Rabies Encephalitis and the Use of Optic Nerve Sheath Diameter to Detect Elevated Intracranial Pressure.

Rabies is a rare but rapidly progressive and almost universally fatal disease. A previously healthy 59-year-old male presented with rabies encephalitis. We measured his optic nerve sheath diameter (ONSD) daily in both eyes using ultrasonography to indirectly monitor for elevated intracranial pressure (ICP). We performed CT and MRI brain on days when his ONSD changed significantly. An increase in ONSD temporally correlated with radiologic findings of cerebral edema and acute subarachnoid hemorrhage (SAH). ONSD measurement is a fast, inexpensive, and widely-available imaging modality that may serve as a surrogate marker for elevated ICP. It may be especially useful in patients who are difficult to be transported to radiology due to the unstable nature of their disease.

Internuclear Ophthalmoplegia Secondary to Cocaine Abuse.

Purpose. To report a case of internuclear ophthalmoplegia (INO) caused by cocaine. Method. We report a case of a 54-year-old female who presented with a left INO three days after snorting cocaine, and we review the literature. Results. MRI of the brain demonstrated several small abnormal foci in the pons on FLAIR and diffusion weighted imaging consistent with ischemic infarction. The patient's symptoms remained stable throughout her hospitalization. She was sent to a rehabilitation facility and was lost to follow-up. Conclusion. In cases of extraocular movement abnormalities, it is important to inquire about recreational drug use.

Efficacy of Orbital Color Doppler Imaging and Neuroimaging in the Diagnosis of Carotid Cavernous Fistulas.

PURPOSE: To evaluate the diagnostic sensitivity and specificity of orbital color Doppler imaging (CDI) and conventional neuroimaging (CT/MRI) compared with cerebral angiography in patients with carotid-cavernous fistulas (CCFs). METHODS: The study design was a retrospective patient chart and imaging review. The authors reviewed 655 charts of all patients who underwent CDI and neuroimaging (CT/MRI) between 2006 and 2015 at one institution. Sixty patients had a presumptive diagnosis of CCF without thrombosis. Thirty-seven patients with 43 events met the inclusion criteria of the study. The diagnostic sensitivity of the 3 noninvasive imaging modalities (CDI, CT, MRI) for CCF was compared with the gold standard 6-vessel cerebral angiography. Significance testing was performed using the 2-tailed Fisher test. RESULTS: Color Doppler imaging had high sensitivity (96.8%) but low specificity (41.7%) for the diagnosis of CCFs with anterior orbital findings. A negative CDI had more diagnostic value than a positive CDI. While an arterial wave form in the superior ophthalmic vein was the most common finding of CCF on CDI, enlargement of the superior ophthalmic vein was the only statistically significant finding. Posterior cortical venous drainage was noted in about 10% of the patients with indirect (low-flow) fistulas, who presented with unilateral orbital signs and symptoms, a finding not previously reported in the literature. CONCLUSION: Color Doppler imaging is a useful noninvasive, radiation-free modality for diagnosis of CCF with anterior drainage, with higher sensitivity than CT or MRI, but equivalent specificity. A significant limitation of CDI is the lack of usefulness in diagnosing fistulas with posterior cortical venous drainage, which carry a risk of intracerebral hemorrhage and stroke. In this series, 10% of unilateral CCFs with anterior orbital signs and symptoms showed angiographic evidence of posterior cortical venous drainage.

A Case Report of Acute Esotropia in a Young Woman following Heroin Withdrawal.

Introduction. Esotropia is a form of strabismus that can give the affected individual a "cross-eyed" appearance. Acute onset of esotropia is an uncommon form; in the vast majority of cases, no underlying neurological etiology is found. Case Presentation. A 22-year-old female with a long history of opiate abuse presented with acute onset of diplopia. She noted her eyes were crossing and started seeing double. She stopped using heroin 11 days prior to presentation. There was large inward deviation of her left eye. Convergence was difficult and accompanied by horizontal nystagmus. Diplopia resolved by covering each eye. Further investigations including imaging studies were normal. Discussion. Acute onset esotropia is rare and must be investigated right away to exclude central nervous system pathologies, where no opiates use is reported. Diplopia in the form of acute esotropia may manifest in up to 30% of individuals undergoing heroin withdrawal. Evaluating acute esotropia requires detailed information of medical history with an emphasis on drug use. Conclusion. Acute onset esotropia with double vision can be caused by abrupt withdrawal of opiates. This case should serve to raise awareness among health care professionals, to avoid costly and unnecessary diagnostic evaluations and interventions.

Air reflux and other sequelae following endoscopic dacryocystorhinostomy.

PURPOSE: To assess postoperative sequelae of endoscopic dacryocystorhinostomy (endoDCR), including rates of air reflux and other otolaryngologic sequelae. METHODS: Patients who underwent endoDCR over a 5-year period were included in a follow-up questionnaire regarding side effects after surgery. The questionnaire included questions regarding tearing, air reflux, and nasal symptoms. RESULTS: Results were obtained on 82 patients (101 endoDCRs). Most patients were women (70.7%) and white (85.4%). The mean postoperative period was 39.7 months (range 8-66 months). The most common sequela was air reflux from the puncta (46 cases, 45.5%). Of the 82 patients, 58.7% experienced symptoms only "rarely," while 18.5% had symptoms daily. Air reflux was most commonly associated with nose blowing (73.9%). Success of endoDCR correlated with presence of air reflux (p = 0.0044). All patients with air reflux preferred having air reflux to epiphora. Epistaxis was present in 8 cases (7.9%) and nasal congestion in 21.8% of the cases. CONCLUSIONS: Treatment for epiphora with endoDCR results in air reflux in almost half of patients, which is minimally bothersome to patients. The presence of air reflux highly correlates with resolution of epiphora and has a similar incidence in external and endoDCRs.