Malignant Hypertension and the Role of Ophthalmologists: A Review Article.

Malignant hypertension (MHT) is a sudden and severe increase in systemic blood pressure (BP) associated with advanced bilateral retinopathy. It comes under a broader term, called hypertensive emergency, where an acute rise in BP results in end-organ damage. The condition usually requires hospital admission and intensive care management. Although there are lots of sophisticated machines and laboratory tests present to diagnose various organ damage, the role of ophthalmologists will still be at the top. A record of the acute rise of BP to a defining level and simple ophthalmoscopy with high clinical suspicion can save a patient's life and preserve target organ function by timely referral. So, every ophthalmologist should be aware of this dangerous condition. In this review, we have tried to compile all the current knowledge regarding malignant hypertension that an ophthalmologist may require in day-to-day practice.

Visual outcome after endovascular intervention in Takayasu arteritis.

Takayasu arteritis is a chronic multisystem vasculitis which has been known to be associated with myriad of ophthalmological manifestations. Steroids and immunomodulators are the mainstay of medical management in early stages of disease. We report the case of a 15-year-old girl with complaints of diminution of vision in both the eyes. Her ophthalmic examination suggested a diagnosis of Takayasu retinopathy with posterior ischemic optic neuropathy in her left eye and ocular ischemic syndrome in the right eye. Digital subtraction angiography revealed a significant narrowing of major vessels originating from the arch of aorta and the left vertebral artery. She underwent left subclavian artery and left vertebral artery balloon angioplasty followed by left vertebral artery stenting. Her vision improved significantly postprocedure, suggesting that endovascular intervention in the later stages of disease is a promising treatment modality for Takayasu retinopathy.

Turbulent Flow in a Cavernous Sinus Lesion: Does It Suggest Something?

A 14-year-old boy who had been complaining of double vision for the previous month was referred for neuro-ophthalmological evaluation. He was carrying a diagnosis of a cavernous sinus haemangioma causing a right VIth nerve palsy, based on imaging elsewhere. He reported having a boil at the angle of his mouth, which was associated with left-sided facial cellulitis, two weeks before the onset of the diplopia. His blood investigations showed a leukocytosis with elevated inflammatory markers. Re-evaluation of the magnetic resonance imaging suggested a sac-like out-pouching in the intracavernous part of the right internal carotid artery with differential intensity suggestive of turbulent flow. On the basis of the clinico-radiological findings, a diagnosis of mycotic aneurysm of the cavernous sinus part of internal carotid artery was made. A high index of suspicion is required to detect this rare clinical entity, which is associated with a potentially catastrophic clinical course.

Segmented retinal analysis in pituitary adenoma with chiasmal compression: A prospective comparative study.

PURPOSE: The aim of this study was to determine the alteration in ganglion cell complex and its relationship with retinal nerve fiber layer (RNFL) thickness as measured by spectral-domain optical coherence tomography (OCT) in pituitary adenoma cases and also its correlation with visual field (VF). METHODS: This is a prospective comparative study wherein detailed neuro-ophthalmic examination including perimetry, RNFL and ganglion cell layer inner plexiform layer (GCL-IPL) thickness were measured preoperatively in the cases of pituitary adenoma with chiasmal compression with visual symptoms and field changes who were planned for neuro-surgical intervention. These parameters were repeated 1 year after the surgery. GCL-IPL, RNFL parameters were compared with controls and were correlated with VF mean deviation (MD). The diagnostic power of GCL-IPL was tested using the receiver operating characteristic (ROC) curve. Healthy age and sex-matched controls without any ocular and systemic abnormality were taken for comparison. RESULTS: Twenty-four patients qualified the inclusion criteria. A significant thinning of GCL-IPL (P = 0.002) and RNFL (P = 0.039) was noticed in the pituitary adenoma group. GCL-IPL (r = 0.780 P < 0.001) and RNFL (r = 0.669, P < 0.001) were significantly correlated with the MD. The ROC curve values of GCL-IPL were 0.859 (95% confidence interval 0.744% to 0.973) and of RNFL were 0.731 (95% confidence interval 0.585-0.877). The diagnostic ability of GCL-IPL was more as compared to the RNFL analysis, although it was statistically insignificant (P = 0.122). CONCLUSION: GCL-IPL measurements on the OCT are a sensitive tool to detect early anterior visual pathway changes in chiasmal compression for pituitary adenoma patients.

