Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy

Botulinum Toxin Injection for the Treatment of Third, Fourth, and Sixth Nerve Palsy: A Meta-Analysis

The efficacy of botulinum toxin injection for the treatment of third, fourth, and sixth nerve palsy was evaluated. PubMed, Scopus, EMBASE, Web of Science, and Google Scholar databases were searched. Data about the duration of palsy (acute vs chronic), cause of the palsy, type of toxin used, mean dose, and other background characteristics were collected. Outcome variables were success rate (defined by alleviation of diplopia or reduction in eye deviation) and standardized mean difference of prism diopter and abduction deficit before and after injection. The Joanna Briggs Institute checklist was implemented for the risk of bias assessment. The analysis included 38 articles, comprising 643 patients. The overall treatment success rate in acute and chronic nerve palsy was 79% and 33%, respectively. The success rate was not significantly different between different subgroups of age, type of botulinum toxin, pre-injection prism diopter, etiology of the palsy, duration of follow-up, and mean dose of botulinum toxin injection. However, in both acute and chronic palsy, diabetes etiology was accompanied by the highest success rate. Overall symptomatic response to botulinum injection was 84% (95% CI: 67% to 96%), whereas functional response was observed in 64% (95% CI: 47% to 79%) of the patients. The odds ratio for the success rate of treatment of palsies with botulinum toxin versus expectant management was 2.67 (95% CI: 1.12 to 6.36) for acute palsy and 0.87 (95% CI: 0.17 to 4.42) for chronic palsy. Botulinum toxin can be used for the treatment of acute third, fourth, and sixth nerve palsy, especially in patients with acute palsy and more severe tropia. [J Pediatr Ophthalmol Strabismus. 2024;61(3):160-171.].

Characteristics and Prognosis of Binocular Diplopia in Patients With Giant Cell Arteritis

BACKGROUND

Giant cell arteritis (GCA) is a large vessel vasculitis associated with a risk of permanent ophthalmologic complications. Data about diplopia prognosis in GCA are scarce. This study was designed to better characterize diplopia in newly diagnosed GCA patients.

METHODS

All consecutive patients diagnosed with GCA from January 2015 to April 2021 in a French tertiary ophthalmologic center were retrospectively reviewed. GCA diagnosis relied on a positive temporal artery biopsy or high-definition MRI.

RESULTS

Among 111 patients diagnosed with GCA, 30 patients (27%) had diplopia. Characteristics of patients with diplopia were similar to other GCA patients. Diplopia resolved spontaneously in 6 patients (20%). Diplopia was attributed to cranial nerve palsy in 21/24 patients (88%), especially third (46%) and sixth cranial nerve (42%). Ocular ischemic lesions occurred in 11 of the 30 patients with diplopia (37%); 2 patients developed vision loss after initiation of corticosteroids. In the remaining 13 patients, diplopia resolved after treatment onset in 12 patients (92%) with a median delay of 10 days. Patients treated intravenously tended to have a quicker improvement than those treated orally, but with a similar resolution rate of diplopia at 1 month. Two patients had relapse of diplopia at 4 and 6 weeks after an initial treatment course of 24 and 18 months, respectively.

CONCLUSIONS

Diplopia is a rare feature at GCA diagnosis, but should raise clinician suspicion for GCA when associated with cephalic symptoms and prompt the initiation of corticosteroids to prevent ocular ischemic complications.

Retrospective Analysis of Factors Related to the Long-Term Recovery of Third, Fourth, and Sixth Cranial Nerve Palsy with Etiologies and Clinical Course in a Tertiary Hospital

Purpose

Although various studies have explored the causes and clinical aspects of cranial nerve palsies, there remains a significant gap in understanding the prognostic factors that influence outcomes. In this study, we sought to address this gap by investigating the incidence, etiologies, clinical courses, and factors associated with long-term recovery, with the aim of enhancing the knowledge base in this field and providing valuable insights for improved patient care.

