Erythropoietin Protects against Retinal Damage in A Rat Model of Optic Neuropathy via Glial Suppression.

OBJECTIVE: Traumatic optic neuropathy (TON) causes partial or complete blindness because death of irreplaceable retinal ganglion cells (RGCs). Neuroprotective functions of erythropoietin (EPO) in the nervous system have been considered by many studies investigating effectiveness of this cytokine in various retinal disease models. It has been found that changes in retinal neurons under conditions of glial cells are effective in vision loss, therefore, the present study hypothesized that EPO neuroprotective effect could be mediated through glial cells in TON model. MATERIALS AND METHODS: In this experiment study, 72 rats were assessed in the following groups: intact and optic nerve crush which received either the 4000 IU EPO or saline. Visual evoked potential and optomotor response and RGC number were assessed and regenerated axons evaluated by anterograde test. Cytokines gene expression changes were compared by quantitative reverse transcription polymerase chain reaction (qRT-PCR). Density of astrocytes cells, assessed by fluorescence intensity, in addition, possible cytotoxic effect of EPO was measured on mouse astrocyte culture in vitro. RESULTS: in vitro data showed that EPO was not toxic for mouse astrocytes. Intravenous injection of EPO improved vision, in terms of visual behavioral tests. RGCs protection was more than two times in EPO, compared to the vehicle group. More regenerated axons were determined by anterograde tracing in the EPO group compared to the vehicle. Moreover, GFAP immunostaining showed while the intensity of reactive astrocytes was increased in injured retina, systemic EPO decreased it. In the treatment group, expression of GFAP was down-regulated, while CNTF was upregulated as assessed by qRT-PCR in the 60th day post-crush. CONCLUSION: Our study showed that systemic administration of EPO can protect degenerating RGCs. Indeed, exogenous EPO exerted neuroprotective and neurotrophic functions by reducing reactive astrocytic gliosis. Therefore, reduction of gliosis by EPO may be considered as therapeutic targets for TON.

Bilateral Vision Loss in an Adult Patient with Woakes' Syndrome: An Unprecedented Case.

Purpose: To report a rare case of Woakes' syndrome presented with bilateral vision loss. Methods: A 28-year-old male with a 1-year history of vision loss in the left eye was referred to the neuro-ophthalmology clinic after sudden vision loss in his right eye. A detailed review of clinical findings and the presumed pathophysiological basis of vision loss was performed. Results: Neuroimaging revealed bilateral massive nasal polyps, sphenoid sinus mucocele formation, and optic nerve dehiscence inside the sphenoid sinus. The vision in the right eye was restored after pulse corticosteroid therapy; however, the left eye remained severely visually compromised even after nasal polypectomy and mucocele drainage. Conclusion: Sinonasal disorders should be sought for patients with unexplained vision loss, as prompt intervention could be vision-saving in these patients.

Evaluation of pro-oxidant antioxidant balance in retinopathy of prematurity.

INTRODUCTION: Retinopathy of prematurity (RoP) is a vasoproliferative disorder caused by the abnormal development of retinal vessels in premature neonates. It is one of the major causes of childhood blindness, which is increasing with the increasing survival rate of low birth weight and premature neonates. This study has aimed to evaluate the role of oxidative stress and peroxidant antioxidant balance (PAB) in the pathogenesis and prediction of RoP. MATERIALS AND METHODS: A total of 154 neonates weighing <1500 g admitted at the NICU of Ghaem Hospital, Mashhad, Iran, were enrolled in this cross-sectional study between 2018 and 2020. Blood samples were collected on the first day of birth to assess the peroxidant and antioxidant balance. The demographic, prenatal, and clinical course and postnatal problems were also recorded. The neonates were examined for RoP and divided into control (healthy) and affected (ROP) groups. RESULTS: There were significant differences between the two groups in gestational age, duration of oxygen therapy, and first and fifth minute Apgar score (P < 0.005). The mean PAB in infants without and with ROP was 19.79 HK (Hamidi-Koliakos) and 38.45 HK, respectively (P < 0.0001). Also, the mean PAB in neonates with ROP grade 1 and 2 was 36.69 HK and 45.53 HK, respectively (P = 0.002). CONCLUSION: According to our findings, the PAB level can be helpful in predicting ROP incidence. With increasing PAB, the possibility of ROP severity will increase.

