Surgical site infection is a relatively rare complication of strabismus surgery; however, if it occurs, it can have permanent impact on the patient. Prior existing case reports and questionnaire-based studies have described different types of surgical site infections that can occur post strabismus surgery. It is not only important to know how to identify and treat such cases, but also to know how to prevent them, in addition to identifying the causative risk factors. In this review, we discuss 10 such cases of various types of infection that occurred post strabismus surgery and how they were managed. Our aim is to provide a comprehensive guideline by which clinicians can appropriately manage such cases.

Purpose: To understand the practice patterns in the management of pediatric optic neuritis in India and detect the gaps in evaluation and management. Methods: An online survey-based study questionnaire was shared among ophthalmologists in the last quarter of 2024. The questionnaire included questions pertaining to the clinical experience, evaluation, and management of optic neuritis in children. Results: Seventy ophthalmologists across India participated in the survey. Of these, 45% had a formal neuro-ophthalmology training and 42% had more than 5 years of experience in managing pediatric optic neuritis. Most respondents managed under less than five cases every month. Participants with under 5 years’ clinical experience reported higher rates of myelin oligodendrocyte glycoprotein-associated disease and post-infectious ON followed by neuromyelitis optica spectrum disorder, multiple sclerosis, and chronic relapsing inflammatory optic neuritis. Visual fields (50%) and optical coherence tomography (45%) were frequently requested ocular investigations. Magnetic resonance imaging brain and spine with contrast and fat-suppressed sequence was recommended by 23% of respondents, serological workup in 91%, and cerebrospinal fluid analysis in 17%. For treatment, intravenous methylprednisolone (IVMP) was used by 94% for 3 days (45%) or 5 days (53%). 34% ophthalmologists advised IVMP dosing at 30 mg/kg. In recurrent cases, those with less than 5 years’ experience more often repeated neuroimaging (P = 0.050) and initiated IVMP irrespective of vision (P = 0.046). Conclusions: This survey highlights the variability in diagnostic testing and management practices of pediatric optic neuritis among ophthalmologists in India underscoring the need for developing, guiding, and following standardized practice guidelines.

PURPOSE:To report the clinical presentation and surgical outcomes of patients with Duane syndrome with primary position hypertropia, with or without coexisting horizontal deviation. METHODS:We retrospectively reviewed records of patients diagnosed with Duane syndrome with vertical and associated horizontal deviations from January 2008 to July 2017. We collected data regarding patient age, gender, refractive error, presence or absence of amblyopia and history of strabismus surgery, as well as clinical subtype of Duane syndrome, abnormal head posture, measurement of horizontal and vertical deviation, and outcomes of strabismus surgery. Success was defined as post-operative primary position hypertropia <4 prism diopters (PD) and horizontal deviation <10 PD. RESULTS:During this period, a total of 590 patients with Duane syndrome were seen. Of these, 18 patients (10 males and 8 females) met the study criteria, giving a prevalence of 3%. Median age was 21 years. Seventy-eight percent cases had type III Duane syndrome. Ten patients underwent surgical correction, of which four patients had to undergo a second procedure after a median of 19 months. Sixty-seven percent of the patients had associated primary position exotropia with median deviation of 30 PD. Seventeen percent of patients had only primary position hypertropia with median 10 PD. All patients had overshoots. Primary position horizontal deviation improved from 25 PD to orthotropia, and vertical deviation improved from 10 PD to orthotropia. Lateral rectus recession with Y split was the most frequent procedure performed, and we saw a median reduction of 10 PD hypertropia with this procedure. Median follow-up period was 13 months. Success was achieved in 60% of the patients who underwent surgery. Given the small sample size, it was difficult to compare the efficacy of different procedures. CONCLUSION:Current study suggests that primary position vertical deviation might exist in 3% of patients with Duane syndrome. All patients had associated overshoots, which were predominantly of a mixed mechanism. Forty percent of the patients needed re-surgery. Well-designed, prospective possibly multicentric studies are necessary to understand the mechanism of overshoot, and consequently the primary position hypertropia to plan accurate management for these patients.

