Acute Myopic Shift after a Single Dose of Acetazolamide: A Case Report and Review of the Literature.

We report the case of a 32-year-old male who presented with an acute myopic shift as a result of uveal effusion following a single administration of 250 mg acetazolamide. The drug was discontinued and following cycloplegia and topical steroid therapy, we observed progressive deepening of the anterior chamber, reopening of the iridocorneal angle, and complete resolution of the myopic shift after 5 days. A literature review since 1956 identified 23 cases, including ours, which developed a myopic shift after a median time of 24 h (3 - 24) following a median dose of 500 mg (125 - 1000) acetazolamide, with about a third complicated by angle closure ocular hypertension. This presumed idiosyncratic reaction can occur without prior drug exposure and independent of the phakic status. Treatment options include systematic drug withdrawal associated with cycloplegia, anti-glaucomatous agents, and/or corticosteroids. Full recovery is achieved within about 5 days (2 - 14). Given the widespread use of acetazolamide, awareness of this idiosyncratic reaction is crucial to avoid complications of acute angle-closure glaucoma.

[Outbreak of myopia in pediatrics : management, prevention and treatment]. / Épidémie de myopie en pédiatrie : prise en charge, prévention et traitement.

The worldwide incidence and prevalence of myopia has increased. The age of onset of this refractive disorder has inversely decreased. In addition to genetic and familial factors, environmental factors related to a sedentary lifestyle and activities in highly solicited near vision seem to have an impact on the development of axial myopia, that is an early and non-reversible elongation of the eyeball. Prevention of the development of myopia in pediatrics through simple daily measures plays therefore a fundamental role. In addition, pharmacological treatments, and specific optical treatments for controlling myopia have shown encouraging results in reducing the risk of long-term complications of progressive myopia, that is increased risk of developing cataract, glaucoma, retinal detachment, or maculopathy.

L'incidence et la prévalence mondiales de la myopie ont augmenté. L'âge de survenue de ce trouble réfractif a quant à lui diminué. Outre les facteurs génétiques et familiaux, des facteurs environnementaux liés à la sédentarité et aux activités en vision proche hautement sollicitée semblent avoir un impact sur le développement de la myopie axile, c'est-à-dire une élongation précoce et non réversible du globe oculaire. La prévention du développement de la myopie par des mesures quotidiennes simples joue donc un rôle fondamental. En outre, des traitements pharmacologiques et par moyens auxiliaires spécifiques dits « freinateurs ¼ ont montré des résultats encourageants pour diminuer le risque de complications à long terme de la myopie progressive, tels qu'un risque augmenté de développer une cataracte, un glaucome, un décollement de rétine ou une maculopathie.

Clinical Classification of Acquired Concomitant Esotropia.

BACKGROUND: Classification and management of acquired concomitant esotropia is controversial. We sought to establish a simple clinical classification in order to determine in which cases further investigations in search of underlying pathologies are necessary. PATIENTS AND METHODS: Observational retrospective study of the files of 175 consecutive patients examined in our unit between 2009 and 2018 for acute convergent strabismus. One hundred and nine patients were selected, after exclusion of infantile, incomitant, or mechanical esotropias, residual esotropias, and patients examined on a single occasion. All patients received a complete orthoptic and ophthalmological examination. We grouped the patients according to their common characteristics. RESULTS: We established the following categories: 1. Acute esotropia of large angle (20 to 45 prism diopters [PD]), accompanied by mild hyperopia (mean 1.2 D) in children (n = 16) and moderate myopia (mean 3.7 D) in adolescents and adults (n = 13). 2. Decompensated micro-esotropia, which is distinguished from the other categories by the presence of abnormal retinal correspondence (n = 33). 3. Decompensated esophoria, with intermittent deviations of 5 to 30 PD, esotropia being compensated part of the time (n = 25). 4. Esotropia present only at a distance in patients over 50 years of age (n = 20). 5. Small-angle esotropia (< 15 PD) greater at a distance, associated with oculomotor cerebellar syndrome (n = 2). Complementary examinations (MRI or CT scan) were performed on 21 patients, leading to the discovery of a posterior fossa astrocytoma in a 4-year-old boy. CONCLUSIONS: The recognition of decompensated micro-esotropia and esophoria, as well as distance esotropia of the elderly, avoids unnecessary additional investigations, which are indicated in any type of acute comitant strabismus if associated with any neurological sign or symptom (e.g., headaches, nausea, vertigo, imbalance, poor coordination, nystagmus, or papilledema). In the absence of neurological findings, there is no consensus about the indication of neuroimaging in large-angle acquired concomitant esotropia, but long-term follow-up of patients that do not undergo neuroimaging is strongly recommended in order to identify later occurring intracranial diseases. This is of particular importance with children.

