Presumed Latent Tuberculosis-related Intermediate Uveitis Manifesting as Recurrent Vitreous Hemorrhage

Purpose@#We report a case of recurrent vitreous hemorrhage in a patient with presumed latent tuberculosis-related intermediate uveitis, and we review the literature.Case summary: A 58-year-old male visited our clinic complaining of ocular pain, conjunctival hyperemia, decreased vision, and uncontrolled intraocular pressure (IOP) in the left eye. The best-corrected visual acuity (BCVA) was 0.4 and the IOP of the left eye was 34 mmHg. Slit lamp examination revealed conjunctival hyperemia, corneal edema, and inflammatory cells in the anterior chamber and anterior vitreous; fundus examination revealed mild vitreous opacity attributable to vitritis. The high IOP and the intraocular inflammation were treated with antiglaucoma agents and corticosteroids under the impression of chronic anterior uveitis and uveitic glaucoma. Of the tests performed to identify the cause of the uveitis-related vitreous hemorrhage, the interferon-gamma release assay was positive. A presumptive diagnosis of latent tuberculosis-related uveitis was made after pulmonary tuberculosis was excluded by our respiratory internal medicine department. Isoniazid was administered for 9 months. The vitreous hemorrhage recurred 1 month after antituberculosis therapy commenced but, at 2 months, all of the hemorrhage was absorbed and the BCVA improved to 1.0 without further recurrence. @*Conclusions@#Intraocular tuberculosis can present with various clinical manifestations. If tuberculosis-related uveitis is presumed, tests for latent and manifest tuberculosis should be scheduled to allow of early diagnosis and immediate antituberculosis therapy.

Clinical Features and Course of Acquired Third Cranial Nerve Palsy

Purpose@#The purpose of our study was to investigate the clinical features and course of acquired third cranial nerve (CN3) palsy. @*Methods@#We retrospectively reviewed the medical records of 40 consecutive patients who underwent at least 3 months of follow-up clinical evaluation from March 2016 to December 2019 who were admitted to the ophthalmologic department or referred from other departments of Samsung Changwon Hospital and diagnosed with acquired CN3 palsy. @*Results@#The average age of patients with acquired CN3 palsy was about 64.6 ± 15.9 years and the mean follow-up period was 4.4 ± 8.4 months. Microvasculopathy (twelve patients, 30.0%) was the most common etiology followed by brain vascular lesions (eight patients, 20.0%), and tumors (eight patients, 20.0%). The complete recovery rate was 67.5% and non-isolated CN3 palsy was recorded in 30.0% cases of which six cranial nerve palsy (in eight patients, 66.7%) was the most common. Microvasculopathy (42.9%) and tumors (66.7%) were the most common features in the recovery and persistent groups, respectively. Extraocular movement limitation at the first visit was smaller in the recovery group (−2.4 ± 1.1) than in the persistent group (−3.2 ± 0.6); the difference was statistically significant (p = 0.039). Pupil involvement was found in one (8.3%) patient from the microvascular group and in eight (61.5%) patients from the compressive lesion group. @*Conclusions@#The microvascular group or those with a low degree of extraocular movement limitation at the first visit had the highest recovery rate in acquired CN3 palsy. Although compressive lesions showed high pupillary involvement, imaging study should be considered for confirmation rather than attempting to discriminate the causative disease based solely on pupil involvement.

Clinical Features and Course of Acquired Third Cranial Nerve Palsy

Purpose@#The purpose of our study was to investigate the clinical features and course of acquired third cranial nerve (CN3) palsy. @*Methods@#We retrospectively reviewed the medical records of 40 consecutive patients who underwent at least 3 months of follow-up clinical evaluation from March 2016 to December 2019 who were admitted to the ophthalmologic department or referred from other departments of Samsung Changwon Hospital and diagnosed with acquired CN3 palsy. @*Results@#The average age of patients with acquired CN3 palsy was about 64.6 ± 15.9 years and the mean follow-up period was 4.4 ± 8.4 months. Microvasculopathy (twelve patients, 30.0%) was the most common etiology followed by brain vascular lesions (eight patients, 20.0%), and tumors (eight patients, 20.0%). The complete recovery rate was 67.5% and non-isolated CN3 palsy was recorded in 30.0% cases of which six cranial nerve palsy (in eight patients, 66.7%) was the most common. Microvasculopathy (42.9%) and tumors (66.7%) were the most common features in the recovery and persistent groups, respectively. Extraocular movement limitation at the first visit was smaller in the recovery group (−2.4 ± 1.1) than in the persistent group (−3.2 ± 0.6); the difference was statistically significant (p = 0.039). Pupil involvement was found in one (8.3%) patient from the microvascular group and in eight (61.5%) patients from the compressive lesion group. @*Conclusions@#The microvascular group or those with a low degree of extraocular movement limitation at the first visit had the highest recovery rate in acquired CN3 palsy. Although compressive lesions showed high pupillary involvement, imaging study should be considered for confirmation rather than attempting to discriminate the causative disease based solely on pupil involvement.