Purpose: To characterize the severity of vision loss, dose-related adverse effects, and visual outcomes in ethambutol-induced toxic optic neuropathy (ETON) patients. Methods: A prospective observational study was conducted in a tertiary eye center in South India between July 2019 and December 2021. Consecutive adults (age >18 years) taking revised antitubercular regimens and diagnosed with ETON were included. Data collected regarding patient demographics, presentation, dose-related severity of vision loss, and visual outcomes after drug discontinuation were analyzed. Results: We analyzed 214 eyes from 107 patients (mean age: 51.1 ± 13 years; male: female ratio = 2:1). The median follow-up time was 11 months (interquartile range: 4–14 months). Mean visual acuity improved from 1.2 ± 0.6 log of minimum angle of resolution (logMAR) at presentation to 0.8 ± 0.6 logMAR at the final follow-up. Patients above 60 years old had the worst visual acuity at presentation and had the least improvement at the last follow-up compared to those in younger age groups (1.3–1.2 logMAR, P = 0.2). The mean exposure time to ethambutol was 6.8 ± 3.3 months, and the mean dose was 1042 ± 247 mg/day, that is, 16.7 ± 4 mg/kg/day. Mean presenting best corrected visual acuity (BCVA; 1.3 ± 0.6 logMAR) was worse in patients taking a higher dose of ethambutol (≥16 mg/kg) compared to those taking <16 mg/kg (mean BCVA: 1 ± 0.5 logMAR). Conclusion: Higher age and higher doses of ethambutol were associated with an increased risk of vision loss and worse vision at presentation. Prolonged exposure to high-dose ethambutol, as in fixed drug dose combinations, leads to severe visual impairment which might be partially reversible.

BACKGROUND:There is sparse literature on radiological findings in cases of monocular elevation deficit (MED). We conducted this study to report magnetic resonance imaging (MRI) characteristics of extra-ocular muscles and oculomotor nerves in patients with congenital MED and to investigate its patho-mechanisms. METHODS:We included patients with congenital MED without prior strabismus surgery. The cross-sectional area (CSA) of the extra-ocular muscles in quasi-sagittal and quasi-coronal scans was measured manually on 2-mm-thick T2-weighted MRI images using Osirix MD software. Oculomotor nerves were imaged with balanced steady state free precession (bFFE) sequence. Clinical findings of Bell's phenomenon and forced duction test (FDT) for inferior rectus (IR) muscle were recorded. RESULTS:Eleven patients were included. The median CSA of superior rectus (SR) muscle at mid-orbit section was significantly lesser in the affected eye (8.83 mm2, Inter-quartile range (IQR): 5.39-11.36 mm2) than in the normal eye (13.63 mm2, IQR: 10.99-16.92 mm2), p = .02. From 11 patients, 10 had a thinner SR muscle on the affected side. Bell's phenomenon was intact in six patients. Forced duction test was positive for IR muscle in five cases. Oculomotor nerve was thinner on the affected side in two patients. CONCLUSIONS:Majority patients with congenital MED have a hypotrophic SR muscle, due to dysinnervation or primary muscle pathology. Bell's phenomenon may or may not be present in these conditions, and its presence does not warrant a supra-nuclear cause.

PURPOSE:To describe the demographics and clinical profile of exotropia from patient data obtained from a multi-tiered ophthalmology hospital network in India. METHODS:This cross-sectional hospital-based study included the data of 2,664,906 patients presenting to the hospital network from August 1, 2010 to January 31, 2021. Data were collected using an electronic medical record system. Data were collected regarding demographics, age at presentation, vision assessment with complete ophthalmic evaluation, and strabismus assessment. RESULTS:During this period, 31,333 (1.18%) patients were diagnosed with exotropia. There was an insignificant male predominance (54.68%) and a significant association with higher socioeconomic status (82.21%). The mean age of patients was 23 ± 19.66 years. However, most presented with exotropia in the first decade of life (10,904, 34.8%). Majority of the subjects with exotropia were students (16,109, 51.41%). Majority of (13,147, 41.96%) the patients were from rural areas. The most common type of exotropia was constant exotropia (12,106, 38.64%), followed by intermittent exotropia (11,574, 36.94%), secondary exotropia (4533, 14.47%), and congenital exotropia (1752, 5.59%). Associated pattern strabismus was seen in a minority (V-pattern: 457, 1.46%; A-pattern: 128, 0.41%) of patients. Extraocular muscle surgery was performed on 4477 (14.29%) patients. CONCLUSION:Exotropia was more common in males who presented to our hospital in their first decade of life. As this is the most crucial age for binocular vision and sensory development, early and timely screening by trained pediatric ophthalmologists is a must in schools. This analysis showed that only a tenth of the affected patients underwent surgical correction to treat exotropia.

