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A Bitot spot is a conjunctival lesion, classically associated with severe vitamin A deficiency. In this paediatric series, we describe conjunctival lesions indistinguishable from Bitot spots, seen in the presence of normal vitamin A levels. This descriptive case series was performed by retrospective review of case notes, including all patients with Bitot-like spots found to have normal serum vitamin A levels, seen at the Hospital for Sick Children, Toronto, between 2006 and 2016. Data collected included age at presentation, ophthalmic and systemic diagnoses, and the presence of recognised genetic mutations. Histopathology was reviewed in one case. Ten patients with Bitot-like spots with laboratory-confirmed normal serum vitamin A levels were identified. The conjunctival lesions were indistinguishable clinically and histopathologically from classic Bitot spots and were noted to occur in a range of anterior segment pathologies, including aniridia, WAGR syndrome, Axenfeld–Rieger syndrome, and blepharokeratoconjunctivitis. Bitot-like spots are found in children with a number of anterior segment pathologies in the absence of vitamin A deficiency. This study adds weight to the observation that Bitot-like spots can occur without vitamin A deficiency. We report their presence in children with predominantly genetic eye conditions of the anterior segment.

Purpose: To explore the application of preoperative fusional convergence amplitudes in the selection of a target angle for non-adjustable suture strabismus surgery with deteriorated intermittent esotropia and diplopia. Methods: Thirty-one consecutive cases of presumed acquired non-accommodative, deteriorated intermittent esotropia managed surgically between 2005 and 2016 were reviewed retrospectively. For each individual, a target angle (deviation angle for which surgery was based) was selected preoperatively after analysis of fusional convergence amplitudes. Outcomes in patients selected for overcorrection at 6 meters (target angle > angle in primary position at 6 meters) were compared to those who had planned surgery based on a target angle that did not exceed their measured angle (target angle ≤ angle in primary position) at 6 meters. Results: All 31 patients achieved binocular single vision in primary position at both near and 6 meters without prisms, orthoptic therapy, or additional surgery at 4 to 6 months postoperatively. Greater mean correction in the target angle > angle in primary position group compared to the target angle ≤ angle in primary position group was observed, but this difference was not statistically significant ( P = .57). Conclusions: Among this diagnostically specific cohort with intermittent esotropia with symptomatic diplopia and measurable binocular single vision preoperatively, targeted surgery based on an analysis of preexisting fusional convergence amplitudes had an outcome that compared favorably to that of documented adjustable suture strabismus surgery. [ J Pediatr Ophthalmol Strabismus . 2018;55(6):375–381.]

PurposePhaeohyphomycosis are melanin-containing fungi that rarely infect the eye. We describe three cases of ocular infection with some unusual clinical features.MethodsSeries of three case reports describing three different presentations of phaeohyphomycosis of the eye, their histopathology, and management.ResultsCase 1 mimicked an inflamed conjunctival naevus and was excised on this basis, revealing a conjunctival retention cyst containing pigmented fungal hyphae. Case 2 showed a wooden foreign body incidentally associated with pigmented fungal hyphae, which required treatment with topical antifungal therapy. Case 3 clinically was thought to be a perforated uveal melanoma and comprised an extensive plaque of pigmented fungal hyphae over ulcerated cornea.ConclusionThe pigmented melanin containing hyphae of phaeohyphomycosis mimicked melanocytic lesions in two cases and was an incidental finding in the context of a surface foreign body.

The purpose of this study was to improve communication between the ophthalmology and histopathology departments at Royal Hallamshire Hospital, Sheffield, by effectively changing the structure and completion of the histopathology request form through the process of a successful audit. This aimed to ensure that comprehensive information was made available to the histopathologist. An audit was performed by review of 710 histopathology request forms, completed by the ophthalmology department, over a 1-year period, between July 2005 and June 2006 inclusive. Results were used to re-model the ophthalmic histopathology request form. New forms were circulated and all forms completed over a 3-month period, between January 2008 and March 2008, were reviewed, thus closing the audit loop. On the basis of audit results of 710 histopathology request forms, a new histopathology request form was created, which was easier to complete. Review of the 224 new histopathology request forms showed improved percentages of completion of important sections of the form. Through the audit process we have created a new ophthalmic histopathology request form that is more user-friendly for the ophthalmologist and more consistently provides the necessary information for the ophthalmic histopathologist. This has improved efficiency and effectiveness of communication between the specialities, which should contribute to minimise the chances of medical error and improved turnaround times for the planning and delivery of patient care.

This study investigated the impact of focal brain lesions on causal reasoning about everyday events that led to adverse outcomes. Participants with focal lesions involving frontal and posterior brain regions and matched healthy control participants were compared in their causal inference judgments about intentional human actions, unintentional human actions and physical events. Compared to the control group, those with frontal lesions, especially to right-sided ventromedial and lateral regions, differentiated less between intentional and unintentional acts. Imaging studies have implicated ventromedial frontal regions in the processing of social and emotional material, while lateral frontal regions have been linked to abstract reasoning and executive control. Difficulties in both social/emotional processing and in abstract reasoning and executive control may impair sensitivity to intentionality when making causal inferences.

