Non-Arteritic Ischemic Optic Neuropathy Following COVID-19 Vaccination in Korea: A Case Series

Background@#To report the clinical manifestations of non-arteritic anterior ischemic optic neuropathy (NAION) cases after coronavirus disease 2019 (COVID-19) vaccination in Korea. @*Methods@#This multicenter retrospective study included patients diagnosed with NAION within 42 days of COVID-19 vaccination. We collected data on vaccinations, demographic features, presence of vascular risk factors, ocular findings, and visual outcomes of patients with NAION. @*Results@#The study included 16 eyes of 14 patients (6 men, 8 women) with a mean age of 63.5 ± 9.1 (range, 43–77) years. The most common underlying disease was hypertension, accounting for 28.6% of patients with NAION. Seven patients (50.0%) had no vascular risk factors for NAION. The mean time from vaccination to onset was 13.8 ± 14.2 (range, 1–41) days. All 16 eyes had disc swelling at initial presentation, and 3 of them (18.8%) had peripapillary intraretinal and/or subretinal fluid with severe disc swelling. Peripapillary hemorrhage was found in 50% of the patients, and one (6.3%) patient had peripapillary cotton-wool spots. In eight fellow eyes for which we were able to review the fundus photographs, the horizontal cup/ disc ratio was less than 0.25 in four eyes (50.0%). The mean visual acuity was logMAR 0.6 ± 0.7 at the initial presentation and logMAR 0.7 ± 0.8 at the final visit. @*Conclusion@#Only 64% of patients with NAION after COVID-19 vaccination have known vascular and ocular risk factors relevant to ischemic optic neuropathy. This suggests that COVID-19 vaccination may increase the risk of NAION. However, overall clinical features and visual outcomes of the NAION patients after COVID-19 vaccination were similar to those of typical NAION.

The Comparison of Long-term Surgical Results for Sensory Exotropia and Comitant Exotropia

Purpose@#To compare the long-term surgical outcomes of patients with sensory and concomitant exotropia and to define the factors associated with successful surgical outcomes in those with sensory exotropia. @*Methods@#The medical records of patients with sensory exotropia who underwent operations and were followed-up for at least 2 years were retrospectively reviewed. We enrolled patients exhibiting only best-corrected visual acuities ≤ 20/100 of the operated eyes. Surgical success was defined as a final distance deviation < 10 prism diopters (PD) with the eye in the primary position. Twenty-eight patients operated upon to treat sensory exotropia and 28 who underwent operations to treat concomitant exotropia who did not differ in terms of the gaze deviation angle were matched in terms of age, sex, and the preoperative distance and near distributions; their surgical outcomes were compared. Factors affecting such outcomes were identified using a multivariate Cox’s proportional hazards model. @*Results@#The mean follow-up times were 91.7 ± 45.8 months in the sensory and 42.6 ± 27.7 months in the concomitant exotropia groups. The cumulative probabilities of surgical success 2 years after surgery were 74.5% in the sensory and 74.4% in the intermittent exotropia groups, thus not significantly different (p = 0.988). The Cox’s proportional hazard model showed that a greater difference between the preoperative distant and near deviations was associated with recurrence (p = 0.091). @*Conclusions@#The long-term surgical outcomes of patients with sensory and concomitant exotropia were comparable. A high-level near-distance disparity increased the risk of recurrence.

Clinical Characteristics of Patients with Intermittent Exotropia According to the Response to Short-term Prism Adaptation Test