Pituitary Apoplexy Secondary to Thrombocytopenia due to Severe Acute Respiratory Syndrome Coronavirus 2 Infection: Report of a Rare Case and Literature Review.

Purpose: To report a 16-year-old female patient with pituitary apoplexy in the setting of coronavirus disease 2019 (COVID-19) infection-related thrombocytopenia in the absence of preexisting pituitary macroadenoma. Methods: The patient had been admitted because of respiratory complications of COVID-19 infection and developed thrombocytopenia, intense headache, and symptoms of cavernous sinus syndrome. Results: Urgent magnetic resonance imaging of the brain depicted a pituitary apoplexy. Conclusion: This case indicated that thrombocytopenia due to COVID-19 could be a predisposing factor for pituitary apoplexy in the absence of underlying pituitary disease.

Bilateral Visual Loss Caused by Pneumosinus Dilatans: Idiopathic Cases are not Always Reversible.

PURPOSE: To report a rare case of primary pneumosinus dilatans (PSD) and to specify the cardinal imaging findings associated with this condition. METHODS: A 20-year-old patient presented with bilateral profound visual loss as a result of primary PSD. A detailed review of clinical findings and presumed pathophysiological basis of vision loss was performed. RESULTS: Other than undiagnosed primary hypothyroidism, no other abnormalities were found. With the diagnosis of PSD, the patient underwent optic nerve decompression through transnasal sphenoidotomy. However, after nine months of follow-up, no improvement in the patient's vision was attained. CONCLUSION: Unlike previous reports of favorable visual results after sphenoidotomy and bilateral decompression of the optic nerves, vision recovery was not achieved in this case.

Comparing Two Inferior Oblique Weakening Procedures: Disinsertion versus Myectomy.

PURPOSE: To compare two methods for treating inferior oblique overaction (IOOA): disinsertion versus myectomy of the muscle. METHODS: In this prospective interventional case series, patients were randomly assigned to undergo either IO myectomy or disinsertion. The changes in vertical and horizontal deviations following these two surgical procedures were evaluated. The postoperative IO function of grade 0 or +1 and the fundus extorsion of grade 0 or +1 was considered as the successful outcome. RESULTS: Thirty-six patients (50 eyes) with a mean age of 12.67 ± 4.05 years were included. In the myectomy group, the mean preoperative hyperdeviation in adduction was 29.5 ± 9.32 prism diopter (PD), which decreased to 9.15 ± 7.86 PD after surgery (P = 0.001). In the disinsertion group, these measurements were 32.73 ± 12.42 and 12.65 ± 9.34 PD before and after the surgery, respectively (P = 0.001). The success rate of surgery based on the IOOA grading was 87.4% and 92.3% in the myectomy and disinsertion groups, respectively (P = 0.780). The successful correction rate of abnormal fundus torsion was 91.6% in the myectomy and 88.4% in the disinsertion group (P = 0.821). In comparison, 48% of the cases in the myectomy group and 50% in the disinsertion group were within the normal range of torsional position postoperatively (P = 0.786). There was no statistically significant difference in terms of changes in the horizontal or vertical deviations, V-pattern, and dissociated vertical deviation between the two groups. CONCLUSION: Both surgical techniques seem to be effective for treatment of inferior oblique muscle overaction.

Temporal Artery Biopsy for Diagnosing Giant Cell Arteritis: A Ten-year Review.

