Health-related quality of life of daily-life-affected benign essential blepharospasm: Multi-center observational study.

PURPOSE: To compare Thais' health-related quality of life (HRQOL) and severity grading, efficacy and safety in daily-life-affected benign essential blepharospasm (BEB) patients at baseline and after Botulinum toxin type A (BTX-A) treatment. DESIGN: Prospective-observational study. PARTICIPANTS: BEB patients with Jankovic rating scale (JRS) at least 3 in both severity and frequency graded from 14 institutes nationwide were included from August 2020 to June 2021. METHODS: Demographic data, HRQOL evaluated by the Thai version of EQ-5D-5L and NEI-VFQ-25 questionnaires, and severity grading score evaluated by Jankovic rating scale (JRS) at baseline, 1, and 3 months after the treatment were collected. The impact of the BTX-A injections and their complications were recorded. RESULTS: 184 daily-life-affected BEB patients were enrolled; 159 patients (86.4%) had complete data with a mean age of 61.40±10.09 years. About 88.05% were female, and 10.1% were newly diagnosed. Most of the patients had bilateral involvement (96.9%) and 12.6% had history of BEB-related accident. After BTX-A treatment, HRQOL improved significantly in 4 dimensions of EQ-5D-5L, except self-care. The EQ_VAS (mean±SD) was 64.54±19.27, 75.13±15.37, 73.8±15.85 (p<0.001) and EQ-5D-5L utility score was 0.748±0.23, 0.824±0.19 and 0.807±0.19 at baseline, 1, 3 months after treatment, respectively. From NEI-VFQ-25, HRQOL also improved in all dimensions, except eye pain. The JRS improved in all patients. Self-reported minor adverse events were 22.6%, which mostly resolved within the first month. CONCLUSION: Daily-life-affected BEB impacted HRQOL in most dimensions from both generic and visual-specific questionnaires. BTX-A treatment not only decreased disease severity, but also improved quality of life.

Correlation between relative afferent pupillary defect and visual field defects on Humphrey automated perimetry: A cross-sectional clinical trial.

PURPOSE: To evaluate the correlations between relative afferent pupillary defect (RAPD) magnitude, assessed using the clinical plus scale and neutral density filters, and visual field parameters in patients with unilateral or asymmetrical bilateral optic neuropathy or retinopathy. METHODS: Fifty-two patients with RAPD, graded by the swinging flashlight test and neutral density filters, were analyzed in this cross-sectional trial. The RAPD clinical plus scale was divided into grade 1+, initial weak constriction; grade 2+, initial stall then dilatation; grade 3+, immediate dilatation; and grade 4+, fixed amaurotic pupil. Patients with positive RAPD underwent a visual field examination with Humphrey automated perimetry that included visual field index (VFI), mean deviation (MD), and pattern standard deviation (PSD). Spearman's rank correlation coefficients and linear regression were used to analyze the association between RAPD grades and visual field parameters. RESULTS: RAPD clinical plus grades were correlated with interocular VFI (r = 0.55, P < 0.001) and MD (r = 0.48, P = 0.004) differences. Average interocular VFI differences were estimated as follows: 16.75 × RAPD plus grade- 7.53. RAPD, graded by neutral density filters, was correlated with VFI (r = 0.59, P < 0.001), MD (r = 0.54, P < 0.001), and PSD (r = 0.34, P = 0.01). CONCLUSIONS: The RAPD plus scale and neutral density filter grading systems were associated with quantitative visual field defect parameters, with VFI showing the strongest association. RAPD clinical grading could substitute more sophisticated central visual field evaluation methods as a low-cost, low-tech, and widely available approach.

Prognostic factors for conversion to generalization in ocular myasthenia gravis.