To report the clinical profile and outcomes of Peripapillary choroidal neovascular membrane (p-CNVM) in patients with idiopathic intracranial hypertension (IIH): at a neuro-ophthalmic care centre. We retrospectively studied records of IIH patients who developed pCNVM seen at our institute from January 1, 2016 to January 1, 2023. Data was collected regarding demographics, body mass index (BMI), Cerebrospinal fluid (CSF) opening pressure, fundus photographs, fluorescein angiography FFA, indocyanine green angiography (ICGA), optical coherence tomography (OCT) and optical coherence tomography angiography (OCT-A), treatment given and outcomes. 7 patients (9 eyes, all women, median age: 30.5 years) met the study criteria. Median BMI was 34.2 kg/m2. Median CSF opening pressure was 33.0 cm H2O. Median time from papilledema diagnosis to CNVM formation was 6.5 (IQR: 4.5-12.25) months. All patients were treated with intravitreal anti-VEGF and acetazolamide. Best corrected Visual acuity (logMAR) worsened in the right eye slightly from, 0.50 (IQR: 0.15-0.90) logMAR at presentation to 0.90 (IQR: 0.57-1.00) LogMAR at final visit. The left eye showed minimal improvement in BCVA from 0.65 (IQR: 0.28-0.95) to 0.37 (IQR: 0.18-0.85) logMAR. One patient underwent shunt surgery, while another needed optic nerve sheath fenestration for IIH. CNVM either resolved completely or was resolving in all patients, while papilledema showed resolution in all patients except one. Peripapillary Type 2 CNVM is an infrequent but significant complication of IIH, Multimodal imaging-including OCT, FFA and ICGA helps in diagnosis and monitoring. We recommend continued that acetazolamide treatment along with concurrent anti-VEGF treatment helps in managing both IIH and pCNVM.

Purpose: To assess the prevalence of alternate etiology/co-existing pathology among patients with amblyopia, and to characterize factors contributing to over-diagnosis of amblyopia. Methods: We retrospectively reviewed records of children (from 1 January 2016 to 31 December 2019) who were initially diagnosed as "amblyopia" but later an alternate diagnosis for subnormal vision was established. Patients who had a best corrected visual acuity (BCVA) of ≤20/32 (0.2 logMAR) after compliant amblyopia therapy were divided into 2 groups: those with refractory amblyopia (BCVA improvement from baseline <1 logMAR line) and residual amblyopia (BCVA improvement from baseline >1 logMAR line). Data was collected for presence/absence of amblyogenic risk factors, history, ocular examination, and investigations leading to the final alternate diagnosis. We analyzed the factors that contributed to the initial over-diagnosis of amblyopia using the diagnostic error evaluation and research (DEER) taxonomy tool. Results: During the study period, 508 children with an initial diagnosis of amblyopia met the study criteria. Among these 508 children, 466 were diagnosed to have amblyopia alone, while 26 children (5.1%, median age: 7 years, 17 boys: 9 girls) were revised to have an alternate diagnosis/co-existing pathology. These 26 patients comprised of 2 groups: children referred to us as amblyopia but rediagnosed to have an alternate diagnosis; and a second subset, initially diagnosed by us to have amblyopia, but later found to have alternate diagnosis/co-existing pathology. Subclinical optic neuritis (50%, 13 children), and occult macular dystrophy (OMD) (38.4%, 10 children) were the most frequent alternative diagnoses. Children with ametropic amblyopia (8/26, 30.7%) were most frequently misdiagnosed. Risk factors that led to an initial diagnosis of amblyopia were: high refractive error and heterotropia in 7 patients each (26.9%), anisometropia in 12 (46.1%), and prior pediatric cataract surgery in 4(15.3%). No improvement in BCVA in 21/26 (80.7%) children led to suspicion of co-existing etiology. Other clues were optic disc pallor (11), subnormal color vision (7), history of parental consanguinity in 7, and preceding febrile illness/rhinitis in 1 child. The DEER taxonomy tool suggested that the most common reasons for diagnostic errors were over-emphasis on amblyopia. Conclusion: Our study suggests that 5% of children diagnosed with amblyopia might have co-existing/alternate etiology. Most common co-existing etiologies were subclinical optic neuropathy, and OMD. No improvement in BCVA, subtle history and examination findings prompted further workup. Not considering co-existing etiologies was the most common reason for an initial overdiagnosis of amblyopia.