PURPOSE: To assess the use of temporal artery biopsy (TAB) in diagnosing giant cell arteritis (GCA) and to evaluate patients' clinical and laboratory characteristics. METHODS: We conducted a retrospective chart review of patients with suspected GCA who underwent TAB and had complete workup in a tertiary center in Iran between 2008 and 2017. The 2016 American College of Rheumatology (ACR) revised criteria for early diagnosis of GCA were used for each patient for inclusion in this study. RESULTS: The mean age of the 114 patients in this study was 65.54 ± 10.17 years. The mean overall score according to the 2016 ACR revised criteria was 4.17 ± 1.39, with 5.82 ± 1.28 for positive biopsies and 3.88 ± 1.19 for negative biopsies (p <0.001). Seventeen patients (14.9%) had a positive biopsy. Although the mean post-fixation specimen length in the biopsy-positive group (18.35 ± 6.9 mm) was longer than that in the biopsy-negative group (15.62 ± 8.4 mm), the difference was not statistically significant (P = 0.21). There was no statistically significant difference between the groups in terms of sex, serum hemoglobin, platelet count, and erythrocyte sedimentation rate. There were statistically significant differences between the biopsy-negative and biopsy-positive groups with respect to patients' age and C-reactive protein level (P < 001 and P = 0.012, respectively). CONCLUSION: The majority of TABs were negative. Reducing the number of redundant biopsies is necessary to decrease workload and use of medical services. We suggest that the diagnosis of GCA should be dependent on clinical suspicion.

Isolated Unilateral Infiltrative Optic Neuropathy in a Patient with Breast Cancer

Metastasis to the optic nerve is very rare. We report a case of metastatic breast cancer to the optic nerve head without the involvement of other ocular or orbital structures. The patient, a 39-year-old female who had been previously treated for breast cancer, reported a gradually progressive decrement in visual acuity of the right eye during the past two months. Fundus examination of the affected eye revealed swelling of the optic disc which was infiltrated by a yellowish mass. Further evaluation using optical coherence tomography and fluorescein angiography showed optic disc swelling. Magnetic resonance imaging revealed no pathologic findings. With a diagnosis of unilateral infiltrative optic neuropathy, we referred the patient to an oncologist for further evaluation.

Isolated unilateral sixth nerve palsy in a patient with nasopharyngeal carcinoma.

Objective: To describe an isolated unilateral sixth nerve palsy, as a rare neuro-ophthalmic presentation of nasopharyngeal carcinoma. Methods: We report a 54-year-old female, known case of nasopharyngeal carcinoma who was treated with chemo-radiotherapy, and presented with isolated right sixth nerve palsy. Magnetic resonance imaging (MRI) indicated extension of tumor to intracranial fossa with clival involvement. Results: The patient was referred to an otolaryngologist for further evaluation and necessary intervention due to invasion of the cancer to intracranial fossa with involvement of right abducens nerve. Conclusions: Although, isolated sixth nerve palsies in adults over the age of 50 are usually ischemic; but in enduring cases, neoplastic processes should be considered.

Inadvertent inferior oblique extirpation during orbital decompression.

PURPOSE: To report a case of inadvertent inferior oblique extirpation during orbital decompression, its management, and postoperative result. METHODS: A 38-year-old female with thyroid eye disease underwent cosmetic right orbital decompression during whichinferior oblique extirpation was noticed. RESULT: The muscle was repaired on the same session (illustrated in the article) with no postoperative diplopia at 3-month follow-up. CONCLUSION: Inferior oblique injury should be considered among the uncommon yet important complications of orbital decompression. It can be easily found and repaired in the same session as demonstrated in this case report.

Traumatic optic neuropathy treatment trial (TONTT): open label, phase 3, multicenter, semi-experimental trial.

PURPOSE: Intravenously administered erythropoietin (EPO) was firstly commenced (phase 1) in patients with indirect traumatic optic neuropathy (TON) by this group in 2011. It was re-tested by another group (phase 2) in 2014. This multicenter clinical trial was designed to compare its effect with intravenous steroid and observation. METHODS: Included were TON patients ≥5 years of age and with trauma-treatment interval of ≤3 weeks. Follow-up visits were set at 1, 2, 3, 7, 14, 30, and at least 90 days after treatment. EPO and methylprednisolone were infused intravenously every day for three consecutive days. Primary outcome measure was change in the best corrected visual acuity (BCVA). Secondary outcomes included change in color vision and relative afferent pupillary defect (RAPD), side effects, and factors affecting the final visual improvement. RESULTS: Out of 120 patients, 100 (EPO: 69, steroid: 15, observation: 16) were finally included. All three groups showed a significant improvement of BCVA which was not significantly different between the groups (adjusted for pretreatment BCVA). Color vision was significantly improved in the EPO group. Late treatment (>3 days) (odds ratio = 2.53) and initial BCVA of NLP (odds ratio = 5.74) significantly worsened visual recovery. No side effect was observed in any group. CONCLUSION: EPO, steroid, and observation showed a significant improvement of BCVA in patients with TON. Initial BCVA of NLP and late treatment (>3 days) were significant risk factors for visual improvement.