Corneal biomechanical properties in patients with kidney transplant.

PURPOSE: The purpose of the study was to evaluate the corneal biomechanical properties in patients post kidney transplant and to compare them with healthy age-matched control. MATERIALS AND METHODS: In this cross-sectional study, 68 patients with kidney transplant (study group) and 68 healthy individuals (control group) were analyzed with ocular response analyzer measurements. Only the right eye of each participant was assessed for corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOPcc), and Goldmann-correlated intraocular pressure (IOPg). RESULTS: The mean CH in the study group was 9.70 ± 1.62 mmHg which was significantly lower than the control group with the mean CH of 10.60 ± 1.49 mmHg (P = 0.001). The mean IOPcc was 18.17 ± 4.00 mmHg and 16.00 ± 3.94 mmHg in the study and control groups, respectively (P = 0.002). CRF and IOPg were not significantly different between groups. CONCLUSION: CH and IOPccare altered in kidney transplant patients.

Endovascular Management of Direct Carotid-Cavernous Fistula: Evolution of Cost Effective Sandwich Technique.

Objective There is a direct fistulous connection between the cavernous segment of the internal carotid artery and cavernous sinus in cases of direct carotid-cavernous fistula (CCF). Endovascular embolization is the mainstay of management in this condition. This study is about the evolution of endovascular treatment methods and the development of a cost-effective technique for embolization of direct CCF at a tertiary care center. Materials and Methods A retrospective analysis was performed of all the cases of direct type CCF embolized by endovascular techniques in our department from 2008 to 2018.Clinical follow-up of these patients was done at 1 week, 3 months, and 6 months. Results A total of 45 patients with 40 having a prior history of head trauma were included in this study. All cases were treated with a transarterial route except one which was treated with the transvenous approach. Detachable balloon s were used in 12 (26.67%) patients, only detachable coils in 14 cases (31.11%), both detachable balloons and coils in 9 cases (20%), and both detachable and push coils, that is, sandwich technique in 8 cases (17.78%). Parent arterial occlusion was performed in 10 patients (22.22%). There was complete resolution of chemosis and bruit in all the patients. Conclusion Endovascular treatment is the mainstay of management in direct CCF. Using more fibered thrombogenic coils in a sandwich manner decreases the cost of the treatment significantly.

Tubulointerstitial nephritis and uveitis syndrome: Our experience.

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a distinct oculorenal disorder of immune origin and accounts for some cases of unexplained recurrent uveitis. We report three cases of TINU syndrome, one of which had primarily come to us with uveitis. It is the occurrence of tubulointerstitial nephritis and uveitis in a patient in the absence of other systemic diseases that can cause either interstitial nephritis or uveitis. TINU syndrome is a diagnosis of exclusion. Our aim in reporting these cases is to highlight the association of nephritis and uveitis, which together form a distinct clinical disorder called the TINU syndrome.

Endoscopic Endonasal Optic Nerve Decompression with Durotomy: Pis Aller in the Mind of a Blind.

