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   Table of Contents - Current issue
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July-September 2022
Volume 12 | Issue 3
Page Nos. 247-377

Online since Tuesday, September 6, 2022

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EDITORIAL  

Neuro-Ophthalmology at a glance p. 247
Guliz Fatma Yavas
DOI:10.4103/2211-5056.355677  
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REVIEW ARTICLES Top

What's new in neuromyelitis optica spectrum disorder treatment? p. 249
Yi-Ching Chu, Tzu-Lun Huang
DOI:10.4103/2211-5056.355617  
Optic neuritis, an optic nerve inflammatory disease presenting with acute unilateral or bilateral visual loss, is one of the core symptoms of neuromyelitis optica spectrum disorder (NMOSD). The diagnosis of NMOSD-related optic neuritis is challenging, and it is mainly based on clinical presentation, optical coherence tomography, magnetic resonance imaging scans, and the status of serum aquaporin-4 antibodies. In the pathogenesis, aquaporin-4 antibodies target astrocytes in the optic nerves, spinal cord and some specific regions of the brain eliciting a devastating autoimmune response. Current pharmacological interventions are directed against various steps within the immunological response, notably the terminal complement system, B-cells, and the pro-inflammatory cytokine Interleukin 6 (IL6). Conventional maintenance therapies were off-label uses of the unspecific immunosuppressants azathioprine and mycophenolate mofetil as well as the CD20 specific antibody rituximab and the IL6 receptor specific antibody tocilizumab. Recently, four phase III clinical trials demonstrated the safety and efficacy of the three novel biologics eculizumab, inebilizumab, and satralizumab. These monoclonal antibodies are directed against the complement system, CD19 B-cells and the IL6 receptor, respectively. All three have been approved for NMOSD in the US and several other countries worldwide and thus provide convincing treatment options.
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The current clinical role of optical coherence tomography angiography in neuro-ophthalmological diseases p. 264
Serdar Bilici, Resat Duman
DOI:10.4103/tjo.tjo_55_21  
After the revolutionary effect of optical coherence tomography (OCT) on ophthalmology practice, recent OCT-based technology OCT angiography (OCT-A) also has rapidly gained a wide clinical acceptance. OCT-A is a noninvasive, depth-resolved imaging tool for the evaluation of retinal vascular changes. Since its introduction, the understanding of retinal vascular diseases, pacychoroid spectrum diseases, and other diseases have been enriched in many ways. More importantly, OCT-A provides depth-resolved information that has never before been available. The whole spectrum of neuro-ophthalmological diseases shows consistent peripapillary and macular capillary changes with structural and functional correlation. The superficial and deeper retinal and choroidal vasculatures are affected depending on the nature of the disease process. Therefore, OCT-A play an important role in the diagnosis and management of optic nerve-related diseases as well. In this review, we summarized existing literature on the use of OCT-A in neuro-ophthalmological diseases such as arteritic anterior ischemic neuropathy, nonarteritic anterior ischemic neuropathy, papillitis, papilledema, multiple sclerosis. Currently, OCT-A has an important position as a useful, noninvasive tool in the evaluation of neuro-ophthalmologic diseases; however, OCT-A has several limitations regarding its technical capabilities in challenging neuro-ophthalmic cases. With the improvement in the technical capacity of OCT-A, it will have a more important place in the diagnosis and follow-up of neuro-ophthalmological diseases in future.
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A review of the management of central retinal artery occlusion p. 273
Reema Madike, Sudha Cugati, Celia Chen
DOI:10.4103/2211-5056.353126  
Central retinal artery occlusion (CRAO), the ocular analog of a cerebral stroke, is an ophthalmic emergency. The visual prognosis for overall spontaneous visual recovery in CRAO is low. Furthermore, the risk of future ischemic heart disease and cerebral stroke is increased due to the underlying atherosclerotic risk factors. There is currently no guideline-endorsed treatment for CRAO. This review will describe the anatomy, pathophysiology, epidemiology, and clinical features of CRAO, and investigate the current and future management strategies.
