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Bodi TB, Klaehn LD, Kramer AM, Bhatti MT, Brodsky MC, Eggenberger ER, Di Nome MA, Leavitt JA, Garrity JA, Chen JJ, Mansukhani SA. Ocular Neuromyotonia: Clinical Features, Diagnosis, and Outcomes. Am J Ophthalmol 2024; 263:61-69. [PMID: 38369222 DOI: 10.1016/j.ajo.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE The purpose of this study was to describe the clinical features, management, outcomes, and diagnostic pitfalls in a large series of patients with ocular neuromyotonia. DESIGN Retrospective cohort. METHODS Patients diagnosed with ocular neuromyotonia from January 1, 2004, through January 1, 2023, seen at one of the 3 Mayo Clinic sites in Rochester, MN, Scottsdale, AZ, and Jacksonville, FL, comprised the study population. We ascertained patients with ocular neuromyotonia through a search using the medical records database. Only patients with an observed episode of ocular neuromyotonia were included and the medical records were reviewed. The main outcome measures were clinical features and outcomes of patients with ocular neuromyotonia. RESULTS Forty-two patients who were diagnosed with ocular neuromyotonia were included. The median age was 58 years (range, 16-80 years). A history of cranial radiation therapy was present in 39 patients (93%). The sixth cranial nerve was involved in 31 patients (74%). Bilateral disease was found in 2 patients (5%). The median time from onset of diplopia to diagnosis was 8 months (range, 1 month-25 years), with a high rate of initial misdiagnosis in 52%. Twenty of 42 patients (48%) were treated with oral medication, of whom 95% had significant improvement or resolution of symptoms. CONCLUSION Prior cranial irradiation is the most common cause for ocular neuromyotonia, affecting the sixth cranial nerve most often. Although delayed and initial misdiagnosis is common, most patients show improved symptoms on medical treatment.
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Affiliation(s)
- Tia B Bodi
- From the Department of Ophthalmology, Mayo Clinic College of Medicine (T.B.B., L.D.K., A.M.K., J.A.L., J.A.G., S.A.M.), Rochester, Minnesota
| | - Lindsay D Klaehn
- From the Department of Ophthalmology, Mayo Clinic College of Medicine (T.B.B., L.D.K., A.M.K., J.A.L., J.A.G., S.A.M.), Rochester, Minnesota
| | - Andrea M Kramer
- From the Department of Ophthalmology, Mayo Clinic College of Medicine (T.B.B., L.D.K., A.M.K., J.A.L., J.A.G., S.A.M.), Rochester, Minnesota
| | - M Tariq Bhatti
- Department of Ophthalmology, The Permanente Medical Group, Kaiser Permanente (M.T.B.), Roseville, California
| | - Michael C Brodsky
- Departments of Ophthalmology and Neurology, Mayo Clinic College of Medicine (M.C.B., J.J.C.), Rochester, Minnesota
| | - Eric R Eggenberger
- Departments of Ophthalmology and Neurology, Mayo Clinic College of Medicine (E.R.E.), Jacksonville, Florida
| | - Marie A Di Nome
- Departments of Ophthalmology and Neurosurgery, Mayo Clinic College of Medicine (M.A.D.N.), Scottsdale, Arizona
| | - Jacqueline A Leavitt
- From the Department of Ophthalmology, Mayo Clinic College of Medicine (T.B.B., L.D.K., A.M.K., J.A.L., J.A.G., S.A.M.), Rochester, Minnesota
| | - James A Garrity
- From the Department of Ophthalmology, Mayo Clinic College of Medicine (T.B.B., L.D.K., A.M.K., J.A.L., J.A.G., S.A.M.), Rochester, Minnesota
| | - John J Chen
- Departments of Ophthalmology and Neurology, Mayo Clinic College of Medicine (M.C.B., J.J.C.), Rochester, Minnesota
| | - Sasha A Mansukhani
- From the Department of Ophthalmology, Mayo Clinic College of Medicine (T.B.B., L.D.K., A.M.K., J.A.L., J.A.G., S.A.M.), Rochester, Minnesota; Departments of Ophthalmology, Mayo Clinic Health Systems (S.A.M.), Eau Claire, Wisconsin, USA.
