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The presence of an elevated anti-glutamic acid decarboxylase (GAD) antibody level has been associated with a number of eye movement abnormalities as well as other findings, including cerebellar ataxia and insulin-dependent diabetes mellitus. Skew deviation in association with anti-GAD antibodies has not been previously reported. Here the authors report a case of alternating skew deviation along with cerebellar-brainstem signs in a patient with an elevated anti-GAD antibody titre. Follow-up neurologic evaluation after treatment with intravenous immunoglobulin revealed improvement in cerebellar-brainstem signs, whereas ophthalmic evaluation was stable.

Ocular graft-versus-host disease is one of the most severe forms of ocular surface disease. Inflammation is clearly the underlying pathophysiologic mechanism that leads to the development and progression of the disease. The cases below highlight the latest diagnostic and management strategies as well as the potential complications of this condition. Autologous serum/plasma tears, along with anti-inflammatory therapy, continue to be the main topical treatment options to help control the symptoms and modulate inflammation. Scleral contact lenses are currently the most effective treatment option, and an effective strategy is to offer this option to patients earlier rather than later in the disease course.

To review the management of visually significant corneal scarring secondary to herpes zoster keratitis (HZK).Literature review.Management options for visually significant corneal scarring secondary to HZK include scleral contact lenses, photorefractive or phototherapeutic keratectomy, lamellar keratoplasty, penetrating keratoplasty, and keratoprosthesis. Many authors recommend tarsorrhaphy in at-risk patients at the time of corneal transplantation. Most published studies either did not mention or did not use systemic antivirals at the time of surgery. Longer quiescent periods before surgical intervention may be associated with increased rates of graft survival. Reports of HZK recurrence after live-attenuated vaccine administration suggest that risks and benefits of the vaccine should be carefully considered. Overall, the prognosis of surgical intervention for corneal scarring due to HZK relies on appropriate patient selection and measures to ensure ocular surface stability. There remains a serious risk of ocular surface instability and corneal melt in these patients. Unfortunately, there is a lack of prospective studies in this area to guide clinical management.Patients with visually significant corneal scarring secondary to HZK may have good outcomes with the appropriate medical and surgical considerations, particularly in the absence of active ocular surface disease and inflammation. Those with active disease may benefit from delaying surgical intervention until a satisfactory quiescent period has been achieved. Prospective studies, such as the proposed Zoster Eye Disease Study, are imperative for validating these principles and determining evidence-based management guidelines.

A limited body of evidence suggests that sleep problems are common in prostate cancer patients undergoing androgen deprivation therapy, yet little is known about sleep characteristics and the effects of poor sleep on daily functioning in this population. This study assessed sleep in 60 prostate cancer patients taking androgen deprivation therapy with wrist actigraphy and daily diaries for 7 days. The Epworth Sleepiness Scale and the general version of the Functional Assessment of Cancer Therapy scale were also administered. On average, total sleep time was 5.9 (SD = 1.4) h, and sleep efficiency was 75% (SD = 12.0) as assessed by actigraphy. There was generally poor concordance between actigraphy and daily diary for most sleep metrics. Subjects reported awakening, on average, 2.7 times per night, most commonly for nocturia and hot flashes. Assessment of daily functioning showed that participants had mild daytime sleepiness, which was predicted by total sleep time (F(1,47) = 4.5, P= 0.04) General quality of life was not impaired. This study supports more research on the predictors of poor sleep in order to identify effective interventions.

Purpose Describe the presentation and management of superior limbic keratoconjunctivitis (SLK)-like inflammation and secondary limbal stem cell dysfunction in the setting of ocular chronic graft-versus-host disease (cGVHD). Methods Retrospective observational case series in a multicenter clinical practice. Participants were 13 patients (26 eyes) with ocular cGVHD and SLK-like inflammation presenting to the University of Illinois at Chicago and BostonSight® between January 1, 2009 and July 1, 2013. Main outcome measures 1) Reversal or worsening of SLK, and 2) development of limbal stem cell dysfunction. Results All eyes showed evidence of SLK-like inflammation and superior limbal stem cell dysfunction manifested by conjunctival injection and superior conjunctival and corneal staining. In addition to aggressive lubrication, management strategies for SLK included topical steroids (20/26), punctal occlusion (18/26), topical cyclosporine (24/26), autologous serum tears (12/26), therapeutic soft contact lens (13/26 eyes) and scleral lenses (4/26 eyes). SLK and limbal stem cell dysfunction were reversed in 23/26 eyes. Three eyes of two patients with long-standing disease demonstrated frank limbal stem cell deficiency (LSCD) and corneal pannus, with one patient requiring multiple reconstructive surgical procedures. Conclusions SLK-like inflammation is an under-recognized condition in patients with severe dry eyes secondary to ocular cGVHD. Untreated SLK can potentially lead to permanent LSCD over time. Early recognition and management of SLK in ocular cGVHD can improve vision, reverse signs, and may prevent these long-term consequences.

