A. Barata

Automated gonioscopy photography for iridocorneal angle grading

Purpose: The aim of this study is to assess the agreement between manual and automated gonioscopy for iridocorneal angle opening. Methods: The research is a cross-sectional observational study. Manual and automated gonioscopy were performed to consecutive patients in a glaucoma clinic. Iridocorneal angle opening grading was performed according to Shaffer’s classification. Automated gonioscopy was performed with NGS-1 automated gonioscope (NIDEK Co., Gamagori, Japan). The automated gonio-photos were graded by two independent observers. Agreement between automated and manual gonioscopy and also among raters was ascertained by Fleiss’ kappa statistic and comparison of area under curve. Results: In total, 88 eyes of 47 subjects were analysed. Mean age was 63 ± 10 years. Twenty eyes (22.7%) were excluded from grading due to poor quality images. Angle closure was detected in 23.4% with dynamic gonioscopy in comparison with 4.3% using automated image grading. The agreement for angle closure diagnosis between dynamic and automated gonioscopy was low (κ = 0.09 ± 0.10; p = 0.18). The area under curve for detecting eyes with angle closure showed poor accuracy between automated and manual methods (area under curve: 0.53 ± 0.05, 95% confidence interval: 0.44–0.62). There was modest inter-rater agreement for angle opening assessment of automated images with Fleiss’ kappa of 0.17 (95% confidence interval: 0.035–0.238). Conclusion: Manual and automated gonioscopy showed only slight agreement for the assessment of iridocorneal angle opening status. Further improvements of the NGS-1 automated gonioscopy and technique are desired for widespread use in a real-life setting.

Unusual third cranial nerve palsy presentation with unexpected distant departure point

Introduction: Oculomotor nerve palsy can arise as a result of a number of different conditions, and the differential diagnosis should take in to account patient’s age, past medical history and clinical presentation. Diplopia, ptosis, restricted ocular movements, exotropia, with or without pupil involvement are common symptoms at presentation. Case Report: We present the clinical case of a 72-year-old Caucasian male with ophthalmological history of right eye amblyopia caused by an untreated esotropia, who went to the emergency room presenting holocranial headache, ptosis and temporary diplopia. The pupils were symmetric with a present but slowed down right direct reflex, and a doubtful Marcus Gunn pupil. The patient was orthotropic. Ocular motility examination showed a limitation in adduction, elevation and depression of the right eye. The patient had a computed tomography (CT) of the brain and orbits, a analytical study, a CT angiography, a brain magnetic resonance, a lumbar puncture, a CT scan of the neck, chest, abdomen and pelvis, a flexible cystoscopy, and a transurethral resection. Once made, the histology of the biopsies of TUR revealed fragments of a infiltrative urothelial carcinoma of high grade. Conclusion: The oculomotor nerve palsy may be the first manifestation of a serious systemic disease and appear in an atypical form in a patient with a previous esotropia. Careful assessment and investigation should be taken. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No. 9, September 2017. ISSN: 0976-3198 Int J Case Rep Images 2017;8(9):613–616. www.ijcasereportsandimages.com Sousa et al. 613 CASE REPORT PEER REVIEWED | OPEN ACCESS Unusual third cranial nerve palsy presentation with unexpected distant departure point Filipa Caiado Sousa, André Diogo Barata, Filipa Teixeira, Vítor Silva