Purpose: To compare the retinal nerve fiber layer (RNFL), ganglion cell-inner plexiform layer thickness, central subfield thickness (CSFT), and parafoveal and perifoveal thickness in children of different age groups with young adult controls by using spectral-domain optical coherence tomography. Methods: This cross-sectional study included children aged 6–17 years and adult controls (18–22 years) – group 1: 6–9 years (57 eyes), group 2: 10–13 years (116 eyes), group 3: 14–17 years (66 eyes), and group 4 (controls): 18–22 years (61 eyes). A mixed-effects model was used to compare the OCT parameters among the groups, along with multivariable analysis. Results: Analysis of 300 eyes of 152 patients was done. Group 2 (99.7 ± 1.1 µm, P = 0.03) and group 3 (100.4 ± 1.5 µm, P = 0.03) had thicker RNFL on average as compared to group 4 (95.6 ± 1.6 µm) on multivariable analysis. In pairwise comparison, group 2 (129.8 ± 2.5 µm, P = 0.02) and group 3 (132.6 ± 2.4 µm, P = 0.004) had thicker inferior RNFL compared to adult controls (122.4 ± 2.5 µm); superior RNFL was thicker in group 2 (129.6 ± 2.0 µm, P = 0.01) and group 3 (131.2 ± 2.6 µm, P = 0.008) compared to group 1 (120.9 ± 2.8 µm). On multivariable analysis, adult controls had thicker CSFT (236.5 ± 2.6 µm) than group 1 (222.7 ± 3.1 µm) and group 2 (229.6 ± 2.3 µm). Similarly, on pairwise comparison, adult controls had thicker parafoveal superior quadrants (320.5 ± 2.5 µm) and inferior quadrants (317.5 ± 2.3 µm) when compared with groups 1 and 2. Conclusion: RNFL thickness seems to increase up to 17 years and then starts reducing, unlike CSFT, which increases with age from 6 to 22 years. A differential growth occurs in the different quadrants of RNFL and macula with age with some quadrants increasing in thickness as compared to the others.

PURPOSE: To study the clinical presentations, visual, and refractive profiles of children with congenital ectopia lentis in a large cohort of patients from a tertiary eye care network in India. MATERIALS AND METHODS: A retrospective review of electronic medical records from December 2012 to December 2020 was conducted. Two hundred and ninety-seven consecutive children ≤18 years of age at presentation were identified and analyzed for demographic details, patient distribution, lens subluxation, visual, and refractive profiles before and after the interventions. RESULTS: Five hundred and ninety-four eyes of 297 (male 56%; n = 166) patients were analyzed. The mean age at presentation was 8.74 ± 3.89. Best-corrected visual acuity (BCVA) at presentation ranged from 0.3 logMAR to 3.5 logMAR; (Snellen: 6/9 – close to face [CF]) (mean 0.89 ± 0.68). High myopia ( n = 201; 33.83%) and mild astigmatism ( n = 340; 57.23%) were more frequent. Temporal ( n = 108; 18.18%) subluxation was most common followed by superior. Lensectomy with limited vitrectomy was performed in 243 eyes of 127 patients (40.90%). Median preoperative BCVA was 1.0 (range: 0.3–3.5 logMAR; 20/40 - CF). Median postoperative BCVA was 0.5 logMAR (6/18) in the pseudophakic group and 0.6 logMAR (6/24) in the aphakic group. Spherical equivalent in myopic children reduced from −12.06 ± 6.84D to −1.57D (−0.25D to − 5.5D) in the pseudophakic group and +9.3D (+5.5D to 15.5D) in the aphakic group. CONCLUSION: This study is a large cohort of children presenting with ectopia lentis. Following intervention, an improvement in the median BCVA and refractive correction was noted in the entire cohort.