[Inferior Rectus Myopexy: Indications and Long-Term Results]. / Myopexie des Musculus rectus inferior: Indikationen und Langzeitergebnisse.

PURPOSE: The rectus inferior myopexy is often used in vertical incomitant deviations without significant deviation in primary position. We analysed the long-term results in different pathologies. METHODS: Retrospective study of patients operated on rectus inferior myopexy between 1984 and 2018. Vertical and torsional deviations were measured in primary position (PP) and 25° downgaze and the field of binocular single vision (FBSV) was evaluated with the Harms tangent screen, establishing a functional score. Postoperative follow-ups took place at 1 month, 6 months and long term (1 - 24 years). RESULTS: 62 patients were included (mean age 41 years, 28 women and 34 men). 47 presented a fourth nerve palsy (group 1) and 15 a reduced depression of other origins (group 2). 31 patients had undergone previous operations and 34 contemporaneous operations with the myopexy. In group 1, preoperative mean vertical deviation was 6.4° in PP and 12.3° on downgaze, postoperative 4° and 7.2°. In group 2, the value decreased from 3.3° in PP and 11.5° on downgaze to 1.2° and 6.6°. Over the years, there has been a decrease in the effect, particularly in group 1. The torsion was hardly influenced in both groups. The median functional score of FBSV improved in group 1 from 10% preoperatively to 39% postoperatively and in group 2 from 25 to 69%. CONCLUSION: The inferior rectus myopexy shows an effective way to reduce the incomitance of vertical deviation without significant influence on torsion. Over the years, there has been a decrease in the effect, particularly in patients with superior oblique paresis. We do not consider inferior rectus myopexy as a classic surgical treatment of superior oblique paresis. We have only used it in special cases.

ASSESSMENT OF MACULAR VASCULATURE OF CHILDREN WITH SICKLE CELL DISEASE COMPARED TO THAT OF HEALTHY CONTROLS USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: This study aims at describing the macular vascular features of the eyes of pediatric patients with the homozygous form of sickle cell disease (SCD) using optical coherence tomography angiography. METHODS: This is a retrospective case series of eyes of pediatric patients with SCD, race- and age-matched to those of healthy individuals. Using optical coherence tomography angiography images of superficial capillary plexus and deep capillary plexus, the nonflow area, vascular density, and foveal avascular zone were measured. The remodeled microvascular foveal architectures obtained on optical coherence tomography angiography and fluorescein angiography were compared. RESULTS: A total of 19 eyes of patients with SCD and 18 eyes of race-matched healthy controls were examined. The best-corrected visual acuity ranged from 75 to 85 letters in all cases. In the SCD series, 8 eyes displayed signs of retinopathy on funduscopy. The foveal avascular zone was significantly enlarged, the foveal vascular density was 8% lower, and there were more perifoveal vascular alterations in the eyes of patients with SCD compared to those of controls. CONCLUSION: The foveal vascular density was significantly reduced and area of the foveal avascular zone was significantly increased in the eyes of patients with SCD. Consistent architectural changes in the perifoveal capillaries were also observed in the pediatric patients with SCD.

Comparative Study of the Usefulness of the Binocular Spot Vision Screener Autorefractor in the Detection of Childhood Visual Disorders.

BACKGROUND: The Spot Vision Screener (SVS) is designed to detect significant ametropia, anisometropia, and strabismus in non-dilated eyes. This study evaluates the efficacy of the SVS in paediatric visual screening. PATIENTS AND METHODS: All children screened during the paediatric visual screening day in Lausanne in 2016 were evaluated with the SVS, conventional monocular autorefractors, and clinical orthoptic examination. Recommendations for a further eye examination of the SVS were compared with those issued from traditional clinical screenings (monocular refraction and orthoptic examination). RESULTS: One hundred and sixty-eight consecutive children were included. The median age was 3.9 years. The SVS median spherical equivalent (SE) was + 0.25 D OU and it detected seven cases of (4.2%) anisometropia (SE difference ≥ 1 D). The conventional monocular autorefractor median SE was - 0.13 D OU and 20 cases of anisometropia (11.9%) were detected. Refraction could not be measured in 1.2% of patients with SVS versus 17.2% with monocular refractors. The SVS screened two manifest strabismus cases against five manifest and > 100 latent strabismus with orthoptic examination. As expected, the SVS was unable to assess reactions to monocular occlusion, visual acuity, and stereovision as well as to detect ocular motility disorders without strabismus in the primary position, and missed two cases of abnormal Brückner reflexes. Overall, the SVS identified 66 suspect patients (39.3%) against 102 (60.7%) after complete clinical examination. CONCLUSIONS: The SVS can be a useful objective screening tool for non-ophthalmologists. However, because it fails to detect ocular motility troubles, organic visual acuity loss, or to assess the visual potential, it should only be used in association with a clinical examination, even in routine screening procedures.

