AIM:To evaluate the clinical, sensory, and motor characteristics of patients with Brown syndrome treated at a tertiary health care center, with a focus on the long-term outcomes of conservative and surgical interventions. MATERIAL AND METHODS:This retrospective case series evaluated 14 patients diagnosed with Brown syndrome. A comprehensive clinical assessment included a detailed history, best-corrected visual acuity, a prism cover test for primary position deviation, nine-gaze motility with quantitative elevation-in-adduction, fundus torsion, and sensory status. Of 14 patients, 11 had congenital Brown syndrome and 3 had acquired forms. Congenital cases were stratified by severity using standard criteria: mild (isolated elevation deficit in adduction with orthophoria; n = 4), moderate (downshoot in adduction with minimal/no primary deviation; n = 2), and severe (significant primary vertical deviation ± abnormal head posture; n = 5). Mild to moderate cases underwent observation with appropriate refractive correction, and acquired cases underwent etiology-specific management, which also included observation for the restrictive strabismus. Severe congenital cases (n = 5) underwent superior oblique chicken suture lengthening. RESULTS:Following a one-year follow-up, mild (n = 4) and moderate (n = 2) congenital cases remained stable without progression under conservative management, whereas acquired etiologies (n = 3) showed resolution after etiology-targeted management. Five patients with the congenital severe form achieved successful primary position alignment after superior oblique chicken suture lengthening, with improvements in objective torsion, abnormal head posture, and stereoacuity, without any adverse outcomes. CONCLUSION:Most cases of Brown syndrome (64%) can be managed by adopting a conservative approach, depending on the etiology and severity. Only severe forms with significant primary position deviation require surgical intervention. Superior oblique chicken suture lengthening is a safe procedure that yields favorable long-term outcomes with minimal complications.

Context:Diabetic cardiomyopathy is an entity with a multifactorial pathophysiology, in which insulin resistance plays a key role. It increases the risk of heart failure with preserved ejection fraction (HFpEF) in type 2 diabetes mellitus (T2DM). The Triglyceride-Glucose Index (TGI) is a novel measure of insulin resistance which is simple to use and may serve as an accessible marker for subclinical HFpEF. Aims:To evaluate the association between TGI and subclinical HFpEF in asymptomatic patients with T2DM and assess its diagnostic performance. Methods:This was a cross-sectional observational analytic study in which 274 asymptomatic T2DM patients aged 18-60 years were enrolled. Patients with known cardiovascular disease, hypertension, macro- and microvascular complications, and other major comorbidities were excluded. TGI was calculated, and all participants underwent 2D echocardiography to assess left ventricular diastolic function. Results:LV diastolic dysfunction (LVDD) was detected in 62.4% of participants. TGI was significantly higher in patients with LVDD (mean 9.69 ± 0.49) versus those without (mean 9.23 ± 0.63), P < 0.001. ROC analysis identified a TGI cutoff of 9.34 as optimal for detecting LVDD, yielding a sensitivity of 80%, a specificity of 63%, and an AUROC of 0.734. To achieve high sensitivity (100%) and NPV (100%), the cutoff of 8.32 is best for screening for LVDD. Conclusions:TGI demonstrates fair diagnostic accuracy for identifying subclinical HFpEF in T2DM. Given its simplicity and cost-effectiveness, it may be considered a valuable screening tool in resource-limited settings.

AIM:To report long-term postoperative outcomes of external dacryocystorhinostomy (Ext-DCR) with U-flap and nasolacrimal intubation in adult patients with small lacrimal sac and primary nasolacrimal duct obstruction (NLDO). MATERIAL AND METHODS:This case series was conducted in a tertiary health care center of North India and included 26 patients who underwent Ext-DCR with U-flap with nasolacrimal intubation for primary NLDO and small lacrimal sac from June 2021 to January 2024 with a minimum follow-up period of 12 months. RESULTS:Out of 26 patients, 22 were females with a mean age of 50 years (range 21-60). All patients had a history of purulent discharge from the affected eye. Excessive bleeding was the most common intraoperative challenge faced in most of the cases (6, 23%). The intubation set was removed 12 weeks after surgery. Two female patients had tube-related complications in the form of granuloma formation, and two patients had tube retraction, one had slitting of the punctum, and another acquired an infection. The remaining 20 patients had an uneventful postoperative period. The outcomes of only 2 patients were reported as failures (8%), and the remaining 24 reported successful outcomes (92%) after 12 months of follow-up. CONCLUSION:Ext-DCR with U-flap and nasolacrimal intubation is an effective procedure with a high long-term success rate in adult patients with a small lacrimal sac and primary NLDO.