Patients and Methods

This retrospective study evaluated the data gathered from subjects who had third, fourth, and sixth cranial nerve palsy at the ophthalmology outpatient clinic of Phramongkutklao Hospital between April 1, 2012, and April 30, 2022.

Results

Among the three nerves, abducens nerve palsy was the most prevalent finding by most commonly involved. Our study revealed that ischemic and compressive lesions were the most common etiology of oculomotor nerve palsy, comprising 24.6% each. In addition, the most common etiology of trochlear and abducens nerve palsy was trauma, at 31.6% and 27.1%, respectively. Compared with the other nerves, oculomotor nerve palsy was associated with a shorter duration onset of symptoms and recovery period. The best recovery outcomes among the various etiologies were inflammation, ischemic events, and trauma in oculomotor, trochlear, and abducens nerve palsy, respectively. Logistic regression revealed that an onset of <7 days and isolated nerve involvement were significantly associated with good long-term outcomes, with an adjusted odds ratio of 1.73 (95% confidence interval, 1.03-2.89) and 2.56 (95% confidence interval, 1.21-5.39) adjusted for the type of cranial nerve palsy, aged at 50 years, sex, diabetes mellitus, hypertension, dyslipidemia, onset at 7 days, and number of cranial nerves involved, respectively.

Conclusion

The onset of symptoms in less than 1 week and isolated nerve involvement were associated with better prognosis in subjects with third, fourth, and sixth cranial nerve palsy.

Improvement in health-related quality of life with Botulinum toxin A injection in acquired superior oblique palsy

Purpose

This study aimed to investigate the outcomes of Botulinum toxin A (BTA) injection into the inferior oblique (IO) muscle for the management of unilateral acute acquired superior oblique palsy (SOP) and to evaluate changes in health-related quality of life post-injection using the Adult Strabismus-20 (AS-20) questionnaire.

Methods

A prospective cohort study was performed in patients with unilateral acute acquired SOP who received BTA injections. Four units of BTA were injected into the ipsilateral IO muscle. Ocular examinations were performed pre-and post-injection, including alignment, ocular movement, and cyclotorsion deviation. The patients' AS-20 questionnaire scores were analyzed.

Results

A total of 21 patients with acute acquired SOP were included. The initial median vertical deviation was 5 PD (range 1-16), which was improved to 0 PD (range 0-10) at both 1 and 6 months post-injection (p < 0.001 and p < 0.001, respectively). The median torsional deviation was 7° (range 2-18) at baseline and resolved to 0 degrees (range -3-5) at the 1-month and 0° (range -2-7) at the 6-month follow-up (p < 0.001 and p < 0.001, respectively). There were significant increases in the overall score (OAS), psychosocial subscale score (PSS), and functional subscale score (FSS) from baseline values at both the 1-month (p < 0.001, p < 0.001, and p = 0.001, respectively) and 6-month follow-up (all p < 0.001).

Conclusion

Injecting BTA into the ipsilateral IO muscle successfully resolved vertical and torsional deviations and significantly improved quality-of-life scores. Our findings show that BTA treatment, as an early treatment for acute acquired SOP, can help patients by significantly improving their quality of life.

Surgical outcomes following strabismus surgery for abducens nerve palsy

PURPOSE

To assess ocular alignment outcomes and their stability for patients who underwent strabismus surgery for abducens nerve palsy and to identify preoperative patient variables that predict surgical success or repeated surgeries.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with abducens nerve palsy and who subsequently underwent strabismus surgery.

RESULTS

A total of 209 patients (386 procedures) were included. The mean number of surgeries for patients was 1.9 ± 1.4. Success was achieved after a single surgery for 112 patients (53.6%), and success was achieved for an additional 42 patients, for a total of 154 patients (73.7%), following all surgeries. Preoperative abduction deficit severity was the only variable predictive of surgical success, with mild deficits having the highest odds of both initial success (OR = 5.555; CI, 2.722-11.336) and final success (OR = 5.294; 95% CI, 1.931-14.512). When analyzing survival time until additional surgery, the median survival was 406 days; abduction deficit severity, older age, other coincidental motility abnormalities, greater magnitude esotropia, and surgical technique were predictive of repeat surgical incidence.

