Disc Oedema in A Patient with Chronic Kidney Disease: A Diagnostic Conundrum.

A 47-year-old woman who presented with headache and blurring of vision was referred to us due to suspicion of idiopathic intracranial hypertension or cerebral sinus venous thrombosis. She had chronic kidney disease and underwent dialysis through multiple ports including the right internal jugular vein (IJV). Her examination showed a best corrected visual acuity of 20/20 in each eye, normal anterior segments in each eye but bilateral papilloedema. Magnetic resonance imaging and venography (MRV) of her brain with contrast showed signs of raised intracranial pressure and a hypoplastic left transverse sinus. An MRV of her neck showed a thrombosis of the right IJV. Her symptoms and papilloedema resolved with carbonic anhydrase inhibitors and anticoagulants. This case highlights an uncommon presentation of papilloedema secondary to raised intracranial pressure from IJV thrombosis and its pathogenesis.

Horizontal rectus muscle transplantation for recurrent and residual strabismus.

Purpose: To report outcomes of muscle transplantation for recurrent/residual strabismus. Retrospective, multicentric, observational study.  Methods: We retrospectively reviewed records of all patients operated at three institutes who underwent transplantation of the resected muscle for re-operations for residual/recurrent strabismus from January 1, 2018, to December 31, 2019. Data were collected regarding age, gender, visual acuity, type of strabismus, fixation preference, associated amblyopia, the surgical procedure performed, preoperative and postoperative primary position deviation, limitation of ductions, associated intra-operative and post-operative complications. Surgical success was defined as heterotropia less than or equal to 8 PD, and cosmetic success was defined as manifest deviation ≤12 PD (at 6 weeks follow up). Results: During this period, we identified records of seven patients (5 men: 2 women, median age: 24 years) who underwent muscle transplantation for residual/recurrent strabismus. Six patients underwent extraocular muscle surgery for residual/recurrent exotropia (XT) and one for residual esotropia (ET). In all the patients, median pre-operative primary position deviation reduced from 40 prism diopters (PD) (range: 30 to 55 PD) to 8 PD (range: 6 PD ET to 10 PD XT) at six-weeks follow-up. Four patients had residual exotropia (10-16PD), two had orthotropia and one patient had small-angle esotropia (6PD) at the last follow-up. Excluding two patients who underwent supramaximal re-recession of lateral rectus (≥11 mm from insertion) and re-resection of medial rectus, 3/5 (60%) patients achieved surgical success, and all (100%) achieved cosmetic success at six-weeks-follow-up. There was mild (up to -1) limitation of duction in all patients except one patient (-2 limitation of abduction) who underwent re-recession of lateral rectus to 11 mm from insertion along with medial rectus re-resection and muscle transplant procedure. No intra-operative or post-operative complications were encountered. No patient reported postoperative diplopia. Conclusions: This study describes the feasibility and successful use of muscle transplantation procedure to correct residual/recurrent strabismus, with or without re-recession, especially in patients planned for surgery in one eye. However, larger prospective studies with longer follow-ups will be needed to establish long-term outcomes and correction achieved from this procedure, and comparison with other approaches for reoperations.

Rapidly progressive vision loss due to fulminant idiopathic intracranial hypertension: a diagnostic and management dilemma.

A 44-year-old obese woman presented with decrease in vision in the right eye (RE) for 3 days. She reported a simultaneous onset of holocranial headache that worsened on bending forward. She denied eye pain, pain on eye movements, and other ocular or neurological complaints. On examination, her distance best-corrected visual acuity was counting fingers at 1 m in the RE and 20/20 in the left eye (LE). Colour vision was subnormal in both eyes (BE). There was grade II relative afferent pupillary defect in the RE. Fundus examination showed disc oedema in BE . Visual fields in the LE showed central scotoma extending nasally. A provisional diagnosis of papillitis was considered. However, contrast-enhanced MRI of the brain and orbits showed evidence of elevated intracranial pressure. Cerebrospinal fluid (CSF) opening pressure was 42 cm H2O while rest of the CSF analysis was normal. Diagnosis was revised to fulminant idiopathic intracranial hypertension. Management with medical therapy and urgent thecoperiteoneal shunt improved visual function in BE.

Management of head tilt in infantile nystagmus syndrome: A case report.

Management of head tilt in infantile nystagmus syndrome (INS) is a challenge. In this case report, we have described successful management of right-sided head tilt in a child with INS by operating on three oblique muscles (superior oblique anterior tenectomy in the right eye, Harada-Ito procedure in the left eye, and inferior oblique recession in the left eye). The child had complete correction of head tilt without causing any cyclovertical strabismus or torsional diplopia postoperatively.