Letters to the Editor Epidural hematomas occur rapidly and are usually stable, attaining maximum size within minutes of injury. We believe that isolated complete third nerve palsy without any other signs or symptoms in our patient was due to the slowly developing extradural hematoma of venous origin displacing the temporal lobe and causing compression of the third nerve. Dilated, sluggish, or fixed pupil (s), bilateral or ipsilateral to the injury occur due to increased intracranial pressure (ICP) or transtentorial herniation. Raised ICP can also have other signs like hypertension, bradycardia, and bradypnea. Transtentorial herniation has the triad of coma, fixed and dilated pupil (s), and decerebrate posturing. In our patient, fundoscopic examination was normal, ruling out raised ICP. Also, transtentorial herniation would have presented with other neurological symptoms, which were absent in our patient. Epidural hematoma accompanied by oculomotor nerve palsy may also occur due to sphenoid sinusitis.[5,6] Stretching of the ipsilateral third nerve initially causes compression of pupilloconstrictor fibers with subsequent paralytic mydriasis. As the uncal herniation progresses, ptosis and weakness of the medial rectus muscle follows sequentially. Patients presenting with isolated third nerve palsy must undergo brain imaging to rule out extradural hematoma. Physicians must be aware of this unusual and treatable cause of isolated third nerve paralysis, as early intervention in such cases results in complete recovery.
Batuk Diyora, Sanjay Kukreja, Naren Nayak, Hanmant Kamble, Alok Sharma
Retinal pigment epithelial tear after intravitreal bevacizumab injection for exudative age-related macular degeneration Sir, Retinal pigment epithelial (RPE) tears have been reported as a result of exudative age-related macular degeneration (AMD) disease process itself as well as various treatment modalities including thermal laser, photodynamic therapy, and antivascular endothelial growth factor (anti-VEGF) therapy.[1] Bevacizumab (Avastin®; Genentech, South San Francisco, CA) is a recombinant humanized monoclonal antibody that binds all the biologically active isoforms of VEGF-A, inhibiting its interaction with receptors found on endothelial cells. It has been used increasingly as an offlabel treatment for exudative AMD.[2-4] We narrate our experience in an elderly patient who developed RPE tear following the
104
Department of Neurosurgery, Lokmanya Tilak Muncipal Medical College and Muncipal General Hospital, Sion, Mumbai, India Correspondence: Dr. Batuk Diyora, Department of Neurosurgery, L. T. M. G. Hospital, Sion (W), Mumbai - 400 022, India. E-mail: [email protected]
References 1. 2.
3.
4. 5.
6.
Clark ES, Gooddy W. Ipsilateral third cranial nerve palsy as a presenting sign in acute subdural haematoma. Brain 1953;76:266-78. Pevehouse BC, Bloom WH, McKissock W. Ophthalmologic aspects of diagnosis and localization of subdural hematoma. An analysis of 389 cases and review of the literature. Neurology 1960;10:1037-41. Ramirez RE, Hibri N, Brennan MW. Recurrent subtemporal epidural hematoma with second, third and fourth cranial nerve compression. Comput Radiol 1984;8:37-41. DiTullio MV Jr. Epidural hematoma with complete third nerve paralysis in an awake patient. Surg Neurol 1977;7:193-4. Cho KS, Cho WH, Kim HJ, Roh HJ. Epidural hematoma accompanied by oculomotor nerve palsy due to sphenoid sinusitis. Am J Otolaryngol 2011;32:355-7. Stefanis L, Przedborski S. Isolated palsy of the superior branch of the oculomotor nerve due to chronic erosive sphenoid sinusitis. J Clin Neuroophthalmol 1993;13:229-31. Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.137177
second injection of bevacizumab for occult choroidal neovascular membrane. A 79-year-old nondiabetic and nonhypertensive female patient presented with sudden diminution of vision in her right eye of 1-week duration. The presenting visual acuity was counting fingers at one foot in the right eye and 20/30; N6 in the left eye. Fundus examination revealed submacular hemorrhage along with hard drusen in the right eye and hard drusen in the left eye [Figure 1a]. Fundus fluorescein angiography (FFA) showed blocked fluorescence due to submacular hemorrhage, multiple petechial hyperfluorescent lesions consistent with hard drusen, and a hyperfluorescent lesion in the bed of the submacular hemorrhage corresponding to occult choroidal neovascular membranein the right eye and tiny hyperfluorescent lesions consistent with macular hard drusen in the left eye [Figure 1b]. Optical coherence tomography (OCT) showed irregular RPE thickening and loss of foveal contour in the right eye and normal scan in the left eye [Figure 1c]. Based on the above features (FFA and OCT correlation), a diagnosis of occult choroidal neovascular membrane was made in the right eye. The patient opted for intravitreal bevacizumab injection (1.25 mg in 0.1 mL).
Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014
Letters to the Editor
a
b a c
Figure 1: (a) Color fundus photograph showing submacular hemorrhage along with hard drusen in the right eye and multiple hard drusen at the macula in the left eye, (b) Late-phase fundus fluorescein angiography (FFA) photograph of the right eye showing blocked fluorescence due to submacular hemorrhage, a hyperfluorescent lesion in the bed of the submacular hemorrhage corresponding to occult choroidal neovascular membrane, (c) Optical coherence tomography (OCT) photograph of the right eye showing irregular retinal pigment epithelial (RPE) thickening and loss of foveal contour in the right eye
b Figure 2: (a) Color fundus photograph of the right eye showing central clearing of submacular hemorrhage 4 weeks post bevacizumab injection, (b) Optical coherence tomography (OCT) photograph of the right eye showing small neurosensory detachment 4 weeks post bevacizumab injection
imaging of the macula displayed thickened hyper-reflective RPE layer with obvious tear and adjacent subretinal fluid [Figure 3c].
a
b
c Figure 3: (a) Color fundus photograph of the right eye revealing a crescentric area of denuded retinal pigment epithelial (RPE) involving foveal region 4 weeks after the second bevacizumab injection, (b) Late-phase fundus fluorescein angiography (FFA) photograph of the right eye showing retinal pigment epithelial (RPE) tear with central blocking hypofluorescence and adjacent crescentric hyperfluorescence after the second bevacizumab injection, (c) Optical coherence tomography (OCT) picture of the right eye displaying thickened hyper-reflective retinal pigment epithelial (RPE) layer with obvious tear and adjacent subretinal fluid
Shaikh et al. estimated the incidence of RPE tears following intravitreal bevacizumab therapy for choroidal neovascularization associated with AMD at 1.6%.[5] Anti-VEGF injections may contribute to RPE tears by causing loss of tight junction gene transcription resulting in decreased RPE intercellular adherence. Furthermore, anti-VEGF therapy leads to contraction of choroidal neovascular membranes. Our case had occult choroidal neovascular membrane in the right eye. The patient developed RPE tear after the second intravitreal bevacizumab injection. Ophthalmologists should be aware of the fact that RPE tears although rare, may occur after intravitreal bevacizumab therapy for choroidal neovascularization associated with AMD.
Sunil Kumar Singh, Satyen Deka1 She achieved 20/60; N24 in the right eye 4 weeks post bevacizumab intravitreal injection. Fundus examination of the right eye revealed clearing of submacular hemorrhage centrally [Figure 2a]. OCT of the right eye showed small neurosensory detachment [Figure 2b]. The patient underwent the second injection of intravitreal bevacizumab. The patient returned 4 weeks later with diminution of vision in the right eye. Best-corrected visual acuity was 20/200; N36 in the right eye. Fundus examination revealed a crescentric area of denuded RPE involving the foveal region [Figure 3a]. FFA showed RPE tear with central blocking hypofluorescence and adjacent crescentric hyperfluorescence [Figure 3b]. OCT
Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014
Vitreoretina Services, North Bengal Eye Centre, Siliguri, West Bengal, 1Sri Sankaradeva Nethralaya, Guwahati, Assam, India Correspondence: Dr. Sunil Kumar Singh, Consultant Vitreoretinal Surgeon, North Bengal Eye Centre, Siliguri - 734 001, West Bengal, India. E-mail: [email protected]
References 1. 2.
3.
Hoskin A, Bird AC, Sehmi K. Tears of detached retina pigment epithelium. Br J Ophthalmol 1981;65:417-22. Gelisken F, Inhoffen W, Partsch M. Retinal pigment epithelial tear following after photodynamic therapy for choroidal neovascularization. Am J Ophthalmol 2001;131:518-20. Spandau UH, Jonas JB. Retinal pigment epithelium tear after intravitreal
105
Letters to the Editor
4.