CONCLUSIONS

In our patient cohort, preoperative abduction deficit was an important predictor of both surgical success and repeat surgical incidence for abducens nerve palsy. Older patient age, additional motility abnormalities, and greater amounts of baseline strabismus were also associated with greater likelihood of multiple surgeries.

Intraocular vascular analysis using optical coherence tomography angiography in patients with vascular paralytic strabismus

Purpose

To investigate changes in peripapillary and macular vessel density (VD) in vascular paralytic strabismus using optical coherence tomography angiography (OCTA).

Methods

Medical records of patients who recovered from monocular vascular paralytic strabismus were retrospectively analyzed. Age, sex, presence of underlying diseases, strabismus type and severity, time to recovery, and visual acuity at diagnosis were evaluated. VD in the optic disc area and macular capillary plexus density were estimated using OCTA. The effect of paralytic strabismus on intraocular VD was investigated by comparing VD between the paralysis and contralateral eyes. To analyze hemodynamic changes, VD changes in the paralysis eye during the attack and recovery were compared.

Results

Thirty-one patients (mean age, 64.1±13.0 years; 21 males, 10 females) were included and mean recovery time was 3.0±1.6 months. The most common paralysis was sixth nerve palsy (54.8%). When comparing OCTA results between the paralysis and contralateral non-paralysis eyes, foveal VD in the superficial capillary plexus (SCP) was significantly lower in the paralysis eye (P = 0.034); however, VD in the optic disc area was not different. In the paralysis eye, foveal VD in the SCP significantly increased after paralysis recovery (P = 0.04). During attack, the maximal deviation angle and severity of duction limitation were significantly related to foveal VD in SCP. The greater the deviation angle and the more severe the eye movement restriction, the lower the foveal VD in SCP.

Conclusions

Transient retinal ischemia of the paralysis eye was observed in a patient with paralytic strabismus, which corresponded to the degree of deviation angle and ocular motor restriction. Ischemic factors, which are the etiology of vascular paralytic strabismus, affect intraocular blood flow.

Etiologic Distribution of Isolated Trochlear Palsy: Analysis of 1,020 Patients and Literature Review

BACKGROUND AND PURPOSE

Trochlear palsy is the most common cause of vertical diplopia. The etiologies of trochlear palsy have shown a large discrepancy among the studies. This study aimed to establish the clinical features and underlying etiologies of isolated trochlear palsy by recruiting the patients from all departments in a referral-based university hospital.

METHODS

We reviewed the medical records of 1,258 patients who had a confirmed diagnosis of isolated trochlear palsy at all departments of Seoul National University Bundang Hospital, Seongnam, South Korea, from 2003 to 2020. We also compared the proportion of etiology with that of the patients pooled from the previous studies.

RESULTS

The most common etiology was congenital (n = 330, 32.4%), followed by idiopathic (n = 256, 25.1%), microvascular (n = 212, 20.8%), and traumatic (n = 145, 14.2%). These four etiologies explained 92.5% of isolated trochlear palsy. Patients were mostly managed by ophthalmologists (n = 841, 82.5%), followed by neurologists (n = 380, 37.3%), emergency physicians (n = 197, 19.3%), neurosurgeons (n = 75, 7.4%), and others (n = 18, 1.8%). The etiologic distribution of isolated trochlear palsy in the current study did not differ from that of 2,664 patients pooled from the previous studies.

CONCLUSIONS

The proportion of etiologies of isolated trochlear palsy differs according to the age ranges of the patients and specialties involved in the management. The etiologic distribution of isolated trochlear palsy in the current study was comparable to the pooled result of previous reports.

