A case of tubulointerstitial nephritis and uveitis syndrome after suspected drug-induced acute interstitial nephritis

Distinguishing between late-onset TINU syndrome and drug-induced AIN remains difficult given that patients with TINU syndrome may develop uveitis long after the onset of AIN. Therefore, ophthalmic examination is required not only upon diagnosis but also continuously or when eye symptoms, and relapse of urinary findings are observed.

Ocular manifestations in children with developmental delay in an eye hospital of northern Bangladesh

Background: The aim of this study was to identify common ocular manifestations in children with developmental delay in an eye hospital of northern part of Bangladesh.Methods: It was a retrospective medical record review of children with developmental delay who attended the pediatric ophthalmology department in an eye hospital from January 2019 to December 2019. Data were collected for their age, gender, past medical history, ophthalmic examination findings and systemic problems. Ophthalmic examination included examination of lid and adnexa, anterior and posterior segment examination and assessment of squint and refraction.Results: Medical records of 102 with developmental delay were identified and studied (59 boys and 43 girls, mean age 1.57 years, 53.9% aged <1 year). Of these children, 44 (43.1%) were referred by the pediatricians. The most common past medical histories were perinatal asphyxia (42.2%), history of convulsion (30.4%), neonatal seizures (9.8%) and history of speech delay (1%). On ophthalmic examination, 30 (29.5%) had poor vision, 20 (19.6%) had refractive error, 23 (22.5%) had Strabismus and 11 (10.8%) had nystagmus. Optic atrophy was also observed among 11 children (10.8%).Conclusions: Ocular manifestations are commonly seen in children with developmental delay which can be cause of severe visual impairment and overall disability in later life. Hence an early ophthalmologic screening and intervention in these children by developing good referral network between ophthalmologist and pediatricians can help to substantially improve the developmental and academic achievement.

Computer Vision Syndrome Prevalence and Ocular Sequelae among Medical Students: A University-Wide Study on a Marginalized Visual Security Issue

Introduction: This study aimed to discover and document the potential of visual and ocular sequelae of computer vision syndrome (CVS) among medical students. Methods: This cross-sectional case-control study was conducted on medical students (n=4030) of five universities in Egypt. All students completed a specially designed and validated CVS questionnaire survey (CVS-F3). Students with ≥5 CVS symptoms constituted a risk group (n=352), while students with 1-4 CVS symptoms constituted a low-symptoms group (n=3067). Students from the control and risk groups were examined using objective methods, such as visual acuity, subjective refraction, dry eye disease tests, and anterior segment and fundus examinations. Students who complained of visual blur underwent multifocal electroretinography mfERG examinations (mfERG group). Results: The CVS-F3 indicated that 84.8% of students had complaints that might be related to CVS, however, our ophthalmic examination group revealed only a 56% CVS prevalence rate. The most common single screen type used by 70.4% of students was the smartphone, and the most common complaint was headache (50.2%). Multivariate logistic regression analysis revealed that CVS was significantly associated with increased screen-hours, including >2 screen-hours daily (odds ratio [OR], 2.48; P<0.0001), >2 screen-hours at night (OR, 1.79; P=0.003), and ≥3 screen-years (OR, 1.69; P=0.006). In the mfERG group, 37% demonstrated reduced amplitudes of mfERG rings and quadrants, indicating reduced foveal responses. Conclusion: CVS-questionnaires overestimate the true CVS prevalence and sequelae, which could be accurately detected by objective ophthalmic examination. Smartphones primarily caused CVS among students, with CVS severity increasing in correlation with shorter eye-to-screen distance and frequent use. Contact lens wearing doubled the risk of CVS development and augmented its severity. CVS might affect macular integrity with screen-induced foveal dysfunction. Clinical Trials Registration: PACTR201811618954630.

A monoklonális gammopathia szemészeti jelei és szövődményei.

