Perineuritis or infiltration of optic nerve sheath? A presentation of diffuse large B cell Gastric lymphoma.

Optic perineuritis is an inflammatory disorder involving the optic nerve sheath. It is currently considered as a part of idiopathic orbital inflammatory disease which also includes dacryoadenitis, orbital myositis, superior orbital fissure, and cavernous sinus syndrome (Tolosa hunt syndrome). As it is idiopathic, it is considered a diagnosis of exclusion. Another important differential is optic nerve lymphoma. Isolated optic nerve lymphoma associated with systemic involvement has been described in literature. We report a case that presented as third nerve palsy but later on developed central retinal vein occlusion and was ultimately diagnosed as primary gastric lymphoma of diffuse large B cell type.

Combined resection-recession in true divergence excess sensory exotropia.

PURPOSE: To assess the effect of combined resection and recession on the same lateral rectus muscle in patients with true divergence excess sensory exotropia. METHODS: Patients were divided into two groups. One group of patients underwent combined resection-recession of the lateral rectus muscle in one eye (LR group); the other group, with exodeviation of >40Δ for distance underwent additional ipsilateral medial rectus resection (LR + MR group). Postoperative measurements were taken at 1 week, 1 month, and 3 months. RESULTS: Eleven patients were included in the study (mean age, 23.5 ± 6.7 years): 7 in the LR group and 4 in the LR + MR group. For the LR group, mean preoperative deviation was 35.7Δ ± 3.5Δ at distance and 16.3Δ ± 3.9Δ at near. The mean near-distance disparity (NDD) was 11.4Δ ± 2.7Δ. The mean lateral rectus recession was 8.6 ± 1.1 mm: the mean resection, 4.3 ± 0.5 mm. At 3 months, mean deviation at distance was 8.3Δ ± 2.1Δ; at near, 3.1Δ ± 1.6Δ (P = 0.01). The NDD was 5.7Δ ± 2.7Δ (P = 0.01). For the LR + MR group, mean preoperative deviations at distance was 65.0Δ ± 12.9Δ; at near, 35.0Δ ± 12.2Δ. The mean NDD was 30.0Δ ± 4.0Δ. Mean lateral rectus recession was 9.5 ± 1.8 mm; the mean resection, 4.8 ± 0.8 mm. The mean medial rectus resection was 5.5 ± 0.6 mm. At 3 months, mean deviation at distance was 8.3Δ ± 2.1Δ; at near, 3.1Δ ± 1.6Δ (P = 0.06). The NDD was 5.7Δ ± 2.7Δ (P = 0.06). CONCLUSIONS: In our study combined resection and recession of the same lateral rectus muscle in patients with divergence excess sensory exotropia significantly reduced the NDD, with no adverse outcomes.

Bilateral hemorrhagic proptosis due to an uncommon cause in ocular emergency.

A 19-year-old male patient presented to the ocular emergency services with sudden onset of proptosis, pain, and bloody discharge. Further evaluation revealed bilateral visual acuity of finger counting close to face vision with an accurate projection of rays. Computed tomography scan of the head and orbit revealed diffuse orbital hemorrhage (mainly along the ocular coats) in the absence of any subperiosteal or intracranial hemorrhage. A complete hematological workup was done and it revealed decreased factor IX levels (9% of normal) consistent with hemophilia B (Christmas disease). The patient was managed medically with factor IX supplementation. At the end of 6 weeks, patient's visual acuity improved to 20/20 in both the eyes.

Tarsal buckle with conjunctival prolapse following levator plication for unilateral congenital ptosis.

An 8-year-old child underwent uneventful levator plication surgery for unilateral congenital ptosis. Postoperative course for initial few days was uneventful but on day 7, the patient was brought with conjunctival prolapse from the undersurface of upper eyelid due to tarsal kinking and eversion. Early medical management was initiated with frequent surface lubrication to avoid conjunctiva dryness. Under general anaesthesia, right-sided conjunctival repositioning was performed with an eyelid spatula supplemented by three forniceal stay sutures to retain the conjunctiva in its anatomical place. To reverse the tarsal kinking, continued downward traction suture was placed for a period of 2 weeks. At the end of 4 weeks, the conjunctival prolapse was completely resolved with a well-formed superior fornix. At the end of 3 months, the symmetric eyelid position was maintained without any additional complications.