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Review of surgical devices using small aperture optics p. 282
Robert Edward T. Ang, Michelle Marie Q. Araneta, Emerson M Cruz
DOI:10.4103/tjo.tjo_45_21  
Small aperture optics work by blocking unfocused peripheral light rays while allowing central light rays to focus on the retina. This pinhole effect creates an extended depth of focus and has been used in presbyopia correction, improving intermediate and near vision without markedly affecting distance vision. Another beneficial effect of small aperture optics is reducing aberrations caused by irregular corneas or irregular pupils. The first small aperture surgical device was the Kamra corneal inlay used on the nondominant eyes of presbyopic emmetropes. The pinhole concept was also adapted into the IC-8 intraocular lens (IOL) for presbyopia correction during cataract surgery and by the XtraFocus piggyback device to lessen unwanted aberrations in eyes with irregular corneas or pupils. The IC-8 IOL can be placed monocularly or binocularly with mini-monovision for further near vision improvement. The XtraFocus piggyback device can be placed either in the sulcus or capsular bag. The aim of this literature review is to synthesize evidence on the efficacy, safety, and patient-reported outcomes on surgical devices utilizing small aperture optics. A comprehensive search on PubMed was conducted with the keywords “small aperture optics,” “small aperture corneal inlay,” “small aperture IOL,” “Kamra corneal inlay,” “IC-8 IOL,” and “XtraFocus.” In this review, we describe the progression of small aperture surgical devices, patient criteria, visual outcomes, complications, satisfaction, and recommendations for surgical success.
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ORIGINAL ARTICLES Top

Evaluation of electrophysiological changes in migraine with visual aura p. 295
Mualla Sahin Hamurcu, Neslihan Bayraktar Bilen
DOI:10.4103/2211-5056.354281  
PURPOSE: The purpose of this study was to evaluate the electrical responses in the retina and cortex of migraine patients with electrophysiological tests and compare with healthy controls. MATERIALS AND METHODS: This prospective study included 18 migraine patients with visual aura and 28 healthy controls. Pattern-reversal visual evoked potentials (VEP) and flash electroretinography (fERG) of migraine patients during the headache-free period were compared with healthy controls. RESULTS: There were statistically significant differences in VEP results: P100 and N75 amplitudes increased significantly (P = 0.025 and P = 0.007 respectively) and P100 latency decreased significantly in migraine patients (P = 0.022). Furthermore, fERG scotopic combined cone and rod amplitude increased significantly in migraine patients (P = 0.01). CONCLUSION: Migraine brain displays abnormal visual evoked responses in between migraine attacks. In migraine eye, scotopic cone and rod response increased. The results of this study support the hyperexcitability of the retina and cortex in patients with migraine.
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Automated grating contrast-sensitivity: The easy test for hidden visual loss in recovered optic neuritis patient p. 301
Indra Tri Mahayana, Dhimas Hari Sakti, Tatang Talka Gani
DOI:10.4103/tjo.tjo_21_21  
PURPOSE: Residual visual loss is an important predictor of optic neuritis relapse and progression. This study aimed to investigate the hidden residual visual loss in patients with optic neuritis using automated contrast-sensitivity (CS) function testing. MATERIALS AND METHODS: This cross-sectional study investigated 29 recovered optic neuritis patients (age: 27.69 ± 13.32 years, range: 13–51). Twenty age-matched controls with normal visual acuity (VA, in LogMAR) were recruited, for comparison with patients' VA and CS function after stable recovery from optic neuritis (6 months of follow-up). CS tests used a novel software that displays a single set of Gabor patches (2 cycles per degree at 10° ×10° of visual angle) with contrasts grating from 100% to 0.1%. RESULTS: There were 13 adolescent patients (63.6%: retrobulbar neuritis [RN]; 36.4%: papillitis), 14 adult patients (50%: RN; 42.9%: papillitis), and only 2 older patients (all with neuroretinitis). There was improvement of VA in the patient group at first diagnosis and follow-up (VA initial vs. final: 1.438 ± 1.134 vs. 0.235 ± 0.272, P < 0.001). This VA improvement was similar to control group (P = 0.052). In CS, there were significant differences in patient versus control groups (69.069% ± 70.235% vs. 27.215% ± 25.27%, P = 0.025). Linear regression showed that initial VA and CS function could not predict final VA (P = 0.183 and P = 0.138, respectively). CONCLUSIONS: Patients with optic neuritis showed decreased CS compared to control group which indicated the residual visual loss. Automated CS testing is useful in detecting residual visual loss in patients who recovered from optic neuritis.