Association between migraine and risk of ocular motor cranial nerve palsy

To assess association between migraines and development of ocular motor cranial nerve palsy (CNP) and finding risk factors using the National Sample Cohort database from the Korea National Health Insurance Service. Data was analyzed from 4,234,341 medical screening examinees aged 20–90 years in 2009. Cox proportional hazard regression analysis was used to the adjusted hazard ratios (HR) for ocular motor CNP according to presence of migraine. Subgroup analysis was performed to evaluate effect of other factors on association of migraine with ocular motor CNP. A total of 5806 participants (0.14% of subjects) developed ocular motor CNP and were assigned to CNP group, 4,048,018 were assigned to control group, with an average of 8.22 ± 0.93 years of follow-up. Incidence of ocular motor CNP increased in migraine group compared to control. After adjusting potential confounding variables, HR for ocular motor CNP was 1.166 (confidence interval [CI] 1.013–1.343) in migraine group. Subgroups of relatively younger age less than 65 years (HR = 1.267, 95% CI 1.067–1.504), male gender (HR = 1.228, 95% CI 1.000–1.122), smokers (HR 1.426, 95% CI 1.127–1.803), and diabetes mellitus patients (HR = 1.378, 95% CI 1.045–1.378) showed a stronger association between migraines and development of ocular motor CNP. Our population-based cohort study demonstrated a significant association between presence of migraines and incidence of ocular motor CNP. Especially, relatively younger age, males, smokers, and diabetes patients with migraines could have a higher risk of developing ocular motor CNP.

Clinical outcomes and etiology of acquired sixth cranial nerve palsy

ABSTRACT

The objective of this study was to investigate the difference in clinical features according to age and factors affecting recovery of acquired sixth cranial nerve (CN6) palsy.A total of 156 patients with acute CN6 palsy between March 2016 and August 2021 who were followed up for at least 3 months were included in this study. Etiology, rate of recovery, and factors associated with recovery were retrospectively investigated.The average age of patients with CN6 palsy was about 60years and the mean duration of recovery was about 2.5 months. Of 156 patients, 72 (46.15%) had a microvascular etiology and 25 (16.03%) patients had a brain vascular lesions. Brain neoplasm, trauma, and "others" were found in 10 (6.41%), 11 (7.05%), and 15 (9.62%) patients, respectively. Among the total of 156 patients, 28 (17.95%) failed to completely recover. Non-isolated CN6 palsy with other cranial nerve palsies were recorded in 29 (18.59%) cases. Comparison of age (<50years vs ≥50years), between recovery and non-recovery groups showed that etiology was significantly different.The recovery rate of acquired CN6 palsy was about 82% and about 27% of patients had brain lesions. Also, varying rates and duration of recovery were found according to etiology, so we should be pay attention to diagnosis of causative disease in CN6 palsy patients.

Stroke risk after ocular cranial nerve palsy - A systematic review and meta-analysis

BACKGROUND

Isolated ischemic ocular cranial nerve palsies (OCNP) involving the 3rd, 4th and 6th cranial nerves (CN) are prevalent conditions in ophthalmic practice. However, it is not clearly established whether such patients are at increased risk of stroke after onset of OCNPs.

METHODS

Medline, PubMed, Embase and Cochrane Central registers were systematically searched for eligible studies comparing isolated ischemic OCNPs against matched controls on the subsequent development of stroke with at least two years of follow up. Case reports and series were excluded. Appropriate studies were entered for meta-analysis to determine hazard ratios. Search and data extraction was completed on 22 Feb 2021. Random effect models were used to generate pooled hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Three studies were suitable for meta-analysis (total n = 2,756 OCNP cases and 21,239 matched controls). The meta-analysis demonstrated a hazard ratio of 5.96 (4.20-8.46 95% CI) of subsequent stroke after isolated OCNP within the first year. The hazard ratio reduced to 3.27 (2.61-4.10 95% CI) after five years although remains raised at 2.49 (1.53-4.06 95% CI) up to 12 years. The highest risk was demonstrated with 3rd cranial nerve palsies. Two additional studies assessed the risk of stroke with newly diagnosed diabetics and compared OCNPs against lacunar stroke. These studies did not demonstrate a significant increased risk of stroke, although they may be statistically underpowered.

CONCLUSION

Ischemic OCNPs represent a significant risk factor for development of subsequent stroke in a similar magnitude to transient ischemic attack within the first year.