Purpose To report the association of chronic ocular hypotony with the development of progressive corneal ectasia and hydrops. Methods Retrospective case series. Results Three patients with ocular hypotony were referred for corneal evaluation and found to have ectasia and acute corneal hydrops in their hypotonous eye(s). Clinically, the globes were easily deformable with either external digital palpation and/or simple blinking. All 3 patients had a history of chronic iridocyclitis, including one with juvenile idiopathic arthritis. In each case, the area of thinning was narrow and arcuate in configuration, distinctive from other ectatic disorders. Also uncharacteristically, the acute hydrops resolved rapidly within 2 to 3 weeks without surgical intervention. In 1 case, severe thinning with perforation occurred requiring urgent penetrating keratoplasty. Conclusions This case series demonstrates a unique clinical entity in which corneal ectasia and hydrops developed in the setting of ocular hypotony and easily deformable corneas, in a pattern unlike previously described forms of ectasia. Acute hydrops, even with associated corneal perforation, demonstrated a short and self-limited course. Corneal ectasia and irregular astigmatism should be suspected as a cause of unexplained visual loss in the ever-increasing number of patients with chronic, stable ocular hypotony. Further study is warranted to determine the pathophysiology of corneal ectasia in this setting, which may include mechanical and inflammatory factors.

A healthyman in his mid-20swas referred to evaluate persistent, stable metamorphopsia in the left eye for 1 year. He had an enlarged blind spot in his left visual field for 2 years and denied symptoms of headaches, photophobia, blurred vision, or eye pain. Within the last year, the patient stated he had a 2-diopter hyperopic shift in his refraction of the left eye. He had undergone2magnetic resonance imaging (MRI) studiesofhis orbits over the previous year. Both were read as normal.Hismedical historywas significant for attention-deficit/hyperactivity disorder anddepression.Hedeniedanypreviousocular surgical proceduresor traumatoeithereye.Hewas prescribed bupropion. His visual acuitywas20/20ODand20/25OS.His extraocularmotility, pupils, and confrontationvisual fieldswerenormal. Intraocularpressureswere 18and 16mmHg in the right and left eyes, respectively.Anterior segment slitlampexamination findingswereunremarkable in each eye. On ophthalmoscopic examination, the cup-disc ratio was 0.2, with both optic nerves appearing healthy with sharp margins. Retinal vessels were normal and the foveal reflex was sharp in each eye. The appearance of the macula in the left eye is shown in Figure 1. Optical coherence tomography with enhanced depth imaging (OCT-EDI) was normal in the right eyeandshowedundulations in thepapillomacular bundle at the level of the retinal pigment epithelium (RPE) in the left eye. Kinetic perimetry did not show enlargement of the blind spot or other visual field defect in each eye. Quiz at jamaophthalmology.com Fundus photograph of left eye A Fluorescein angiography of left eye B

We report a 9-month-old boy with bilateral pseudoptosis associated with elevated IOP. The patient had previously undergone bilateral trabeculectomies and Ahmed tube placement and right cataract extraction and penetrating keratoplasty. At presentation, the right eye IOP was 24 mm Hg and the left eye IOP was 32 mm Hg. Approximately 2 weeks after dorzolamide was added to the treatment regimen for the left eye, the mother reported that the ptosis had resolved. We suggest several explanations for the resolution of the ptosis.

The West Nile virus (WNV) is a mosquito-borne infection that can be fatal to humans, equines, and avians, among others. WNV was first introduced to the United States in 1999 and is rapidly spreading across the country. Urban catch basins are thought to be prime breeding sites for mosquitoes, especially those identified as WNV carriers. The pilot study reported here was conducted in a city in southeastern Pennsylvania where there are 70,000 catch basins. The purpose of the study was 1) to determine whether catch basins are breeding sites for mosquitoes and 2) to test the effectiveness of a larvicide that uses a bacteria, Bacillus sphaericus, to eliminate mosquitoes in urban catch basins. The two-pronged study determined that catch basins are ideal locations for mosquitoes, especially Culex pipiens, and that B. sphaericus is an effective larvicide.