Upper Blepharoplasty and Lateral Wound Dehiscence.

PURPOSE: To report the frequency of lateral wound dehiscence (LWD) after upper blepharoplasty (UB), a technique and its outcome to prevent LWD. MATERIALS AND METHODS: A retrospective review was performed for cases of LWD after UB presenting between 2003 and 2009, and then a prospective comparative study was performed between February 2009 and March 2013. For the comparison, subjects were divided into two groups based on intraoperative assessment of lateral wound tension (same technique and surgeon). Group 1 received 1-3 orbicularis/subcutaneous buried sutures (6-0 polyglactin) before interrupted 6-0 nylon skin closure. Group 2 underwent skin closure only. Subjects, who had re-operation, skin healing disorders, and incomplete follow-up (<6 months), were excluded. P < 0.05 was considered as statistically significant. RESULTS: There were 14 (14/678, 2%) cases with LWD with a mean age of 36.2 years in the audit (2003-2009). The prospective study included 68 subjects (68/293, 23.2%) in Group 1 and 225 in Group 2. Gender and simultaneous forehead and eyebrow procedures were similar between groups (P = 0.3 and P = 0.4 respectively). Group 1 was statistically significantly younger at mean age of 41.4 years, compared to Group 2 at 56.1 years (P = 0.000). The frequency of LWD significantly (P = 0.04) decreased to 0.3% (1/293). CONCLUSION: In the presence of wound tension on skin closure (intraoperative assessment), tension relieving buried orbicularis/subcutaneous 6-0 polyglactin suturing of the lateral UB incision could prevent LWD.

Fluorescein Dye Disappearance Test: A Reliable Test in Assessment of Success After Dacryocystorhinostomy Procedure.

PURPOSE: To evaluate the reliability indices of 5-minute fluorescein dye disappearance test (FDDT) for anatomical and subjective successes after dacryocystorhinostomy (DCR) procedure and to propose a paradigm in assessment of patients with tearing after DCR. METHODS: In a retrospective study, results of FDDT (176 eyes of 176 patients) were tested against the success rates after both external (135 eyes) and endoscopic endonasal (41 eyes) DCR and bicanalicular silicone intubation. Subjective success was defined as no symptom or intermittent excess tear (without overflow) in cold weather and anatomical success as free passage on irrigation test. Irrigation was performed at the time of tube removal in 58 eyes and at the last follow up in 118 eyes. Fluorescein dye disappearance test and subjective success were assessed either 1 week after tube removal (58 eyes) or at the last follow up (118 eyes). Grades 0 and 1 were considered as negative FDDT, and grades 2 and 3 as positive FDDT. RESULTS: Included patients who had primary acquired (94.9%) and traumatic (5.1%) nasolacrimal duct obstruction had a mean age of 49.8 years and a mean follow up of 11.7 months. There were 15 cases with previously failed DCR. The mean time of tube removal was 7.2 weeks (SD = 2.2). Final anatomical and subjective success rates were 95.5% (168/176) and 92% (162/176), respectively. Fluorescein dye disappearance test showed a sensitivity of 100% and a specificity of 86.3% for the anatomical success. They were 85.7% and 88.2% for the subjective success, accordingly. CONCLUSIONS: All anatomically failed DCR showed a positive FDDT (100% sensitivity) in this series. The proposed paradigm offers a less invasive approach to post-DCR epiphora.

