Apraxia of eyelid opening: clinical features and therapy

PURPOSE

Botulinum toxin injection is the treatment of choice in cases of benign essential blepharospasm. However, about 10% of the patients do not get sufficient effect from this treatment, and many of them have concomitant apraxia of lid opening.

METHODS

Over a 3-year period we treated 12 patients. Three had pure apraxia of lid opening and in the other nine it was associated with blepharospasm. All patients were initially treated with botulinum toxin injections with poor results. They underwent surgical treatment like blepharoplasty, limited myectomy, aponeurosis repair, and/or frontalis suspension. Some of them needed post operative botulinum toxin injections in the pretarsal part of orbicularis oculi muscles.

RESULTS

This combined therapy gave good functional and aesthetic results.

CONCLUSIONS

The specific causes of blepharospasm and apraxia of lid opening are unknown, but these two conditions coexist in some patients and can be difficult to treat. It is important to make a correct diagnosis, and a combined surgical and botulinum toxin treatment can be very effective.

Long-term botulinum toxin treatment increases employment rate in patients with cervical dystonia

We examined the impact of cervical dystonia (CD) and long-term botulinum toxin (BTX) treatment on employment status. Data on employment status at onset of CD, at initiation of BTX treatment, and at evaluation of long-term treatment were obtained from 62 CD patients aged 31-66 years (median, 53 years; 61% females) who had been treated for a median of 5 years (range, 1.5-10 years). The employment rate fell from 84% at the onset of CD to 47% before initiation of BTX treatment. With long-term BTX treatment, 72% of those who worked at the initiation of treatment stayed employed, and 67% of those on sick leave returned to work. A younger age and a higher level of education increased the probability of being employed and avoiding disability benefits. Among those who were younger than 55 years at evaluation of BTX treatment (n = 40), the employment rate increased from 47% to 65% with treatment, and among the male patients, it reached the level of the general population (86%). About half of the 34% who received disability benefits did so already before the BTX treatment was initiated.

Neuropathological changes in ten cases of neuronal intermediate filament inclusion disease (NIFID): a study using α-internexin immunohistochemistry and principal components analysis (PCA)

Ten cases of neuronal intermediate filament inclusion disease (NIFID) were studied quantitatively. The alpha-internexin positive neurofilament inclusions (NI) were most abundant in the motor cortex and CA sectors of the hippocampus. The densities of the NI and the swollen achromatic neurons (SN) were similar in laminae II/III and V/VI but glial cell density was greater in V/VI. The density of the NI was positively correlated with the SN and the glial cells. Principal components analysis (PCA) suggested that PC1 was associated with variation in neuronal loss in the frontal/temporal lobes and PC2 with neuronal loss in the frontal lobe and NI density in the parahippocampal gyrus. The data suggest: 1) frontal and temporal lobe degeneration in NIFID is associated with the widespread formation of NI and SN, 2) NI and SN affect cortical laminae II/III and V/VI, 3) the NI and SN affect closely related neuronal populations, and 4) variations in neuronal loss and in the density of NI were the most important sources of pathological heterogeneity.

[Temporal arteritis and cerebrovascular complications]

BACKGROUND

Giant cell (temporal) arteritis is a systemic vasculitis of large and medium sized arteries causing severe visual loss and cerebrovascular accidents. We have treated several patients who developed stroke because of giant-cell arteritis despite high-dose corticosteroid treatment.

METHODS

We undertook a Medline search in order to find predictive factors for risk of developing irreversible ischaemic complications in giant-cell arteritis. There are only a few reported cases in the literature, mostly retrospective studies.

RESULTS

Stroke is a relatively rare neurologic complication, preceded by transient visual disturbances and jaw claudication. On the other hand, it is suggested that the rate of cranial ischaemic complications is inversely related to the intensity of inflammatory response.

CONCLUSIONS

Cranial ischaemic complications can occur despite corticosteroid treatment. Low-dose aspirin as adjuvant therapy should be considered in patients with giant cell arteritis. Large, multicentre, randomized studies are required in order to define the best treatment for giant cell arteritis and for the prevention of cerebrovascular complications.