5.
bevacizumab for exudative age-related macular degeneration. Am J Ophthalmol 2006;142:1068-70. Meyer CH, Mennel S, Schmidt JC, Kroll P. Acute retinal pigment epithelial tear following intravitreal bevacizumab (Avastin) injection for occult choroidal neovacularisation secondary to age related macular degeneration. Br J Ophthalmol 2006;90:1207-8. Shaikh S, Olson JC, Richmond PP. Retinal pigment epithelial tears after intravitreal bevacizumab injection for exudative age-related macular degeneration. Indian J Ophthalmol 2007;55:470-2.
An unusual case of posterior cerebral artery infarct in otherwise healthy man
Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.137178
any change. After another 1 month his intraocular pressure was 23 mmHg. He was started on Lumigan eye drop at bed time in OU. The intraocular pressure was 16 mmHg after 2 weeks of treatment
Sir, We would like to share our experience by highlighting the role of an ophthalmologist in confrontation, automated perimetry, and clinical examination especially in patients with the high risk factors like diabetes and blood pressure as they can lead to silent infarcts and stroke. A 65-year-old male patient presented to the ophthalmology outpatient department with complaints of watering in both the eyes since 1 week. On Ocular Examination visual acuity in both eyes (OU) was 20/40 (6/12) improving to 20/30 (6/9) with pinhole. His ocular movements were normal in all the gazes. Anterior segment examination including colour vision was within normal limits. Fundus examination revealed deep cup in both eyes with cup disc ratio of 0.3:1 in OD and 0.6:1 in OS. Rest of the fundus findings were within normal limits. On refraction the vision was improving to 20/30 with +2.75DS/-3.00 DCyl in OD and +1.50DS/-0.75 DCyl in OS. Intraocular pressure (IOP) by Goldmann applanation tonometer was found to be 14 and 15 mmHg in OD and OS, respectively. In view of asymmetrical cupping of optic disc, Humphreys perimetry was done which revealed left homonymous hemianopia [Figure 1]. Gonioscopy revealed open angles. Blood pressure was 140/90 mmHg. The neurological examination including higher functions was within normal limits. MRI showed an infarct in the area of the right occipital cerebral hemisphere and right cerebellum [Figure 2] MR angiography revealed a posterior cerebral artery infarct. The glycosylated hemoglobin was 10 mg% and rest of the blood profile including coagulation and lipid profile was altered. After cardiologist and neurologist opinion, he was prescribed vasodialators, statins, and advised strict control of his blood pressure and diabetes. He followed up at every 15 days. At 12 week follow up, the Goldmann applanation tonometer readings were 29 mmHg in OD and 27 mmHg in OS. On subsequent followup his IOP remained consistently high and therefore he was investigated for open angle glaucoma. Central corneal thickness was 534 in the right eye and 532 in the left eye. The average RNFL thickness done by OCT was 71 in OD and 61 in OS. His HVF charting did not show 106
Figure 1: Humphreys visual field showing left homonymous hemianopia at first visit
Figure 2: Infarct in the region of right cerebral hemisphere and cerebellum
Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014
Copyright of Oman Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Batuk Diyora, Sanjay Kukreja, Naren Nayak, Hanmant Kamble, Alok Sharma
Retinal pigment epithelial tear after intravitreal bevacizumab injection for exudative age-related macular degeneration Sir, Retinal pigment epithelial (RPE) tears have been reported as a result of exudative age-related macular degeneration (AMD) disease process itself as well as various treatment modalities including thermal laser, photodynamic therapy, and antivascular endothelial growth factor (anti-VEGF) therapy.[1] Bevacizumab (Avastin®; Genentech, South San Francisco, CA) is a recombinant humanized monoclonal antibody that binds all the biologically active isoforms of VEGF-A, inhibiting its interaction with receptors found on endothelial cells. It has been used increasingly as an offlabel treatment for exudative AMD.[2-4] We narrate our experience in an elderly patient who developed RPE tear following the
104
Department of Neurosurgery, Lokmanya Tilak Muncipal Medical College and Muncipal General Hospital, Sion, Mumbai, India Correspondence: Dr. Batuk Diyora, Department of Neurosurgery, L. T. M. G. Hospital, Sion (W), Mumbai - 400 022, India. E-mail: [email protected]
References 1. 2.
3.
4. 5.
6.