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Lee SK, Lee MS. Ocular neuromyotonia: a review of diagnosis and treatment. Curr Opin Ophthalmol 2022; 33:465-470. [PMID: 35980029 DOI: 10.1097/icu.0000000000000894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The current review will cover the clinical presentation, causes, epidemiology, differential diagnoses, workup, and treatment of ocular neuromyotonia (ONM) in detail. RECENT FINDINGS While ONM largely remains a unilateral eye movement disease affecting adults with a history of sellar radiation, recent case reports highlight an expansion of this presentation to include bilateral, pediatric, and congenital cases. SUMMARY ONM is a rare but recognizable ocular motility disorder involving sustained contraction of the extraocular muscle, commonly resulting in intermittent diplopia. Diagnosis of ONM relies upon a thorough history and clinical exam, with particular attention to history of radiotherapy and eccentric gaze testing. Treatment with carbamazepine remains first-line therapy, although other membrane stabilizing agents and surgical interventions can be effective.
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Affiliation(s)
| | - Michael S Lee
- Departments of Ophthalmology, Neurology, and Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
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Shingai Y, Endo H, Endo T, Osawa SI, Nizuma K, Tominaga T. Ocular neuromyotonia caused by a recurrent sphenoidal ridge meningioma. Surg Neurol Int 2021; 12:219. [PMID: 34084646 PMCID: PMC8168646 DOI: 10.25259/sni_38_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background Ocular neuromyotonia (ONM) is a rare ocular motility disorder characterized by involuntary paroxysmal extraocular muscle contraction and is caused by radiation therapy, vascular compression, and inflammatory disease. This study includes a rare case of ONM caused by a recurrent meningioma. Case Description A 56-year-old man presented with diplopia due to the right oculomotor nerve palsy caused by a sphenoidal atypical meningioma, with improved symptoms after initial surgery. During the next 7 years, he underwent local radiation therapy, second surgery, and Gamma Knife radiosurgery to control the tumor's repetitive recurrence around the right anterior clinoid process. After these treatments, residual tumor was controlled for the next 3 years. However, 3 months after his last visit, he started to suffer from the right ONM and visual disturbance. The magnetic resonance imaging results revealed a rapid growth of the posterior part of the residual tumor, involving the right oculomotor nerve. The third tumor resection was performed to prevent further aggravation of the symptoms. Decompression of the right oculomotor nerve was achieved, and ONM disappeared immediately after surgery. Conclusion If nerve compression by the tumor is clearly indicated with the neuroradiological assessment, surgical intervention is the treatment of choice to improve ONM.
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Affiliation(s)
- Yuto Shingai
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan.,Department of Neurosurgery, Kohnan Hospital, , Tohoku University, Sendai, Miyagi, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Shin-Ichiro Osawa
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Kuniyasu Nizuma
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan.,Department of Neurosurgical Engineering and Translational Neuroscience, Graduate School of Biomedical Engineering, , Tohoku University, Sendai, Miyagi, Japan.,Department of Neurosurgical Engineering and Translational Neuroscience, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
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Stockman AC, Dieltiëns M, Janssens H, Van Lammeren M, Beelen L, Van Bellinghen V, Cassiman C. Ocular Neuromyotonia: Case Reports and Literature Review. Strabismus 2018; 26:133-141. [DOI: 10.1080/09273972.2018.1467469] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abducens neuromyotonia: a delayed neuro-ophthalmic complication of cranial radiation. Can J Ophthalmol 2016; 51:e157-e158. [DOI: 10.1016/j.jcjo.2016.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/11/2016] [Accepted: 05/17/2016] [Indexed: 11/23/2022]
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Strabismus Surgery in Patients With Ocular Neuromyotonia: Potential Unmasking of the Condition and Effective Management Tool. J Neuroophthalmol 2016; 36:259-63. [PMID: 27023310 DOI: 10.1097/wno.0000000000000371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ocular neuromyotonia (ONM) is a rare motility disorder in which paroxysms of tonic extraocular muscle contraction from abnormal ocular motor nerve firing result in episodic diplopia and strabismus. Medical therapy with membrane-stabilizing agents has varied success. A surgical approach to treatment has not yet been described. We report the outcomes of strabismus surgery in patients with ONM. METHODS We describe 3 patients with sixth nerve