AIM:The study aimed to explore the association between duration of smartphone usage and tear film parameters in adolescents through a hospitalbased cross-sectional study. MATERIAL AND METHODS:A detailed history regarding smartphone usage was obtained, followed by tear film assessment for all the study participants. Tear meniscus height (TMH), Tear film break up time (TBUT), and Schirmer's I test were done for all participants. Then they were classified into four groups, based on daily smartphone usage: &lt; 2 hours/day, 2-4 hours/day, 4-6 hours/day, and &gt; 6 hours/day. RESULTS:123 smartphone users of the adolescent age group aged 10-19 years (mean age: 16.6 ±2.8 years) were included. The mean values of tear film parameters were as follows: TMH was 0.25 ±0.1 mm, Schirmer's I was 17.7 ±9.2 mm, and TBUT was 10.5 ±5.7 seconds. Participants using smartphones for &gt; 6 hours/day had a significantly higher prevalence of reduced TMH (&lt; 0.25 mm) compared to those with lower usage durations (p &lt; 0.0001). Similar trends were observed for Schirmer's I and TBUT values, indicating a statistically significant association between prolonged smartphone use and tear film dysfunction (p &lt; 0.0001). Notably, 72.7% of eyes in the &gt; 6 hours/day group exhibited tear film dysfunction, significantly higher than in other groups. CONCLUSION:Prolonged smartphone use adversely affects tear film stability and ocular surface health in adolescents. Awareness and appropriate measures to limit excessive screen time are essential to prevent tear film dysfunction and associated ocular discomfort.

BACKGROUND:Tricuspid valve (TV) pouch is a rare entity associated with ventricular septal defect (VSD). It is even rarer to cause right ventricular (RV) inflow obstruction. CASE SUMMARY:A 43-year woman presented with exertional palpitations for 2 years, diagnosed with a large TV pouch causing significant RV inflow obstruction without pulmonary arterial hypertension (PAH). Cardiac magnetic resonance revealed a large perimembranous VSD with bidirectional flow into the TV pouch, which had no effective communication with the right ventricle, preventing a significant left-to-right shunt and PAH. Surgical correction involved partial excision of the pouch and closure of the VSD, preserving the TV integrity. DISCUSSION:This case highlights a rare hemodynamic presentation of the TV pouch and its potential to cause RV inflow obstruction and prevent PAH in a large VSD. TAKE-HOME MESSAGE:Follow-up (at least every 3-4 years) for these cases where VSDs are spontaneously closed by TV or aneurysmal membranous septum would be beneficial.

Tolosa–Hunt syndrome (THS) is caused by idiopathic granulomatous inflammation of the cavernous sinus, superior orbital fissure, or orbit, presenting with painful ophthalmoplegia due to palsy of one or more ocular motor nerves. It may be associated with autoimmune and systemic inflammatory conditions such as lupus, sarcoidosis, and Wegener’s granulomatosis. The diagnosis is based on the clinical presentation, neuroimaging with a magnetic resonance imaging of the brain with contrast, which shows cavernous sinus thickening, isointense tissue on T1, hypo- or isointense on T2, contrast enhancement, and lateral convexity of the cavernous sinus, with possible extension into the orbital apex; and a rapid response to steroids. As a diagnosis of exclusion, blood and cerebrospinal fluid studies are performed to rule out other causes of painful ophthalmoplegia when THS is suspected. We are reporting a challenging and intriguing case of THS successfully managed with a multidisciplinary approach.

INTRODUCTION:Acute acquired comitant esotropia is characterized by sudden-onset, large-angle comitant esotropia occurring in adults and older children. The condition differs from infantile esotropia in its acute presentation, typically occurring after the age of 6 months, when binocular vision has developed. While many cases of AACE are idiopathic or attributed to functional factors such as excessive near work with digital devices, neurological etiologies can account for up to 10% of cases and must be investigated to rule them out. Here we are reporting an unusual association of acute acquired comitant esotropia and bilateral idiopathic optic neuritis in two boys. METHODS:Acute acquired comitant esotropia (AACE) is an uncommon form of esotropia that typically presents after early childhood and is characterized by the sudden onset of esodeviation without limitation of ocular motility. While most cases are idiopathic or associated with excessive near work, neurological causes must be systematically excluded. Here, we report two cases of AACE associated with bilateral idiopathic optic neuritis in the pediatric age group and emphasize the importance of comprehensive neuro-ophthalmic evaluation in these cases. RESULTS:Both patients presented with sudden-onset large-angle esotropia associated with diplopia and visual impairment. Visual evoked potential abnormalities and neuroimaging findings confirmed bilateral idiopathic optic neuritis. Treatment with systemic corticosteroids resulted in visual recovery, followed by successful strabismus surgery with excellent alignment and functional outcomes. CONCLUSIONS:AACE in pediatric patients should not be dismissed as benign without a comprehensive evaluation. This case series underscores the importance of neuro-ophthalmic assessment, including visual evoked potentials and magnetic resonance imaging, to identify rare but critical associations such as optic neuritis. Prompt recognition and appropriate treatment are essential for optimal visual and functional recovery.