Visual signs and symptoms in patients with the visual variant of Alzheimer disease.

BACKGROUND: Prominent visual symptoms can present in the visual variant of Alzheimer's disease (VVAD). Ophthalmologists have a significant role to play in the early diagnosis of VVAD. METHODS: We retrospectively reviewed the files of ten consecutive patients diagnosed with VVAD. All patients had a full neuro-ophthalmologic examination, a formal neurological and neuro-psychological testing, and cerebral MRI to confirm diagnosis. In addition, functional neuroimaging was obtained in seven patients. RESULTS: The common primary symptom at presentation with all patients was difficulty with near vision (reading difficulty n = 8, "visual blur" in near vision n = 2), and difficulty writing (n = 3). Following assessment, impaired reading and writing skills were evident in 9/10 and 8/10 patients respectively. Median distance visual acuity was 20/25 and at near the median visual acuity was J6. Partial homonymous visual field defect was detected in 80 % (8/10) of the patients. Color vision was impaired in all patients when tested with Ishihara pseudoisochromatic plates, but simple color naming was normal in 8/9 tested patients. Simultanagnosia was present in 8/10 patients. Vision dysfunction corresponded with cerebral MRI findings where parieto-occipital cortical atrophy was observed in all patients. PET scan (5 patients) or SPECT (2 patients) revealed parieto-occipital dysfunction (hypometabolism or hypoperfusion) in all 7 tested patients CONCLUSIONS: Visual difficulties are prominent in VVAD. Dyslexia, incomplete homonymous hemianopia, preserved color identification with abnormal color vision on Ishihara, and simultanagnosia were all symptoms observed frequently in this patient series. Ophthalmologists should be aware of the possibility of neurodegenerative disorders such as VVAD in patients with unexplained visual complaints, in particular reading difficulties.

Nonsurgical treatment of cyclic esotropia.

Cyclic esotropia is characterized by a 24-hour period of straight eye position followed by 24 hours of large-angle esotropia. Possible mechanisms include notably progressive loss of compensation of a latent strabismus. The classic treatment is surgical correction of the angle measured on the days with manifest deviation. We report the first case of cyclic esotropia successfully treated by prismatic correction of the latent strabismus present on "straight" days.

[Eye and the environment]. / Œil et environnement.

The eyes are exposed to multiple environmental factors, which affect visual development, comfort, and visual health. While overexposure to sunlight can cause ocular surface and retinal pathologies, insufficient exposure to daylight could significantly contribute to myopia progression. New artificial lights, namely LED, have a higher risk of retinal phototoxicity, and could alter ocular circadian rhythm. The significant increase of prevalence of ocular allergies could be caused by the proliferation of environmental polluting substances, like tobacco smoke, fuel combustion by-products, or phtalates, which are found in many types of plastics. Finally, some dietary supplements could play a protective role in certain types of ocular pathologies, namely retinal pathologies.

Fourth cranial nerve palsy and Brown syndrome: two interrelated congenital cranial dysinnervation disorders?

Based on neuroimaging data showing absence of the trochlear nerve, congenital superior oblique palsy is now classified as a congenital cranial dysinnervation disorder. A similar absence of the abducens nerve is accompanied by misinnervation to the lateral rectus muscle from a branch of oculomotor nerve in the Duane retraction syndrome. This similarity raises the question of whether some cases of Brown syndrome could arise from a similar synkinesis between the inferior and superior oblique muscles in the setting of congenital superior oblique palsy. This hypothesis has gained support from the confluence of evidence from a number of independent studies. Using Duane syndrome as a model, we critically review the accumulating evidence that some cases of Brown syndrome are ultimately attributable to dysgenesis of the trochlear nerve.

Inferior oblique muscle recession with and without superior oblique tendon tuck for treatment of unilateral congenital superior oblique palsy.

