[Painful ophthalmoplegias]

Painful ophthalmoplegias have numerous etiologies and are often the presenting sign of a severe disease. Anatomic localization of the lesion is essential in interpreting neuroimaging.

Binocular diplopia. A practical approach

BACKGROUND

Diplopia is a common complaint in both inpatient and outpatient neurologic practice. Its causes are many, and special historical and examination features are important to localization and accurate diagnosis.

REVIEW SUMMARY

This review is divided into 2 sections: the first related to diagnosis and the second to treatment of binocular diplopia. In the diagnostic section, emphasis is placed on identification of historical and examination features that can help to differentiate diplopia caused by dysfunction of cranial nerves versus neuromuscular junction, or orbital extraocular muscle. Techniques available to the neurologist for examining ocular motility and ocular misalignment and focused laboratory testing to evaluate diplopia are discussed in detail. The final section covers the various treatments for binocular diplopia, with recommendations regarding the utility of each treatment for different types of diplopia.

CONCLUSIONS

A logical step-by-step approach applied to each patient with diplopia will help prevent misdiagnosis and improve patient care.

[Effectiveness of plasma exchange in Miller Fisher syndrome--a case report]

BACKGROUND

We report a successful treatment by plasma exchange(PE) in the case of Miller Fisher syndrome.

CASE

A 71-year-old woman rapidly developed diplopia and unsteady gait, and was admitted to Minami-matsuyama Hospital on day 3 of her illness. Ophthalmological and neurological examination on admission revealed bilateral complete external ophthalmoplegia with moderate mydriasis, cerebellar ataxia, and weakness of biceps reflexs, but her consciousness was intact. Protein concentration in the cerebrospinal-fluid was slightly increased and serum anti-GQlb IgG antibody was positive. With the diagnosis of Miller Fisher syndrome, PE was carried out on days 12, 14, and 16. After PE, ophthalmoplegia and cerebellar ataxia improved markedly. The ocular symptoms resolved after a month.

CONCLUSION

The findings indicate that PE is a beneficial treatment in Miller Fisher syndrome during the acute phase of the disease.

A noisy zygoma fracture—complication of carotid-cavernous sinus fistula: total recovery of monocular blindness and frozen-eye after endoarterial coil embolization

A case of a patient with a zygoma fracture in combination with a carotid-cavernous sinus fistula--an arterio-venous fistula between the internal carotid artery and the cavernous sinus--is presented. The most frequent cause is trauma, but the carotid-cavernous sinus fistula itself may have been the cause of trauma. The patient showed complete loss of ocular motility and total monocular blindness. Treatment of the fistula with endoarterial coil embolization was followed by improvement of vision and ocular motility, until finally complete recovery of ocular functions, which is exceptional. In this case, careful analysis of the MRA's showed that the CCSF most likely developed in the posttraumatic phase.

Paralytic strabismus as a manifestation of lyme borreliosis

Lyme disease is a multi-system organ disorder caused by Borrelia burgdorferi. Although ocular manifestations have been reported, these remain a rare feature of the disease. This report shows a 49-years old patient that has been bitten by a tick and as consequence of which developed symptoms of the Lyme disease. In 1998 the patient was hospitalized in our Eye Clinic due to operating treatment of the paralytic strabismus (abductal nerve paralysis), as a rare feature of the Lyme disease. Postoperative squint angle was significantly reduced, but without any temporal movement. Diplopia was still present, though slightly reduced with the use of prism eyeglasses. The improvement of the quality of life was achieved, as well as the patient's satisfaction.

Orbital apex syndrome

PURPOSE OF REVIEW

Visual loss from optic neuropathy and ophthalmoplegia involving multiple cranial nerves are the hallmarks of an orbital apex syndrome. Historically, the terms superior orbital fissure, orbital apex, and cavernous sinus have been used to define the anatomic locations of a disease process. However, the diagnostic evaluation and management is similar for each of these entities. The authors reviewed the literature on the diagnosis and evaluation of disorders involving the orbital apex.