The course of cervical dystonia and patient satisfaction with long-term botulinum toxin A treatment

In 78 patients with idiopathic cervical dystonia (CD), we studied the course of the disease and the patients' satisfaction with long-term botulinum toxin A (BTX) treatment (median 5.5 years, range 1.5-10). On a seven-point scale ranging from excellent to worsening, the effect of treatment was scored as excellent or good by 52% of patients and moderate by 33%. The independent scores of the treating neurologists were excellent or good in 65% and moderate in 27%, respectively, and correlated well with the patients' scores. The 'Global Burden of Disease', as expressed on Visual Analog Scales (VAS, 0-10) before and at evaluation of treatment, was reduced by a median of 4 in individual patients. By combining these outcome measures, 67% of the patients were characterized as having a good effect, and 33% an unsatisfactory effect. This outcome (good or unsatisfactory effect) was independent of the severity of head deviation or complexity pattern of CD prior to treatment, the delay from onset to start of BTX treatment, or the number of treatments. The complexity pattern remained stable during treatment in 64% of the patients, became less complex in 19%, whereas 17% of the patients developed more complex patterns.

[Optic nerve sheath meningeoma--from expectation to active treatment]

The management of optic nerve sheath meningeoma has been controversial and difficult. The conservative strategy was "to wait and see" until the patient became blind on the affected eye. Surgical excision had poor outcome and, with the exception of a few anecdotal case stories, led to blindness or postoperative eye motility disturbances. It has been long known that radiation therapy can prevent tumour progression, but the end result was very often visual deterioration and blindness. A few recent well documented studies describe how stereotactic fractionated conformal radiotherapy can provide stabilisation or improvement in the visual function in optic nerve sheath meningeoma. This article gives an overview, illustrated by a case story.

Neuro-ophthalmological findings in sarcoidosis

PURPOSE

This review emphasizes the importance of neuro-ophthalmological signs and symptoms in sarcoidosis. The presence of ophthalmological and neuro-ophthalmological findings may lead to diagnosis of the disease and the initiation of adequate treatment.

MATERIAL AND METHODS

Patients who had been diagnosed with neurosarcoidosis during the period 1990 - 2001 were identified from the departmental diagnostic index. The history, clinical, laboratory and imaging data of patients were analysed.

RESULTS

Fifteen patients were identified, four men and 11 women, with a mean age of 44.1 years (range 26-65 years). In six of the 15 (40%), neurological deficits were the initial symptoms. Nine (60%) had known sarcoidosis at the time of presentation. Ten patients (66%) had ophthalmological/neuro-ophthalmological symptoms and signs.

CONCLUSION

Neuro-ophthalmological symptoms may develop early in neurosarcoidosis. If neuro-ophthalmological symptoms arise in patients with established biopsy-proven sarcoidosis, the diagnosis is usually easy to make. However, a number of patients with neurosarcoidosis may present with neuro-ophthalmic symptoms before systemic involvement becomes obvious. In this situation the diagnosis is challenging, and the major goal is to establish the presence of systemic sarcoidosis.

Uveal melanomas with optic nerve extension: report of two cases diagnosed by transvitreal biopsy, one of them with a multicentric tumour

PURPOSE

To report two cases of invasive uveal melanomas, one of which showed multifocality.

METHODS

Clinical examination, ultrasonography, colour Doppler analysis, cytological and histopathological evaluations.

RESULTS

Transvitreal biopsy (case 1) or fine needle aspiration biopsy (FNAB) (case 2) revealed malignant melanomas in both patients. Light microscopy and immunohistochemical examinations substantiated the diagnosis of mixed cell type melanomas. In addition, one patient had a multifocal melanoma with papilloedema and colour Doppler findings suggestive of optic disc involvement.