Purpose@#To evaluate the prevalence of the prism adaptation response in patients with intermittent exotropia (IXT) using the short-term prism adaptation test (PAT) and to assess factors associated with prism adaptation response in IXT patients. @*Methods@#A case-controlled retrospective analysis was performed on 113 patients with IXT without prior surgical treatment.Age, sex, visual acuity, refraction, stereoacuity, control scale, type of exotropia, history of occlusion, and presence of accom-panying visual symptoms were recorded. Prism alternate cover test (PACT) was performed with fixation targets at 6 m and 1/3 m. All patients underwent short-term PAT wearing prism glasses that offset the exodeviation previously measured by PACT. After 30 minutes, angle deviation was measured, and patients were classified into either an increase group, which had an increase in deviation ≥5 prism diopters after short-term PAT, or a no-change group. Analysis was performed to investigate the clinical factors influencing the increase in exodeviation after short-term PAT. @*Results@#Fifty patients (44.2%) showed an increase ≥5 prism diopters during distance or near fixation after short-term PAT compared to the previous PACT: 12 patients (10.6%) showed an increment at distance fixation, and 45 patients (39.8%) showed an increase at near fixation. At distance fixation, the increase-group had a significantly smaller maximum angle measured by PACT. At near distance, age at PAT, maximum distance angle, minimum distance angle, maximum near angle, minimum near angle, angle fluctuation at near, and IXT type showed significant associations with positive short-term PAT response. In the multivariate analysis, older age and smaller maximum near angle were significantly associated with positive short-term PAT response at near fixation. @*Conclusions@#Short-term PAT could be helpful in older IXT patients with a small maximum angle of deviation at near fixation to mitigate the vergence aftereffect and show the maximum angle of deviation.

Clinical Features of Duane Retraction Syndrome: A New Classification

Purpose@#We sought to provide a new classification system for Duane retraction syndrome (DRS) according to type and angle of strabismus during primary gaze and to analyze the clinical features of each DRS type. @*Methods@#The medical records of 65 DRS patients who visited the department of pediatric ophthalmology at Seoul National University Children's Hospital between 2010 and 2017 were retrospectively analyzed. Patients whose angle of exotropia at primary gaze exceeded 3 prism diopters (PDs) were classified as “Exo-Duane,” those whose angle of strabismus at primary gaze did not exceed 3 PDs were classified as “Ortho-Duane,” and those whose angle of esotropia at primary gaze exceeded 3 PDs were classified as “Eso-Duane.” @*Results@#Among 65 DRS patients, Ortho-Duane was the most common (53.8%) type, followed by Eso-Duane (33.8%) and Exo-Duane (12.3%). The mean age at diagnosis was significantly higher in the Exo-Duane group than the Ortho-Duane or Eso-Duane group (p = 0.003 and p < 0.001, respectively). A predominance of left eye involvement was observed in the Ortho-Duane (62.9%) and Eso-Duane (90.9%) groups. The frequencies of upshoot, downshoot, fissure narrowing, and globe retraction were not significantly different among the subgroups. Head-turn was more frequent in Eso-Duane patients than in Exo-Duane or Ortho-Duane patients (p = 0.001 and p < 0.001, respectively). Myopia accounted for the most common refractive error among Exo-Duane patients (71.4%), while hyperopia was found more often in both Ortho-Duane (64.7%) and Eso-Duane (85.0%) patients. The majority of patients showed gross stereoacuity (93.1%), and a large proportion had good stereoacuity (Exo-Duane 60.0%, Ortho-Duane 81.3%, Eso-Duane 87.5%). @*Conclusions@#Our newly proposed classification of DRS according to type and angle of strabismus at primary gaze was practically useful and showed potential for use as an objective guideline in the clinical setting.

Fusion and Suppression in Patients with Unilateral Idiopathic Epiretinal Membrane

Purpose@#To investigate the presence of fusion and suppression in patients with unilateral idiopathic epiretinal membrane (ERM). @*Methods@#Thirty-five patients with unilateral idiopathic ERM received a full ophthalmologic exam including best corrected visual acuity (BCVA). Patients were divided into suppression and non-suppression groups according to the results of 4 Prism Dioptre Base-out Test and Worth 4 Dot test. Age, symptoms, duration of ERM, BCVA, average M-chart score, results of Titmus test and optical coherence tomography parameters were compared between the two groups. Factors associated with suppression were also evaluated. @*Results@#Eleven (31%) of 35 patients had suppression. The BCVA (0.18 ± 0.12 vs. 0.29 ± 0.12 p = 0.019) and stereopsis (2.25 ± 0.27 vs. 2.66 ± 0.62, p = 0.009) were significantly lower in the suppression group than the non-suppression group. Median age was older (63.21 ± 9.64 vs. 70.82 ± 6.80, p = 0.013) and duration of ERM (7.86 ± 3.69 vs. 18.54 ± 14.92 months, p = 0.004) was longer in the suppression group than the non-suppression group. Average M-chart score was higher in the suppression group. However, not all the patients suffered from metamorphopsia, including the suppression group when using binocular vision. @*Conclusions@#Unilateral suppression is common in unilateral idiopathic ERM and influences the patient’s stereopsis. Suppression was significantly correlated with age, duration of symptoms and metamorphopsia.