BACKGROUND: Progressive vision loss is a dismal sequelae of idiopathic intracranial hypertension (IIH) and secondary intracranial hypertension with cerebro-venous sinus thrombosis (CVST). The initial management revolves around weight loss, acetazolamide, steroids, and diuretics. A subset of unfortunate patients, refractory to medical therapy, need surgical intervention in the form of CSF diversion or optic nerve decompression (OND). The ONDd is an emerging alternative with encouraging early results. AIM: In our study, we share our experience of ONDd by endoscopic endonasal corridor, highlighting the technical nuances of procedure and discuss the indications of the same in the era of advanced technology. MATERIALS AND METHODS: A retrospective, noncomparative review of the medical records of all the patients of IIH (ICHD-III criteria) with severe vision loss, refractory to medical treatment, and with established objective evidence of papilledema was done. All the patients were operated in our department by endoscopic endonasal sheath fenestration. RESULTS: Nine patients (M:F 3:6) underwent endoscopic endonasal optic nerve decompression (2016-2019) approach for medically refractive IIH (n = 6) and CVST (n = 3). The mean age of population was 21.44 ± 5.14 years; 6 patients had improvement in headache and 6 had improvement in visual acuity. The visual acuity deteriorated in two patients (n = 1 IIH and n = 1 CVST with dural AVF). One patient needed postoperative lumbar drain for CSF leak, while none had meningitis. CONCLUSION: Endoscopic optic nerve sheath fenestration is minimally invasive and effective alternative with promising outcome in the management of medical refractory IIH or CVST.

Mycotic Aneurysm of Intracavernous Internal Carotid Artery Presenting as Cavernous Sinus Syndrome.

Mycotic intracranial aneurysms are infectious aneurysms accounting for 0.7%-6.5% of all intracranial aneurysms and are most commonly located in distal branches of the middle cerebral arteries, particularly at the bifurcation area. They are caused by weakening of the vessel wall secondary to infection of a segment of the artery that can be endovascular as in infective endocarditis or extravascular as in meningitis or cavernous sinus thrombophlebitis. The rare occurrence of the mycotic cavernous internal carotid artery aneurysm, its variable clinical picture and limited knowledge of its natural course is a challenge for both diagnosis and management.

Ethambutol-induced optic neuropathy in renal disorder: a clinico-electrophysiological study.

OBJECTIVE: To report the spectrum of ethambutol induced optic neuropathy in a group of renal patients with tuberculosis and the role of visual evoked response (VER) in evaluating this disorder. METHODS: Twenty-three renal patients who were started on ethambutol as a part of anti-tubercular treatment for tuberculosis in India, were divided into 4 groups based on glomerular filtration rate (GFR): group 1-chronic kidney disease (CKD) with GFR < 10 mL/min; group 2-CKD with GFR 10-30 mL/min; group 3-GFR > 30 ≤ 60 mL/min; and group 4-GFR > 60 < 90 mL/min. Detailed clinical and electrophysiological (VER) examinations were carried out in all patients before starting the treatment with ethambutol and at a 3-month interval. Twenty healthy subjects formed the control group. RESULTS: Ethambutol optic neuropathy developed in 6 (26%) patients with higher incidence (40%) in end-stage renal disease (group 1: CKD on dialysis). Vision was recovered in 4 cases on stoppage of ethambutol, whereas 2 patients (group 1: CKD on dialysis) developed bilateral severe irreversible visual loss and also had associated hepatic dysfunction. Three patients of ethambutol optic neuropathy showed increased latency in VER recording prior to visual loss and 1 patient showed demyelinating lesions in both optic nerves and optic radiation. CONCLUSIONS: Ethambutol should be avoided in renal disorder patients in view of the high incidence of toxic optic neuropathy. Follow-up VER can detect sub-clinical ethambutol toxicity and would be useful for early diagnosis of optic neuropathy.

Glycemic Control and Long-term Complications in Pediatric Onset Type 1 Diabetes Mellitus: A Single-center Experience from Northern India.

OBJECTIVE: To study glycemic control, mortality and long-term complications in children with type 1 diabetes (T1D). DESIGN: Cross-sectional study. SETTING: Referral centre at a government teaching hospital. PARTICIPANTS: Patients with T1D with age £18 years at onset. METHODS: We retrospectively collected demographic data from computer records from 1991 to 2015. Prospective study for outcomes was conducted between 2012 and 2016. MAIN OUTCOME MEASURES: Mortality rate, glycosylated hemoglobin (HbA1c), and microvascular complication rate. RESULTS: The proportion of T1D patients (n=512) <5 years of age at onset was 18.6% between 1995 and 2004, and 24.2% in 2005-2014 (P<0.001). Twenty eight patients had died out of 334 whose living status was known (mortality 1.1 per 100 patient-years over 2549 patient-years follow up). Median (range) HbA1c (n=257) was 8.3% (5.1-15.0%). At least one episode of severe hypoglycemia (coma/seizure/inability to assist self) had occurred in 22.8% patients over two years. Hypertension was present in 11.7% patients. Microvascular complications screen in 164 eligible patients [median (range) age 20 (8-45) y and duration of diabetes 9.1 (5-30) y] showed diabetic nephropathy in 3.0%, proliferative retinopathy in 3.6% and LDL cholesterol >100 mg/dL in 34% patients. CONCLUSIONS: The mortality rate and prevalence of hypertension were high, given the short duration of diabetes of the patients. The proportion of patients with age ≤5 years at onset of diabetes has increased at our center.