PurposeTo describe the construction and diagnostic accuracy of a modularized, virtual reality (VR)-based, pupillometer for detecting relative afferent pupillary defect (RAPD) in unilateral optic neuropathies, vis-à-vis, clinical grading by experienced neuro-ophthalmologists.MethodsProtocols for the swinging flashlight test and pupillary light response analysis used in a previous stand-alone pupillometer was integrated into the hardware of a Pico Neo 2 Eye® VR headset with built-in eye tracker. Each eye of 77 cases (mean ± 1SD age: 39.1 ± 14.9yrs) and 77 age-similar controls were stimulated independently thrice for 1sec at 125lux light intensity, followed by 3sec of darkness. RAPD was quantified as the ratio of the direct reflex of the stronger to the weaker eye. Device performance was evaluated using standard ROC analysis.ResultsThe median (25th – 75th quartiles) pupil constriction of the affected eye of cases was 38% (17 – 23%) smaller than their fellow eye (p<0.001), compared to an interocular difference of +/-6% (3 – 15%) in controls. The sensitivity of RAPD detection was 78.5% for the entire dataset and it improved to 85.1% when the physiological asymmetries in the bilateral pupillary miosis were accounted for. Specificity and the area under ROC curve remained between 81 – 96.3% across all analyses.ConclusionsRAPD may be successfully quantified in unilateral neuro-ophthalmic pathology using a VR-technology-based modularized pupillometer. Such an objective estimation of RAPD provides immunity against biases and variability in the clinical grading, overall enhancing its value for clinical decision making.

A man in his 80s, with a history of diabetes, hypertension and coronary artery disease, presented with bilateral painless progressive vision loss 2 years prior. His examination showed subnormal best corrected visual acuity of 20/50 and 20/80 in the right eye and left eye (LE), respectively, grade II relative afferent pupillary defect in LE, normal anterior segment, intra-ocular pressure (IOP) and defective colour vision in both eyes (BE). Fundus examination revealed optic disc pallor, disc collaterals and grade 2 hypertensive retinopathy in BE. Automated perimetry showed advanced field loss in BE. MRI of the brain and orbits with contrast showed signs of raised intracranial pressure, and magnetic resonance angiogram of the brain showed multiple arterio-venous channels along with the right transverse and sigmoid sinuses. The patient was referred to a neuroradiologist for further evaluation, and cerebral angiogram confirmed multifocal high-flow dural arterio-venous fistulae at right jugular foramen, transverse and sigmoid sinuses. He underwent Onyx liquid embolization.

PURPOSE:To evaluate the clinical profile of myopic strabismus fixus (MSF) in children and surgical outcomes of silicone band loop myopexy. METHOD:We retrospectively reviewed records of children presenting with MSF who underwent silicone band loop myopexy between January 2008 and December 2020 at a tertiary eye care center. Data concerning demographics, refractive error, axial length, extra-ocular motility, and ocular alignment pre-operatively and post-operatively, intra- and post-operative complications, ocular and systemic associations, were evaluated. The long-term effects of band loop myopexy on ocular alignment stability, motility improvement, and myopia progression were analyzed. Surgical outcome was defined as post-operative orthotropia or heterotropia less than or equal to 20 PD. RESULTS:A total of0 eyes of 7 patients (median age: 5 years; 5 boys and 2 girls) who underwent band loop myopexy were included in the study. Among them, three children underwent bilateral and four children underwent unilateral band loop myopexy. Medial rectus recession was performed only in two patients as a part of initial procedure. The median follow-up duration was 7 years. Most of the children, i.e. six of them presented with esotropia-hypotropia and only one patient presented with exotropia-hypotropia complex. The median pre-operative measurements were esotropia of 62.5 PD, hypotropia of5 PD, and exotropia of4 PD. Postoperative average primary position deviation measured was close to 9-10 PD of esotropia. The overall motility improved to -1 from -3. CONCLUSION:The clinical profile of MSF in children is almost similar to adults. This condition is a rare entity among adults as well as children. Majority of children with MSF presented with esotropia-hypotropia complex. Silicone band loop myopexy with or without medial rectus recession proves to be a reliable surgical procedure as it provides stable outcomes in terms of ocular alignment and motility among children.