Surgical treatments in inferior oblique muscle overaction.

PURPOSE: To compare the outcomes of surgical procedures in the treatment of inferior oblique muscle overaction (IOOA) as a common disorder of ocular motility. METHODS: This retrospective study was performed on patients with primary and secondary IOOA who underwent three surgical treatment procedures including disinsertion, myectomy and anterior transposition, between 2001 and 2011. Type of strabismus, ocular alignment, presence of pre-and post-operative dissociated vertical deviation (DVD), pre- and post-operative degree of IOOA were obtained using specified checklist. RESULTS: A total of 122 eyes of 74 patients with mean age of 13 ± 11.7 (range, 1-51) years were included in this study. Disinsertion was performed on 12 eyes (9.8%), myectomy in 91 eyes (74.6%) and anterior transposition in 19 (15.6%). Preoperative V-pattern and DVD existed in 67 and 17 eyes; after surgery they remained in only 10 and 8 eyes, respectively. The success rate (IOOA <+1), in disinsertion, myectomy and anterior transposition groups were 91.7%, 97.8%, and 89.5%, respectively and these measures did not change after 6 months. Overall, 53.3% (n = 65) and 38.5% (n = 47) of eyes had preoperative esotropia and exotropia. Preoperative hypertropia and hypotropia were observed in 16.4% (n = 20) and 3.3% (n = 4) of eyes, respectively. After surgery there were no cases of additional strabismus. However, residual hypertropia was seen in 9 eyes, while preoperative hypotropia increased in one patient who underwent anterior transposition surgery. Esotropia and exotropia were not observed in any surgical treatment groups postoperatively. CONCLUSION: We conclude that all these three procedures are effective for treatment of primary or secondary IOOA with minimum side-effects.

Optic atrophy in thalassemia intermedia.

A 21-year-old man with thalassemia intermedia presented with progressive decrease in vision and was found to have severe bilateral optic atrophy. Orbital and brain neuroimaging revealed massive diffuse expansion of the diploe of the craniofacial bones, narrowing of the optic canals, and expansion of hematopoietic tissue in the sellar region with compression of the optic chiasm. Although increased bone marrow is a well-known consequence of thalassemia, optic atrophy due to and such marked extramedullary expansion of hematopoietic tissue is a very rare phenomenon. Decompression of extramedullary hematopoietic tumors from thalassemia may be achieved with blood transfusions alone without the need for radiation or surgery. These findings suggest careful periodic ophthalmic examination of thalassemic patients.

Erythropoietin: a novel treatment for traumatic optic neuropathy-a pilot study.

BACKGROUND: To determine the visual outcome and safety of intravenous erythropoietin in patients with indirect traumatic optic neuropathy (TON). METHODS: In a university-based hospital, from December 2008 to March 2010, seven cases with indirect TON (EPO group) received three intravenous (IV) injections of 10,000 IU of recombinant human erythropoietin in three successive days. They were compared to eight patients with indirect TON who had received no specific treatment from December 2006 to November 2008 (observation group). The primary end point was best-corrected visual acuity (BCVA) in both groups at last follow-up and secondary measure was systemic adverse effects of medication in the EPO group. RESULTS: Mean ages of patients in the observation and EPO groups were 23.3 (SD = 10.8) and 19.7 (SD = 12.1) years, respectively. Mean follow-up in the observation and EPO groups were 5.8 (SD = 3.8) and 7.0 (SD = 5.8) months, respectively. Mean best-corrected visual acuity (BCVA) significantly (p = 0.028) improved from 1.82 logMAR (SD = 1.27) at initial visit to 0.94 logMAR (SD = 0.82) at last follow-up in the EPO group, whereas the observation group showed an insignificant (p = 0.285) improvement from 2.55 log MAR (SD = 0.62) to 2.32 logMAR (SD = 0.83). Mean final BCVA was significantly higher in the EPO group than in the observation group (p = 0.012). Two cases developed mild transient systemic hypotension during EPO injection. CONCLUSIONS: Intravenous erythropoietin may be a new effective and safe treatment for patients with indirect TON.