Missed retinal breaks in rhegmatogenous retinal detachment.

AIM: To evaluate the causes and associations of missed retinal breaks (MRBs) and posterior vitreous detachment (PVD) in patients with rhegmatogenous retinal detachment (RRD). METHODS: Case sheets of patients undergoing vitreo retinal surgery for RRD at a tertiary eye care centre were evaluated retrospectively. Out of the 378 records screened, 253 were included for analysis of MRBs and 191 patients were included for analysis of PVD, depending on the inclusion criteria. Features of RRD and retinal breaks noted on examination were compared to the status of MRBs and PVD detected during surgery for possible associations. RESULTS: Overall, 27% patients had MRBs. Retinal holes were commonly missed in patients with lattice degeneration while missed retinal tears were associated with presence of complete PVD. Patients operated for cataract surgery were significantly associated with MRBs (P=0.033) with the odds of missing a retinal break being 1.91 as compared to patients with natural lens. Advanced proliferative vitreo retinopathy (PVR) and retinal bullae were the most common reasons for missing a retinal break during examination. PVD was present in 52% of the cases and was wrongly assessed in 16%. Retinal bullae, pseudophakia/aphakia, myopia, and horse shoe retinal tears were strongly associated with presence of PVD. Traumatic RRDs were rarely associated with PVD. CONCLUSION: Pseudophakic patients, and patients with retinal bullae or advanced PVR should be carefully screened for MRBs. Though Weiss ring is a good indicator of PVD, it may still be over diagnosed in some cases. PVD is associated with retinal bullae and pseudophakia, and inversely with traumatic RRD.

Comparison of Eye Drop Instillation Before and After Use of Drop Application Strips in Glaucoma Patients on Chronic Topical Therapy.

PURPOSE: To evaluate the impact of using drop application strips on eye drop instillation in glaucoma patients on chronic topical ocular hypotensive therapy. METHODS: A total of 72 patients with primary open-angle glaucoma with an uncorrected visual acuity of 3/60 or more, self-administering topical antiglaucoma medication for >1 year were evaluated. One eye of each patient was included in the study. Patients were instructed to instill 0.5% carboxymethyl cellulose drop in 1 eye. They were then instructed to instill the same drop using the drop application strips. RESULTS: Mean age of the patients included in the study was 50.39 ± 12.04 years. Before assistance of drop application strips, 35 (48.61%) patients placed the drop into the eye without any contact of the dropper nozzle, and, after application of the drop application strips, 66 (91.67%) patients placed the drop in the eye without any contact (P=0.025). The number of patients putting the first drop of drug into the eye without spilling over the adenexae increased from 30 (41.67%) to 45 (62.5%) after application of the strip (P<0.001). The mean number of drops instilled to get 1 drop into the eye decreased from 2 ± 0.95 to 1.56 ± 0.78 when the drop application strip was used (P<0.001). CONCLUSIONS: Use of a drop application strip causes a significant decrease in contact of the eye drop bottle nozzle with the eyeball and eyelid, decreases the number of drops instilled to get 1 drop into the eye, and is associated with an overall improvement in eye drop instillation.

Peripheral ulcerative keratitis associated with chronic malabsorption syndrome and miliary tuberculosis in a child.

A 16-year-old girl presented with pain, redness, watering, and blurring of vision in her right eye. Slit lamp examination revealed the presence of peripheral ulcerative keratitis (PUK) and nodular scleritis. On clinical examination, the patient had stunted growth, low body mass index, and enlarged axillary nodes. Giardia cysts were present in the stool sample and histopathology of axillary lymph nodes showed caseating necrosis suggestive of tuberculosis (TB). A diagnosis of PUK with chronic malabsorption syndrome secondary to giardiasis and miliary TB was made. Oral metronidazole, anti-tubercular treatment, high protein diet and vitamin supplements were started. Topical steroids were started for peripheral ulcerative lesions following, which the PUK resolved.