Összefoglaló. Célkitűzés: A monoklonális gammopathia szemészeti jeleinek és szövődményeinek vizsgálata. Betegek és módszerek: Két nagy budapesti hematológiai ellátóhely 1999 és 2020 között diagnosztizált és/vagy kezelt, monoklonális gammopathiát mutató betegeit vizsgáltuk (42 beteg 84 szeme, 42,86% férfi; átlagéletkor 63,83 ± 10,76 év). A hematológiai diagnózis 3 esetben bizonytalan jelentőségű monoklonális gammopathia, 34 esetben myeloma multiplex, 3 esetben parázsló myeloma, 1-1 esetben Waldenström-macroglobulinaemia és amyloidosis voltak. Kontrollcsoportként véletlenszerűen kiválasztott, hasonló korcsoportú, hematológiai betegség nélküli egyéneket vizsgáltunk (43 beteg 86 szeme, 32,56% férfi; átlagéletkor 62,44 ± 11,89 év). A szemészeti vizsgálat előtt minden személy kitöltötte a Szemfelszíni Betegség Index (OSDI-) kérdőívet. A szemészeti vizsgálat során a látóélesség vizsgálata mellett pupillatágítást követően réslámpás vizsgálatot végeztünk. Eredmények: Monoklonális gammopathiában az OSDI-érték szignifikánsan magasabb volt, mint a kontrollokban (p = 0,002). Gammopathiában 3 beteg 5 szeménél (5,95%) találtunk potenciális szaruhártya-immunglobulinlerakódást. Gammopathiában szárazszem-betegség 66,67%-ban, szürke hályog 55,95%-ban, Meibom-mirigy-diszfunkció 20,24%-ban, hátsó kérgi szürke hályog 19,05%-ban, egyéb szaruhártyahegek és -homályok 17,86%-ban, krónikus szemhéjgyulladás 14,29%-ban, szemészeti eltérés hiánya 11,90%-ban, macula- és/vagy retinadrusen 9,52%-ban, szaruhártya-immunglobulinlerakódás 5,95%-ban, epiretinalis membrán 5,95%-ban, korábbi szürkehályog-műtét 5,95%-ban, glaucoma 4,76%-ban, Fuchs-dystrophia 2,38%-ban, perifériás retinadegeneráció 2,38%-ban, chorioidea naevus 2,38%-ban, diabeteses retinopathia 1,19%-ban, arteria centralis retinae elzáródás 1,19%-ban, vena centralis retinae ágelzáródás 1,19%-ban, amblyopia 1,19%-ban volt kimutatható. A szárazszem-betegség (p = 0,002), a hátsó kérgi szürke hályog (p = 0,001), a szürke hályog (p<0,00001) és az egyéb szaruhártyahegek és -homályok (p = 0,01) szignifikánsan magasabb arányban fordultak elő a monoklonális gammopathiát mutató betegekben, mint a kontrollokban. Következtetés : Monoklonális gammopathiában a szárazszem-betegség és a szürke hályog a leggyakoribb szemészeti eltérés. A monoklonális gammopathia potenciális szemészeti jelei és szövődményei miatt javasoljuk a betegek évenkénti szemészeti ellenőrzését, életminőségük javítása érdekében. Orv Hetil. 2021; 162(38): 1533–1540. Summary. Objective: To examine ocular signs and ocular comorbidities in monoclonal gammopathy. Patients and methods: We analyzed patients from two large referral hematology centers in Budapest, who were diagnosed and/or treated with monoclonal gammopathy between 1997 and 2020 (84 eyes of 42 patients, 42.86% male, mean age 63.83 ± 10.76 years). Before the ophthalmic examination, the subjects filled in the Ocular Surface Disease Index (OSDI) questionnaire. Ophthalmic examination included visual acuity test and slit-lamp examination following dilation of the pupil. Results: OSDI scores were significantly higher in subjects with monoclonal gammopathy than in controls (p = 0.002). Among gammopathy subjects, we observed potential corneal immunoglobulin deposition in 5 eyes of 3 patients (5.95%). In gammopathy subjects, there was dry eye disease (66.67%), cataract (55.95%), Meibomian gland dysfunction (20.24%), posterior cortical cataract (19.05%), corneal scars and degenerations (17.86%), chronic blepharitis (14.29%), absence of ocular complaint (11.90%), macular or retinal drusen (9.52%), corneal immunoglobulin deposition (5.95%), epiretinal membrane (5.95%), previous cataract surgery (5.95%), glaucoma (4.76%), Fuchs dystrophy (2.38%), peripheral retinal degeneration (2.38%), chorioideal naevus (2.38%), diabetic retinopathy (1.19%), central retinal artery occlusion (1.19%), central retinal vein branch occlusion (1.19%) and amblyopia (1.19%). The proportion of dry eye disease (p = 0.002), posterior cortical cataract (p = 0.001), cataract (p<0.00001), and corneal scars and degenerations (p = 0.01) were significantly higher in gammopathy subjects than in controls. Conclusion: Dry eye disease and cataracts are the most common ocular comorbidities in patients with monoclonal gammopathy. Therefore, due to the potential ocular signs and comorbidities of monoclonal gammopathy, we suggest a regular, yearly ophthalmic checkup of these patients to improve their quality of life. Orv Hetil. 2021; 162(38): 1533–1540.