Factors Associated with the Prognosis after Operation in Children with Recurrent Intermittent Exotropia

BACKGROUND: To describe factors affecting the prognosis after operation for recurrent intermittent exotropia (X[T]) in children. METHODS: Clinical records of 50 patients who underwent operation for recurrent X(T) by a single surgeon were reviewed. The age at diagnosis of X(T), and first and second operations, deviation angle at distance and near, surgical method, concurrent vertical strabismus, stereoacuity, and Worth's Four Dot (W4D) examination before reoperation were analyzed, along with the postoperative deviation angle. A successful surgical outcome was defined as orthophoria, esodeviation ≤ 5 prism diopters, or exodeviation ≤ 10 prism diopters at distance. RESULTS: Among the 50 recurrent exotropes who underwent surgery and were followed up for more than 1 year postoperatively, 13 showed recurrent exotropia and 1 showed consecutive esotropia. The mean age at reoperation was 8.49 ± 2.19 years, and the mean duration of postoperative follow-up was 27.78 ± 12.02 months. Good near fusion before reoperation was a significant factor in the success of surgery (P = 0.006). Smaller postoperative deviation angle measured immediately and 2 months after surgery were related to smaller final deviation angle (P = 0.027 and P = 0.022, respectively). CONCLUSION: Peripheral suppression lowers the success rate of operation for recurrent X(T) in children. Overcorrection rather than orthotropia should be the target of immediate postoperative deviation angle. Peripheral suppression status and immediate and 2-month postoperative deviation angle may be important clues for predicting the final result of operation for recurrent X(T).

Long-term Lens Complications Following Removal of Persistent Pupillary Membrane

PURPOSE: We evaluated the long-term surgical outcome and lens complications in children with persistent pupillary membrane following removal using vitreous scissors. METHODS: Patients diagnosed with persistent pupillary membrane who received surgical treatment from 1987 to 2012 were retrospectively reviewed. The removal was performed using vitreous scissors after instillation of miotics. The minimum follow-up period after surgery was four years. Factors of age, sex, visual acuity, refractive errors, and complications during or after surgery were evaluated. RESULTS: A total of 32 eyes of 26 patients were included. The mean age at the initial visit was 22.6 ± 34.7 (range, 0.9 to 141.2) months, and the mean age at surgery was 43.7 ± 36.0 (range, 1.0 to 142.5) months. There were no intraoperative complications using vitreous scissors, and all lesions were completely removed. After a mean follow-up period of 6.5 ± 3.3 (range, 4.0 to 14.8) years, the best corrected visual acuity at the final visit was 0.6 ± 0.9 logarithm of the minimum angle of resolution, and two eyes (6.3%) presented with lens opacity during follow-up. CONCLUSIONS: In children with persistent pupillary membrane, there were no intraoperative complications, and only two patients presented with lens change during the long-term postoperative follow-up period. Surgical removal should be considered a safe and effective treatment for patients with visually significant persistent pupillary membrane.

Stereopsis before and after Inferior Oblique Weakening Surgery

PURPOSE: To analyze stereopsis change before and after inferior oblique weakening surgery. METHODS: We retrospectively reviewed the medical records of 31 patients who had undergone inferior oblique weakening surgery. The factors analyzed included sex, age at surgery, preoperative and postoperative visual acuity (VA), time from first detection to surgery, degree of inferior oblique overaction (IOOA), primary/secondary IOOA, exotropia/hypertropia, bilaterality, and type of surgery. RESULTS: Eighteen patients with a mean age 7.3 ± 3.1 years exhibited stereopsis of 60 arc seconds or better before surgery and 17 had stereopsis better than 60 arc seconds after surgery. Postoperatively, stereopsis improved in 13 patients and deteriorated in 9. Better preoperative VA and the absence of superior oblique underaction were associated with better preoperative stereopsis. Better preoperative VA, postoperative VA, and the presence of head tilt were associated with better postoperative stereopsis. Unilateral inferior oblique weakening surgery and accompanying hypertropia were associated with improved stereopsis, while the absence of hypertropia was associated with deteriorated stereopsis. CONCLUSIONS: In this retrospective study, 58.1% of patients tended to have bifoveal fixation. When a vertical deviation is present in the primary position due to unilateral IOOA, IO weakening surgery can be expected to improve binocular function.