ABSTRACT: Patients with ocular myasthenia gravis (OMG) are frequently treated to prevent the development of generalized myasthenia gravis (GMG). This retrospective cohort study aimed to assess prognostic factors associated with conversion to GMG.We analyzed the time from the onset of OMG symptoms to GMG in relation to demographic variables, clinical findings, initial investigation results, and treatment regimens using Kaplan-Meier survival curves and multivariate Cox proportional regression analysis.Of 115 patients diagnosed with OMG (median follow-up time, 2.9 years), 28 (30.4%) developed GMG. The 2-year probability of GMG conversion was 23.7%. Patients with thymic abnormalities and a positive response to repetitive facial nerve stimulation had a significantly higher risk than those with negative results (hazard ratios [HR] 4.28, P < .001 and HR 3.84, P = .04, respectively). Treatment with immunosuppressants was found to be a preventive factor for secondary generalization (HR 0.36, P = .02).Patients with OMG had a low risk of developing GMG. Immunosuppressive treatments may mitigate disease progression. Chest imaging and repetitive nerve stimulation should be routinely performed to assess the risk of generalization.

Clinical Prediction Score for Early Neuroimaging in Acquired Isolated Oculomotor Nerve Palsy.

PURPOSE: An immediate neuroimaging investigation in patients with isolated oculomotor nerve palsy (ONP) remains controversial. We aimed to develop a clinical prediction score to determine whether or not acquired isolated ONP patients require prompt imaging. METHODS: A retrospective study was performed. Demographic data and clinical presentations were collected to determine predictive factors favored for early brain imaging using multivariate logistic regression analysis. RESULTS: Ninety-seven eyes of 96 patients diagnosed with isolated ONP were included. Forty-one eyes (42.3%) were caused by ischemia, while the other 56 eyes (57.7%) were caused by non-ischemic etiologies, namely aneurysm (n = 22), trauma (n = 18), inflammation (n = 5), tumor (n = 4), and others (n = 7). Eighty-two eyes (84.5%) had undergone neuroimaging study due to initially suspected non-ischemic causes. Only 36 (43.9%) revealed concordant diagnosis. The potential clinical predictors favored for neuroimaging using multivariate logistic regression analysis were age 10‒50 years (adjusted odds ratio [aOR] 9.01, 95% CI: 1.25‒64.8), age 51‒70 years (aOR 1.71, 95% CI: 0.46‒6.35), history of head trauma (aOR 7.14, 95% CI: 1.19‒42.9), absence of vascular risk factors (aOR 3.85, 95% CI: 1.23‒12.1), and poor pupillary response (aOR 6.96, 95% CI: 1.99‒24.3). The predictor scores with an area under the ROC curve of 0.852 were 4, 1, 4, 3, and 4, respectively. The optimum cut-point was 3 for a sensitivity of 96% and specificity of 44%. CONCLUSION: Patients with acquired isolated ONP should be considered early neuroimaging studies when they are younger than 50 years old, have a history of head trauma, have no history of vascular risk factors, or have poor pupillary reaction.

Incidence Rate and Risk Factors for Contralateral Eye Involvement among Patients with AIDS and Cytomegalovirus Retinitis Treated with Local Therapy.

PURPOSE: To calculate the incidence of, and to identify the risk factors for developing contralateral eye involvement among patients with AIDS and unilateral cytomegalovirus retinitis (CMV retinitis), who were treated, in the era of highly-active antiretroviral therapy (HAART), with repetitive intravitreal ganciclovir injections. MATERIALS AND METHODS: The clinical records of 119 patients were included. The main outcome measurement was the occurrence of contralateral eye involvement. RESULTS: Over a mean follow-up period of 1.6 years, the overall incidence rate of contralateral involvement was 0.17/person-year. The cumulative incidence of contralateral involvement at 6 months and 1 year was 23.8% and 28.4%, respectively. Receiving HAART at the visit before the event was associated with a decreased risk of developing contralateral retinitis (hazard ratio [HR] = 0.26, P = 0.002). CONCLUSIONS: The use of HAART, associated with subsequent immune recovery, significantly reduced the incidence of contralateral eye involvement by approximately 75% among patients in our setting.

Incidence Rate and Risk Factors for Contralateral Eye Involvement among Patients with AIDS and Cytomegalovirus Retinitis Treated with Local Therapy.

