[Cavernous sinus lymphoma mimicking Tolosa-Hunt syndrome]

INTRODUCTION

Tolosa-Hunt syndrome is characterized by painful ophthalmoplegia due to idiopathic granulomatous inflammation of the cavernous sinus. Steroid therapy dramatically reverses the symptoms and clinical signs. Because they also may respond to steroids, tumors such as lymphoma and meningioma and orbital tumors can make differential diagnosis difficult.

EXEGESIS

We report the case of a 78-year-old male patient in whom systemic lymphoma associated with inflammation of the cavernous sinus was uncovered by painful, gradually progressing, ophthalmoplegia mimicking Tolosa-Hunt syndrome.

CONCLUSION

When faced with a clinical picture suggestive of the existence of Tolosa-Hunt syndrome clinical workup is mandatory and should lead to diagnosis of exclusion.

Disinsertion of the inferior oblique muscle for treatment of superior oblique paresis

PURPOSE

To examine the safety and efficacy of disinsertion of the inferior oblique muscle in the treatment of long-standing ipsilateral superior oblique paresis.

METHODS

This retrospective study included 52 patients who underwent disinsertion of the inferior oblique muscle over a 5-year period. Mean age at presentation was 30.8 years (range: 1-70 years). All patients had long-standing unilateral superior oblique paresis and overaction of the ipsilateral inferior oblique muscle. Information recorded included pre- and postoperative vertical deviation, pre- and postoperative Hess chart error scores, reoperation rate, and symptom relief.

RESULTS

Following surgery, mean vertical deviation was reduced from 12.9 to 4 prism diopters, while mean Hess chart error score decreased from 596 to 258. This procedure alone resulted in satisfactory symptom relief in 84.6% of patients. The only complication was significant undercorrection requiring further surgery in 13.6% of patients and prisms in 1.8%. When further surgery was needed, the procedure of choice was tucking of the affected superior oblique. Recession of the contralateral inferior rectus was carried out when superior oblique tucking was believed to be unsuitable.

CONCLUSIONS

Disinsertion of the inferior oblique muscle is a safe and effective treatment for the majority of long-standing idiopathic unilateral superior oblique pareses.

[Post-cataract surgery diplopia: etiology and treatment]

PURPOSE

To know the causes and treatment of diplopia observed after cataract surgery.

METHODS

We make a descriptive retrospective study on 19 cases with persistent binocular diplopia following cataract surgery.

RESULTS

They were classified by aetiology in four groups: myotoxic effects in surgery act (47.4%), alteration in binocular vision (amblyopia, previous strabismus or long sensory deprivation) (47.4%), refractive alterations (5.2%) and previous disease. Initially, treatment with prisms, was tolerated on 47.4%; surgery was required on 36.8%, botulinicum toxin on 5.3% and penalty on 10.5% to avoid diplopia. Eventually, 36.8% of patients went on with diplopia, just only one lay equal, disappearing on 63.2% because binocular vision was recovered or suppressed by themselves or by penalty.

CONCLUSIONS

Diplopia after cataracts surgery, is a serious complication that surgeons must take into account. In spite of the different treatments used, it is not easy to get its disappearance.

Erdheim-Chester disease: two cases of orbital involvement

Erdheim-Chester disease (ECD) is an increasingly recognised form of fibro-inflammatory process characterised by xanthomatous histiocytes containing large amounts of ingested lipid, plasma cells, macrophages and Touton-type giant cells. Ophthalmic involvement in ECD has been reported in only 22 cases. We describe two patients, one presenting with diabetes insipidus and subsequently developing orbital pseudotumours and retroperitoneal fibrosis, the other presenting with exophthalmos and diplopia. The first patient was treated with cladribine and subsequently developed sudden onset of bilateral blindness while the second required radiation therapy for the retro-orbital process and developed radiation retinopathy. These cases typify the variable presentation and course in patients with ECD.

Incidence of ocular misalignment and diplopia after uneventful cataract surgery

PURPOSE

To evaluate the incidence of ocular misalignment and diplopia after uneventful cataract surgery.

SETTING

An outpatient private practice eye institute.

METHODS

One hundred thirty-eight patients referred to 1 cataract surgeon were prospectively evaluated. Orthoptic evaluations were performed within 1 month before and then 1 day, 1 week, and 1 month after cataract surgery. Anesthesia was by retrobulbar injection, and cataract extraction was done by phacoemulsification.