RECENT FINDINGS

High-resolution MRI is the preferred modality for evaluating most lesions involving the orbital apex. CT is a useful tool in the setting of trauma, to evaluate bone involvement, or when MRI is contraindicated. Although laboratory studies may be useful adjuncts in the diagnostic evaluation of lesions involving the orbital apex, surgical biopsy is often required for definitive diagnosis.

SUMMARY

Orbital apex syndromes may result from a variety of inflammatory, infectious, neoplastic, iatrogenic/traumatic, and vascular conditions. A detailed history with review of systems is important in narrowing the differential diagnosis. Management is directed at the underlying cause and may be guided by surgical biopsy. Corticosteroids may be useful if an inflammatory etiology is suspected, but should be used with caution.

Painful ophthalmoplegia: Overview with a focus on tolosa-hunt syndrome

Painful ophthalmoplegia is an important presenting complaint to emergency departments, ophthalmologists, and neurologists. The etiological differential diagnosis of painful ophthalmoplegia is extensive and consists of numerous sinister etiologies including vascular (eg, aneurysm, carotid dissection, carotid-cavernous fistula), neoplasms (eg, primary intracranial tumors, local or distant metastases), inflammatory conditions (eg, orbital pseudotumor, sarcoidosis, Tolosa-Hunt syndrome), infectious etiologies (eg, fungal, mycobacterial), and other conditions (eg, microvascular infarcts secondary to diabetes, ophthalmoplegic migraine, giant cell arteritis). A systematic approach to the evaluation of painful ophthalmoplegia can lead to prompt recognition of serious disorders that if left untreated, can be associated with significant morbidity or mortality. Inflammatory conditions such as Tolosa-Hunt syndrome and orbital pseudotumor are highly responsive to corticosteroids, but should be diagnoses of exclusion.

Ophthalmoplegic migraine

Ophthalmoplegic migraine is a rare condition, previously thought to represent a variant of migraine. Recent observations regarding its usual clinical presentation and common magnetic resonance imaging findings have given rise to speculation that this illness is more likely to represent an inflammatory cranial neuropathy. The recent revision of the International Headache Classification has reclassified ophthalmoplegic migraine from a subtype of migraine to the category of neuralgia. In this article, potential pathophysiological mechanisms are discussed. The typical clinical presentation of ophthalmoplegic migraine generally involves transient migraine-like headache accompanied by often long-lasting oculomotor, abducens or, rarely, trochlear neuropathy with diplopia and (if oculomotor nerve is involved) pupillary abnormalities and ptosis. Ophthalmoplegic migraine generally occurs in children, but a number of adult cases have been reported. Prognosis is good because symptoms almost always resolve, but, after several episodes, some deficits may persist. Differential diagnosis is rather large, although most other possible causes of ophthalmoplegia and headache have distinctive presentations or can be excluded with fairly straightforward diagnostic testing. Optimal prophylactic and acute treatment is still unclear, but migraine prophylactic medications such as b blockers and calcium channel blockers have been proposed. Steroids have been used with mixed results.

[Painful ophthalmoplegia secondary to larynx carcinoma]

CASE REPORT

We present a case of metastatic larynx cancer in the cavernous sinus. It presented itself as a right sixth cranial nerve palsy which progressed into a painful ophthalmoplegia with normal CT and RNM in its early stages.

DISCUSSION

We must suspect a cavernous sinus invasion in patients with cranial nerve palsies and with a history of malignancy, despite negative radiologic findings. Tumoral invasion of the skull base has been described in pharyngeal neoplasms but it is exceptional in larynx carcinomas.

Major review: the clinical spectrum of pediatric myasthenia gravis: blepharoptosis, ophthalmoplegia and strabismus. A report of 14 cases

BACKGROUND

Myasthenia gravis is infrequently encountered in pediatric ophthalmology practice. The purpose of this study is to evaluate the clinical spectrum of this condition in children and to identify factors that may aid the clinician in its diagnosis and management.

SUBJECTS AND METHODS

A retrospective chart review was performed on all pediatric patients presenting with myasthenia gravis to the Departments of Pediatric Ophthalmology and Neuro- ophthalmology at the Texas Children's Hospital from 1989-1999. Information regarding mode of presentation, myasthenic classification, ocular and systemic involvement, diagnostic investigations, therapy and outcome was collected and evaluated.