PURPOSE: To compare the surgical results in patients with congenital superior oblique palsy treated with inferior oblique recession (IOR) versus those treated additionally with superior oblique tendon tuck (IOR+SOT). METHODS: A consecutive, nonrandomized series of patients with congenital superior oblique palsy with vertical deviations in adduction between 10° and 20° were retrospectively reviewed. In the first series, patients were treated with IOR; in the second series, patients were treated with IOR+SOT. We examined the effects of surgery on binocular alignment and on the field of binocular single vision. RESULTS: Each group consisted of 20 patients. Preoperative ocular deviations were similar in both groups. Postoperative residual vertical deviations were not different in the primary position or in downgaze; however, significantly better alignment was achieved in the IOR+SOT group in adduction and downgaze in adduction. Consecutive Brown pattern occurred in 18 of 20 patients who underwent IOR+SOT versus 5 of 20 who underwent IOR. Residual torsion was not statistically different. The field of binocular single vision improved to 92% (range, 28%-100%) after IOR and to 96% (range, 64%-100%) after IOR+SOT (P = 0.20). CONCLUSIONS: IOR alone is a suitable procedure for most congenital superior oblique palsies with a moderate-to-large vertical deviation in adduction, resulting in a lower incidence of consecutive Brown pattern than with IOR+SOT.

Absence of the fourth cranial nerve in congenital Brown syndrome.

PURPOSE: To elucidate the aetiology of congenital Brown syndrome. METHODS: Four consecutive patients diagnosed with unilateral congenital Brown syndrome had a comprehensive standardized ocular motility examination. Any compensatory head posture was measured. Brain magnetic resonance imaging (MRI) with regard for the IV cranial nerve (CN) was performed in all patients. Orbital MRI was performed in 2/4 patients, with images acquired in eight directions of gaze and superior oblique (SO) muscle areas compared. RESULTS: CN IV could not be identified bilaterally in two patients, but was absent only on the side of the Brown syndrome in the two other patients. On the normal side, orbital MRI revealed a smaller SO muscle area in upgaze than in downgaze, demonstrating normal actions of this muscle. On the side of the Brown syndrome, the SO area remained the same in upgaze and in downgaze and approximately symmetric to the area of SO in downgaze on the normal side. CONCLUSIONS: These cases add further anatomical support to the theory of paradoxical innervation in congenital Brown syndrome. CN IV was absent in two patients on the side of the Brown syndrome, but without muscle hypoplasia. SO muscle size did not vary in up- and downgaze, which we interpreted as a sign of constant innervation through branches of CN III.

Peripapillary neovascular membrane: a rare cause of acute vision loss in pediatric idiopathic intracranial hypertension.

We report a 14-year-old boy who presented with vision loss secondary to peripapillary neovascular membrane (PPNVM) as the initial and only symptom of papilledema secondary to idiopathic intracranial hypertension. After one lumbar puncture, visual acuity progressively recovered during the course of 1 week and further improved with the administration of oral acetazolamide. One year after the onset of vision loss, the patient's visual acuity had recovered to baseline measurements. The previously active PPNVM had involuted into a residual peripapillary fibrotic scar. To our knowledge, this is the first report of PPNVM complicating idiopathic intracranial hypertension in a child.

Visual loss after orthopedic procedures.

Perioperative visual loss (PVL) is a very rare and unpredictable complication of surgery performed at distance from the visual pathways, mostly after spine or cardiac procedures. We report 6 consecutive patients with PVL after routine orthopedic procedures (osteosynthesis for complex fracture of the femur [2], total hip arthroplasty [2], hip prosthesis arthroplasty [1], bilateral simultaneous total knee arthroplasty [1]) and reviewed the literature on the subject. An ischemic optic neuropathy was diagnosed in all cases, and visual loss was bilateral in 5 of 6 patients. Partial visual improvement occurred in only 3 of 11 eyes. No specific therapy is available for PVL. Postoperative visual disturbances should prompt without delay an ophthalmic evaluation because emergent correction of anemia, systemic hypotension, or hypovolemia might improve visual prognosis of PVL.

Disorders of pupillary structure and function.

Neurologists are frequently consulted because of a pupillary abnormality. An unequal size of the pupils, an unusual shape, white colored pupils, or a poorly reactive pupil are common reasons for referral. A directed history and careful observation of the iris and pupil movements can bear out ocular pathology such as congenital or structural anomalies as the cause of abnormal pupils. Thereafter, it is important to evaluate the neurologic causes of anisocoria and poor pupil function. The first part of this article emphasizes pupillary abnormalities frequently encountered in infants and children and discusses some of the more common acquired iris structural defects. The second part focuses on evaluation of lesions in the neural pathways that result in pupillary dysfunction, with particular attention to those conditions having neurologic, systemic, or visual implications.