CONCLUSION

Transvitreal biopsy for histology or cytology is a reliable procedure to obtain an accurate diagnosis without delay of a lesion adjacent to the optic nerve head. In our two cases the biopsy findings led to enucleation.

[Choice of neuroradiological methods in ophthalmology--the eye and the lacrimal apparatus]

With improved imaging methods, the possibility of demonstrating pathological changes in the visual pathways has increased substantially. However, optimal evaluation of visual disorders requires familiarity with the anatomy and pathology of the visual pathways, and with the many advances in neuroimaging. The purpose of this article is to provide clinicians with a practical approach for selecting the most appropriate imaging modalities. Choice of technique is discussed with reference to anatomical regions rather than a complete list of diseases. Ophthalmoscopy reveals many intraocular abnormalities. Imaging studies help in cases where opaque media preclude a view of the fundus. In addition, imaging studies assist in confirming the extraocular extent of the lesion. The advantages and disadvantages of x-ray, computed tomography and magnetic resonance imaging are discussed and illustrated by examples.

[Choice of neuroradiological methods in ophthalmology--the optic nerve, muscles of the eye and orbit]

Optimal imaging of the orbital structures presents a challenge. Images of this region may be disturbed by ocular movements, and orbital fat may prevent visualisation of the optic nerve and retrobulbar lesions. In this article, we intend to provide practical guidelines for the evaluation of orbital abnormalities, on the basis of our own experiences and a study of selected literature. Computed tomography (CT) and magnetic resonance imaging (MRI) are both useful for the detection and characterisation of orbital abnormality. However, for diagnostic work-up of the optic nerves, contrast-enhanced, fat-suppressed MRI best demonstrates the pattern and severity of optic nerve abnormality and allows assessment of the intracranial part of the optic nerves and associated intracranial abnormality. In the case of bony involvement, spiral CT imaging is the modality of choice. It is quick, inexpensive and allows multiplanar reconstruction. Not uncommonly, CT as well as MRI may be needed to characterise an orbital lesion.

[Neuroradiological imaging of the 3rd, 4th and 6th cranial nerves]

The ocular motor cranial nerves (III, IV, VI) control the eye movements in a near association with the higher cortical areas. Clinically, the most common presentation of abnormal ocular motility is double vision. Identifying the cause of ocular nerve palsy can be difficult, and a large percentage of such cases still remains undiagnosed, even in a new era of neuroradiological techniques. Close co-operation between the clinician and the radiologist is necessary for the selection of the best imaging methods for the specific clinical problem, in order to set the aetiological and topological diagnosis. This article provides a practical review of advances in neuroimaging of the ocular motor nerves.

Contrast-enhanced ultrasound Doppler examination of the retrobulbar arteries

PURPOSE

To evaluate the diagnostic usefulness of an ultrasound contrast agent in examination of the retrobulbar arteries.

MATERIAL AND METHODS

Ten healthy volunteers received a galactose-based echo-contrast medium (Levovist) by i.v. infusion. The ophthalmic, central retinal, the nasal and the temporal posterior ciliary arteries and the short ciliary arteries were studied in 19 eyes by color and spectral Doppler ultrasonography before and after contrast administration. Peak systolic and end diastolic velocities and spectral Doppler indices (pulsatility and resistive) were assessed. The quality of the spectral and color Doppler imaging of the arteries were visually graded on a 5-point scale.

RESULTS

There were significant differences in pre- and post-contrast peak systolic velocities in the ophthalmic arteries (p<0.05), but not in the other retrobulbar arteries, or in any of the spectral Doppler indices. After contrast administration the mean spectral Doppler score for vessels poorly visualized before contrast increased from 2.2 (+/-0.4) to 3.1 (+/-0.9). The number of short ciliary arteries with sufficient spectral Doppler quality increased from 7 prior to contrast to 14 following contrast. Prior to the infusion of Levovist, 62 (73%) out of 85 retrobulbar arteries could be evaluated with a sufficient spectral Doppler quality. Following the administration of contrast 66 (78%) arteries had sufficient spectral Doppler quality. However, by combining the results of the pre- and post-contrast examinations, sufficient spectral Doppler quality was obtained in 77 (91%) of the 85 retrobulbar arteries.