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Clinical outcomes and comparison of intraocular lens calculation formulas in eyes with long axial myopia p. 305
Robert Edward T. Ang, Aprille June B. Rapista, Jocelyn Therese M. Remo, Melody Ana T. Tan-Daclan, Emerson M Cruz
DOI:10.4103/tjo.tjo_7_21  
PURPOSE: The purpose of this study was to report the clinical and refractive outcomes of eyes with long axial length (AL) and high myopia that underwent cataract surgery and compare the performance of intraocular lens (IOL) calculation formulae on these eyes. Materials And Methods: This retrospective cohort included 183 eyes that underwent cataract surgery from January 2010 to December 2018. Demographics, AL, postoperative best-visual acuities, IOL power data, and postoperative complications were recorded. Refractive outcomes were analyzed and absolute predicted errors were compared between five IOL calculation formulas. RESULTS: The mean age included in the study was 65.4 ± 9.39 years with a mean AL of 26.76 ± 1.75 mm. Postoperatively, the mean sphere, cylinder, and manifest refraction spherical equivalent were 0.22 D ± 0.54, −0.78 D ± 0.50, and − 0.16 D ± 0.50, respectively. The average IOL power implanted was 11.12 D ± 4.59 D. No intraoperative complications were encountered, but there was one incidence of retinal tear with detachment reported postoperatively (0.55%). The Kane formula had the lowest mean absolute predicted error (MAE). A significant positive correlation between increasing AL and MAE was seen in the Sanders, Retzlaff and Kraft-Theoretical (SRK-T) and Ladas formulae but not statistically significant when the Kane, Barrett Universal II, and the Emmetropia Verifying Optical (EVO) formulae were used. CONCLUSION: Cataract surgery in eyes with long ALs and high myopia is safe with a low incidence of intraoperative and postoperative complications. The Kane, Barrett, and EVO formulae were equally accurate in calculating the IOL power and achieved the least amount of residual error postoperatively.
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Incidence and association of ocular manifestations with the disease severity in COVID-19 patients of northern region of India p. 312
Aalok Kumar, Lavanya Anuranjani
DOI:10.4103/tjo.tjo_12_22  
PURPOSE: Our study aims to find the incidence of ocular manifestations and to investigate the relation of ocular manifestations with the disease severity among coronavirus disease 2019 (COVID-19) patients. MATERIAL AND METHODS: Our study is a cross-sectional study done between May 15, 2020, and April 15, 2021, at Hind Institute of Medical Sciences, Lucknow, India. All COVID-19 patients who got admitted to our center between May 15, 2020, and April 15, 2021, were included in our study. We included 261 patients in our study. Diagnosis of COVID-19 was made by testing the nasal and pharyngeal swabs by (reverse transcriptase-polymerase chain reaction [RT-PCR]). An RT-PCR test positive was the criteria for admission in the COVID ward. Statistical analyses were performed using the Mann–Whitney U-test, Chi-square test, and Kolmogorov–Smirnov test. P < 0.01 was considered statistically significant. RESULTS: We included 261 patients in our study. Out of 261 patients, ocular manifestations were found in 43 (16.4%) patients. The patients with ocular manifestations had higher neutrophil counts, erythrocyte sedimentation rate (ESR), procalcitonin (PCT), C-reactive protein (CRP), and D-dimer values (P < 0.001). Patients with ocular manifestations were relatively more symptomatic concerning fever and myalgia. CONCLUSION: The incidence of ocular manifestations in COVID-19 patients was 16.4%. Ocular manifestation was significantly associated with raised neutrophil counts, CRP, ESR, PCT, and D-dimer values. Ocular manifestation was also significantly associated with higher body temperature and higher mean age. The findings of the study are suggestive of more severe disease in patients of COVID-19 with ocular manifestations.