RESULTS

Cataract surgery was performed in 118 patients. Preoperatively, 16 patients had ocular misalignment; 10 were phoric, 4 were intermittently tropic, and 2 were tropic. Follow-up evaluation was obtained for 101 patients (86%) at 1 day, 91 (77%) at 1 week, and 88 (75%) at 1 month. A change in ocular alignment occurred in 22 of 101 patients (22%) at 1 day, 9 of 91 (10%) at 1 week, and 6 of 88 (7%) at 1 month. Only 1 patient who had a change in alignment at 1 month was symptomatic.

CONCLUSIONS

A persistent change in ocular alignment after uneventful cataract surgery occurred in 7% of patients. However, symptomatic diplopia was uncommon (1 in 118; 0.85%) in this relatively small series.

Diplopia after cataract surgery

PURPOSE

To evaluate the cause of diplopia after cataract surgery.

SETTING

Cataract surgery at 7 hospitals and examination of diplopia at a central eye hospital.

METHODS

This study comprised 18 eyes of 17 patients with diplopia that developed after cataract surgery in which retrobulbar anesthesia was used. The Hess screen test was done to diagnose oculomotor dysfunction.

RESULTS

Several cases showed superior or inferior deviation of the globe, but most patients had nonuniform disturbances of eye movement. Examination of 3 patients by the Hess chart within 1 week after surgery showed paralysis of eye muscles but an overaction at a later stage, evident by reversal of eye position 1 month later. Surgery for strabismus was performed in 6 cases. One case with diplopia improved spontaneously 3 months after cataract surgery and achieved good alignment.

CONCLUSIONS

The Hess screen test was useful for comparing changes in oculomotor function before and after surgery. Oculomotor dysfunction after cataract surgery may be caused directly by traumatic injury during administration of anesthesia or surgery using bridle sutures or indirectly from sensitivity to anesthetic agents.

Endonasal endoscopic reduction of blowout fractures of the medial orbital wall

PURPOSE

This article describes the endonasal endoscopic reduction (EER) of blowout fractures (BOFs) of the medial orbital walls and reports the clinical results.

PATIENTS AND METHODS

Sixteen patients who underwent EER for a BOF of the medial orbital wall were analyzed. The surgical indications for treatment were diplopia, limitation of eye movements, and significant enophthalmos. They were followed-up for at least 3 months after the surgery. Surgical techniques, surgical results, and postoperative complications were reviewed.

RESULTS

There were no significant intraoperative or postoperative complications. Fourteen patients showed complete resolution of symptoms after the surgery. One patient, who had persistent diplopia and remaining enophthalmos, underwent medial wall reconstruction with a Medpor surgical implant (Porex Surgical Inc, College Park, GA) by a transorbital approach. Another patient, who had residual enophthalmos, had correction of enophthalmos after insertion of a Medpor implant. Both patients are now symptom-free.

CONCLUSION

The results indicate that EER is a safe and effective technique for the treatment of BOFs of the medial orbital wall.

Blepharoptosis-induced superior keratoconus

PURPOSE

This clinical case report demonstrates blepharoptosis-induced corneal steepening and its subsequent resolution after blepharoptosis surgery.

METHODS

A 62-year-old man complaining of blurred vision without apparent cause on clinical examination underwent keratometry and computerized corneal topography, which revealed superior corneal steepening in both eyes. Bilateral upper eyelid blepharoptosis surgery was performed.

RESULTS

Three months after blepharoptosis surgery, repeat computerized corneal topography revealed normal corneal contours with improved vision in both eyes.

CONCLUSIONS

Blepharoptosis is a common condition that may induce superior corneal ectasia that is not evident by manifest refraction, slit-lamp examination, or keratometry. Computerized corneal topography can help detect such subtle corneal abnormalities and guide therapy.

Sino-orbital fistula: two case reports

A fistula between the paranasal sinuses and the orbit as a late complication of orbital fractures is rare and may present with intermittent symptoms due to air passing into the orbit. A case note review of two patients with sino-orbital fistula is presented. Two patients, 23- and 30-year-old males, presented with intermittent symptoms of globe displacement, diplopia or discomfort months after repair of an orbital floor fracture with a synthetic orbital floor implant. The symptoms occurred after nose blowing. They were both cured by removal of the implant and partial removal of the tissue surrounding the implant. A sino-orbital fistula may complicate the otherwise routine repair of an orbital floor fracture, but may be cured by removal of the implant and part of the surrounding pseudocapsule.

