), other autoimmune disorders (9.9%), myelin oligodendrocyte glycoprotein antibody-associated disorder (MOGAD, 5.3%), multiple sclerosis (MS, 1.8%), and postinfection (0.6%). In the other autoimmune disorders group, 2 patients developed systemic lupus erythematosus (1.2%), 2 Sjogren’s syndrome (1.2%), 1 RA (0.6%), 1 anti-NMDAR (0.6%), 3 anti-Jo1 (1.8%), 2 c-ANCA (1.2%), 1 anti-centromere (0.6%), and 5 nonspecific autoimmune disorders (2.9%). In the idiopathic group, 38.6% developed single isolated ON, 1.8% relapsing isolated ON and 11.1% chronic relapsing inflammatory optic neuropathy.Conclusion: The most common form of acute ON in this study, similar to other Asian countries, was idiopathic. Idiopathic-ON shared some phenotypes with NMOSD and MOGAD. We also reported patients with anti-NMDAR, anti-Jo1, c-ANCA and anti-centromere disorders. Improvements in antibody detection have widened the range of possible etiologies of acute ON. The study highlighted the important role of antibodies in creating effective treatments in the future.Keywords: optic neuritis, multiple sclerosis, neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein antibody-associated disorder, autoimmune disorders, postinfection

Thanatporn Threetong,1,2 Anuchit Poonyathalang,1 Pisit Preechawat,1 Panitha Jindahra,3 Tanyatuth Padungkiatsagul,1 Kavin Vanikieti1 1Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Ophthalmology, Faculty of Medicine, Burapha University, Chonburi, Thailand; 3Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Tanyatuth PadungkiatsagulDepartment of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok 10400, ThailandTel +662 201 1526Fax +662 201 2729Email blu_c16@hotmail.comPurpose: To evaluate the initial treatment response to low doses of prednisolone, compared with moderate doses, in ocular myasthenia gravis (OMG).Patients and Methods: A retrospective chart review of patients with adult-onset (age ≥ 15 years old) OMG, who were treated with prednisolone, was conducted. Subjects were divided into two groups according to their prednisolone dosing regimen. The low-dose group was defined as those with an average 12-week cumulative dose of prednisolone < 0.435 mg/kg/day and the moderate-dose group averaged 0.435– 1.000 mg/kg/day. The primary outcome of interest was the comparison of clinical response to prednisolone at 12 weeks between the low-dose and moderate-dose groups. The secondary outcome was the difference in adverse events between treatment groups.Results: Of 34 subjects, 16 subjects (47.1%) were male. The mean age at onset was 44.0± 18.1 years. The most common presenting ocular feature was ptosis with ophthalmoplegia (22 subjects, 64.7%), followed by isolated ptosis (nine subjects, 26.5%) and isolated ophthalmoplegia (three subjects, 8.8%). Half of the subjects were treated with low-dose prednisolone and the other half were treated with moderate-dose prednisolone. There were no substantial differences in baseline characteristics between treatment groups. After 12 weeks of treatment, nine of 17 subjects (52.9%) and 13 of 17 subjects (76.5%) in the low- and moderate-dose groups, respectively, were regarded as responsive to the prednisolone treatment (P=0.28). Adverse events were exclusively observed in the moderate-dose group.Conclusion: Treatment of OMG with an average 12-week cumulative dose of prednisolone < 0.435 mg/kg/day (low dose) shows a comparable responsive outcome to 0.435– 1.000 mg/kg/day of prednisolone (moderate dose). Treating OMG with low-dose prednisolone can minimize prednisolone-related adverse events. However, a prospective randomized controlled trial with a larger study population is warranted in order to gain more insight into the proper dosage of prednisolone for OMG.Keywords: ocular myasthenia gravis, low dose, moderate dose, prednisolone, treatment outcome

