Case Report: Asymptomatic Skew Deviation Secondary to Chronic Ischemic Infarction of the Cerebellum.

SIGNIFICANCE: Skew deviation is likely encountered clinically more often than previously thought. Cerebellar causes of skew deviation appear to be the rarest cause and should be considered by clinicians when encountering patients with findings consistent with skew deviation. PURPOSE: This case report describes an undiagnosed, asymptomatic skew deviation in an established glaucoma patient returning for routine follow-up. Appropriate diagnosis and subsequent neuroimaging identified a chronic ischemic cerebellar infarction. CASE REPORT: A 72-year-old man presented for a routine glaucoma follow-up examination. Cover test revealed a 10-prism diopter left hypertropia, which worsened in right gaze and left head tilt. Double Maddox rod testing showed 5° excyclotorsion of the right eye and no torsion in the left eye. Upright-supine testing was positive. Given the patient's noticeable right head tilt, left hypertropia, increased excyclotorsion of his lower eye, and positive-upright test, the patient was diagnosed with a skew deviation. Brain MRI revealed a chronic, undiagnosed cerebellar ischemic infarction, a known cause of skew deviation and the associated ocular tilt reaction. CONCLUSIONS: It can be challenging to identify skew deviations and their underlying causes. When clinically encountering a vertical deviation, appropriate tests (cover-uncover test, Parks-Bielschowsky three-step test, ocular torsion testing, and upright-supine test) are imperative to help make the correct diagnosis. Neuroimaging can then be pursued in hopes of identifying the underlying cause.

Case Report: Bilateral Horizontal Gaze Palsy (1 + 1 Syndrome): A Supranuclear Gaze Palsy.

SIGNIFICANCE: A rare case of bilateral horizontal gaze palsy with intact vertical gaze eye movements and largely intact vestibulo-ocular reflex is presented owing to demyelinating lesions of the patient's bilateral paramedian pontine reticular formations and left infranuclear abducens nerve from the patient's recently diagnosed multiple sclerosis. PURPOSE: The purpose of this study was to report on a rare case of bilateral horizontal gaze palsy from a supranuclear lesion in a patient with a recent diagnosis of multiple sclerosis. CASE REPORT: A 43-year-old African American woman presented urgently for evaluation of her inability to move her eyes into either horizontal gaze. Vertical conjugate movements remained intact, as did three of four extraocular muscles with horizontal vestibulo-ocular reflex testing, suggesting a supranuclear palsy. Magnetic resonance imaging revealed two demyelinating lesions in her inferior pons, which spared her nuclear and internuclear horizontal gaze pathways, as well as three of four extraocular muscles of her infranuclear horizontal gaze pathway as evidenced by her largely intact vestibulo-ocular reflex. This suggested bilateral paramedian pontine reticular formation lesions (supranuclear) and a mild left abducens nerve palsy (infranuclear). CONCLUSIONS: Close evaluation of extraocular motilities and a solid understanding of the supranuclear, nuclear, internuclear, and infranuclear components of the horizontal gaze pathway can help identify challenging gaze palsies when encountered in a clinical setting. Appropriate neuroimaging can then be performed with an emphasis on the suspected location of the lesion(s) based on the patient's clinical findings.

Concomitant multiple myeloma spectrum diagnosis in a central retinal vein occlusion: a case report and review.