CONCLUSION

Contrast enhancement increased the number of detectable retrobulbar vessels. However, in the case of good quality pre-contrast imaging of the retrobulbar vessels, the use of Levovist did not add any substantial diagnostic information. The optimal spectral Doppler results were obtained when both pre- and post-contrast examinations were performed.

To test or not? The value of diagnostic tests in cervical dystonia

It has long been suspected that idiopathic cervical dystonia is result of a dysfunction of the brain, but the cause of the disease has been elusive. The purpose of this study was to determine the diagnostical value of different radiological and laboratory tests in cases of cervical dystonia. Cerebral computer tomography and/or cerebral magnetic imaging were carried out in all of the 149 patients who were included in this study. A total of 25 scans revealed some minor findings that did not alter patients' management. Of the 128 cervical plain x-ray examinations, 63.1% showed degenerative changes. Cerebrospinal fluid (CSF) was examined in 125 patients, and was normal in 103. Some degree of pathology was found in the remaining 22 CSF samples. All patients under the age of 50 years were tested for serum ceruloplasmin and no decreased level was found. Seven patients had elevated ANA titre; four of them also developed Botulinum toxin antibodies. We can conclude that the detection rate of pathologic findings in patients with idiopathic cervical dystonia is similar to what we can expect in the general population, provided the neurological findings are normal apart from the involuntary movements. In the adult form of typical cervical dystonia we do not recommend any standard laboratory or imaging tests if the neurological examination is normal aside from the abnormal head movements.

Significance of inflammatory changes in the brainstem in forensic autopsy cases

Brain stem encephalitis is an uncommon disease. In order to assess the significance of inflammatory changes in the brain stem in a forensic autopsy material we reviewed the findings over a 12-year period. Between January 1st 1982-December 31st 1993, neuropathological examination of the brain was carried out in 29% of the autopsy cases from the Institute of Forensic Medicine, University of Oslo. Out of 4546 brains, 110 (2.2%) showed microglial nodules and perivascular lymphocytic cuffing in the lower brain stem. In 66 of the cases (60%), the abnormalities were limited to the nucleus and/or the spinal tract of the fifth cranial nerve. Only 16 of the 39 cases with more widespread changes, diagnosed as brain stem encephalitis, had a serious underlying or concomitant disease. Three particular cases of brain stem encephalitis are reported in more detail. In all three cases we suggest that the brain stem inflammatory changes may be either the direct or a contributory cause of death.

The ophthalmology of internal carotid artery dissection

PURPOSE

Carotid dissection is an important cause of cerebral and retinal ischemic symptoms, especially in young adults. This article presents a patient material and also includes a review of the ophthalmologic signs and symptoms of carotid dissection.

MATERIAL AND METHODS

Twenty-eight patients with spontaneous dissection of the extracranial internal carotid artery dissection underwent a neuro-ophthalmological examination.

RESULTS

Twenty-three patients had oculosympathetic paresis. Two experienced transient monocular blindness; in one the episodes were provoked by sitting up from a supine position. One patient presented with a monocular visual field defect, due to posterior ischemic neuropathy, and two others with homonym hemianopia. Diplopia, caused by an incomplete VIth cranial nerve palsy was recognised in one.

CONCLUSION

All but one patient presented with detectable ophthalmologic symptoms or signs. Very often the ophthalmologist is the first medical contact for patients with internal carotid artery dissection. The condition is serious, and a prompt evaluation and treatment is indicated to prevent irreversible sequelae.

Ocular findings in allogeneic stem cell transplantation without total body irradiation

OBJECTIVE

To evaluate the ophthalmologic complications in hematologic patients after allogeneic stem cell transplantation (ASCT) without total body irradiation.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

A total of 150 ASCT patients.