Clark ES, Gooddy W. Ipsilateral third cranial nerve palsy as a presenting sign in acute subdural haematoma. Brain 1953;76:266-78. Pevehouse BC, Bloom WH, McKissock W. Ophthalmologic aspects of diagnosis and localization of subdural hematoma. An analysis of 389 cases and review of the literature. Neurology 1960;10:1037-41. Ramirez RE, Hibri N, Brennan MW. Recurrent subtemporal epidural hematoma with second, third and fourth cranial nerve compression. Comput Radiol 1984;8:37-41. DiTullio MV Jr. Epidural hematoma with complete third nerve paralysis in an awake patient. Surg Neurol 1977;7:193-4. Cho KS, Cho WH, Kim HJ, Roh HJ. Epidural hematoma accompanied by oculomotor nerve palsy due to sphenoid sinusitis. Am J Otolaryngol 2011;32:355-7. Stefanis L, Przedborski S. Isolated palsy of the superior branch of the oculomotor nerve due to chronic erosive sphenoid sinusitis. J Clin Neuroophthalmol 1993;13:229-31. Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.137177
second injection of bevacizumab for occult choroidal neovascular membrane. A 79-year-old nondiabetic and nonhypertensive female patient presented with sudden diminution of vision in her right eye of 1-week duration. The presenting visual acuity was counting fingers at one foot in the right eye and 20/30; N6 in the left eye. Fundus examination revealed submacular hemorrhage along with hard drusen in the right eye and hard drusen in the left eye [Figure 1a]. Fundus fluorescein angiography (FFA) showed blocked fluorescence due to submacular hemorrhage, multiple petechial hyperfluorescent lesions consistent with hard drusen, and a hyperfluorescent lesion in the bed of the submacular hemorrhage corresponding to occult choroidal neovascular membranein the right eye and tiny hyperfluorescent lesions consistent with macular hard drusen in the left eye [Figure 1b]. Optical coherence tomography (OCT) showed irregular RPE thickening and loss of foveal contour in the right eye and normal scan in the left eye [Figure 1c]. Based on the above features (FFA and OCT correlation), a diagnosis of occult choroidal neovascular membrane was made in the right eye. The patient opted for intravitreal bevacizumab injection (1.25 mg in 0.1 mL).
Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014
Letters to the Editor
a
b a c
Figure 1: (a) Color fundus photograph showing submacular hemorrhage along with hard drusen in the right eye and multiple hard drusen at the macula in the left eye, (b) Late-phase fundus fluorescein angiography (FFA) photograph of the right eye showing blocked fluorescence due to submacular hemorrhage, a hyperfluorescent lesion in the bed of the submacular hemorrhage corresponding to occult choroidal neovascular membrane, (c) Optical coherence tomography (OCT) photograph of the right eye showing irregular retinal pigment epithelial (RPE) thickening and loss of foveal contour in the right eye
b Figure 2: (a) Color fundus photograph of the right eye showing central clearing of submacular hemorrhage 4 weeks post bevacizumab injection, (b) Optical coherence tomography (OCT) photograph of the right eye showing small neurosensory detachment 4 weeks post bevacizumab injection
imaging of the macula displayed thickened hyper-reflective RPE layer with obvious tear and adjacent subretinal fluid [Figure 3c].
a
b
c Figure 3: (a) Color fundus photograph of the right eye revealing a crescentric area of denuded retinal pigment epithelial (RPE) involving foveal region 4 weeks after the second bevacizumab injection, (b) Late-phase fundus fluorescein angiography (FFA) photograph of the right eye showing retinal pigment epithelial (RPE) tear with central blocking hypofluorescence and adjacent crescentric hyperfluorescence after the second bevacizumab injection, (c) Optical coherence tomography (OCT) picture of the right eye displaying thickened hyper-reflective retinal pigment epithelial (RPE) layer with obvious tear and adjacent subretinal fluid
Shaikh et al. estimated the incidence of RPE tears following intravitreal bevacizumab therapy for choroidal neovascularization associated with AMD at 1.6%.[5] Anti-VEGF injections may contribute to RPE tears by causing loss of tight junction gene transcription resulting in decreased RPE intercellular adherence. Furthermore, anti-VEGF therapy leads to contraction of choroidal neovascular membranes. Our case had occult choroidal neovascular membrane in the right eye. The patient developed RPE tear after the second intravitreal bevacizumab injection. Ophthalmologists should be aware of the fact that RPE tears although rare, may occur after intravitreal bevacizumab therapy for choroidal neovascularization associated with AMD.