PURPOSE: To calculate the incidence of, and to identify the risk factors for developing contralateral eye involvement among patients with AIDS and unilateral cytomegalovirus retinitis (CMV retinitis), who were treated, in the era of highly-active antiretroviral therapy (HAART), with repetitive intravitreal ganciclovir injections. MATERIALS AND METHODS: The clinical records of 119 patients were included. The main outcome measurement was the occurrence of contralateral eye involvement. RESULTS: Over a mean follow-up period of 1.6 years, the overall incidence rate of contralateral involvement was 0.17/person-year. The cumulative incidence of contralateral involvement at 6 months and 1 year was 23.8% and 28.4%, respectively. Receiving HAART at the visit before the event was associated with a decreased risk of developing contralateral retinitis (hazard ratio [HR] = 0.26, P = 0.002). CONCLUSIONS: The use of HAART, associated with subsequent immune recovery, significantly reduced the incidence of contralateral eye involvement by approximately 75% among patients in our setting.

The Difference of Treatment Results between Botulinum Toxin A Split Injection Sites and Botulinum Toxin A Non-Split Injection Sites for Hemifacial Spasm.

OBJECTIVE: To compare hemifacial spasm treatment results between Botulinum toxin A split injection sites and Botulinum toxin A non-split injection sites. MATERIAL AND METHOD: Thirty-one hemifacial spasm patients were randomly assigned into the non-split injection sites group (injecting Botulinum toxin A to the zygomaticus major and risorius each) or split injection sites group with the same amount of Botulinum toxin A as the first method (injection Botulinum toxin A to the zygomaticus major and minor and risorius two injections each) The main outcomes are onset of improvement and effective duration of treatment. RESULTS: Fifteen patients were assigned to non-split injection sites group and 16 patients were assigned to split injection sites group. The median onset of improvement in non-split injection sites group and split injection sites group was 4.0 and 4.5 days, respectively (p = 0.984). The effective duration of treatment in the non-split injection sites group was 60.0 days and in the split injection sites group was 54.5 days (p = 0.582). CONCLUSION: The splitting of injection sites did not signicantly improve the efficacy of Botulinum toxin A in the treatment of hemifacial spasm.

Clinical presentation, aetiology and prognosis of orbital apex syndrome.

OBJECTIVES: To present the clinical features, determine the causes and evaluate the prognosis of orbital apex syndrome in patients of Songklanagarind Hospital. METHODS: A retrospective review was conducted of patients diagnosed with orbital apex syndrome between January 1, 2002 and December 31, 2008. RESULTS: In our series, the major cause of orbital apex syndrome was carotid-cavernous sinus fistula, for which 30 patients were diagnosed. After excluding those patients whose condition was caused by carotid-cavernous sinus fistula, 50 patients (58 eyes) were analyzed. The mean age of the patients was 47.60 ± 18.88 years (27 male patients and 23 female patients). The most common presenting symptom was blurred vision (86%). The median duration of the presenting symptom was 37.5 d. Of the 50 patients the most frequent aetiology of orbital apex syndrome was neoplasia (48%), of which lymphoma was the most common in this group. After treatment, the vision of 19.4% of the patients improved and proptosis improved by 68.4%. CONCLUSIONS: The most common presenting symptom of orbital apex syndrome was blurred vision. The most frequent aetiology of orbital apex syndrome of all patients was carotid-cavernous sinus fistula, while the next most frequent was neoplasm, of which lymphoma was the most common in this group. Patients had a good outlook, after treatment directed at the cause, with a modest improvement in vision and exophthalmos in more than half of patients.

Correlation between clinical grading and quantification by neutral density filter of relative afferent pupillary defect (RAPD).