Metastasis to choroid is the most common intraocular malignancy, arising most frequently from carcinoma of breast in women and lung in men. Recent case reports have described successful use of intravitreal bevacizumab to achieve local control of such tumours. Five cases of choroidal metastases from varying primaries: breast, lung, and colon were treated with intravitreal bevacizumab, and tumour response observed and documented with serial photographs and B-scans. Four of the five tumours were seen to progress despite intravitreal bevacizumab treatment. Intravitreal bevacizumab as the primary treatment of choroidal metastases is not recommended and should not delay more effective alternative treatments.

To prospectively evaluate the safety and effectiveness of hepatic intraarterial injection of yttrium 90 ((90)Y) tetraazacyclododecane tetraacetic acid (DOTA) lanreotide as a treatment for patients with progressive large-volume somatostatin receptor-positive liver metastases from neuroendocrine tumors.The study was local ethics committee approved, and all patients gave informed consent. Twenty-three patients (13 men, 10 women; age range, 21-69 years; median age, 57 years) with histologically proved large-volume liver metastases from neuroendocrine cancers were treated. All patients had radiologic evidence of liver disease progression and high uptake of indium 111 ((111)In) pentetreotide at scintigraphy. Selective hepatic intraarterial injection of (90)Y-DOTA-lanreotide (total of 36 treatments; median activity per dose, 1 GBq) was administered with or without embolization. Treatment cycles were performed in 8-week intervals. Clinical, biologic, and radiologic tumor responses were assessed 8-12 weeks after each treatment cycle. Objective tumor response was classified according to World Health Organization response criteria as complete regression, partial response, stable disease, or disease progression. Kaplan-Meier survival curves were used to calculate 1-year survivals.Partial response to treatment was achieved in three (16%) of 19 patients, and stable disease was achieved in 12 (63%). Four (21%) of 19 patients had continued disease progression. Clinical improvement was reported by 14 (61%) of the 23 patients, and a reduction in biologic marker levels was observed in nine (60%) of 15 patients. Reversible hematologic toxicity (National Cancer Institute common toxicity criteria grade2) occurred in three patients. The 1-year survival rate was 63% (median survival time, 15 months).Hepatic intraarterial injection of (90)Y-DOTA-lanreotide is a safe and effective palliative treatment for patients with progressive large-volume somatostatin receptor-positive liver metastases from neuroendocrine tumors.

We systematically reviewed the evidence for determining the best radiological imaging for characterizing hepatocellular carcinoma (HCC) in cirrhotic patients in 997 articles between 1995 and 2001. We selected only prospective and retrospective cohorts of patients, excluding both case reports and studies without separate data on HCC. Only 29 studies, comprising 918 patients, fulfilled the inclusion criteria: 10 used the explanted liver as the reference standard of diagnosis. All except one, either found no statistically significant difference between imaging modalities or had no direct comparison of sensitivity between different modalities of imaging; 16 studies evaluated HCC among cirrhotic patients and had biopsy or imaging as the reference standard for diagnosis. However, no one imaging technique was shown to be superior. In two studies, data of a HCC subgroup was derived from the studies evaluating different kinds of focal hepatic lesions. No conclusion could be drawn because of the small sample size. One study addressed the issue of therapeutic impact. The evidence for choosing the best modality of imaging for characterizing HCC in cirrhotic patients is inadequate. Large multicentre studies with defined reference standards for diagnosis, and studies evaluating therapeutic impact are needed.

Computed tomography (CT) has developed a well-recognised role within paediatric uroradiology, especially in imaging of trauma, malignancy (in particular Wilms' tumour), atypical infection, and congenital urogenital abnormalities. CT can also be used for problem solving in nephrolithiasis and renal transplant assessment. These applications are illustrated and discussed, with an emphasis on particular information that can be gained from the CT study.

Purpose Malignant melanoma of the eye is an uncommon condition that is important to recognise. We describe three cases in which ocular foreign bodies have masqueraded as ocular malignant melanoma. Methods Interventional case reports. Results Case 1 describes diathermy-induced carbon particle implantation, during plaque therapy for the treatment of uveal melanoma, mimicking recurrence with extra-scleral invasion. Case 2 shows a foreign body called 'mullite' mimicking conjunctival melanoma. Case 3 demonstrates a conjunctival foreign body called 'illite' that mimicked a limbal melanocytic lesion, clinically thought to be either melanocytoma or melanoma. Conclusion This report highlights the importance of careful history taking, examination, and appropriate biopsy in cases of suspected malignant melanoma, to prevent unnecessary and potentially radical treatment.