RESULTS

Fourteen patients were included in the study whose ages ranged from 1-17 years at presentation. One patient had congenital myasthenia gravis and 13 had juvenile myasthenia gravis. Thirteen of 14 (93%) patients presented with ocular findings; two of whom had associated systemic disease at presentation. Six of 14 (43%) patients had systemic involvement during the course of their illness, of whom three (21%) had respiratory compromise requiring assisted ventilation. Thirteen of 14 (93%) patients received pyridostigmine as first line treatment. Ten of 14 (71%) patients had a favorable response. A favorable response was defined as improvement in the extraocular motility to within 10 prism diopters of orthotropia with resolution of the blepharoptosis. Three of 14 patients (21%) received a combination of pyridostigmine and steroids, all of whom had a favorable response. Seven of 14 patients (50%) underwent thymectomy; all had a favorable response. Two of 14 patients (14%) required both blepharoptosis and strabismus surgery.

CONCLUSION

Pediatric myasthenia gravis may present initially to the ophthalmologist and should be considered in any pediatric patients with blepharoptosis and an ocular motility disturbance. Prompt diagnosis may be associated with significant reduction in morbidity. A favorable response to medical and surgery therapy was noted in most of our patients.

Unusual presentation of central nervous system relapse with oculomotor nerve palsy in a case of CD56-positive acute myeloid leukemia following allogeneic stem cell transplantation

Allogeneic stem cell transplantation (allo-SCT) plays an important role in the treatment of infants and children with acute myelogenous leukemia (AML). Leukemic relapse after allo-SCT is responsible for a high rate of treatment failure. Extra-medullary relapse (EMR), without involvement of bone marrow, is rare compared to medullary relapse. CD56, the neural cell adhesion molecule, may contribute to the higher frequency of CNS relapse in CD56-positive AML. We observed an isolated EMR on the oculomotor nerve of a 17-month-old girl 12 weeks after cord blood transplantation (CBT), who was transplanted because of CD56-positive AML. Diagnosis of relapse was suspected clinically and confirmed by magnetic resonance imaging (MRI), and fluorescence-activated cell sorter (FACS) and chimerism analysis of cerebrospinal fluid (CSF). Therapy consisted of intra-thecal chemotherapy, CNS irradiation, and systemic immunomodulation by cyclosporin A (CsA) and basiliximab withdrawal. Twenty-one months after relapse, the patient shows full remission of symptoms and previously described oculomotor nerve infiltration.

Abrupt-onset oculomotor paralysis: an endocrine emergency

Pituitary apoplexy is a severe and potentially life-threatening condition that may be highly variable in its clinical presentation. We report a 37-year-old man presenting to the emergency department with diplopia that abruptly developed while he was eating canned and bottled food prepared at home. A computed tomography scanning revealed an isodense mass within the sellar region and, subsequently, a magnetic resonance imaging showed a pituitary apoplexy causing a compression of the right III and VI oculomotor nerves. There was no improvement with hydrocortisone therapy and the patient underwent a transsphenoidal excision of the mass with an uneventful course. Pituitary apoplexy may raise in the appropriate setting the suspicion of botulism. The abrupt-onset paralysis of oculomotor nerves has been described as the chief presenting sign of pituitary apoplexy in only few cases including this. A pathophysiology, differential diagnosis with botulism and other causes of multiple cranial nerve paralysis, and treatment are described.

[Diagnostic and therapeutic approaches in oculomotor paralyses]

OBJECTIVES

We wish to unify current criteria regarding oculomotor paralysis (POM). Based on our experience, we have designed a diagnostic-therapeutic protocol which permits an early approach, especially since botulinum toxin has been used for treatment.

DEVELOPMENT

To make things easier to understand, we start with the concept of POM, including the physiopathogenic description of phenomena secondary to eye movements. Then we consider the aetiological-topographical incidence and assess the overall causes of POM and the relative frequency of the involvement of the different cranial oculomotor nerves. Finally, we consider each cranial nerve more fully from two different angles: the aetiologic-topographic diagnosis and therapeutic attitudes.