Limbal schwannoma: Clinicopathological study of a case with review of literature.

Schwannomas involving the perilimbal conjunctiva is an extremely rare clinical entity and has been reported scantily in literature. In this case, a 27-year-old healthy female presented with a pinkish smooth globular mass involving the limbus in the superonasal quadrant of the left eye. The mass was completely excised and histopathology revealed an encapsulated tumor, with cells displaying elongated nuclei, bland chromatin, and few Verocay bodies with palisaded nuclei, suggestive of schwannoma. Immunohistochemistry showed strong S100 positivity. This case thus highlights schwannoma as a differential diagnosis of limbal masses.

Papilledema revisiting after sinus angioplasty of chronic cerebral venous sinus thrombosis.

This case series aimed to review the significance of revisiting papilledema after successful cerebral venous sinus thrombosis (CVST) management with sinus angioplasty. Four patients presented with blurring and transient obscuration of vision with papilledema, headache, tinnitus, and vomiting. On magnetic resonance venography and digital subtraction angiography, chronic transverse sinus thrombosis was diagnosed for which patients underwent endovascular intervention (stenting). After the resolution of CVST, patients developed the recurrence of symptoms which on digital subtraction angiography revealed dural arteriovenous malformation (DAVM). DAVM and papilledema resolved with endovascular embolization. This case series highlights a need of constant monitoring of CVST cases after the endovascular intervention.

Encephalocele presenting as lower lid swelling: A rare case report.

Encephalocele is a rare congenital abnormality characterized by abnormal protrusion of brain and meninges through an opening in the skull. We report an 8-year-old girl who presented with a swelling in the right lower lid for the last 6 years. In her infancy, she had undergone surgery for a very small swelling located in the right nasolacrimal area. On further clinicoradiological evaluation, anterior encephalocele was diagnosed. This case highlights the uncommon site of anterior encephalocele; misdiagnosis and mismanagement of which could result in dreaded complications such as meningitis and cerebrospinal fluid leaking fistula formation.

A case report of rim enhancing lesion at the orbital apex.

We report a case of partial third nerve palsy resulting from a cystic lesion located at the orbital apex. Imaging was suggestive of cystic schwanomma but histopathology of the lesion confirmed epidermoid cyst, which is a rare tumour of the orbit.

Inferior petrosal sinus route microcatheterization study and embolization for primary orbital varix.

PURPOSE: Primary orbital varix is a rare lesion but difficult to treat. Our main aim was to demonstrate the varices and their central venous communication and to explore the feasibility of embolization of these lesions. METHOD: In four patients with clinical suspicion of varix, in whom MRI showed retro-global vascular channels, microcatheter digital subtraction angiography (DSA) of the varices was performed using femoral venous access. Embolization was carried out in two patients. RESULTS: In all four patients orbital varices could be accessed with a microcatheter through inferior petrosal sinus and ophthalmic vein (superior or inferior) route. Microcatheter angiography showed opacification of varices and demonstrated their central venous communication. Two patients were treated with coil embolization. Complete resolution of symptoms was seen in one patient and partial relief in the other. CONCLUSION: The study presents microcatheterization of orbital varices via the inferior petrosal sinus-cavernous sinus-ophthalmic vein route with injections into distal ophthalmic veins for demonstration of these variceal sacs and their central venous connection. Coiling to disconnect the venous communication should be the primary goal of embolization.