[Progressive paralysis of divergence in an adult with midbrain angioma]

A 37-year-old woman was admitted to the hospital with the complaint of progressive horizontal diplopia of six years' duration when viewing distant objects. On admission she had a slight left convergent strabismus. Homonymous diplopia was present beyond 50 cm and increased on distance fixation. Both eyes were fully mobile in the horizontal plane with a mild decrease in the velocity of horizontal eye movement to the left, and slight impairment of upward eye movement. The left eye did not fully adduct during convergence. The right pupil was slightly larger than the left. Prism cover test showed 6 delta esophoria at 30 cm and 14 delta esophoria at 5 m. The Hess chart showed a convergent deviation. MRI revealed a small right-side paramedian lesion of the midbrain tegmentum lying ventral to the aqueduct of Sylvius, at the level between the superior colliculi and the intercollicular area. A venous angioma with arteriovenous shunts in the right midbrain was diagnosed by angiography. We suggest that lesions that damage the divergence neurons in the tegmentum of the midbrain and also interrupt the supranuclear fibers having an inhibitory effect on the convergence neurons may produce homonymous diplopia on distant fixation combined with the esotropia.

Meningeal carcinomatosis manifested as bilateral progressive sensorineural hearing loss

OBJECTIVE

Meningeal carcinomatosis is defined as the diffuse infiltration of the leptomeninges and subarachnoid space by malignant cells metastasizing from systemic cancer. The authors describe a rare case of meningeal carcinomatosis initially appearing as bilateral progressive sensorineural hearing loss.

PATIENT

A 57-year-old man with lung cancer was referred to the authors' clinic because of progressive hearing loss, tinnitus, dizziness, and blurred vision for 1 month.

RESULTS

Magnetic resonance imaging revealed abnormal leptomeningeal enhancement. Meningeal carcinomatosis was diagnosed by the detection of malignant cells in the cerebrospinal fluid after lumbar puncture. The patient died 1 year after diagnosis.

CONCLUSIONS

Meningeal carcinomatosis must be considered in the differential diagnosis in cancer patients with bilateral progressive sensorineural hearing loss. Gadolinium-enhanced magnetic resonance imaging is a useful complementary diagnostic tool before lumbar puncture.

SFEMG in ocular myasthenia gravis diagnosis

BACKGROUND AND OBJECTIVE

In typical cases, the patient's history and clinical examination make it possible to diagnose ocular myasthenia gravis (OMG). But, in many cases a clear clinical picture is not present and OMG diagnosis is very difficult because gold diagnostic standard tests are not available. The diagnostic tests for OMG are usually unable to display a good sensitivity and specificity simultaneously. In this paper, we studied 86 cases submitted for suspected OMG.

METHODS

The patients were studied clinically and with various other tests used in OMG diagnosis (SFEMG, repetitive nerve stimulation, Ab anti AChR titration, tensilon test).

RESULTS AND CONCLUSION

SFEMG showed the highest sensitivity (100%) while Ab anti AChR showed the highest specificity (100%). To our knowledge this is the largest population of suspected OMG studied using most of the diagnostic parameters, reported in the literature.

Asymmetric sweating in a child with multiple sclerosis

A 10-year-old male with multiple sclerosis complained of excessive sweating on the right side of the forehead and shoulder on relapse 3 months after the onset of multiple sclerosis. Because the neurologic evaluation revealed no abnormalities in the sudomotor function, it is likely that the hyperhidrosis resulted from a lesion in the central or preganglionic sympathetic nervous system. Magnetic resonance imaging demonstrated a high-intensity lesion involving the left hypothalamus on T(2)-weighted imaging. Thus hypothalamic involvement might be the reason for the hyperhidrosis in this patient.

Phacoemulsification and intraocular lens placement in eyes with cataract and congenital coloboma: visual acuity and complications

PURPOSE

To evaluate the safety and complications of phacoemulsification in a series of patients with congenital coloboma and cataract.

SETTING

University-based hospital practice.