Challenges of personal protective equipment use among ophthalmologists during the COVID-19 pandemic: A multicenter international study

Purpose: To explore the possible challenges and difficulties of using Personal Protective Equipment (PPE) in ophthalmic practice during the Coronavirus disease 2019 (COVID-19) pandemic. Methods: This is a multicenter, international survey among practicing ophthalmologists across different countries. The survey was conducted from September 9th to October 24th, 2020. It included a total of 23 questions that navigated through the currently adopted recommendations in different clinical situations. The survey also assessed the convenience of using various PPE in ophthalmic practice and addressed the clarity of the examination field while using various PPE during clinical or surgical procedures. Results: One hundred and seventy-two ophthalmologists completed the survey (101 from Egypt, 50 from the USA, and 21 from four other countries). The analysis of the responses showed that most ophthalmologists use face masks without significant problems during their examinations, while face shields followed by protective goggles were the most inconvenient PPE in the current ophthalmic practice. Moreover, most of the participants (133, 77.3%) noticed an increase in their examination time when using PPE. Furthermore, a considerable percentage of the respondents (70, 40.7%) stopped using one or more of the PPE due to inconvenience or discomfort. Conclusions: Due to the unique nature of the ophthalmic examination, certain PPE are not ophthalmologist-friendly. Innovative PPE should be tailored for prompt, more convenient, and clearer ophthalmological practice.

Unilateral acute posterior multifocal placoid pigment epitheliopathy in a convalescent COVID-19 patient

Background To report a case of unilateral acute posterior multifocal placoid pigment epitheliopathy (APMPPE) in a Hispanic convalescent COVID-19 female patient. Case presentation A 35-year-old Hispanic female with exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was evaluated due to unilateral visual loss. Ophthalmic examination and diagnostic tests were consistent with APMPPE. Discussion Ocular changes can be observed in patients with COVID-19. A complete ophthalmic evaluation must be performed in patients with low vision after SARS-CoV-2 infection.