Our objective was to compare the agreement between virtual reality perimetry (VRP) (order of magnitude, OM) and static automated perimetry (SAP) in various neuro-ophthalmological conditions. We carried out a retrospective analysis of visual field plots of patients with various neuro-ophthalmological conditions who underwent visual field testing using VRP and SAP and between 1 January and 31 May 2022. Two fellowship-trained neuro-ophthalmologists compared the visual field defects observed on both devices. Per cent agreement was used to compare the interpretation of the two examiners on both techniques. The study criteria were met by 160 eyes from 148 patients (mean age 44 years, range 17-74 years). The most common aetiologies were optic atrophy due to various causes, optic neuritis, ischaemic optic neuropathy, and compressive optic neuropathy. Overall, we found good agreement between VRP and SAP for bitemporal (93.8%), hemianopic (90.8%), altitudinal (79.4%), and generalised visual field defects (86.4%). The agreement was acceptable for central/centrocaecal scotomas and not acceptable for enlarged blind spots. Between the two examiners there was good agreement for bitemporal (92.3%), hemianopic (82%), altitudinal (83%), and generalised field defects (76.4%). The results of our study suggest that VRP gives overall good agreement with SAP in various neuro-ophthalmological conditions, especially those likely to produce hemianopic, altitudinal, and generalised visual field defects. This could be useful in various settings; however, future larger studies are needed to explore real-world utilisation.

Background: Circumscribed interests (CI) in autism are highly fixated and repetitive interests, generally centering on non-social and idiosyncratic topics. The increased salience of CI objects often results in decreased social attention, thus interfering with social interactions. Behavioural, biomarker and neuroimaging research points to enhanced social functioning in autistic children in the presence of animals. For instance, neuroimaging studies report a greater activation of reward systems in the brain in response to animal stimuli whereas eye-tracking studies reveal a higher visual preference for animal faces in autistic individuals. This potentially greater social reward attached to animals, introduces the interesting and yet unexplored possibility that the presence of competing animal stimuli may reduce the disproportionately higher visual attention to CI objects.Method: We examined this using a paired-preference eye-tracking paradigm where images of human and animal faces were paired with CI and non-CI objects. 31 children (ASD n = 16; TD n = 15) participated in the study (3391 observations).Results: Autistic children showed a significantly greater visual attention to CI objects whereas typical controls showed a significantly greater visual attention to social images across pairings. Interestingly, pairing with a CI object significantly reduced the social attention elicited to human faces but not animal faces. Further, in pairings with CI objects, significantly greater sustained attention per visit was seen for animal faces when compared to human faces. Conclusions: These results thus suggest that social attention deficits in ASD may not be uniform across human and animal stimuli. Animals may comprise a potentially important stimulus cate-gory modulating visual attention in ASD.

