Ophthalmology

Ophthalmology

OBJECTIVE

This study described the etiology and clinical profile of non-glaucomatous optic neuropathy (NGON) cases in a tertiary government hospital in Quezon City, Philippines.

This was a retrospective, cross-sectional study of patients seen at a neuro-ophthalmology clinic of a tertiary referral center in Quezon City, Philippines from January 01, 2008 to December 31, 2020. The patients’ medical records were reviewed and the following data were extracted and analyzed: demographic data, mechanism of NGON, and clinical profile.

A total of 911 patient records were reviewed. Most patients were males (61.3%) within the economically productive age group (72.7%). Overall, the top three mechanisms that contributed to NGON were (1) trauma-related (25.9%), (2) ischemic (19.8%), and (3) inflammatory causes (18.0%). When patients were stratified by age, the most common causes in the pediatric group were traumatic (33.9%), inflammatory (28.6%), and papilledema-related (11.3%) optic neuropathies. In the middle age group, traumatic (29.1%), inflammatory (18.5%), and ischemic (17.8%) etiologies predominated. Among the elderly, ischemic (44.0%), drug-induced (26.1%), and compressive (17.9%) causes were most frequently identified.

Traumatic optic neuropathy emerged as the leading cause of vision loss from NGON in both pediatric and middle aged groups. In the absence of trauma, further investigations should focus on inflammatory and papilledema-related etiologies in the pediatric and middle aged groups. Among the elderly, ischemia and drug-induced toxic optic neuropathies were the most prevalent, with thorough history-taking being crucial for identifying medication-related causes.

OBJECTIVE

To compare the frequency and severity of color vision defects between diabetes mellitus (DM) patients without retinopathy and those with mild non-proliferative diabetic retinopathy (NPDR), and to evaluate the relationship between these color vision defects and capillary blood glucose (CBG) levels.

This was a cross-sectional, hospital-based study conducted over a seven-month period at the Ophthalmology Outpatient Department of Cardinal Santos Medical Center. Thirty-five (35) DM patients (70 eyes) aged 50 to 75 years with best-corrected visual acuity of ≥20/50 and no more than mild NPDR were included. Patients with moderate or severe NPDR, macular edema, optic nerve pathology, or significant cataracts were excluded. All participants underwent visual acuity testing, fundus examination, and color vision assessment using the Ishihara pseudoisochromatic plates and Farnsworth D-15 tests conducted under standardized lighting conditions. CBG was measured using the finger-prick method. Main outcome measures included the proportion and type of color vision defects, their association with DR classification, and CBG levels. Statistical analyses included descriptive statistics, the Fisher exact test, the Mann-Whitney U test for the Farnsworth D-15 Color Confusion Index (CCI), and Spearman correlation between CBG and CCI.

Tritan-type defects were the most common, accounting for 36.2%. Color vision defects were observed in 91.3% (64 eyes) of patients with no DR, while defects were seen in all eyes (100%) with mild NPDR (5 eyes). However, this difference was not statistically significant (p = 1.000). There was no significant correlation between CBG levels and color vision scores. Mean CCI scores were similar between groups (p = 0.394), indicating no substantial difference in defect severity.

Color vision defects may be more prevalent in early NPDR compared to no DR, but this difference was not significant in this sample. No correlation was found between CBG levels and color vision performance. Color vision testing may serve as a useful adjunctive screening tool for early diabetic retinal changes; however, further studies with larger sample sizes are necessary.

OBJECTIVE

To determine the pupillary parameters of adult patients with type 2 diabetes mellitus (DM) using the Reflex PLR© mobile application and to correlate these parameters with glycosylated hemoglobin (HbA1C) levels.

This was a single-center, prospective, observational, cross-sectional study conducted at Ospital ng Makati from June to August 2024. Study participants were patients with type 2 DM without diabetic retinopathy and non-diabetics who served as the control group. Participants underwent blood chemistry testing and pupillometry using the Reflex PLR© mobile app. The study outcomes were maximum and minimum pupillary diameters, amplitude, and latency.

There were 44 study participants: 26 non-diabetics and 18 diabetic patients. The two groups had similar pupillary baseline diameters (p = 0.72; p = 0.30), maximum pupillary diameters (p = 0.82; p = 0.89), minimum pupillary diameters (p = 0.85; p = 0.89), pupillary amplitudes (p = 0.88; p = 0.55), and pupillary latencies (p = 0.53; p = 0.47) for the right and left eyes, respectively. The relationship between pupillary parameters and HbA1C levels showed no significant variations in baseline diameter (p = 0.21; p = 0.45), maximum diameter (p = 0.65 for the right eye; p = 0.46 for the left eye), minimum diameter (p = 0.77; p = 0.46), amplitude (p = 0.89; p = 0.83), and latency (p = 0.31; p = 0.22).

The study did not demonstrate any significant correlation between pupillary parameters and HbA1C levels. Pupillary changes in diabetes may have been more dependent on factors such as disease duration and the presence of complications rather than glycemic control alone.

OBJECTIVE

To describe a case of dengue-associated bilateral neuroretinitis in a young female adult.

This is a case report.

