Orbital apex inflammation: a curious case of COVID-19.

A 25-year-old man presented to an urgent care facility with sudden loss of vision in his right eye, diplopia, and anosmia. He tested positive by reverse-transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Nine days later, he presented at our emergency department, at which time ophthalmic examination revealed reduced visual acuity in the right eye, with poor color vision and a relative afferent pupillary defect. He had a moderate adduction deficit and mild hypertropia of the right eye, with an intermittent exotropia. Magnetic resonance imaging of the orbits revealed asymmetric, abnormal enhancement of the right optic nerve sheath extending to the right orbital apex. His ocular symptoms resolved completely with systemic steroids. All infectious and inflammatory labs returned negative except for COVID-19. Ocular findings have been consistently implicated throughout this pandemic. This case highlights an unidentified presentation with optic nerve involvement and orbital inflammation.

Kikuchi-fujimoto disease with bilateral uveitis.

Kikuchi-Fujimoto disease (KFD), also called histiocytic necrotizing lymphadenitis, is rare condition that usually presents with lymphadenitis and fever. KFD has been associated with many infectious disease processes, predominantly viral. Association with systemic inflammatory processes has been described. Here we present a case of KFD with the rare ocular manifestation of bilateral anterior uveitis, and corresponding findings on magnetic resonance imaging (MRI).

Comparing ocular muscle limitation tests for clinical trial use.

OBJECTIVE: To evaluate portable methods for documenting ocular muscle limitation that might be used at multiple sites in a clinical trial. METHODS: In a prospective consecutive case series, 2 examiners independently evaluated 3 methods of ocular muscle duction testing: a grading scale of 0 to -5 that is in clinical use, the Kestenbaum limbus test using a ruler to measure the millimeters of ocular movement, and an adapted cervical range of motion (CROM) device that measures ocular movement in degrees. Twenty consenting patients (mean age, 55 years) with diplopia, 8 with ocular myasthenia gravis, 11 with a cranial nerve III or VI palsy, and 1 with dysthyroid ophthalmopathy were studied. RESULTS: For Kestenbaum measures, between examiners the standard deviation of the difference for all ductions was 1.9 mm (r = 0.75, P =.01); 95% of differences were 4 mm or less. For the CROM device, the standard deviation of the difference was 7.1 degrees; 95% of differences were 15 degrees or less (r = 0.73, P =.01). For each examiner, the CROM standard deviation of the difference was less than 2 degrees (r = 0.98, P =.01). For the grading scale, the 2 examiners had the same score in 85% of ductions (r = 0.92, P =.01). CONCLUSIONS: The Kestenbaum test and the CROM device gave similar interexaminer repeatability. The repeatability for CROM measures for each examiner was high but was considerably less between examiners. The grading scale gave similar results between examiners.

Optic neuritis: correlation of pain and magnetic resonance imaging.

PURPOSE: To demonstrate whether the magnetic resonance imaging (MRI) localization of the abnormal enhancement of the optic nerve can be related to the pain or pattern of visual field loss associated with acute optic neuritis. DESIGN: Retrospective observational series and MRI review from a referral neuro-ophthalmology service. PARTICIPANTS: Seventy-three women and 23 men with acute optic neuritis who had high resolution gadolinium-enhanced fat-suppressed MRI within twenty days of the onset of visual loss. METHODS: The presence of eye or other fifth cranial nerve (V(1)) pain, and pain with eye movement ipsilateral to the affected optic nerve or no eye pain was recorded. The neuroradiologist reviewed the MRI, masked to the affected eye, and recorded the length and segment (orbital, canalicular, intracranial, or combination of segments) of abnormal optic nerve enhancement. The presenting visual field defects were characterized as diffuse, central, arcuate, nasal or temporal. MAIN OUTCOME MEASURES: The types of pain and patterns of field loss were correlated with the segments of optic nerve enhancement in the affected eye. RESULTS: Five patients had nerves that did not enhance and were excluded from the outcome analysis. In the 91 patients with abnormal enhancement, 70 experienced eye/V(1) pain, 67 had pain with eye movement and 17 patients had no pain. Enhancement of the orbital optic nerve occurred in 66 patients, 93.9% who had eye/V(1) pain and 92.4% who had pain with eye movement. In the 25 patients with enhancement of the canalicular, intracranial or both segments, without orbital involvement, 32% had eye/V(1) pain and 24% had pain with eye movement. No pain occurred in 3% with enhancement of the orbital segment and in 60% with enhancement of the other optic nerve segments. The length of enhancement moderately correlated with eye/V(1) pain (r = 0.49, P = 0.01) and pain with eye movement (r = 0.37, P = 0.01). Patients with enhancement longer than 10 mm had pain five times (P = 0.004) more frequent than did those with enhancement

Acute occipital demyelinating lesion appearing as an infarct on diffusion magnetic resonance imaging.

PURPOSE: To report a case of a 27-year-old woman who presented with an acute right homonymous visual field deficit due to demyelination diagnosed by postprocessing analysis of the magnetic resonance imaging (MRI). DESIGN: Observational case report. METHODS: Magnetic resonance imaging analysis with an exponential diffusion-weighted imaging. RESULTS: On MRI, a left occipital lesion with mild enhancement after gadolinium infusion on the T1-weighted image, bright signal with some mass effect on the T2-weighted image, and the diffusion-weighted imaging suggested a diagnosis of an acute infarct. With the use of the exponential image technique, the T2 hyperintense signal present on the diffusion study was almost completely eliminated, changing the diagnosis and treatment plan. Subsequent examinations and MRI confirmed the diagnosis of demyelinating disease. CONCLUSIONS: In diseases such as cerebral ischemia and demyelination, MRI diffusion is often abnormal because such diseases modify the integrity of central nervous system structures. A technique that subtracts the T2 contribution to the diffusion-weighted imaging analysis supported a diagnosis of an acute demyelinating episode that was subsequently confirmed.