METHODS

A retrospective review was conducted of consecutive patients who had coloboma and cataract and had phacoemulsification between January 1987 through December 1998. Complications and visual acuity 2 months postoperatively were assessed.

RESULTS

Mean age of 7 cases at the time of surgery was 41.6 years +/- 11.1 (SD). Visual acuity improved in 6 of 7 eyes; 1 eye had no change. Six eyes had no serious complications. In 1 eye, a retinal detachment was observed postoperatively, but there was no loss in visual acuity. Another patient developed postoperative monocular diplopia from exposure of the intraocular lens (IOL) edge within the inferonasally located corectopia associated with the coloboma. Nonsurgical treatment was unsuccessful, but this symptom resolved after surgical pupilloplasty.

CONCLUSIONS

The results of this small case series affirm that clinically significant cataract develops at a younger age in eyes with congenital coloboma than in eyes with typical age-related nuclear sclerotic cataract. Monocular diplopia, a potential complication after cataract surgery in these eyes, can be managed by pupilloplasty. The improved vision in this study indicates that phacoemulsification and IOL placement are safe and beneficial in patients with typical congenital coloboma and cataract.

[Diplopia as first symptom of a bronchogenic carcinoma]

BACKGROUND

PATIENTS

In about 30% of patients with orbital metastases, these metastases are detected before the primary tumour is known. Less than 5% of orbital metastases are located in extraocular muscles. We report on a patient with diplopia caused by diminished abduction of the left eye as first symptom of a bronchogenic carcinoma.

PATIENT

A 86-year-old patient presented with a newly developed diplopia. On examination, the left eye showed a diminished abduction, ptosis and miosis. Pharmacological testing revealed peripheral Horner's syndrome. On cranial magnet resonance tomography, the lateral rectus muscle belly was enlarged. A chest X-ray showed a large tumour (6 cm in diameter) of the left upper lobe with multiple metastases to the lungs. Further examinations revealed a large cell bronchogenic carcinoma with metastases to the lungs, adrenal glands, and the lateral rectus muscle.

CONCLUSIONS

Diplopia caused by metastases to extraocular muscles is rare as first sign of a bronchogenic carcinoma. The combination of peripheral Horner's syndrome with diminished abduction of the homolateral eye primarily suggests a lesion of the cavernous sinus. The bronchogenic carcinoma could not be causative for Horner's syndrome in the patient presented here, however an undetected tumor-infiltration of the postganglionic region cannot be excluded. This case demonstrates that in all patients with newly developed diplopia and Horner's syndrome, even in absence of orbital signs, apart from a ophthalmological examination detailed radiographic or magnetic resonance tomographic imaging is necessary of both skull base and orbita.

[Changes in corneal topography after photorefractive keratectomy in myopia and their elimination]

Topographic disorders in the cornea, regression of the refraction effect, and subepithelial corneal opacities are characteristic complications of photorefraction keratectomy. Disorders in corneal topography are early haze, asymmetrical haze, and optic zone decentration. Disorders in topography lead to decrease in visual acuity, numerous optic effects (monocular doubling, aureola, blurred image, etc.). Methods for these complications control by means of transepithelial ablation, which is carried out with due consideration for the data of topographic examinations under pseudofluorescence control, normalizes corneal topography in the majority of cases, notably increases visual acuity, decreases doubling, etc. No side effects were observed after transepithelial phototherapeutic keratectomy for a period of up to 12 months.

The usefulness of the cervical range of motion device in the ocular motility examination

OBJECTIVES

To determine if the cervical range of motion (CROM) device, an instrument designed to assess the range of motion in the cervical spine, may be suited for accurately quantifying the magnitude of a patient's abnormal head posture, limitation of ductions, or range of single binocular vision at distance fixation.

METHODS

The CROM device was used to measure abnormal head postures in 10 subjects and limitations of ductions in 12 patients by 2 masked observers. In addition, it was used to test the diplopia field in 17 patients at one third of a meter and 6 m. These findings were compared with a standard diplopia field performed on a Goldmann perimeter.