Facial and Abducens Nerve Palsies Following COVID-19 Vaccination: Report of Two Cases

A broad spectrum of neurological side effects has been reported after immunisation for COVID-19, including functional neurological disorders, cerebral vascular events, cerebral venous thrombosis, intracerebral haemorrhage, neuroleptic malignant syndrome, cranial nerve palsies, and otologic manifestations. Multiple cranial neuropathies have also been reported following vaccination in which involvement of VII nerve is the most prevalent, followed by the VI, III, and IV nerves. We describe two male patients, one with with facial nerve palsy and the other with abducens nerve palsy following COVID-19 vaccination. The patient with facial nerve palsy received the AstraZeneca vaccine 2 days before the symptoms began. In contrast, the patient with the abducens palsy had received his first dose of the Sinopharm vaccine 7 days previously. Both patients demonstrated a gradual recovery within the next 2 months. Further studies are required to investigate the proper relationship between cranial nerve palsies and vaccinations.

Binocular Visual Rehabilitation in Paralytic Strabismus by Botulinum A Toxin Chemodenervation

Purpose

To investigate the effect of botulinum A toxin (BTXA) chemodenervation in paralytic strabismus patients without surgical correction.

Methods

A retrospective chart review of 51 patients who were diagnosed as paralytic strabismus and underwent BTXA chemodenervation was performed. The patients were divided into four groups according to the cause of paralytic strabismus of vasculopathy, neoplasm, trauma, and idiopathic. They were also divided into two groups of early and late treatment according to the initiation time of BTXA chemodenervation after the onset of strabismus (3 months), and of the initial strabismus type of exotropia and esotropia. We investigated the changes of angle of deviation and diplopia after BTXA chemodenervation.

Results

The average deviation of angles decreased by 25.2 prism diopter (PD) (35.1 to 9.9 PD) in total patients, and the overall success rate was 64.7% (33 by 51), and the there was no statistically significant difference in success rate between each group divided by the cause of paralytic strabismus. According to the treatment timing, the deviation of the angle decreased by 28.0 PD (36.8 to 8.8 PD) in the early treatment group, and 21.3 PD (33.5 to 12.2 PD) in late treatment group at the time of the last postinjective follow-up. According to the initial strabismus type, the average angle of deviation decreased by 20.3 PD (35.6 to 15.3 PD) in exotropia group by cranial nerve 3 palsy, and 24.4 PD (32.5 to 8.1 PD) in esotropia by cranial nerve 6 palsy.

Conclusions

BTXA chemodenervation reduced the angle of deviation and the number of patients with diplopia regardless of the cause of paralytic strabismus. Early BTXA chemodenervation can be considered as the first treatment of choice in paralytic strabismus, especially in esotropia patients.

Liver enzymes and risk of ocular motor cranial nerve palsy: a nationwide population-based study

This study aimed to assess the associations between liver enzymes including γ-glutamyl transferase (GGT) and the development of ocular motor cranial nerve palsy (CNP) using the National Sample Cohort database from Korea's National Health Insurance Service. We analyzed data from 4,233,273 medical screening examinees aged 20 years or more in 2009. Study participants were followed up until December 31, 2018. A Cox proportional hazard regression analysis was performed for quartiles of liver enzymes to determine the linkage between each value and ocular motor CNP using quartile 1 as a reference after adjusting for potential confounders. A total of 5,807 (0.14%) patients developed ocular motor CNP during the follow-up period of 8.22 ± 0.94 years. The incidence of ocular motor CNP gradually increased as the GGT levels increased. The highest quartile of the GGT group had hazard ratio (HR) of 1.245 (95% confidence interval [CI], 1.136-1.365). Regarding alanine aminotransferase (ALT), the highest quartile of the ALT group had HR of 1.141 (95% CI, 1.049-1.241). However, the incidence of ocular motor CNP did not gradually increase as the ALT levels increased. The coexistence of the increased level of GGT, metabolic syndrome, and obesity showed a stronger association with ocular motor CNP development (HR, 1.331; 95% CI, 1.173, 1.511) compared to having a single factor or two factors. In conclusion, our population-based cohort study demonstrated a significant association between serum GGT level and the incidence of ocular motor CNP, suggesting that GGT could be a new clinical marker for predicting the occurrence of ocular motor CNP.