Fluorescein Angiographic Abnormalities in the Contralateral Eye with Normal Fundus in Children with Unilateral Coats' Disease

PURPOSE: We report the detection of peripheral retinal vascular abnormalities in the fellow eye with normal fundus in children with unilateral Coats' disease. METHODS: The clinical records of patients diagnosed with Coats' disease were retrospectively reviewed. We recorded the subjects' characteristics and obtained fundus photography and fluorescein angiography (FA) images. The main outcome measure was peripheral vascular abnormalities in the contralateral eye with normal fundus in children with unilateral Coats' disease, observed with FA. RESULTS: Out of 47 patients with Coats' disease, two (4.3%) were diagnosed with clinically bilateral Coats' disease. Of the 45 patients with presumed unilateral Coats' disease, four (8.9%) had bilateral abnormal peripheral vasculature in FA. The mean age of these four patients was 6.4 ± 5.4 years (range, 1 to 14 years), and three patients were male (75%). All four had peripheral retinal nonperfusion, and two (50%) received laser photocoagulation due to peripheral leakage with telangiectatic vessels. CONCLUSIONS: Coats' disease may more often be a bilateral disease with asymmetry than previously thought. Patients with Coats' disease should undergo careful examination of the fellow eye with FA in order to detect and treat vascular abnormalities that are not visible clinically.

Intravenous Neostigmine Test for Diagnosis of Ocular Myasthenia Gravis

PURPOSE: In the present study, we evaluated the validity of intravenous neostigmine administration combined with alternate prism cover test (APCT) measurement as a confirmatory diagnostic method for confusing cases of myasthenia gravis with ocular involvement. METHODS: Neostigmine was administered intravenously in 26 suspicious myasthenic diplopia patients under electrocardiographic monitoring. Distance deviation at primary position was evaluated with APCT at 5, 10, 15, 20, and 30 minutes after intravenous injection of neostigmine. Margin reflex distance was also evaluated at each time point. RESULTS: Seven of 26 patients were diagnosed as myasthenic diplopia based on a positive neostigmine test. Among these patients, 6 had strabismus at the primary position and 5 patients had ptosis. In patients who showed positive results, all 6 patients showed improvement of strabismus. However, ptosis was not improved in 1 patient. The improvement of strabismus and ptosis reached a peak at 10 to 15 minutes after neostigmine administration. CONCLUSIONS: Intravenous neostigmine administration combined with APCT is a rapid, objective and safe method in hard-to-diagnose cases of myasthenia gravis with ocular involvement. When performing the neostigmine test for myasthenia gravis with ocular involvement, not only the lid position but also strabismus should be evaluated quantitatively to avoid a false negative results.

Ophthalmologic Features of Lennox-Gastaut Syndrome

PURPOSE: To describe the characteristics and frequency of ophthalmologic findings in patients with Lennox-Gastaut syndrome (LGS). METHODS: The medical records of patients diagnosed with LGS at Seoul National University Children's Hospital from January 2004 to August 2014 were retrospectively reviewed. The records of 34 patients (mean age ± standard deviation, 2.66 ± 3.51 years; male, 58.8%) were reviewed. The primary measure was the incidence of ophthalmologic manifestations. RESULTS: Of the 34 patients, 88.2% had at least one ocular abnormality. Refractive error (52.9%) was the most frequently observed ophthalmologic manifestation in patients with LGS, followed by strabismus (32.4%), cortical visual impairment (23.5%), and retinopathy of prematurity (8.8%). Among these cases, seven patients had exotropia and three had esotropia. CONCLUSIONS: LGS is a childhood-onset epileptic encephalopathy with variable ophthalmologic manifestations, the most frequent being refractive errors. Patients with suspected LGS should be examined regularly because ophthalmological features can change during their disease course.