Purpose: To report the clinical presentations, neuroimaging findings, and surgical outcomes in patients with acute acquired non-accommodative comitant esotropia (AACE). Methods: A retrospective review of records of all patients diagnosed as having AACE between January 2011 and December 2019 across three tertiary eye care centers was done. Cases with AACE onset after age 1 year were included. Patients were divided into two groups based on age of onset of esotropia: childhood (16 years or younger) and adult (older than 16 years). Surgical success was defined as postoperative horizontal deviation of 8 prism diopters (PD) or less at the last follow-up visit. Results: A total of 338 patients (220 males and 119 females; mean age at presentation: 12.60 ± 9.8 years) met the study criteria. The mean age at onset of esotropia in the childhood and adult onset groups was 3.61 ± 1.1 and 26.6 ± 8.7 years, respectively. There were significantly more individuals with myopia (30%) in the adult onset group compared to the childhood onset group (6%) ( P = .004). Thirty-seven (16%) had positive neuroimaging findings (16.4% adult onset vs 9.4% childhood onset). A total of 148 (44%) patients underwent surgery for esotropia, and the overall success rate was 73%. Mean preoperative esotropia was comparable in either group ( P = .20), but surgical success was better in the adult onset group (75.6% vs 66.3% in the childhood onset group). Mean duration of follow-up postoperatively was 13.6 ± 12 months. Conclusions: Two-thirds of the patients had childhood onset of AACE. Intracranial pathology was found in 1 of 6 patients. Surgical success was better in the adult onset group, which was not influenced by preoperative esotropia, neuroimaging findings, or refractive status, but was dependent on age at onset of esotropia and duration between onset and intervention. [ J Pediatr Ophthalmol Strabismus . 2023;60(3):218–225.]

We report clinical and optical coherence tomography (OCT) differences among patients with occult neuroretinitis and non-arteritic anterior ischaemic optic neuropathy (NAAION). We retrospectively reviewed records of patients with a final diagnosis of occult neuroretinitis and NAAION seen at our institute. Data were collected regarding patient demographics, clinical features, concomitant systemic risk factors, visual function, and optical coherence tomography (OCT) findings at presentation and subsequent follow-up. Fourteen and 16 patients were diagnosed to have occult neuroretinitis and NAAION, respectively. Patients with NAAION were slightly older (median age 49, inter-quartile range [IQR]: 45-54 years, versus 41, IQR: 31-50 years) than patients with neuroretinitis. Seventy-five per cent of patients with NAAION were male versus 43% with neuroretinitis (p = 0.07). Systemic risk factors were present in 87.5% of patients with NAAION versus 21.4% in patients with neuroretinitis (p = 0.001). At presentation, all patients presented with blurred vision, had similar visual function, and had optic disc oedema. In addition, none of the patients had evident retinitis lesions, but 10 (71%) showed evident retinitis lesion at follow-up. Neuroretinitis patients had more often vitreous cells (64% versus 6%, p = 0.001), and subretinal fluid (78.6% versus 37.5%, p = 0.03) than the patients with NAAION. In summary, NAAION patients tended to be slightly older, more often male, and had associated systemic diseases more often than those with neuroretinitis. Neuroretinitis patients more often had posterior vitreous cells and subretinal fluid on OCT. However, larger prospective studies are needed.

A 47-year-old woman who presented with headache and blurring of vision was referred to us due to suspicion of idiopathic intracranial hypertension or cerebral sinus venous thrombosis. She had chronic kidney disease and underwent dialysis through multiple ports including the right internal jugular vein (IJV). Her examination showed a best corrected visual acuity of 20/20 in each eye, normal anterior segments in each eye but bilateral papilloedema. Magnetic resonance imaging and venography (MRV) of her brain with contrast showed signs of raised intracranial pressure and a hypoplastic left transverse sinus. An MRV of her neck showed a thrombosis of the right IJV. Her symptoms and papilloedema resolved with carbonic anhydrase inhibitors and anticoagulants. This case highlights an uncommon presentation of papilloedema secondary to raised intracranial pressure from IJV thrombosis and its pathogenesis.

A preschool girl presented with sudden-onset bilateral painless loss of vision from 2 days prior. Child’s examination showed light perception vision, sluggishly reacting pupils, otherwise normal anterior segment, healthy optic disc and retina in both eyes. MRI of brain and orbit with contrast revealed thickened left part of the optic chiasm with contrast enhancement extending proximally to bilateral optic tract and hyperintensities in the left thalamus and periventricular white mater. Considering the topographical distribution of lesions in the brain, neuromyelitis optica spectrum disorder was suspected. The child was started on intravenous methylprednisolone followed by tapering oral steroids. Serological testing was positive for myelin oligodendrocyte glycoprotein (MOG) and negative for aquaporin-4 antibodies. This case represents an unusual case of MOG associated demyelination disorder where the distribution of lesions showed chiasmal involvement along with optic tract, thalamus and deep white mater lesions.