Intact sensory fusion in a child with divergence paresis caused by a pontine glioma

Divergence Palsy due to Divalproex and Oxcarbazepine

OBJECTIVE

This case series is the first to describe divergence palsy as an adverse effect of antiepileptic drug use. Diplopia is a common adverse effect of antiepileptic drugs, but no explanatory motility deficit has ever been reported.

METHODS

We present 2 patients, 1 on oxcarbazepine and 1 on divalproex, each with a normal examination result between spells and divergency palsy when symptomatic.

RESULTS

Discontinuation of the antiepileptic medication led to resolution of the episodes in both cases. Rechallenge with the offending agent after washout in one patient resulted in recurrence of diplopia and divergence palsy, both resolving after subsequent withdrawal of the antiepileptic.

CONCLUSIONS

Antiepileptic drugs may cause divergence palsy.

Acute-onset esotropia: should we look inside?

The authors report a case of acute onset of comitant esotropia with diplopia in a 5-year-old boy with a diffuse pontine glioma. On first presentation, the angle of esodeviation was 30 prism diopters at distance fixation and 25 prism diopters at near fixation. Neurological symptoms appeared 10 weeks after the first visit.

Double Vision Worth a Double Take

An 18-year-old girl presented with an acute acquired comitant esotropia. Investigation showed a brainstem glioma. Discussion of types of acute acquired comitant esotropia, differential diagnosis and neurologic work-up is given. Review of the literature involving acute acquired comitant esotropia is provided.

Divergence insufficiency and demyelinating disorder

PURPOSE

To describe a divergence insufficiency in a young woman.

METHODS

Case report.

RESULTS

A 38-year-old woman presented with a episode of homonymus horizontal diplopia at distance. She was orthophoric at near but had esotropia at distance. Neurological evaluation was normal but multiple demyelinating lesions were shown in the magnetic resonance scan, with increased intrathecal Ig G production. Double vision improved after corticosteroid mega-doses.

CONCLUSIONS

An acute onset of diplopia due to divergence insufficiency in a young adult may be associated with a demyelinating disorder.

Restoration of fusion in children with intracranial tumors and incomitant strabismus

PURPOSE

Intracranial tumors may cause eye misalignment and interruption of sensory fusion. The ocular misalignment may be permanent or may be corrected after tumor treatment with or without specific strabismus treatment. This report analyzes the binocular vision outcome of children with misaligned eyes from brain tumors who regain orthotropia.

DESIGN

A retrospective noncomparative case series.

PARTICIPANTS

Twenty-three surviving children less than 18 years of age with a new heterotropia and absence of fusion associated with the development of a brain tumor.

INTERVENTIONS

Tumor resection/radiation/chemotherapy and necessary strabismus management.

MAIN OUTCOME MEASURE

Stereopsis (>/= 4 of 10 circles) measured with the Randot II stereo test at near fixation.

RESULTS

Fourteen children regained orthotropia either after tumor therapy, strabismus treatment, or both. Ten of these 14 children with realigned vision regained high-grade stereovision. Nine patients did not regain orthotropia and were excluded. The mean age at tumor diagnosis of the fusing group was 9.9 years (range, 3-17 years) compared with 8.5 years (range, 6-12 years) in the four realigned nonfusing patients. The mean duration of misalignment was 12 months (range, 2-51 months) for the fusing group, and 45 months (range, 14-120 months) for the nonfusing group.

CONCLUSIONS

Children and adolescents with brain tumor-associated eye misalignment may regain the ability to fuse if their misalignment can be corrected. An improved prognosis was noted for those patients when the misalignment had been present for a shorter duration. These data suggest that the outcome may be better for incomitant strabismus than that reported for acute comitant esotropia.