Abstract Thyroid eye disease (TED), also known as Graves’ orbitopathy, is an autoimmune inflammatory disorder of the orbit that may lead to vision-threatening complications such as dysthyroid optic neuropathy (DON). DON results from compression of the optic nerve at the orbital apex by enlarged extraocular muscles and inflamed orbital tissues and constitutes an ophthalmic emergency. We report a case of active TED with progressive visual loss and steroid-refractory DON, in which timely bilateral orbital decompression resulted in marked and rapid improvement in visual acuity. This case highlights the importance of early recognition of optic nerve involvement and prompt escalation to surgical management when medical therapy fails.

BACKGROUND:Coronary stent infection (SI) is a rare but catastrophic complication, occurring in 0.3% to 6% of cases post-percutaneous coronary intervention (PCI). Early diagnosis and surgical interventions are crucial for definitive diagnosis and management. CASE SUMMARY:A 52-year-old man underwent PCI for an inferior wall myocardial infarction to the left circumflex artery (LCx) with a single sirolimus-eluting stent. He developed a fever 10 days later due to methicillin-sensitive Staphylococcus aureus. Imaging showed a coronary cameral fistula with a left atrial appendage (LAA) mycotic aneurysm. He was treated with antibiotics, stent explantation, abscess drainage, and fistula repair; however, he developed refractory vasoplegia and died 2 days post-surgery. DISCUSSION:Coronary SI requires a high index of suspicion. The use of multimodality imaging and multidisciplinary approaches to diagnose and manage infection is essential. Late and complicated stent infections have a high mortality rate. TAKE-HOME MESSAGES:Coronary SI is an important differential diagnosis for fever post-PCI. Prompt diagnosis, multimodality imaging, and early intervention are needed.

We are reporting a rare incidence of right-sided familial unilateral Brown syndrome in two sisters with successful long-term outcomes of superior oblique (SO) chicken suture. Two sisters, 12 and 15 years old, presented with outward deviation and diminution of vision in the right eye (OD) since birth, as informed by the mother. Other family members were not affected. Exaggerated Guyton’s tendon traction test was strongly positive for SO in the right eye of both patients, and SO chicken suture with horizontal muscle strabismus surgery was performed. Patients were orthophoric in postoperative period, and alignment was maintained until 24 months of follow-up. Thus, we can conclude that SO chicken sutures are an effective surgical option in patients with Brown syndrome for improving elevation in adduction and hypotropia in the primary position. To the best of our knowledge, this is the first report of familial Brown syndrome from India.

Möbius syndrome (MBS) is a rare congenital disorder characterized by facial and abducens palsy which is usually bilateral and may involve multiple cranial nerves. Additional features, such as craniofacial anomalies, tongue malformations, and limb defects, may also be present. The etiology of this syndrome is not well established but the ischemic necrosis of the brainstem leading to hypoplasia of the cranial nerve nuclei is the supposed to be most likely one. MBS leads to a large angle esotropia along with bilateral limitation of abduction with delayed diagnosis, which is very challenging to correct with a single procedure. There are only a few reports illustrating the surgical outcome of strabismus in MBS. In this case report, we describe an unusual case of unilateral MBS who presented with large esotropia since childhood and was managed by two-stage strabismus surgery, including unilateral medial rectus (MR) muscle recession followed by vertical recti transposition. The final primary position alignment was satisfactory. Therefore, MR muscle recession alone is an effective first procedure of choice for mild-to-moderate esotropia in patients with MBS, whereas severe cases may further require the transposition of vertical recti. As it is a congenital condition, early surgical intervention may prevent amblyopia and provide an opportunity for the development of binocular single vision. Hence, prompt diagnosis and early surgical intervention are of utmost importance in these cases.

Abstract A 25-year-old female presented with complaints of deviation of the right eye since 2 years of age after an episode of tubercular meningitis (TBM). The extraocular movements showed a −4 limitation on adduction and depression and a −2 limitation on elevation in the right eye, whereas the movements were full and free in the left eye. The downgaze saccades were poor, but the pursuit was normal. Magnetic resonance imaging showed atrophy of the third nerve and mild midbrain atrophy. Thus, the clinical and radiological findings were consistent with a childhood-onset acquired third nerve palsy with downgaze palsy likely secondary to TBM. This case highlights the unusual association of downgaze palsy with third nerve palsy after an episode of TBM.