Altered vision during motion: an unusual symptom of cerebellar dysfunction, quantifiable by a simple clinical test.

PURPOSE: To report a series of patients with cerebellar dysfunction and altered vision during motion, and to quantify their visual impairment in motion with a simple clinical test. METHODS: Twenty consecutive patients suffering from cerebellar dysfunction and altered vision during motion were examined between 1994 and 2007. A control group consisted of 20 age- and sex-matched healthy people. All patients had a full neuro-ophthalmic examination. Near visual acuity (NVA) was measured at rest (static NVA) and during chair rotation (dynamic NVA). Distance visual acuity (DVA) was measured at rest (static DVA) and during rotation of the patient's head (dynamic DVA). RESULTS: Only four of the 20 patients reported altered vision during motion spontaneously. The remaining 16 patients admitted this unusual visual disturbance only when asked specifically. All patients exhibited abnormal eye movements, including saccadic smooth pursuit (20/20), dysmetric saccades (15/20), nystagmus (19/20) and impaired suppression of vestibulo-ocular reflex (VOR) (20/20). During rotation of the examination chair (dynamic NVA), the drop in NVA averaged 5.6 lines (range 1-10 lines). During rotation of the patient's head (dynamic DVA), the drop in DVA averaged only 2.5 lines (range 0-10 lines). For the control group, there was no significant drop in NVA under dynamic conditions. CONCLUSION: Patients with cerebellar dysfunction rarely complain spontaneously of altered vision during motion. However, specific questioning may bring up this unusual symptom. The use of a simple clinical test, consisting of NVA measurement during rotation of the examination chair (dynamic NVA), allows practitioners to quantify the level of visual impairment in patients presenting altered VOR modulation.

Acute reversible Charles Bonnet syndrome precipitated by sudden severe anemia.

PURPOSE: To report the sudden onset of reversible Charles Bonnet syndrome precipitated byacute severe anemia. METHODS: The charts of three patients (Usher syndrome, bilateral macular degeneration, and bilateral retinal vein occlusion) with acute Charles Bonnet syndrome in the setting of severe anemia were reviewed. RESULTS: Anemia resulted from bladder surgery, recto-colitis, and severe urinary tract infection. Hemoglobin ranged from 78 to 86 g/L. Decreased visual acuity and formed visual hallucinations (giants, flowers, animals) were present in all three patients. Rapid reversal of Charles Bonnet syndrome and visual acuity improvement followed blood transfusion. CONCLUSIONS: Acute severe anemia can precipitate Charles Bonnet syndrome, which may be reversible by blood transfusion.

Tumors of the caruncle: a clinicopathologic correlation.

PURPOSE: To determine the types and incidence of caruncular lesions and to investigate the correlation between clinical and histologic diagnosis. DESIGN: Retrospective, observational case series. METHODS: Records of patients with a lesion of the caruncle that was excised and submitted to our ocular pathology department between January 1979 and May 2005 were reviewed. Lesions were classified by histologic type and correlated with patient age, gender, and preoperative clinical diagnosis. RESULTS: A total of 195 consecutive caruncular lesions from 191 patients were identified. Twenty-four different types of lesions were identified; the most common were nevi (n = 92, 47%) and papillomas (n = 29, 15%). One keratoacanthoma was identified. One hundred eighty-three lesions (93.8%) were benign, six (3.1%) were premalignant, and five (2.6%) were malignant. Preoperative clinical diagnosis corresponded to postexcision histologic diagnosis in 73 cases (37.4%). Suspected malignancy was a common reason for excision (61 cases, 31.3%), but malignancy was confirmed in only three (4.9%) of 61 cases. Two of the five malignant lesions were clinically thought to be benign. CONCLUSIONS: We hereby report the first caruncular keratoacanthoma. The rarity and variety of caruncular lesions make clinical diagnosis difficult. Malignancy is clinically overestimated, and some malignant lesions can take a benign aspect, justifying close photographic follow-up of all lesions. Because caruncular malignant melanoma is associated with poor prognosis, pigmented lesions should be monitored carefully. In the absence of clear criteria for malignancy, any change in color, size, or vascularization of a caruncular lesion should hasten excision.