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Binocular therapy as primary intervention in adults with anisometropic amblyopia p. 317
Kaushik Murali, Arpitha Ramesh, Sowmya Raveendra Murthy, Aditya Goyal
DOI:10.4103/tjo.tjo_37_21  
PURPOSE: Refractive correction and patching is the timetested mainstay of treatment for anisometropic amblyopia within the critical period of visual development. Binocular therapies using dichoptic training which overcome suppression by balancing the contrast between two eyes has been increasingly gaining ground. We evaluated the efficacy of dichoptic training in the adult population with anisometropic amblyopia. This study aims to evaluate the effectiveness of dichopticbased active vision therapy, using “VisuoPrime” software as primary intervention, in adults with anisometropic amblyopes. MATERIALS AND METHODS: A prospective interventional study in adults (18–40 years) with anisometropic amblyopia was conducted from August 2019 to March 2020. METHODS: Twentynine subjects with anisometropic amblyopia played binocular games through “VisuoPrime” software 30 min daily for 6 weeks. Bestcorrected visual acuity (BCVA) and binocularity was assessed at 1 and 3 months. Student's paired ttest, Wilcoxon signedrank sum test and MannWhitney tests were used. Statistical package of SPSS version 20.0 was used for analysis, considering P < 0.05 as statistically significant. RESULTS: BCVA of the amblyopic eye improved from 0.60 ± 0.40 logMAR to 0.45 ± 0.29 logMAR and 0.38 ± 0.23 logMAR at 1 and 3 months, respectively (P = 0.0001). Near acuity improved from 0.21 ± 0.14 to 0.14 ± 0.08 logMAR and 0.1 ± 0.04 logMAR at 1 and 3 months respectively (P < 0.0001). Improvement in stereopsis was observed in 24% of subjects which maintained at 3 month followup. CONCLUSION: Dichopticbased active vision therapy using “VisuoPrime” software was effective as a primary modality in adults with anisometropic amblyopia.
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Effect of teprotumumab on intraocular pressure in thyroid-associated ophthalmopathy p. 325
Modupe O Adetunji, Brian J Nguyen, Brendan McGeehan, Madhura A Tamhankar, Cesar A Briceno
DOI:10.4103/tjo.tjo_30_22  
PURPOSE: To examine changes in intraocular pressure (IOP) in patients with thyroid eye disease (TED) following teprotumumab. MATERIALS AND METHODS: A retrospective review of 17 patients with TED who received teprotumumab between January 2020 and September 2021 was conducted. IOP, extent of proptosis, and clinical activity score were reviewed at baseline and at 6 weeks, 12 weeks, and 24 weeks for patients undergoing teprotumumab treatment. The primary outcome measure was change in IOP, while secondary outcome measures included changes in proptosis and clinical activity score. RESULTS: Of the 17 patients (34 eyes) with TED who were treated with teprotumumab, the mean age was 50.5 years, and 15 (88%) were female. The mean baseline IOP was 20 mm Hg (range 13–28), and the mean baseline clinical activity score was 3.8 (range 0–6). Of the 34 eyes examined at baseline, examinations were repeated in 16 at 6 weeks, 26 at 12 weeks, and 8 at 24 weeks. At week 6 of treatment, mean IOP decreased by 4.9 mm Hg (P < 0.0001). At week 12 of treatment, mean IOP decreased by 4.6 mm Hg (P < 0.0001). Mean IOP was decreased at last record of follow-up by 4.9 mm Hg (P < 0.0001). CONCLUSION: Among patients with TED, teprotumumab treatment was associated with a reduction in IOP.