paresis and ONM of the affected lateral rectus muscle who underwent strabismus surgery. All patients had a history of radiation therapy for intracranial tumors. Ophthalmologic and orthoptic examinations were performed with appropriate medical and neuroradiologic evaluation. Preoperative and postoperative data are presented and analyzed. RESULTS Two patients were noted to have ONM after their first strabismus surgery for a sixth nerve palsy. Patients 1 and 2 had 3 surgeries, whereas Patient 3 had 1 operation. Extraocular muscles operated on included the medial rectus and lateral rectus. Preoperative primary gaze baseline esotropia ranged from 35 to 75 prism diopters (Δ). All patients achieved improvement in ocular alignment and motility. Postoperative primary gaze deviations ranged from orthotropia to 20Δ of esotropia. Abduction deficits were unchanged or improved. The follow-up period ranged from 15 months to 2 years. CONCLUSIONS Patients with ONM of a paretic rectus muscle can achieve binocular fusion with strabismus surgery. ONM may manifest postoperatively in patients with a sixth nerve palsy and a contractured medial rectus who, preoperatively, were not noted to have ONM.
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Sychev YV, McInnis CP, Francis CE. Abducens ocular neuromyotonia as a delayed complication of oropharyngeal carcinoma treated with radiation. Head Neck 2016; 38 Suppl 1:E2428-31. [PMID: 26836222 DOI: 10.1002/hed.24370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 10/14/2015] [Accepted: 11/25/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Ocular neuromyotonia (ONM) is a disorder characterized by periodic involuntary extraocular muscle contraction that occurs almost exclusively in the setting of prior radiation to the sella or skull base. We present the first case of abducens neuromyotonia associated with oropharyngeal carcinoma. METHODS AND RESULTS We report a case of a 63-year-old patient with abducens ONM occurring 16 years after radiation treatment for oropharyngeal squamous cell carcinoma. A literature review was performed using Medline and PubMed databases to search for all documented cases of abducens neuromyotonia. Our review found 20 cases of abducens neuromyotonia but none after radiotherapy (RT) to the oropharynx. CONCLUSION Abducens ONM can occur because of disease at anatomic locations remote from the course of the sixth cranial nerve, most likely because of the irradiated area exceeding the intended field. Our case also supports the fact that RT can significantly precede symptom onset. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2428-E2431, 2016.
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Affiliation(s)
- Yevgeniy V Sychev
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Colin P McInnis
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Courtney E Francis
- Department of Ophthalmology, University of Washington, Seattle, Washington
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Arrambide G, Rovira A, Tur C, Montalban X. NMO spectrum disorders: how wide is the spectrum? Mult Scler 2014; 20:1417-9. [DOI: 10.1177/1352458514546517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Georgina Arrambide
- Centre d’Esclerosi Múltiple de Catalunya (Cemcat)/Neuroimmunology, Hospital Universitari Vall d’Hebron; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alex Rovira
- Magnetic Resonance Unit (IDI), Hospital Universitari Vall d’Hebron,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carmen Tur
- Centre d’Esclerosi Múltiple de Catalunya (Cemcat)/Neuroimmunology, Hospital Universitari Vall d’Hebron; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Centre d’Esclerosi Múltiple de Catalunya (Cemcat)/Neuroimmunology, Hospital Universitari Vall d’Hebron; Universitat Autònoma de Barcelona, Barcelona, Spain
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Partial Third Nerve Palsy and Ocular Neuromyotonia From Displacement of Posterior Communicating Artery Detected by High-Resolution MRI. J Neuroophthalmol 2013; 33:263-5. [DOI: 10.1097/wno.0b013e31829eb397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
A 27-year-old woman noticed diplopia when gazing left and paresthesia of the left face and headache of the left side for 8 months. Abduction and supraduction of the left eye were moderately restricted. Hypoesthesia of the face innervated by the ophthalmic branch of the left trigeminal nerve was detected. Visual disturbance due to optic neuropathy developed 5 months later. MRI with gadolinium revealed a mass lesion extending from the left cavernous sinus to the orbital apex. Ocular neuromyotonia and corresponding diplopia were induced by sustained right gaze. Such episodes occurred almost every day on awaking in the morning. Prednisolone (60 mg/day) was given and the headache and visual disturbance ameliorated in two days. The diplopia disappeared in 4 days. The patient remains free from these symptoms after 6 months. This is the first report of ocular neuromyotonia associated with Tolosa-Hunt syndrome.