RESULTS

For 10 subjects with abnormal head postures, the findings of the 2 observers had a mean+/-SD difference of 1.0 degrees +/-0.7 degrees (P=.15, paired t test). For the assessment of limitations of ductions, the findings of the 2 observers had a mean+/-SD difference of 1.1 degrees +/-2.6 degrees (P=.17, paired t test). For the 17 patients undergoing diplopia field testing, the results obtained on the Goldmann perimeter and with CROM device at the same test distance were essentially identical (mean+/-SD difference of 1.3 degrees +/-0.95 degrees; P=.88, paired t test); however, there was a significant difference between the results at one third of a meter and 6 m (mean+/-SD difference of 6.0 degrees +/-1.1 degrees for esotropic patients [P=.001]; mean+/-SD difference of 6.0 degrees +/-2.6 degrees for exotropic patients [P=.002]).

CONCLUSION

The CROM device seems to be suitable for testing abnormal head postures, limitations of ductions, and the range of single binocular vision. Arch Ophthalmol. 2000;118:946-950

Malignant pilocytic astrocytoma in the medulla oblongata: case report

A 27-year-old woman visited our hospital with chief complaints of abducens nerve palsy and cerebellar symptoms. On computerized tomographic scanning and magnetic resonance imaging, a tumor with strong enhancement was found on the dorsal side of the medulla oblongata. A tumor was excised by suboccipital craniotomy and C1 laminectomy. Histologically, many Rosenthal fibers together with pilocytic tumor cells were found in some regions, but a very high Ki-67 labeling rate accompanied by cells with nuclei of irregular size and giant cells was observed in other regions. The tumor was diagnosed as malignant pilocytic astrocytoma originating from pilocytic astrocytoma by transformation. The biological behavior of pilocytic astrocytoma is obscure in several respects. We report our experience of a case of malignant pilocytic astrocytoma that developed in the brain stem and progressed extremely rapidly.

Isolated bilateral abducens nerve palsy in primary sphenoidal sinus non-Hodgkin lymphoma

Isolated bilateral abducens nerve palsy is a rare complication of intracavernous tumors. A middle-aged man complaining of chronic horizontal diplopia was found to have bilateral abducens palsy as an initial manifestation of a massive non-Hodgkin lymphoma, originating from the sphenoidal sinus. This case is unique in two respects: the initial clinical presentation of isolated bilateral abducens involvement and the nature of the tumor, since only two cases of sphenoidal sinus lymphoma have been reported.

Ocular deviation after unilateral laser in situ keratomileusis

Laser keratomileusis and excimer laser photorefractive keratectomy in situ are widely used therapies for treating myopia. The corrections of refractive error by glasses or contact lens result in a relatively equal refractive correction on both eyes. However, refractive surgery on a single eye can cause a focus disparity between both eyes and may result in the impairment of fusion leading to strabismus. This article aims to report a case where diplopia and esotropia occurred 1 month after laser keratomileusis (LASIK) in situ for the correction of myopia.

Botulinum toxin treatment versus conservative management in acute traumatic sixth nerve palsy or paresis

PURPOSE

Botulinum toxin (BTX), injected into the ipsilateral medial rectus muscle, has been advocated for the management of acute traumatic sixth nerve palsy or paresis. We conducted a multicenter, nonrandomized, data collection study to evaluate recovery rates of patients treated with either conservative measures or BTX.

METHODS

All members of the American Association for Pediatric Ophthalmology and Strabismus and the North American Neuro-Ophthalmology Society were invited to enroll patients with acute traumatic sixth nerve palsy or paresis during a 2-year period (between March 1996 and February 1998). The BTX group was defined as patients who received a BTX injection within 3 months of injury. Recovery at 6 months from injury was defined as absence of diplopia in the primary position and a distance esotropia of no more than 10 PD in the primary position. Nonrecovered patients with less than 6 months of follow-up (n = 15) were excluded.

RESULTS

Eighty-four eligible patients were enrolled by 46 investigators. Sixty-two patients (74%) were treated conservatively and 22 (26%) with BTX. Sixty-two patients (74%) had unilateral palsy, and 22 (26%) had bilateral palsy. Recovery rates were similar between BTX and conservatively treated patients (overall: 73% vs 71%, P = 1.0; unilateral: 81% vs 83%, P = 1.0; bilateral: 50% vs 38%, P = 0.66, respectively).

CONCLUSIONS

In this prospective multicenter study of acute traumatic sixth nerve palsy or paresis, patients treated with either BTX or conservative measures had similar high recovery rates.