A 25-year-old female was referred for evaluation of bilateral blurring of vision during the convalescent stage of dengue fever. Visual acuity was 20/80 in each eye. Fundoscopy showed mild optic disc swelling, macular thickening, and hard exudates bilaterally. Dengue-associated neuroretinitis was considered. Intravenous methylprednisolone treatment for three days resulted in significant improvements in visual function and resolution of fundus abnormalities.

Dengue is a potential etiology of neuroretinitis in endemic areas, especially in those who develop visual symptoms during the convalescent phase. Prompt recognition and treatment may prevent long-term visual impairment.

OBJECTIVE

To describe the clinical presentation, management and outcome of a rare case of isolated oculomotor nerve palsy in an immunocompromised adult secondary to a central nervous system (CNS) tuberculoma.

This is a case report.

A Filipino male in his 30s developed severe throbbing headache followed by binocular diplopia and drooping of the right upper eyelid. Findings were compatible with a neurologically-isolated pupil-involving, complete oculomotor nerve palsy on the right. Brain magnetic resonance imaging demonstrated enlargement and contrast enhancement of the cisternal portion of the right oculomotor nerve. Serologic testing was positive for the human immunodeficiency virus (HIV) and syphilis. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis and elevated protein. CSF polymerase chain reaction was positive for Mycobacterium tuberculosis (TB). The patient was treated with penicillin, quadruple anti-Koch’s, and anti-retrovirals. Eyelid position and ocular motility improved after treatment. Aberrant regeneration of the right oculomotor nerve was observed with elevation of the right eyelid on downgaze (pseudo-Graefe sign).

CNS tuberculoma may present as a neurologically-isolated oculomotor nerve palsy, particularly in immunocompromised individuals. In TB-endemic countries, like the Philippines, it should be considered in the differential diagnosis. Early recognition and appropriate antimicrobial therapy can lead to neurologic improvement.

OBJECTIVE

To present a rare case of nine syndrome in a middle-aged patient with stage IV chronic kidney disease presenting with hypertensive emergency at a tertiary government hospital, and to discuss its clinical presentation, diagnostic approach, and management within the realities of limited-resource settings.

This is a case report.

A 45-year-old woman with uncontrolled hypertension and stage IV chronic kidney disease came to the emergency department with acute dizziness and vomiting. On neurologic examination, she had left horizontal conjugate gaze palsy and an adduction deficit of the left eye with intact abduction and an abducting nystagmus of the right eye consistent with one-and-a-half syndrome. In addition, she had left-sided facial weakness and right lower limb weakness suggesting nine syndrome. Brain imaging confirmed a left posterior pontine infarct. Treatment for neuroprotection and blood pressure control led to significant improvement in ocular symptoms and muscle strength.

This report describes a rare case of nine syndrome. Careful bedside neuro-ophthalmologic examination, supported by MRI, enabled accurate localization to the paramedian pons. Early recognition allowed timely stroke management and initiation of secondary management, even in a resource-limited setting.

OBJECTIVE

To present a long-term follow-up report of a 10-year-old male with optic nerve glioma who underwent surgical removal and postoperative chemotherapy.

Case report.

A 10-year-old Filipino boy was referred to a tertiary institution for a five-year history of progressive right eye proptosis with vision loss. Pertinent findings included right eye proptosis, lagophthalmos, and limited elevation and adduction. He also had several hyperpigmented lesions on the abdomen and upper torso. Vision on the right was no light perception, with a relative afferent pupillary defect, exposure keratopathy, and optic nerve pallor. Vision on the left eye was 20/20 with a temporal visual field defect. Cranial and orbital computed tomography (CT) scan showed a circumscribed enhancing mass within the right intraconal space with widened right optic nerve canal. Additional magnetic resonance imaging (MRI) revealed a heterogeneously enhancing mass diffusely involving the intraorbital and intracanalicular segments of the right optic nerve suspicious for optic nerve glioma. He underwent excision of the orbital portion of the mass via lateral orbitotomy. Histopathology showed pilocytic astrocytoma. Eight cycles of chemotherapy with carboplatin and vincristine was completed. Significant improvement of globe position and resolution of ocular exposure was achieved postoperatively with residual right ptosis. These findings remained stable at six years after treatment.

Optic nerve gliomas with intracanalicular and chiasmal extension can be managed with surgical removal of the orbital component and postoperative chemotherapy. This can result in improvement of proptosis and long-term remission.

OBJECTIVE

To report a case of orbital apex syndrome due to metastatic adenocarcinoma of the orbit in an adult male.

This is a case report.

A 52-year-old male presented with a subacute onset of ophthalmoplegia, ptosis, and vision loss secondary to an optic neuropathy. Orbital apex syndrome was the primary consideration. Laboratory workup ruled out infectious and inflammatory etiologies. Neuroimaging revealed an irregular, intraconal mass in the left orbit. During the disease course, a new supraorbital mass lesion was noted. Incisional biopsy, histopathology and immunohistochemistry (IHC) revealed positive Cytokeratin 7 and negative Cytokeratin 20 expression, suggestive of metastatic adenocarcinoma.

Diagnosis of orbital apex syndrome requires careful integration of clinical evaluation, laboratory testing, and imaging. When a mass lesion is present, biopsy and IHC staining can be critical in determining the primary origin of a malignancy.