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Affiliation(s)
- Akihiko Oohira
- Department of Ophthalmology, Tokyo Women's Medical University School of Medicine
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Inoue T, Hirai H, Shimizu T, Tsuji M, Shima A, Suzuki F, Matsuda M. Ocular neuromyotonia treated by microvascular decompression: usefulness of preoperative 3D imaging. J Neurosurg 2012; 117:1166-9. [DOI: 10.3171/2012.9.jns112361] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ocular neuromyotonia is a rare ocular motility disorder characterized by involuntary contraction of extraocular muscles resulting in paroxysmal diplopia. Although ocular neuromyotonia is reported as a rare complication after radiation therapy, there are a few cases of ocular neuromyotonia in the absence of irradiation. In the reported cases the possibility of vascular compression has been suggested on radiological imaging. The authors report a case of ocular neuromyotonia treated by microvascular decompression of the third cranial nerve, supporting the hypothesis that neurovascular compression may play a role in its pathogenesis. The usefulness of preoperative 3D imaging for microvascular decompression is also discussed.
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Affiliation(s)
- Takuro Inoue
- 1Department of Neurosurgery, Subarukai Kotoh Kinen Hospital
| | - Hisao Hirai
- 1Department of Neurosurgery, Subarukai Kotoh Kinen Hospital
| | - Toshiki Shimizu
- 2Department of Neurosurgery, Subarukai Hino Kinen Hospital; and
| | - Masayuki Tsuji
- 1Department of Neurosurgery, Subarukai Kotoh Kinen Hospital
| | - Ayako Shima
- 3Department of Neurosurgery, Shiga University of Medical Science, Shiga, Japan
| | - Fumio Suzuki
- 1Department of Neurosurgery, Subarukai Kotoh Kinen Hospital
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Novel case of ocular neuromyotonia associated with thyroid-related orbitopathy and literature review. Optom Vis Sci 2012. [PMID: 23190720 DOI: 10.1097/opx.0b013e31827731bf] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To present a novel case of pupillary involvement in ocular neuromyotonia (ONM), a rare ocular syndrome that causes intermittent diplopia because of an abnormal delay in extraocular muscle relaxation and to conduct a literature review. METHODS A case report is presented to demonstrate clinical characteristics and treatment of ONM. In addition, a literature review is conducted by searching Medline and Embase databases. Data are collected from all known published cases listed in these databases to collate patient demographic data, presumed etiology or associated pathologies, and treatment strategies. RESULTS The presented case demonstrates successful carbamazepine treatment of thyroid-related orbitopathy-associated ONM involving cranial nerve III. A review of the literature elicits 66 published cases of ONM, three of which were deemed to be associated with thyroid-related orbitopathy. The most common cause of reported ONM is suprasellar pathology, comprising approximately 60% of documented cases. Most published ONM cases (n = 41) were treated with carbamazepine, demonstrating a success rate of 87.8%. Of the published cases, cranial nerve III was involved 56% of the time, cranial nerve VI was affected in 39% of cases, and only 9% of ONM cases involved cranial nerve IV. CONCLUSIONS Ocular neuromyotonia is a rare cause of intermittent diplopia. Unlike most neurologic etiologies of diplopia, this syndrome can often be treated effectively with carbamazepine by stabilizing the neural cell membrane. To the authors' knowledge, this is the first presentation of ONM associated with thyroid-related orbitopathy, demonstrating bilateral but asymmetric miosis during episodes of muscle spasm.
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