OBJECTIVE: To investigate the correlation between clinical grading in plus scale and quantified relative afferent pupillary defect (RAPD) using the neutral density filter bar. MATERIAL AND METHOD: This was a prospective analytical cross sectional study. Sixty-nine patients of any ocular disease with relative afferent pupillary defects were prospectively examined. The RAPD was graded twice in each patient by the clinical grading plus scale (grade 1+ to 4+) and then by using a neutral density filter (NDF) bar Patients with an abnormal pupil or had been dilated with medication were excluded. Both clinical grading of RAPD and quantified RAPD by the NDF bar were performed by the same physician. All patients were tested by the same technique. Statistical analysis was done to compare the results of both methods. RESULTS: The RAPD grading by the clinicalplus scale correlated significantly with the grading by the neutral density filter bar (p < 0.05). The four clinical grades had corresponding values in the neutral density log unit: grade 1+ < or = 0.6 log unit (94.7%), grade 2+ = 0.6-0.9 log unit (85%), grade 3+ = 1.2-1.5 log unit (88.3%), grade 4+ > or = 1.8 log unit (84.6%). CONCLUSION: The results of the two methods of grading RAPD using the plus scale and the neutral density filter bar are comparable. Each grade had a corresponding value in log units. In a clinical setting where neutral density filter bars are not available, the authors can grade RAPD using the plus scale.

Evaluating the effects of ice application on patient comfort before and after botulinum toxin type A injections.

OBJECTIVE: To evaluate the efficacy of ice application in reducing pain during botulinum toxin type A injections. DESIGN: Prospective, randomized, single-blind clinical study. MATERIAL AND METHOD: Sixty patients who underwent botulinum toxin A treatment on their faces were included in the present study, divided into three groups, group 1 had ice applied 5 minutes before the injection, group 2 ice was applied 5 minutes after the injection, and group 3 served as a control, receiving an injection without ice application. A numeric pain distress scale was used to assess pain intensity. Any complications arising from the injections were also recorded. RESULTS: Sixty patients were studied between July 2007 and March 2008. The ages ranged from 32 to 76 years (mean, 58.15 +/- 10.51 years) and 49 (81.7%) were female. Forty-five (75.0%) had hemifacial spasm and fifteen (25.0%) had blepharospasm. The numeric pain distress scale was completed immediately after the injections and the results were 3.55 +/- 1.85, 5.15 +/- 2.81 and 6.1 +/- 2.63 in groups 1, 2, and 3 respectively. The ratings indicated that pain was significantly reduced in group 1 compared to group 3 (p = 0.005), but there was not a significant difference between groups 1 and 2 (p = 0.109) or between groups 2 and 3 (p = 0.448). There was a significant difference in the rate of bleeding after the injections between groups 1 and 2 (p = 0.0472), but no significant difference between groups 1 and 3 (p = 0.106) and groups 2 and 3 (p=1). CONCLUSION: Using an ice application 5 minutes before or after injection showed no difference but both significantly reduce pain compared to without ice application, while 5-minute application before injection had significantly decreased the bleeding compared to both 5 minutes after injection and without ice application. The ice application is helpful in pain relief whereas the before-injection has lesser bleeding than after-injection modality.

Three years experience of suprasellar tumors in neuro-ophthalmology clinic.

OBJECTIVE: To examine pre-treatment ophthalmic presentations and treatment results and to identify factors that may influence improved visual outcomes in patients with suprasellar tumor MATERIAL AND METHOD: The medical records of patients with suprasellar tumors who were diagnosed between July 2005 and June 2008 in the neuro-ophthalmology clinic of Songklanagarind Hospital were retrospectively reviewed by two ophthalmologists. Pre-treatment ophthalmic presentations and treatment results were analyzed. Determinants of improved visual outcomes were identified by using univariate and multivariate regression analysis. RESULTS: Of 40 patients, 55% were male and 45% were female, with a median age of 38 years. The most common pre-treatment ophthalmic presentations were blurred vision (92.5%), headache (10%) and eye pain (5%). The most common tumor was pituitary adenoma (macroadenoma and prolactinoma). Visual improvement was achieved in pituitary adenoma in 20 of 25 eyes (80%), meningioma in 8 of 12 eyes (67%) and other tumors in 2 of 5 eyes (40%). No determinants related to better visual outcomes were found. CONCLUSION: The most common presentation of suprasellar tumor was blurred vision. There were no pre-treatment factors that related to visual outcomes in the present study.