INTERVENTION

Ophthalmologic examinations of 130/150 patients were made, with particular attention to the occurrence of graft-versus-host disease (GVHD).

RESULTS

One hundred thirty patients with a mean age of 35.5 (SD 10.6) years at the time of ASCT were followed up for a mean of 12 months (range 3-60 months). GVHD developed in 73 patients (56.2%). Of 130 patients, 52 (40.0%) had ocular complications, and 29 (22.3%) of those had GVHD. Keratoconjunctivitis sicca was diagnosed in 13 (10.0%) patients, and 12 (9.2%) had different stages of pseudomembranous conjunctivitis. Cataract developed in 3 patients (2.3%) in the observation period, and 7 (5.4%) had keratitis. Six (4.6%) patients had uveitis, and 8 (6.2%) had retinal hemorrhages. No ischemic retinopathy was found. Bilateral optic disc edema developed in 10 (7.7%) patients.

CONCLUSIONS

Fewer ocular complications were observed in this series than in earlier studies, and the visual outcome was favorable. Cyclosporine has been linked to the development of optic disc edema and ischemic retinal lesions. The latter condition was not observed in the study patients, and the optic disc edema resolved within 1 year in all patients without any detectable visual impairment, in spite of continuation of the drug. Seven patients had acute GVHD at the time of optic disc edema, which is considered to be another manifestation of acute GVHD.

[Opsoclonus and ocular flutter--eye motility disorders of great diagnostic value]

Opsoclonus and ocular flutter are rare but well-defined disorders of the saccadic system. Ocular flutter is a burst of back-to-back horizontal saccades without an intersaccadic interval. If these saccades occur in all directions, the involuntary eye movements are called opsoclonus. The most common aetiologies are paraneoplastic, postinfectious, toxic-metabolic and idiopathic. The underlying malignancy is usually neuronal crest tumors in children or lung, breast or gynaecologic cancer in adults. The appearance of these syndromes should prompt the search for an occult malignancy.

[Visual hallucinations in ophthalmological and neurological diseases]

Visual hallucination can be defined as visual sensory perception without external stimulation, or something that a patient sees that other observers in the same environment do not see. The images may be unformed (lights, streaks, flashes) or formed (objects, people, scenes). Clinical experience indicates that, despite the infrequency with which they are mentioned, visual hallucinations commonly occur in patients with ophthalmological and neurological diseases. Content, duration and timing of visual hallucinations relate to their cause and provide useful clinical information. This paper reviews the topical, pathophysiological and clinical aspects of visual hallucinations.

Visual hallucinations in a case of reversible hypertension-induced brain oedema

Visual hallucinations are commonly associated with seizures, drug effects, psychiatric disorders, or visual loss as 'release' phenomena. We report the case of a previously healthy 65-year-old woman, who was admitted to hospital with intermittent headache episodes accompanied by complex visual hallucinations. During these episodes the patient's blood pressure was 220/120 mmHg. In between symptomatic episodes she had no complaints and felt healthy. The neurological and ophthalmological examinations were normal but cerebral magnetic resonance imaging (MRI) showed multiple white matter abnormalities in the parieto-occipital regions. Rapid reversal of the symptoms and imaging abnormalities occurred concurrently with lowering of blood pressure. The history and the findings were similar to those recently described in the clinicoradiological 'posterior leukoencephalopathy' syndrome. Different pathogenic mechanisms are discussed. Copyright 1998 Lippincott Williams & Wilkins

[Treatment of spasticity with botulinum toxin]

Spasticity is a velocity-dependent pathologic increase in muscle resistance to stretch, and occurs in a variety of neurologic disorders. We report our controlled open study using botulinum toxin A for treatment of adductor spasticity in five patients with advanced multiple sclerosis. Clinical evaluation of spasticity and stiffness of joints is based on the Ashworth Scale and grade of passive abduction. Three patients showed no response; the two others experienced an excellent and longlasting effect. We also describe briefly the different spastic conditions where this treatment has been used successfully.