Eversion of the Third Eyelid Cartilage in a Cat

Background: Eversion of the cartilage of the third eyelid is a rare congenital disease in cats. It is caused by the anterior eversion of the cartilage edge of the third eyelid. Clinical signs may be associated with secondary keratoconjunctivitis, third eyelid gland protrusion, and ocular surface irritation. The diagnosis is made by ophthalmic examination, and treatment consists of surgical resection of the everted cartilage portion. The goal of the present study was to report a case of eversion of third eyelid cartilage in a cat, given that it is an unusual abnormality in this animal species, and an important differential diagnosis to be considered in the disorders of the third eyelid.Case: A 6-year-old neutered female Persian cat was presented with a presumptive diagnosis of protrusion of the third eyelid gland, history of ocular irritation, and epiphora in the left eye. The disorder had been intermittently present since the animal was 1-year-old, with spontaneous disappearance after approximately 15 days. The owner related the reappearance of the disorder to stressful situations, with no previous history of trauma or other ocular alteration. During the ophthalmic examination, suspended solute was observed through biomiscroscopic examination in both eyes, as well as an increase in volume of the third eyelid in the left eye, without other changes. A thorough examination, under general anesthesia, indicated the protruding volume of the cartilage of the everted third eyelid. The third eyelid was pleated in its upper portion, demonstrating that the cartilage of the third eyelid was folded instead of following the curvature of the ocular surface. Under general anesthesia, the cartilage was partially removed through two parallel incisions on the bulbar conjunctival surface, divulsioning 5 mm in length in the vertical portion of the cartilage in a ‘T’ shape, and separating the conjunctiva from the underlying cartilage. The everted portion of cartilage, once removed, was in fact considered curved in its most dorsal portion, in a manner similar to what was reported in dogs. The third eyelid returned to its anatomically correct position after removing the deformed portion of the cartilage. The patient was treated postoperatively with topical drops of tobramycin and dexamethasone 3 mg/mL + 1 mg/mL (Tobradex®), and lubricant based on sodium hyaluronate 2 mg/mL (Hylo®-Gel). No complications were observed in the postoperative consultations during a 8 month follow-up.Discussion: It is suspected that the eversion of the third eyelid cartilage occurs due to a differential growth rate between the posterior and anterior portions of the cartilage; even though other theories have been proposed. The cartilage of the third eyelid can commonly be everted in large dog breeds, being classified as a disease of hereditary character. However, it has rarely been reported in cats, which can be explained by the more elastic histological constitution when compared to that of dogs. The surgical procedure performed in the present case of eversion of the third eyelid cartilage in a cat was in accordance with that described in the literature. Complete recovery of the third eyelid function was achieved, and the patient's ocular health was preserved. The reported case showed a favorable prognosis after diagnosis, associated with correct treatment and postoperative management. Although there was an effective recovery of the third eyelid, the issues related to the pathophysiology of cartilage eversion are unknown. This way, further studies are necessary to elucidate its etiology.

The Importance of Ophthalmic Examination in Initial Diagnostic Process of Xanthoma: Two Case Reports and Literature Review of Cerebrotendinous Xanthomatosis

Background: Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disease where deficiency of sterol 27-hydroxylase leads to reduced production of CDCA. In such cases, life expectancy is only 4–6 decades, with progressive neurologic dysfunction such as dementia and spinal cord paresis, unless the condition is diagnosed early and treated appropriately. Herein, we aim to raise awareness regarding the importance of ophthalmic examination in evaluating of xanthoma. Clinical Cases: Case 1: In a 58-year-old man with no neurological symptoms; bilateral cataracts were detected during the initial diagnostic process. This patient had two siblings with xanthoma; one died from cerebral infarction and the other from biliary tract cancer. Another sibling had premature acute cardiovascular disease without xanthomas. Baseline lipid profiles were nearly within the normal range, while lipoprotein A was approximately 2.5 times higher than the normal. CTX was confirmed by the detection of a homozygous mutation in the CYP27A1 gene and high plasma cholestanol level (8.5 mg/L; reference range 0.0–5.0 mg/L). He has been taking oral CDCA (250 mg, three times daily). Case 2: In a 24-year-old man with no neurological symptoms or intellectual disability, premature bilateral cataracts were detected 1 year prior to diagnosis of CTX. None of his family members had xanthoma or premature cardiovascular disease. Lipid profile showed a similar pattern to that of Case 1; CTX was confirmed by the detection of a homozygous mutation in the CYP27A1 gene and high plasma cholestanol level (21.33 mg/L). One year after starting CDCA (250 mg, three times daily), cholestanol levels dropped to 7.34 mg/L. They were measured annually and identified as 5.08 mg/L, 4.2 mg/L, 4.7 mg/L, and 3.8 mg/L at 24, 38, 61, and 72 months, respectively. It took approximately 2 years for the normalization of his cholestanol level. There were no recurrences of xanthoma or progression of complications in target organs after 6 years of treatment. Conclusion: Early diagnosis improves the outcomes of CTX, allowing proper treatment. Bilateral cataracts caused by cholestanol buildup on the crystalline lens due to CTX usually occur within the first three decades of life. This manifestation does not occur in patients with xanthoma, familial hypercholesterolemia, or sitosterolemia. Taken together, this report suggests that premature bilateral cataracts are a specific marker that can accelerate early diagnosis of CTX. References: (1) Duell PB et al. Diagnosis, Treatment and Clinical Outcomes in 43 Cases with CTX. Journal of Clinical Lipidology. 2018;12:1169 (2) Salen G, Steiner RD. Epidemiology, diagnosis, and treatment of CTX. J Inherit Metab Dis 2017: 40:771