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Microbial profile of lacrimal system Dacryoliths in American Midwest patient population p. 330
Peter M Kally, Amro Omari, Dianne M Schlachter, Robert Folberg, Francesca Nesi-Eloff
DOI:10.4103/2211-5056.354280  
PURPOSE: Dacryoliths of the canalicular pathway are classically attributed to Actinomyces species as the most common organism. However, global shifts toward Streptococcus and Staphylococcus species have been reported. The objective of this article is to update the American Midwest epidemiology of lacrimal system dacryoliths for targeted clinical treatment. MATERIALS AND METHODS: A retrospective chart review from January 2015 to 2021 of patients with a history of surgical procedure for lacrimal removal of dacryolith for canaliculitis, canalicular obstruction, dacryocystitis, and nasolacrimal duct obstruction was included. Specimens were sent for histopathological evaluation and microbial culture. RESULTS: A total of 48 specimens were included. The most common organism isolated for canalicular pathology was Actinomyces spp (23%), followed by Staphylococcus spp (21%) and Streptococcus spp (19%). Histopathological staining accounted for 45% of Actinomyces isolation when culture data inconclusive. In a subgroup analysis of lacrimal sac dacryoliths, the most common organism was Staphylococcus spp (29%). Actinomyces species were not isolated from the lacrimal sac or nasolacrimal duct. CONCLUSION: Actinomyces maintains a microbial predominance in canalicular dacryoliths and requires careful culture and histopathological analysis for its fastidious nature. Lacrimal sac and nasolacrimal duct dacryolith found no isolates of Actinomyces, and the most common organism was Staphylococcus.
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CASE REPORTS Top

A case of aseptic bilateral cavernous sinus thrombosis following a recent inactivated SARS-CoV-2 vaccination p. 334
Syntia Nusanti, Ikhwanuliman Putera, M Sidik, Lukman Edwar, Sukamto Koesnoe, Andhika Rachman, Mohammad Kurniawan, Tri Juli Edi Tarigan, Reyhan Eddy Yunus, Indah Saraswati, Siti Halida Zoraida Soraya, Tiara Grevillea Pratomo, Rina La Distia Nora
DOI:10.4103/tjo.tjo_25_22  
This case report aims to describe the first report of bilateral aseptic cavernous sinus thrombosis (CST) with a recent history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. A 50-year-old woman presented with bilateral proptosis, decreased vision, and ophthalmoplegia 16 days following CoronaVac® vaccine. The visual acuity of the left eye was 20/150, while the right eye was no light perception with a hyperemic optic nerve head. She had a history of hyperthyroidism and currently on warfarin consumption. Laboratory results depicted elevated free T4, free T3, international normalized ratio, and low protein S and C. Magnetic resonance imaging showed bilateral CST, and high-dose methylprednisolone along with fondaparinux was given. The symptoms were significantly resolved, with the visual acuity of the left eye being improved to 20/20 but not the right eye. Bilateral CST has not been previously reported following inactivated SARS-CoV-2 vaccination. The underlying systemic conditions should be taken into consideration for the possibility of the inactivated SARS-CoV-2 vaccine-related event.
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Vitreous cytology as the only diagnostic evidence of central nervous system involvement in a patient with isolated leukemic infiltrative optic neuropathy p. 339
Wen-Yi Wang, Chao-Wen Lin
DOI:10.4103/tjo.tjo_89_20  
A 29-year-old female with treated acute lymphoblastic leukemia in remission presented with blurred vision and pain on movement of the right eye. On examination, visual acuity was 20/25 in the right eye and 20/20 in the left eye. Direct ophthalmoscopy revealed that the optic disc was swollen with peripapillary hemorrhage in the right eye. The rest of the clinical examination was within normal limits. Magnetic resonance imaging demonstrated enhancement of her right optic nerve. Lumbar puncture and bone marrow examination revealed no malignant cells. Only vitreous fluid cytology showed blast cells. Intravitreal injection of methotrexate was given, and repeated vitreous tapping was normal. The vision of her right eye remained 20/20 until 1 year later when optic disc and retinal vascular occlusion was noted. Her vision deteriorated to no light perception within 2 weeks, and optociliary shunt vessels occurred. Isolated disc swelling with positive vitreous cytology can be the first and only presentation of relapsed hematologic disorders. Infiltrative optic neuropathy should be considered in the differential diagnosis of optic disc edema. Vitreous tapping could be considered as the diagnostic procedure even if the results of lumbar puncture were negative.