A variety of atypical manifestations in giant cell arteritis.

Giant cell arteritis (GCA) is a chronic granulomatous vasculitis of large and medium size vessels in the elderly. A new-onset headache is the most frequent symptom. An anterior ischemic optic neuropathy (AION) is one of the most common causes of permanent visual loss. There are four cases with unusual presentation of giant cell arteritis, scalp abscess, prolonged transient monocular visual loss (TMVL), bilateral central retinal artery occlusion (CRAO), and chronic ear pain. All patients had pathologically proven giant cell arteritis, and three of them progressed to blindness in the end. Scalp abscess is a rare sign in GCA. Delay in diagnosis because confusion of the abscess after scalp ischemia with other cutaneous lesions may result in death. TMVL is the forewarning symptom of AION or CRAO in GCA. Early recognition of TMVL is important to make early diagnosis of GCA to prevent blindness. Spontaneous ear pain is extremely rare, and reports have documented delay in diagnosis of GCA resulting in irreversible blindness.

Clinical features, management and outcomes of progressive outer retinal necrosis (PORN) in southern Thailand.

OBJECTIVE: To study the demographics, clinical features, treatment, and visual outcomes of progressive outer retinal necrosis (PORN) in a group of Thai patients. MATERIAL AND METHOD: All cases of AIDS with a clinical diagnosis of PORN in a major tertiary referral hospital in southern Thailand between January 2003 and June 2007 were retrospectively reviewed. Demographic data, clinical features, treatment regimens, and visual outcomes were analyzed. RESULTS: Seven patients (11 eyes) were studied. The mean age was 44.7 years. The median CD4 count was 12 cells/mm3. A known history of cutaneous zoster was documented in 57% of cases. The median follow-up period was 17 weeks. Fifty-seven percent of the patients had bilateral disease. A majority of eyes (45.4%) had initial visual acuity of less than 20/50 to equal to or better than 20/200. About two-thirds of the eyes had anterior chamber cells. Vitritis and retinal lesions scattered throughout both posterior pole and peripheral retina were found in 72.7%. Either intravenous acyclovir in combination with intravitreal ganciclovir injections or intravenous aclyclovir alone was used for initial treatment. Retinal detachment occurred in 54.5%. Final visual acuity worsened (loss of 3 lines on the ETDRS chart or more) in 60%. Visual acuity was no light perception in 45.5% at the final recorded follow-up. CONCLUSION: Demographics, clinical features and treatment outcomes of PORN in this group of Thai patients were comparable with studies from other countries. Visual prognosis is still poor with current treatment regimens.

The validation of the disease-specific questionnaire for health-related quality of life in Thai patients with hemifacial spasm.

OBJECTIVE: To investigate the reliability and validity of the Thai version of disease-specific health-related quality of life instrument for patients with hemifacial spasm (HFS) as well as their response to botulinum toxin treatment. MATERIAL AND METHOD: A Thai version of HFS-30 has been developed with the permission of the author. Thirty patients with HFS were asked to complete this Thai HFS-30, the 6-point disability scale before treatment and between four and six weeks after botulinum toxin injections. Peak improvement (0-100%) was subjectively assessed by each patient between four and six weeks after injection. They were also asked to answer the existing Thai SF-36 questionnaire before treatment to test its correlation with Thai HFS-30. Another group of ten patients completed the questionnaire and then a second identical copy after a 2-week interval. The reliability, validity, and responsiveness were subsequently analyzed. RESULTS: The Thai HFS-30 showed a Cronbach's alpha coefficient of 0.78 and no significant difference of a test-retest reliability. The total content validity was 0.88 (range 0.5-1.0). There were good correlations between both the Physical and Mental Health parts of the Thai HFS-30 and Thai SF-36 (p < 0.05 and p < 0.01, respectively). The Thai HFS-30 also demonstrated a response to treatment similar to the 6-point disability scale and the peak improvement. CONCLUSION: The Thai version of HFS-30 is a valid, reliable, and sensitive to change instrument for disease specific health-related quality of life assessment.