The Incidence Rate of Lymphadenitis after Bacille Calmette-Guérin (BCG) Vaccination

PURPOSE: Bacille Calmette-Guérin (BCG) lymphadenitis is a relatively frequent local adverse reactions after BCG vaccination. Its incidence rate is usually <1%. However, this rate may be different according to BCG strain, vaccination method or skill, etc. In the Republic of Korea, two BCG strains are used: intradermal Danish-1331 or percutaneous Tokyo-172. We surveyed the incidence rates of BCG lymphadenitis. METHODS: This survey was performed in total 25 centers (5 general hospitals, 20 private pediatric clinics). Immunized type of BCG strain in study subjects was verified by directly observing the scar. The occurrence of BCG lymphadenitis was asked to their parent. In cases of BCG lymphadenitis, location, diameter size, progression of suppuration, and treatment method were investigated, as well. RESULTS: The total number of study subjects was 3,342. Among these, the subjects suitable for enrollment criteria (total 3,222; Tokyo strain 2,501, Danish strain 721) were analyzed. BCG lymphadenitis regardless of its size developed in each five of subjects per strains, therefore, its incidence rate was 0.20% in Tokyo and 0.69% in Danish strain, respectively (P=0.086). However, when applying the WHO criteria - the development of lymph node swelling with diameter 1.5 cm or more, the incidence rate of BCG lymphadenitis was 0.16% (4 cases) in Tokyo and 0.42% (3 cases) in Danish strain, respectively. CONCLUSIONS: The incidence rate of lymphadenitis in two BCG types, percutaneous Tokyo and intradermal Danish strain BCG, is 0.20% and 0.69%, respectively. Both rates are acceptable.

Practice Preferences on Dabigatran and Rivaroxaban for Stroke Prevention in Patients with Non-valvular Atrial Fibrillation

OBJECTIVE: Prescription rate of dabigatran and rivaroxaban, which are the direct oral anticoagulants (DOAC), has increased. We have analyzed the prescription trend and medication use of dabigatran and rivaroxaban in patients with non-valvular atrial fibrillation (NVAF). METHODS: It was retrospectively studied from September 2012 to April 2014 using the electronic medical records and the progress notes. Patients with NVAF (n=424) were evaluated on the medication use, prescribing preferences, adverse drug reactions (ADRs) and the availability of prescription reimbursement of dabigatran (n=210) and rivaroxaban (n=214). RESULTS: Dabigatran was prescribed higher than rivaroxaban (23.3% versus 7.5%, p<0.001) in the neurology department, but rivaroxaban was prescribed higher compared to dabigatran in the cardiology department (87.4% versus 74.3%, p<0.001). Dabigatran was prescribed more than rivaroxaban in high risk patients with CHADS2 score ≥ 3 (44.3% versus 31.3%, p=0.006). Dabigatran patients seemed to have more ADRs than patients with rivaroxaban (25.2% versus 11.2%, p<0.001), but no serious thrombotic events and bleeding were found. Only 35.6% (n=151) were eligible for prescription reimbursement by the National Health Insurance (NHI). Bridging therapy (86, 31.5%) and direct-current cardioversion (57, 20.2%) were main reasons of ineligibility for reimbursement. CONCLUSION: Prescription preferences were present in choosing either dabigatran or rivaroxaban for patients with NVAF. Inpatient protocols and procedures considering patient-factors in NVAF need to be developed.

Neurocognitive Outcome in Survivors of Childhood Acute Lymphoblastic Leukemia: Experience at a Tertiary Care Hospital in Korea

This study was conducted to investigate long-term neurocognitive outcomes and to determine associated risk factors in a cohort of Korean survivors of childhood acute lymphoblastic leukemia (ALL). Forty-two survivors of ALL were compared with 42 healthy controls on measures of a neurocognitive test battery. We analysed potential risk factors (cranial irradiation, sex, age at diagnosis, elapsed time from diagnosis, and ALL risk group) on neurocognitive outcomes. ALL patients had lower, but non-significant full-scale intelligence quotient (FSIQ, 107.2 +/- 12.2 vs. 111.7 +/- 10.2), verbal intelligence quotient (VIQ, 107.7 +/- 13.6 vs. 112.2 +/- 11.4), and performance intelligence quotient (PIQ, 106.3 +/- 14.2 vs. 110.1 +/- 10.7) scores than healthy controls. However, patients treated with cranial irradiation performed significantly lower on FSIQ (102.2 +/- 8.1), VIQ (103.3 +/- 11.7), and PIQ (101.4 +/- 13.2) compared to non-irradiated patients and healthy controls. ALL patients also had poor attention, concentration, and executive functions. Among ALL survivors, cranial irradiation was a risk factor for poor FSIQ, being male was a risk factor for poor PIQ, and younger age was a risk factor for poor attention. Therefore, the delayed cognitive effects of ALL treatment and its impact on quality of life require continuing monitoring and management.