Summary: Purpose: The nature of the resection in surgery for intractable medial temporal lobe epilepsy is likely to be a principal factor determining seizure and neuropsychological outcome. However, there is no universally accepted system for describing the characteristics of individual resections to allow comparison between patients and patient groups treated at different institutions. We therefore developed a technique of volumetric analysis of temporal lobe resections. Methods: With comparison of coregistered pre- and postoperative, volumetric magnetic resonance imaging (MRI) scans in 10 subjects, the volumes of six temporal lobe substructures were determined by manual delineation in the pre- and postoperative images for each case, allowing the extent of resection to be determined. Results: The substructures and their extent of resection were measured with acceptable repeatability in each case. Conclusions: We developed a reliable method for the quantitative description of temporal lobe resections. This will be of application in determining the relation between the anatomic nature of the resection in intractable epilepsy and the seizure and neuropsychological outcome.

A 70-year-old man with a history of chronic liver disease presented with increasing scrotal pain and swelling. There was an associated dull left loin pain. His general practitioner had started antibiotics after an ultrasound scan revealed hypervascularity of the testes, suggestive of left epididymo-orchitis. An ultrasound scan also revealed a left varicocoele. Blood tests were unremarkable while urinalysis was positive for blood. A CT urogram revealed an oedematous, congested left kidney secondary to an acute left renal vein thrombus with retrograde flow into the …

There has been a long historical succession of scientific descriptions of the cerebral cortex, usually accompanied by conflicting speculations on its function. It was noted by Thomas S. Kuhn that scientific descriptions are phrased in terms of the prevailing scientific paradigm and that disagreement about the interpretation of observed phenomena is what drives scientists to formulate new theories. The objectives of this study were to examine how the observation of Kuhn can help to gain insight into historical concepts of brain functioning from contemporary descriptions of the cortical gyrations, to examine how these historical concepts are relevant to neurology today, and to demonstrate how subjective these concepts are because they are based on interpretations that may be wrong. The method used here is examination of historical sources that give descriptions and illustrations of the cerebral cortex and contemporary theories of brain function. I have found that the emphases on cortical description have varied according to the prevailing contemporary paradigm. Debates about and between different paradigms mirror some themes in current neuroscience. In conclusion, the observations of Kuhn help to interpret descriptions to shed light on theories of cerebral cortical functioning, and they demonstrate that a scientific description is necessarily highly subjective (since it is phrased in terms of the current paradigm). The insights that can be gained are relevant to modern neurology and neuroscience research.

Background/aims Ocular surface squamous neoplasia (OSSN) is a spectrum of disease, on which few large series have been published, none in particular, from the UK. The purpose of this study is to describe experience of this condition from a UK national ocular oncology centre, including statistical analysis to elucidate factors significant in recurrence. Methods Retrospective review of case notes, clinical photographs and histopathology reports. Results 78 cases were included, of which 10 (12.8%) recurred during the follow-up time (mean 37 months). The 1-year recurrence rate was 10.9%, and 5-year recurrence rate was 18.5% using Kaplan-Meier analysis, with a mean time to recurrence of 9.5 months. Significant factors in recurrence were tumour size and first treatment given. Grade of OSSN, including presence of invasive disease and positive biopsy margins were not found to be statistically significant in recurrence. Conclusions OSSN in an uncommon disease in the UK population. However, when managed appropriately in a specialist centre, it is associated with good outcomes, even in recurrence situations.

Splenic artery aneurysms (SAAs) comprise 60% of visceral artery aneurysms and although they can present at any age, they most commonly present in the fifth and sixth decades of life. They are associated with multiparity and portal hypertension and are more common in women. Historically SAAs greater than 2 cm in diameter are treated surgically because the risk of rupture, particularly during pregnancy, is high. The role of transcatheter embolisation – 5 is still evolving but is likely to become increasingly important as more asymptomatic visceral aneurysms are diagnosed as a result of the ready access to ultrasound, CT and MRI.

Recent work has linked mentalising ability to ventromedial frontal brain regions, the temporal poles and the temporo-parietal junction. The present study set out to examine the performance of participants with focal frontal and posterior lesions and a matched healthy control group on mentalising tasks with different types of pragmatic materials. Four types of materials were used: control physical events, human actions, and direct and indirect sarcastic remarks. Ability to interpret these was tested by asking participants both to explain the events, actions or remarks, and then to choose the best solution from four alternatives presented. Those with frontal lesions were impaired in comprehension of each of the sets of mentalistic materials, but were intact in comprehension of the control non-mentalistic items. There was some evidence linking the generation of free responses for the mentalistic materials to lateral frontal regions; this may be mediated by executive skills. There was also evidence linking selection amongst alternative solutions to right frontal regions, particularly ventromedial areas. There was little evidence that posterior regions played any significant part, at least for the present mentalistic materials. Errors in sarcasm comprehension made by participants with frontal lesions revealed that these were not always literal in nature, suggesting two separable components in comprehension: appreciating that a meaning is not intended literally, and understanding the specific meaning in the social context.