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Ethambutol optic neuropathy with correspondent chiasmitis manifestation in magnetic resonance imaging p. 343
Yu-Wei Lin, Jia-Kang Wang, Tzu-Lun Huang
DOI:10.4103/tjo.tjo_27_21  
We present a case of an older patient with toxic chiasmatic optic neuropathy accompanied by bitemporal hemianopia associated with ethambutol use. The patient experienced gradual visual defect recovery that was concurrent with an improvement of chiasmal enhancement in the repeat magnetic resonance imaging performed at his 6-month follow-up. However, his visual field pattern sharply changed to left inferior homonymous quadrantanopia because of a new episode of occipital lobe infarction. After 2 years, the patient's visual function reached the best-corrected visual acuity of 20/20 in both eyes, although he had the sequela of homonymous quadrantanopia related to the infarction. Optical coherence tomography revealed that the loss on the macular ganglion cell–inner plexiform layer was related to retrograde transsynaptic degeneration caused by ethambutol-related chiasmopathy.
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Idiopathic horner syndrome diagnosed remotely using telemedicine p. 347
Michael A Jordan, Collin M McClelland, Michael S Lee
DOI:10.4103/tjo.tjo_75_20  
Idiopathic Horner Syndrome Diagnosed Remotely using Telemedicine. The novel Coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), pandemic has altered the field of ophthalmology in myriad ways. During the initial lockdown period in March, the use of telemedicine expanded to adhere to public health guidelines. The field of neuro-ophthalmology is an ophthalmic sub-specialty less prone to the use of telemedicine. We present a case of isolated idiopathic Horner syndrome in a 39 year old female diagnosed through telemedicine.
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Presumed diffuse unilateral subacute neuroretinitis and cat-scratch disease: Dual infection in a single patient p. 349
Abdul Rahman Siti-Khadijah, Yaakub Azhany, Mohd Ansul Norwazilah, Ahmad Tarmidzi Nor-Azita
DOI:10.4103/tjo.tjo_92_20  
A healthy 35-year-old Malay woman presented with left eye pain for 1 week, and ocular examination showed evidence of panuveitis. She had granulomatous type of anterior uveitis with secondary high intraocular pressure (IOP). Fundus showed optic disc swelling, mild vitritis, and multiple subretinal lesions, which later formed a migratory track. A diagnosis of presumed diffuse unilateral subacute neuroretinitis was made. At the same time, the serology test for Bartonella henselae was positive. The patient was treated with antiglaucoma medicine and topical steroids. An antihelminthic was initially used, and later, an antibiotic for cat-scratch disease was added. In addition, focal laser photocoagulation was performed. After 3 months, her visual acuity improved together with a reduction in inflammation and well-controlled IOP.
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Optical coherence tomography as a useful adjunct in the early detection of meningioma with optic nerve compression p. 354
En-Che Chang, Jing-Shan Huang, Yu-Chih Hou, Chu-Hsuan Huang, I-Hua Wang
DOI:10.4103/tjo.tjo_54_21  
A 48-year-old woman presented with persistent clouding vision in her lower field in the right eye for 5 months. A small retinal hemorrhage was initially reported. Her visual acuity was 20/30 in the right eye and 20/20 in the left, with normal color vision and pupil response. Fundus examination did not reveal any retinal hemorrhage. Although optical coherence tomography (OCT) showed normal macula and retinal nerve fiber layers in both eyes, asymmetric thinning of the ganglion cell inner plexiform layer was found in the superior macula of the right eye in ganglion cell analysis (GCA). Visual field examination revealed a subtle inferonasal scotoma. Compressive optic neuropathy (CON) was suspected. The visual evoked potential test revealed delayed P100 latency. A tuberculum sellae meningioma was found with right medial optic canal extension. The visual acuity of the right eye returned to 20/25 after decompression surgery. OCT can be used to differentiate between retinopathy and optic neuropathy. GCA can help in the early detection of CON and achieve a good visual outcome after surgery.