Short-Term Clinical Results of Hyperopic LASEK in Korean Patients

PURPOSE: To evaluate short-term clinical outcomes following hyperopic laser-assisted subepithelial keratomileusis (LASEK) in Korean patients. METHODS: This retrospective study included 18 eyes of 10 patients who underwent hyperopic LASEK between May 2005 and March 2013 in Seoul National University Hospital. Visual acuity and spherical equivalent were evaluated preoperatively and at 1 and 3 months postoperatively. High order aberrations and contrast sensitivity were measured before and 3 months after the operation. Alternative prism cover test (APCT) was performed both preoperatively with correction and postoperatively without correction. RESULTS: The mean age of patients was 32 +/- 11 years and the mean spherical equivalent refractive error was -2.95 +/- 1.24 diopters (D). Uncorrected visual acuities were log MAR +0.17 +/- 0.15 and log MAR +0.14 +/- 0.15 at postoperative 1 month and 3 months, respectively and showed no significant difference in best corrected visual acuity (+0.25 +/- 0.30). Spherical equivalent was -0.22 +/- 1.22 D at 1 month and 0.38 +/- 0.91 D at 3 months postoperatively. In 6 patients who had esotropia before the operation, APCT was 7.83 +/- 3.60 prism diopters (PD) esotropia at distance with correction preoperatively and 4.67 +/- 5.65 PD at distance without correction postoperatively. Three patients (16.7%) showed delayed wound healing with 1 (5.56 %) having persistent corneal opacity without significant visual loss. CONCLUSIONS: The effect of LASEK may be comparable for correcting hyperopia and esotropia when compared with the effect of LASIK in previous reports; however, delayed wound healing may be a concern.

Detection of Rotavirus Genotypes in Korea 5 Years after the Introduction of Rotavirus Vaccines

Rotavirus (RV) is one of the most important viral etiologic agents of acute gastroenteritis (AGE) in children. Although effective RV vaccines (RVVs) are now used worldwide, novel genotypes and outbreaks resulting from rare genotype combinations have emerged. This study documented RV genotypes in a Korean population of children with AGE 5 yr after the introduction of RVV and assessed potential genotype differences based on vaccination status or vaccine type. Children less than 5-yr-old diagnosed with AGE between October 2012 and September 2013 admitted to 9 medical institutions from 8 provinces in Korea were prospectively enrolled. Stool samples were tested for RV by enzyme immunoassay and genotyped by multiplex reverse-transcription polymerase chain reaction. In 346 patients, 114 (32.9%) were RV-positive. Among them, 87 (76.3%) patients were infected with RV alone. Eighty-six of 114 RV-positive stool samples were successfully genotyped, and their combinations of genotypes were G1P[8] (36, 41.9%), G2P[4] (12, 14.0%), and G3P[8] (6, 7.0%). RV was detected in 27.8% of patients in the vaccinated group and 39.8% in the unvaccinated group (P=0.035). Vaccination history was available for 67 of 86 cases with successfully genotyped RV-positive stool samples; RotaTeq (20, 29.9%), Rotarix (7, 10.4%), unvaccinated (40, 59.7%). The incidence of RV AGE is lower in the RV-vaccinated group compared to the unvaccinated group with no evidence of substitution with unusual genotype combinations.

Clinical Features of Patients Complaining of Visual Symptoms and Diagnosed with Migraine

PURPOSE: To describe the characteristics of patients who visited Korean ophthalmology clinics complaining of visual symptoms and were diagnosed with migraine. METHODS: A retrospective study was performed by evaluating the patterns of visual symptoms, timing of headaches, and results of ophthalmologic examinations in 31 migraine patients who were recruited from a neuro-ophthalmology clinic. RESULTS: The patients consisted of 9 men and 22 women, with a mean age of 38.1 years (range, 12-71). The average age of symptom onset was 35.7 years (range, 12-64 years). The most common three visual symptoms were blurred vision (35.5%), blind spots (22.6%), and flashes of bright lights (22.6%). Visual symptoms disappeared within 5 minutes in 16 patients (51.6%) and 13 patients (41.9%) experienced visual symptoms before the onset of a headache. Brain magnetic resonance imaging findings in 14 cases revealed normal results and the remaining three patients showed minimal small vessel disease. Except for one patient who had exotropia, there was no other specific abnormality observed upon ophthalmologic examinations. CONCLUSIONS: Most of the migraine patients who first visited an ophthalmology clinic with visual symptoms had no definite ocular abnormalities. Thus, ophthalmologists must be aware that migraines could first present with various visual symptoms in order to make an early diagnosis of migraine.