CONCLUSIONS

The current approach to POM should include a systematic study to classify the disorder as isolated, associated with other neurological causes or of some other type (metabolic, auto-immune, etc). Satisfactory early treatment should include consideration of infilbration with botulinum toxin in all paresis or paralysis presenting with contractures. In cases of total paralysis the contractures may occur within a week of onset of the condition. In partial paralyses close follow-up of three parameters evolution of the degree of ocular deviation, limitation of movement and exploration of passive movements makes it possible to determine the best moment to treat the contracture by injection of botulinum toxin: This treatment resolves or improves the diplopia, with recovery of oculomotor equilibrium, when it is given during the acute phase.

Acute onset of a bilateral areflexical mydriasis in Miller-Fisher syndrome: a rare neuro-ophthalmologic disease

Miller-Fisher syndrome (MFS) is characterized by variable ophthalmoplegia, ataxia, and tendon areflexia. It seems to be a variant of Guillain-Barré syndrome (GBS), but unlike in GBS, there is a primitive involvement of the ocular motor nerves, and in some cases there is brainstem or cerebellum direct damage. The unusual case of MFS in the current study started with a bilateral areflexical mydriasis and a slight failure of accommodative-convergence. Ocular-movement abnormalities developed progressively with a palsy of the upward gaze and a bilateral internuclear ophthalmoplegia to a complete ophthalmoplegia. In the serum of this patient, high titers of an IgG anti-GQ1b ganglioside and IgG anti-cerebellum. anti-Purkinje cells in particular, were found. The former autoantibody has been connected to cases of MFS, of GBS with associated ophthalmoplegia, and with other acute ocular nerve palsies. The anti-cerebellum autoantibody could explain central nervous system involvement in MFS. The role of these findings and clinical implications in MFS and in other neuro-ophthalmologic diseases are discussed.

Progressive visual loss and ophthalmoplegia

A 51-year-old woman with hyperthyroidism presented with a 4-week history of bilateral progressive visual loss despite treatment with oral prednisone. Her visual function improved after bilateral orbital decompression. The indications for and advantages and disadvantages of radiation therapy and orbital decompression in TAO are discussed. The management of intraocular pressure, strabismus, and lid abnormalities in TAO is also addressed.

Eye muscle paralysis after Vipera aspis envenomation

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Cerebral B-cell lymphoma following treatment for Tolosa-Hunt syndrome

We herein report a unique case of cerebral lymphoma which occurred after lymphocytic neuritis of cranial nerves causing Tolosa-Hunt syndrome and demonstrate the histological difference between these two diseases. A 70-year-old woman developed a sensory disturbance in the first and third divisions of the left trigeminal nerve and a left ocular movement disturbance five years before death. Although she was clinically diagnosed to have a schwannoma in the left cavernous sinus, a histologic examination verified a diffuse infiltration of T lymphocytes in the left trigeminal ganglion. Corticosteroid therapy was effective. Thereafter she demonstrated a disturbance of consciousness and dysphasia four years after surgery. A T1-weighted magnetic resonance image (MRI) disclosed high intensity lesions in both the basal ganglia and corpus callosum. She also showed progressive spastic paralysis. At autopsy a diagnosis of primary intracranial B-cell lymphoma was made. Although there was no invasion of the lymphoma cells into the left trigeminal nerves, a mild inflammatory infiltration of T cells still remained.

Fourth cranial nerve palsy in pediatric patients with pseudotumor cerebri

PURPOSE

To describe three children with acute fourth cranial nerve palsy secondary to pseudotumor cerebri.

METHODS

We reviewed the medical records of children younger than 18 years who were diagnosed with pseudotumor cerebri between 1977 and 1997. Pseudotumor cerebri was defined by normal neuro-imaging, elevated intracranial pressure measured by lumbar puncture, and normal cerebrospinal fluid composition.

RESULTS

Three children with pseudotumor cerebri presented with vertical diplopia and clinical signs of fourth cranial nerve palsy including a hypertropia of the affected eye, which increased with adduction and ipsilateral head tilt. The fourth cranial nerve palsy resolved after reduction of the intracranial pressure in all three children.

CONCLUSIONS

Fourth cranial nerve palsy may occur in children with pseudotumor cerebri and may be a nonspecific sign of elevated intracranial pressure.