Tanyatuth Padungkiatsagul,1 Anuchit Poonyathalang,1 Panitha Jindahra,2 Piyaphon Cheecharoen,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 Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Background: Horner syndrome refers to a set of clinical presentations resulting from disruption of sympathetic innervation to the eye and adnexa. Classically, the clinical triad consists of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis. Ocular sympathetic denervation may signify life-threatening causes. Timely investigation and accurate diagnosis are essential in patients with oculosympathetic denervation. Case presentation: A 33-year-old Asian man with a heavy smoking habit presented with a 3-week history of left ptosis and no other complaints. His visual acuity was 20/20 bilaterally. An ophthalmic examination was significant for mild ptosis of his left eyelid and anisocoria (smaller left pupil), which was greater in the dark. Both pupils reacted to light briskly without an afferent pupillary defect. Anhidrosis was found on the medial side of the left forehead. A 10% cocaine test was positive. At his first visit, neurologic examination was unremarkable. Comprehensive radiological investigations were scheduled for a left-sided isolated Horner syndrome. Two weeks after his first visit, he experienced a left-sided headache along with ipsilateral Horner syndrome. Neurologic examination revealed hypoesthesia in the left cranial nerve V1–3 territories. Emergent computed tomography angiography was suspected for petrous part of the left internal carotid artery (ICA) dissection. Magnetic resonance imaging demonstrated an enhancing infiltrative lesion with its epicenter at the left sphenoid bone. The lesion encased the left ICA and invaded the left Meckel cave. Rhinoscopy with incisional biopsy revealed squamous cell nasopharyngeal carcinoma. Conclusion: This case involved an unusual initial presentation of nasopharyngeal carcinoma: isolated Horner syndrome with clinical progression to adjacent structures. Infiltration involving the Meckel cave and ICA at the foramen lacerum can present as postganglionic Horner syndrome associated with trigeminal pain and hypoesthesia. These clinical findings may mimic carotid artery dissection on computed tomography angiography. Detailed magnetic resonance imaging with careful attention to the skull base should be performed. Keywords: Horner syndrome, nasopharyngeal carcinoma, trigeminal

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

Taweevat Attaseth,1 Kavin Vanikieti,1 Anuchit Poonyathalang,1 Pisit Preechawat,1 Panitha Jindahra,2 Duangkamon Wattanatranon3 1Department of Ophthalmology, 2Department of Medicine, 3Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Abstract: Giant cell arteritis is a systemic granulomatous vasculitis affecting medium to large arteries. An arteritic anterior ischemic optic neuropathy is the most common cause of permanent visual loss. Giant cell arteritis is very rare among Asians. We report six patients with biopsy-proven arteritic anterior ischemic optic neuropathy. Demographic data, clinical manifestations, laboratory findings, treatment, and visual outcome are described in detail and compared with Caucasian patients. We found no differences in any clinical features except for sex preference. Moreover, perioptic nerve sheath enhancement was observed in half of our patients. Keywords: giant cell arteritis, temporal artery biopsy, perioptic nerve sheath enhancement, choroidal ischemia, Asian

Panitha Jindahra1,2, Gordon T Plant1,21The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK; 2St Thomas' Hospital, Westminster Bridge Road, London, UKAbstract: Neuromyelitis optica or Devic disease is an inflammatory disorder of the central nervous system. It is caused by antibodies that attack aquaporin 4 water channels in the cell membrane of astrocytic foot processes at the blood brain barrier. It can involve the optic nerve, the spinal cord and beyond. Here we review its pathophysiology, clinical features, and therapy.Keywords: Neuromyelitis optica, Devic disease, NMO-IgG, optic neuritis, transverse myelitis, NMO spectrum disorders

Background Neuromyelitis optica spectrum disorder (NMOSD) occurs more commonly in Asian than Caucasian populations. Few studies have examined the clinical features and visual outcome of optic neuritis (ON) within NMOSD in different racial populations. The objective of this study was to compare the clinical characteristics and long-term visual outcome of a Thai and an American-Caucasian cohort with NMOSD-related ON. Methods Medical records including brain and orbital magnetic resonance imaging (MRI) of 16 consecutive subjects who developed visual loss due to ON as part of NMOSD evaluated at a single American tertiary referral center between 2006 and 2015 were reviewed and compared to those of 16 consecutive similar subjects evaluated at a single Thai tertiary referral center between 2010 and 2016. These cohorts represented the total number of NMOSD-related ON subjects seen during that time at those institutions. Statistical analyses were used for continuous and categorical data sets, and multiple regression analysis was used to adjust for differences in duration of follow-up and number of episodes of ON in each affected eye. Results All subjects within the Thai cohort were Asian, while the American cohort initially consisted of 14 Caucasian, 1 Asian and 1 African-American subject, but the latter two were excluded from analysis. In the Thai cohort, ON occurred in 21 eyes, with a total of 19 episodes, while in the American-Caucasian cohort ON occurred in 22 eyes, with a total of 21 episodes. Aquaporin 4 (AQP4)-antibody was positive in all subjects except for one American-Caucasian subject. The mean follow-up time was 17.8 (± 16.0) and 52.8 (± 51.9) months for the Thai and American-Caucasian populations, respectively. There was no difference between the two cohorts with respect to gender, age of NMOSD and NMOSD-related ON onset, initial clinical presentation of NMOSD, initial visual acuity and automated visual fields, prevalence of swollen optic disc in the acute phase, presence of pain on the affected side, mean time of onset of ON symptoms to MRI examination, distribution of segmental involvement of the anterior visual pathway abnormalities based on MRI findings, mean time of onset of ON symptoms to treatment, final visual acuity and automated visual fields. However, a higher proportion of Thai affected eyes were found to have an initial visual acuity of 20/200 or worse compared with the American-Caucasian cohort. Azathioprine was the most common maintenance treatment (75%) used among Thai subjects in contrast to rituximab (78.6%) among American-Caucasian subjects. Conclusion Despite the different prevalence among Thai and American-Caucasian populations, the clinical characteristics of ON in the NMOSD were very similar across these two populations, other than for more severe visual loss initially among Thai subjects. Notably, long-term visual outcome did not differ between these cohorts despite significant difference in the maintenance treatment regimen. This study did not assess neurological status or outcome. [ABSTRACT FROM AUTHOR]