Secondaries to the eye are the most common type of intraocular malignancy, and visual complaints may be the first presenting symptom. We are reporting a rare incidence of a bilateral sudden loss of vision in an 84-year-old female due to metastasis from pulmonary adenocarcinoma. She presented with complaints of a bilateral sudden loss of vision for 1 month in the right eye (OD) and for 15 days in the left eye (OS). Examination revealed intraocular pressure of 20 mm Hg, total retinal detachment, subretinal fibrosis, multiple choroidal metastases in OD, and raised intraocular pressures (48 mm Hg) along with multiple choroidal metastases with overlying multiple exudative retinal detachments OS. Medical management was advised for ocular symptoms, and she was referred to the medical oncology team for further management. Secondaries may present with sight-threatening complications. A prompt multi-disciplinary approach is mandatory for favorable outcomes.

Abstract Apert syndrome (AS) is a form of acrocephalosyndactyly, which is characterized by craniosynostosis, midfacial hypoplasia, and symmetrical syndactyly of the hands and feet. A 3-year-old female with craniosynostosis, high-arched palate, syndactyly, strabismus, and diagnosed as a case of Apert syndrome was brought to the outpatient department. Strabismus evaluation revealed 35 prism diopters of left convergent squint. Magnetic resonance imaging of the brain and orbit revealed hypoplastic extraocular muscles. A plan to carry out a bilateral medial rectus recession was made. However, intraoperatively, normal-sized muscles were found and the plan was modified to carry out only a left eye medial rectus recession of 5.5 mm. The patient was orthophoric postoperatively, indicating the unusual postoperative outcome in such a case. This report aimed to underline the challenges of managing a case of strabismus and the variable postoperative outcomes encountered in a case of Apert syndrome.

Cannabis is a psychoactive substance consumed worldwide in the form of smoking, vapors, food additives, or beverages. Delta 9 tetrahydrocannabinol (THC) is a primary component responsible for short and long-term effects on various cognitive and motor functions in a dose-dependent manner. The legal status of cannabis has shifted significantly in recent decades. Some regions maintain strict penalties, but others have legalized them for medicinal use. In India, the use of cannabis in any form is illegal; however, the use of bhang, a cannabis beverage made from leaves, is acceptable due to cultural reasons and thus permitted in some places. We report the case of a 28-year-old male who developed massive anterior wall myocardial infarction after consuming bhang during the Holi festival. He presented with sudden retrosternal chest pain, which was initially ignored till it intensified enough, prompting him to seek emergency medical help approximately 24 hours after symptom onset. Cannabis intoxication impaired attention and information processing, leading to delayed presentation. The patient was managed successfully by timely cardiac intervention. The evolving landscape of cannabis regulations necessitates heightened awareness among health authorities about potential cardiovascular risks associated with its consumption, particularly in forms like Bhang, where concentrations are unregulated and variable.

Aortic valve replacement for severe symptomatic Aortic stenosis is a low-risk procedure, but when compounded with coexisting conditions, procedural risk may increase. We present the case of a middle-aged female patient presenting with a constellation of complexities, including oblique sternum, severe dextroscoliosis, severe symptomatic aortic stenosis with bicuspid aortic valve, aortic root distortion, and a relatively rare blood group. Despite multiple problems, she underwent successful surgical aortic valve replacement. This case highlights the importance of a multidisciplinary approach in complex cardiac patients with the utmost need for a heart team concept for patient-centric decision-making.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality throughout the world. The coexistence of COPD and obstructive sleep apnea (OSA) (i.e., overlap syndrome) has been reported in several studies. Both disorders independently increase the risk of cardiovascular complications. Hence, there is a theoretical possibility that cardiovascular parameters may be worse in patients with overlap syndrome compared to those with only COPD. However, this has been sparsely assessed in the literature. This study aimed to compare the clinical characteristics, echocardiography, and sleep parameters amongst COPD patients with and without sleep-related breathing disorders (SRBD). This observational, cross-sectional study included 30 patients with stable COPD. All participants underwent a detailed clinical evaluation, followed by level 1 polysomnography (PSG). Each participant underwent echocardiographic evaluation to estimate mean pulmonary artery pressure from right ventricular systolic pressure (RVSP). Based on their PSG findings, participants were classified into non-SRBD and SRBD groups. Both groups were further compared with respect to clinical characteristics, echocardiographic, and PSG parameters. We found that most of the participants (93.3%) were male, and the mean age of the study population was 56±8.2 years. The only SRBD identified in this study was OSA, which was observed in 80% of participants. In this group, OSA was not associated with obesity. Systemic hypertension (50%) was the most common comorbidity, followed by diabetes mellitus (26.67%), but both were not significantly different between the groups. The mean RVSP was significantly higher amongst OSA patients than non-OSA patients (41.25±14.98 versus 30.83±5.84, respectively; p=0.01). OSA was seen in 80% of participants with stable COPD, even in the absence of obesity. The presence of OSA was associated with a higher RVSP in this patient group.