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Peripapillary choroidal neovascularization associated with optic nerve sheath meningioma p. 360
Wen-Pen Liao, Cheng-Kuo Cheng, Pai-Huei Peng
DOI:10.4103/2211-5056.353125  
Peripapillary choroidal neovascularization (PPCNV), a rare presentation of optic nerve sheath meningioma (ONSM), is associated with various ocular pathologies. Herein, we report a case with characteristics of age-related macular degeneration, PPCNV, optic disc edema, and a retinal–choroidal venous collateral. In addition to the recognition of an orbital base ONSM, magnetic resonance imaging revealed a distended perioptic subarachnoid space with the accumulation of cerebrospinal fluid anterior to the tumor. On the basis of these clinical findings, we postulated the pathogenesis of PPCNV-associated ONSMs.
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Fibrous dysplasia: A rare cause of optic neuropathy p. 364
Sepideh Lotfi Sadigh, Serdar Ozer, Elif G Bulut, Guliz F Yavas
DOI:10.4103/tjo.tjo_27_22  
Fibrous dysplasia (FD) is a progressive and benign osteodystrophic disease where cranial bones are most commonly affected. In this case report, we present a 27-year-old patient with previous diagnosis of FD who was referred to our clinic with sudden loss of visual acuity and color discrimination. Examination of the right eye was normal, whereas visual acuity on the left eye was 6/9 and color vision (CV) with Ishihara test plates was 9/12. The visual field (VF) demonstrated a peripheral concentric defect on the left eye. As visual acuity in the left eye decreased to 6/30 and computed tomography imaging of the brain and orbit showed optic nerve compression by immature bony structures, optic nerve decompression was recommended with the diagnosis of compressive optic neuropathy. Endoscopic transnasal orbital and optic canal decompression was performed. At the postoperative course, visual acuity on the left eye turned to 6/6, CV was 12/12, and VF improved markedly. In subjects with craniofacial FD, a multidisciplinary approach is important. If there is evidence of compressive optic neuropathy, surgery should be performed.
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The clinical presentation and treatment of an invasive conjunctival squamous spindle cell carcinoma p. 370
Chau-Yin Chen, Sheng-Wen Wang, Chien-Hsiung Lai, Hui-Chieh Chuang, Ying-Yu Lin, Jin-Jhe Wang
DOI:10.4103/tjo.tjo_26_21  
Ocular surface squamous neoplasia represents neoplastic epithelial abnormalities of conjunctiva and cornea, ranging from squamous dysplasia to invasive squamous cell carcinoma and is both sight- and life-threatening. Squamous spindle cell carcinoma (SSCC) of conjunctiva is a rare variant with distinct behavior which is thought to be more locally aggressive. We describe an 83-year-old woman with a progressively enlarging huge SSCC in her right eye over the past 2 years. The tumor bulged out with local invasion into intraocular and orbital cavities. Wide excision of the tumor with frozen section control was performed. After surgery, topical 0.03% mitomycin C was given as adjuvant therapy. At 40-month follow-up, the lesion site showed no evidence of local recurrence. This case provides a valuable and complete experience of the clinical presentation for the progression and treatment of this rare disease.
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Personalized multidisciplinary approach of orbital apex foreign body: A case report and literature review p. 374
Yi-Ting Hou, Yi-Hsuan Wei, Chun-Kang Liao, Chih-Feng Lin
DOI:10.4103/tjo.tjo_26_22  
Foreign bodies in the intraconal space are unusual, and lodgment at the orbital apex was even more unusual. High-velocity object injuries, such as gunshots or industrial accidents, are the common causes of intraorbital foreign bodies. It is difficult for surgeons to retrieve foreign bodies from the orbital apex as it is a deep, narrow space with critical surrounding structures. The use of an image-guided navigation system improves the accuracy of transnasal endoscopic surgery and causes less damage. We present a case in which a bullet became lodged in the orbital apex and was successfully removed using transnasal endoscopic surgery with the collaboration of otolaryngologists and ophthalmologists. To summarize, orbital apex foreign bodies are harmful, and prompt removal with a personalized multidisciplinary approach is critical.
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