Multiple myeloma is a neoplastic plasma-cell disorder resulting from malignant plasma cells in the bone marrow. It can cause a hyperviscosity syndrome secondary to the paraproteinaemia associated with the disease. The increased hyperviscosity can lead to retinal vein occlusions and other ocular problems that may challenge clinicians. In patients with multiple myeloma and hypertension and/or diabetes mellitus, retinal changes appear similar and changes due to one disease or the other may be difficult to determine. A 48-year-old white female presented to the clinic with a complaint of blurry vision in her left eye. A full comprehensive ocular examination revealed a central retinal vein occlusion presumably from the patient's history of hypertension, diabetes mellitus and hypercholesterolaemia. Further bloodwork revealed monoclonal protein in the patient's serum and an increased percentage of plasma cells in the bone marrow. She was diagnosed with monoclonal gammopathy of undetermined significance, part of the multiple myeloma disease spectrum. She was referred to a retinal specialist for initiation of intravitreal injections of anti-vascular endothelial growth factor. Multiple myeloma has been implicated in younger patients as an underlying cause of retinal vein occlusions. Multiple myeloma should be considered as a differential diagnosis in young patients with retinal vein occlusions, even if other risk factors for venous occlusion like hypertension, diabetes mellitus and hypercholesterolaemia are present. Timely referral to the patient's primary care physician and haematologist is important for appropriate treatment and control of underlying systemic conditions.

Proteus mirabilis and its role in dacryocystitis.

PURPOSE: Dacryocystitis is a common inflammation of the lacrimal sac, usually from an underlying bacterial infection. Most cases can be attributed to common ocular flora such as Staphylococcus aureus or Streptococcus pneumoniae; however, uncommon bacterial causes such as Proteus mirabilis can still occur. P. mirabilis is a gram-negative bacillus that is found abundantly in people who have undergone long-term catheterization and is uncommonly found in or around the eyes except in people who have undergone long-term catheterization. Proteus species can cause conjunctivitis, canaliculitis, and dacryocystitis and have the ability to manifest into preseptal cellulitis; therefore, timely recognition and treatment are important to prevent potential further complications. CASE REPORT: An 84-year-old white man had several recurrences of acute dacryocystitis that had marginal improvement with empiric antibiotic treatment. Resultant culture of the ocular discharge revealed an uncommon bacterium, P. mirabilis. Successful dosing of oral antibiotics resolved the infection but ultimately the patient required an external dacryocystorhinostomy (DCR) procedure to maintain patency of the nasolacrimal lacrimal system and prevent recurrence. At 3 months after external DCR, the patient was symptom free with no recurrences. CONCLUSIONS: Dacryocystitis has a distinctive clinical presentation and is usually easily treated when appropriate oral antibiotics are directed at the underlying pathogen. In nonresponsive cases, culturing of the ocular discharge should be performed to identify the underlying pathogen. Cases of dacryocystitis caused by Proteus species are usually responsive to several standard antibiotics used orally in eye care; however, culturing and susceptibility testing can streamline the diagnostic and management sequence considerably in unclear or unresponsive cases. Typically, patients with dacryocystitis return to normal after appropriate treatment, but chronic recurrences and epiphora are potential sequelae. Patients should be educated that a DCR surgical procedure may be needed to prevent future recurrences in some cases.

Topical timolol in the treatment of monocular oscillopsia secondary to superior oblique myokymia: a review.

Some reports have outlined many different treatment strategies for superior oblique myokymia (SOM) that attempt to reduce or eliminate patients' symptoms of monocular oscillopsia and/or diplopia. Most treatment strategies have focused solely on oral medications or invasive surgery. The following is a current and critical review of SOM along with its clinical findings/symptoms, demographics, theories of its pathogenesis, management/treatment options, new observations in SOM, as well as a case report to highlight a relatively novel idea for the treatment of SOM: topical timolol eye drops. It also highlights evidence of a new "localized theory" regarding topical ß-blockers' mechanism of action in SOM compared to the previous systemic hypothesis proposed in 1994. The case report shows a 29-year-old female patient who suffered with SOM symptoms for 8-10 years and then experienced a worsening of her symptoms shortly postpartum. The patient was prescribed topical timolol eye drops by the author in the affected eye based on one case report(12) from 1994, which completely eliminated her symptoms within 1-2 days of starting the treatment with any recurrence with the daily use of the drop at the time of this article. Given the robust effect in this case, topical timolol may be a potentially useful drug in the management of SOM given its affordability and safer side effect profile in comparison to the oral medications traditionally used in SOM.