An abstract of the article "Progressive Visual Failure and Occipital Calcification Associated With Coeliac Disease," by P. Jindahra, M. James, and G. T. Plant is presented.

Following a unilateral post-chiasmal lesion of the geniculo-striate pathway, patients develop homonymous visual field defects. Using classical perimetry, patients with 'complete' homonymous hemianopia are unaware of stimuli in the affected hemifield. However, some show preserved vision in the affected hemifield in which the conscious perception of moving stimuli is preserved (Riddoch phenomenon). Prior evidence suggests that preservation of a direct pathway from the lateral geniculate nucleus to visual area 5 (bypassing the primary visual cortex) may be the basis of this type of residual vision. The aim of the present study was to investigate the possibility of a correlation between preserved motion perception in hemianopia and the fibre connectivity density of the underlying pathways. This research was a case-control study carried out in a tertiary care centre between 2019 and 2021. Participants ( n = 48) were divided into two groups: patients with homonymous visual field defects ( n = 20) and normal controls ( n = 28). All participants underwent Humphrey field analysis (outcome = visual field index); kinetic perimetry (outcome = %correct); brain MRI; and diffusion tensor imaging probabilistic tractography (outcome = fibre connectivity density). The difference between %correct in kinetic perimetry and visual field index in Humphrey field analysis provided an indication of the level of preserved motion perception. A significant positive correlation was found between the fibre connectivity density of contralateral lateral geniculate nucleus-contralateral visual area 5 and the preserved motion perception (rho = 0.5965, P < 0.0012) and between the fibre connectivity density of contralateral visual area 5-contralateral lateral geniculate nucleus and the preserved motion perception (rho = 0.5635, P < 0.0012) after adjusting with the Bonferroni method. The area under the curve was 0.7947 for the preserved motion perception in reflecting the fibre connectivity density of contralateral lateral geniculate nucleus-contralateral visual area 5, and 0.7660 for the preserved motion perception in reflecting the fibre connectivity density of contralateral visual area 5-contralateral lateral geniculate nucleus. We have demonstrated an extensive network of pathways connecting visual areas in the two hemispheres via the splenium of the corpus callosum. To our knowledge, this is the first report of a correlation between the preserved motion perception and the fibre connectivity density of the pathways underlying the Riddoch Phenomenon (specifically bilateral lateral geniculate nuclei to visual area 5 contralateral to the lesion). The difference between %correct in kinetic perimetry and visual field index measures the preserved motion perception and is related to the underlying neural damage. The methodology has the potential to evaluate and monitor patients with hemianopia., Competing Interests: The authors report no competing interests., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Guarantors of Brain.)

Improving non-motorized accessibility is essential to enable access to vital services such as education and healthcare. Road networks are often inadequately designed for non-motorized accessibility, and service facilities are not always strategically located to reach the majority of users. Furthermore, design decisions are rarely made with consideration for the diverse needs and walking abilities of a heterogeneous population. Enhancing infrastructure by locating new service facilities and creating accessible paths involves significant investments, requiring a systematic approach to utilize limited resources efficiently. We propose an optimization model to identify optimal locations for new facilities and accessible road segments to maximize non-motorized accessibility to a range of services, taking into account users with different walking abilities. A randomized greedy algorithm is developed to tackle the complex network design and facility location problem. A case study in the Huai Kwang district of Bangkok is discussed to illustrate how this methodology can support strategic decisions to enhance non-motorized accessibility., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Starita et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)