Sunil Kumar Singh, Satyen Deka1 She achieved 20/60; N24 in the right eye 4 weeks post bevacizumab intravitreal injection. Fundus examination of the right eye revealed clearing of submacular hemorrhage centrally [Figure 2a]. OCT of the right eye showed small neurosensory detachment [Figure 2b]. The patient underwent the second injection of intravitreal bevacizumab. The patient returned 4 weeks later with diminution of vision in the right eye. Best-corrected visual acuity was 20/200; N36 in the right eye. Fundus examination revealed a crescentric area of denuded RPE involving the foveal region [Figure 3a]. FFA showed RPE tear with central blocking hypofluorescence and adjacent crescentric hyperfluorescence [Figure 3b]. OCT
Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014
Vitreoretina Services, North Bengal Eye Centre, Siliguri, West Bengal, 1Sri Sankaradeva Nethralaya, Guwahati, Assam, India Correspondence: Dr. Sunil Kumar Singh, Consultant Vitreoretinal Surgeon, North Bengal Eye Centre, Siliguri - 734 001, West Bengal, India. E-mail: [email protected]
References 1. 2.
3.
Hoskin A, Bird AC, Sehmi K. Tears of detached retina pigment epithelium. Br J Ophthalmol 1981;65:417-22. Gelisken F, Inhoffen W, Partsch M. Retinal pigment epithelial tear following after photodynamic therapy for choroidal neovascularization. Am J Ophthalmol 2001;131:518-20. Spandau UH, Jonas JB. Retinal pigment epithelium tear after intravitreal
105
Letters to the Editor
4.
5.
bevacizumab for exudative age-related macular degeneration. Am J Ophthalmol 2006;142:1068-70. Meyer CH, Mennel S, Schmidt JC, Kroll P. Acute retinal pigment epithelial tear following intravitreal bevacizumab (Avastin) injection for occult choroidal neovacularisation secondary to age related macular degeneration. Br J Ophthalmol 2006;90:1207-8. Shaikh S, Olson JC, Richmond PP. Retinal pigment epithelial tears after intravitreal bevacizumab injection for exudative age-related macular degeneration. Indian J Ophthalmol 2007;55:470-2.
An unusual case of posterior cerebral artery infarct in otherwise healthy man
Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.137178
any change. After another 1 month his intraocular pressure was 23 mmHg. He was started on Lumigan eye drop at bed time in OU. The intraocular pressure was 16 mmHg after 2 weeks of treatment
Sir, We would like to share our experience by highlighting the role of an ophthalmologist in confrontation, automated perimetry, and clinical examination especially in patients with the high risk factors like diabetes and blood pressure as they can lead to silent infarcts and stroke. A 65-year-old male patient presented to the ophthalmology outpatient department with complaints of watering in both the eyes since 1 week. On Ocular Examination visual acuity in both eyes (OU) was 20/40 (6/12) improving to 20/30 (6/9) with pinhole. His ocular movements were normal in all the gazes. Anterior segment examination including colour vision was within normal limits. Fundus examination revealed deep cup in both eyes with cup disc ratio of 0.3:1 in OD and 0.6:1 in OS. Rest of the fundus findings were within normal limits. On refraction the vision was improving to 20/30 with +2.75DS/-3.00 DCyl in OD and +1.50DS/-0.75 DCyl in OS. Intraocular pressure (IOP) by Goldmann applanation tonometer was found to be 14 and 15 mmHg in OD and OS, respectively. In view of asymmetrical cupping of optic disc, Humphreys perimetry was done which revealed left homonymous hemianopia [Figure 1]. Gonioscopy revealed open angles. Blood pressure was 140/90 mmHg. The neurological examination including higher functions was within normal limits. MRI showed an infarct in the area of the right occipital cerebral hemisphere and right cerebellum [Figure 2] MR angiography revealed a posterior cerebral artery infarct. The glycosylated hemoglobin was 10 mg% and rest of the blood profile including coagulation and lipid profile was altered. After cardiologist and neurologist opinion, he was prescribed vasodialators, statins, and advised strict control of his blood pressure and diabetes. He followed up at every 15 days. At 12 week follow up, the Goldmann applanation tonometer readings were 29 mmHg in OD and 27 mmHg in OS. On subsequent followup his IOP remained consistently high and therefore he was investigated for open angle glaucoma. Central corneal thickness was 534 in the right eye and 532 in the left eye. The average RNFL thickness done by OCT was 71 in OD and 61 in OS. His HVF charting did not show 106
Figure 1: Humphreys visual field showing left homonymous hemianopia at first visit
Figure 2: Infarct in the region of right cerebral hemisphere and cerebellum
Oman Journal of Ophthalmology, Vol. 7, No. 2, 2014
Copyright of Oman Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