Metastatic Small Cell Neuroendocrine Carcinoma to the Orbit Manifesting as Total Ophthalmoplegia

PURPOSE@#To report a case of primary ureteral small cell neuroendocrine carcinoma metastasis in the left orbital wall, with a review of the literature.CASE SUMMARY: A 79-year-old male visited our clinic with a 10 day history of ocular pain, ptosis, and ophthalmoplegia in the left eye. He had been diagnosed with diabetes mellitus and was being treated for prostate adenocarcinoma. The corrected visual acuity was 0.8 in the right eye and 0.5 in the left eye. An extraocular movement test showed total ophthalmoplegia, mild exophthalmos, and ptosis in the left eye. Orbital computed tomography (CT) and magnetic resonance imaging showed an irregular mass-like enhancement in the superolateral orbital wall of the left eye, suggesting infectious and inflammatory orbital disease. After antibiotic treatment, high dose systemic steroids were administered. However, there was no improvement and the orbital CT was again performed, with no changes. A surgical biopsy for differentiating orbital tumors was performed and diagnosed as a metastatic orbital small cell neuroendocrine carcinoma. Using positron emission tomography, he was later diagnosed with a metastatic orbital small cell neuroendocrine carcinoma with multiple metastases.@*CONCLUSIONS@#When the patient has a mass-like lesion on imaging with ocular pain, ophthalmoplegia, or ptosis, a surgical biopsy should be performed to make a diagnosis and determine the optimal management.

A Case of Ciliary Body Tuberculoma Causing Sclera Melting

PURPOSE: To report a case of ciliary body tuberculoma, which induced scleral melting. CASE SUMMARY: A 32-year-old man, who was diagnosed with miliary pulmonary tuberculosis 1 week earlier, presented with a conjunctival injection and mass on his right eye 3 months in duration. On excisional biopsy, melted sclera and exposed uveal tissue were found; acid-fast stain was positive. Two months after anti-tuberculosis treatment, anterior granulomatous uveitis and granuloma formation on the anterior chamber angle developed. A low-dose systemic steroid therapy was added. Six weeks after systemic steroid therapy, anterior uveitis and granuloma on anterior chamber angle disappeared. CONCLUSIONS: We experienced a case of ocular tuberculosis on the ciliary body. A low-dose systemic steroid along with multi-drug anti-tubercular therapy may be an effective treatment of ciliary body tuberculoma.

Two Cases of Orbital Apex Syndrome

PURPOSE: To report two cases of orbital apex syndrome: one induced by penetrating orbital injury and the other by severe optic nerve swelling associated with bacterial meningitis. METHODS: We have experienced a 40-year-old male after penetrating orbital injury who complained of loss of vision, ocular pain, ptosis, hypesthesia of forehead, and total ophthalmoplegia. The CT image of this patient showed a severe retrobulbar hemorrhage and marked enlargements of extraocular muscles. In a 62-year-old male who had a same symptom after headache and decreased mentality, a bacterial meningitis was diagnosed from CSF study and we saw a very severe swelling of the unilateral entire optic nerve and optic nerve sheath in CT. We managed these two patients with a large amount of systemic RESULTS: In 40-year-old man, there were improvements of ptosis and visual acuity from negative light perception to positive, but ophthalmoplegia was not improved. In 62-year-old man, ptosis and ophthalmo-plegia were improved after early antibiotics administration and papilledema disappeared two months after development, but visual acuity was not improved from negative light perception.

Therapeutic Effects of Psychosocial Programs in the Day Care Service on Cognitive Impairment and Depressive Symptoms in the Elderly Patients / 신경정신의학

Cognitive impairment and depression are the most common symptoms affecting the elderly on physical and mental states. Studies have shown that these symptoms in mild cases are improved by psychosocial intervention, emphasizing the importance of therapeutic intervention provided in the community. The purpose of this study was to investigate whether the psychosocial program at a geriatric day care service has any therapeutic effect on the cognitive function and depressive symptoms in the elderly and whether such effect can be maintained. The experimental group was composed of 37 elderly patients attending the day care service at the mental health center located in Kwangju county, Kyonggi province. The control group was composed of 22 elderly patients who either refused intervention or who dropped out of the program. Cognitive function was assessed with the Korean version of the Mini-Mental State Exam(MMSE-K) and depressive symptoms were assessed with the Short-form Geriatric Depression Scale(SGDS) The experimental group and the control group were compared on the score of on each test, which was administered before and after the program and 10 weeks after discontinuation of program. In the experimental group, the scores acquired immediately after the program and at 10 weeks of follow-up were also compared. The results showed that psychosocial intervention at a geriatric day care service was significantly associated with the change in SGDS scores dependent on time but not significantly associated with the change in MMSE-K scores. In the experimental group whose follow-up assessment was possible, it was further shown that 43% of patients had increased SGDS scores 10 weeks after the program ended, indicating that depressive symptoms had worsened. This study suggests that psychosocial therapeutic intervention in the geriatric day care service improve depressive symptoms but not cognitive functions in the elderly. In addition, for a considerable percentage of subjects in the experimental group, the improvements in depressive symptoms were not sustained after the intervention was withdrawn. These findings proposes a need of strengthening therapeutic intervention to maintain such effect.