A Case of Epidural Abscess Complicated from Acute Mastoiditis Caused by Streptococcus pneumoniae / 소아감염

Acute otitis media (AOM) is one of the most common childhood infectious diseases. Despite antibiotic treatment for AOM, AOM and its complication still continue to develop. Acute mastoiditis is a serious complication of AOM and epidural abscess constitutes the commonest of all intracranial complication of AOM. Neurological complication of acute mastoiditis are rare but can be life threatening. Their presentation may be masked by the use of antibiotics. We report the rare case of acute otitis media progressing to acute mastoiditis, epidural abscess formation and lateral sinus thrombophlebitis caused by Streptococcus pneumoniae in a child. She was admitted with acute otitis media with fever. Despite proper antibiotics, acute mastodititis and epidural abscess were developed, and after surgical drainage and antibiotics therapy she was recovered without sequalae.

A Case of Acquired Ocular Motor Apraxia Accompanied with Esotropia due to Multiple Brain Infarcts

PURPOSE: We present a case of acquired ocular motor apraxia accompanied with esotropia due to multiple brain infarcts. CASE SUMMARY: A 59-year-old male was referred for diplopia that started 9 years before presentation and continued after multiple brain infracts including right cerebellum, right occipital lobe, medulla oblongata and inferior pons. At initial examination, his best corrected visual acuity was 20/22 in the right eye and 20/25 in the left eye and he had 12 prism diopter (PD) esotropia at distance and near in primary gaze with correction. His duction and version were normal; however, his horizontal saccade was notably decreased. Two years and 8 months after presentation, the patient had 15 PD esotropia at distance and near with correction. His duction and version were normal and vertical saccadic eye movements were observed. However, horizontal saccade disappeared. The patient also exhibited a distinguishing head thrust following the order for saccadic eye movement. He was diagnosed with an acquired ocular motor apraxia accompanied with esotropia. During the follow-up period the patient underwent bilateral recession of the medial rectus. The usual diplopia and his horizontal esodeviation improved to 3 PD of esotropia at distance. CONCLUSIONS: Multiple brain infarcts can result in an acquired ocular motor apraxia accompanied with esotropia. Varying types of ocular motor disorders should be considered in patients with a previous medical history of brain infarct.

Bilateral Optic Neuropathy in Middle-Aged Woman Associated with Charcot Marie Tooth Disease Type 2A: A Case Report

PURPOSE: Charcot-Marie-Tooth disease type 2A (CMT2A) is caused by mutations in the mitofusin 2 (MFN2) genes associated with variable central nervous system (CNS) involvement. The authors report a case of a middle-aged woman with genetically confirmed CMT type 2 (CMT2), combined with delayed-onset bilateral optic neuropathy. CASE SUMMARY: A 47-year-old woman presented with complaints of subacute decrease of visual acuity in both eyes. Her corrected visual acuity was 20/200 in the right eye and 20/320 in the left eye. Fundus photographs revealed bilateral disc pallor and diffuse retinal nerve fiber layer defects. No papillomacular bundle defect was observed. Goldmann perimetry showed central scotoma in both eyes. She had suffered from muscle wasting of the legs and foot deformities such as high arches and hammer toes since childhood and required a wheelchair for ambulation. A series of CMT gene mutation tests revealed an MFN2 gene mutation, c.617C>T (p.Thr206Ile), and the patient was diagnosed with CMT2A. CONCLUSIONS: Charcot-Marie-Tooth disease is a common inherited neuromuscular disorder and CMT2A, an axonal CMT neuropathy, is associated with bilateral optic neuropathy. Therefore, suspecting CMT and testing for gene mutations as part of the work-up in patients with subacute bilateral optic neuropathy associated with peripheral neuropathy is critical.