Infranuclear Eye Movement Disorders

Infranuclear motility disorders are such of the cranial nerves, the extraocular muscles or changes in the orbit but definitely peripheral to the nuclei of the cranial nerves. Characteristic are movement deficits, a compensatory head posture and the pattern of incomitancy. The secondary angle of deviation is usually larger than the primary. Combined pareses suggest a lesion in the cavernous sinus, orbital apex or a multilocular event. It is essential to rule out supranuclear disorders, especially if the motility deficit is atypical. For clarification, an individual risk assessment is recommended, paying particular attention to risk factors.

Clinical Characteristics for Predicting Recovery of Acquired Fourth Cranial Nerve Palsy

BACKGROUND

Fourth cranial nerve palsy is the most common disease diagnosed in patients with vertical diplopia. Although it is reported to present a good prognosis, there are currently no agreed on prognostic factors that anticipate the recovery of the palsy other than the etiology. The purpose of this study was to investigate the prognostic factors of acquired fourth cranial nerve palsy.

METHODS

The medical records of consecutive patients diagnosed with acquired unilateral fourth cranial nerve palsy from 2010 to 2020 and followed up for ≥6 months were retrospectively reviewed. The cause and degree of palsy, ocular deviation (horizontal, vertical, and cyclo), and fundus torsion were reviewed. The cause of palsy was classified as ischemic, traumatic, intracranial mass, others, or idiopathic. Patients were divided into 2 groups according to palsy recovery: complete recovery (group CR) or not CR (group NCR). The clinical characteristics of the 2 groups were compared, and the risk factors for incomplete recovery were investigated.

RESULTS

Thirty-five patients (25 men) were included in the study. The average age was 55.94 ± 16.11 years. CR was achieved in 23 patients (65.7%), and the time to recovery was 3.91 ± 4.03 months. The most common cause was traumatic (40.0%), followed by ischemia (37.1%), intracranial mass (11.4%), others (8.6%), and idiopathic (2.9%). The degree of palsy and fundus torsion was significantly higher in group NCR (P = 0.010 and P = 0.001). Severe oculomotor limitation, large fundus torsion, and intracranial mass cause rather than ischemic cause indicated a higher risk of incomplete or no recovery (P = 0.016, P = 0.009, and P = 0.043).

CONCLUSION

Identifying whether a patient has an intracranial mass, severe oculomotor limitation, or large fundus excyclotorsion may be useful for predicting the recovery of acquired unilateral fourth cranial nerve palsy.

Clinical Factors Affecting Recovery Periods of Vascular and Idiopathic Acquired Paralytic Strabismus

Purpose: Clinical factors affecting the recovery period in patients with vascular or idiopathic paralytic strabismus were evaluated.Methods: This study involved a retrospective review of medical records of patients diagnosed with vascular and idiopathic acquired paralytic strabismus. Vascular paralysis was defined in cases of hypertension, diabetes mellitus, or cardiovascular disease. The angle of deviation and limitation of extraocular movement were evaluated at each visit. Recovery was defined as the absence of diplopia and complete resolution of limitation of extraocular movement. Factors affecting recovery success and recovery period were analyzed.Results: We retrospectively reviewed data of 145 patients consisting of 87 with vascular paralytic strabismus (cranial nerve [CN] III: 21, CN IV: 28, CN VI: 38) and 58 with idiopathic paralytic strabismus (CN IV: 20, CN VI: 24, CN III: 14). The recovery rate did not significantly differ between vascular (60.9%) and idiopathic (63.8%) groups (p = 0.15). The recovery period was longer in the vascular group (130.1 ± 145.1 days) than in the idiopathic group (92.6 ± 76.6) (p = 0.02). Age at onset was significantly associated with the recovery period in both vascular and idiopathic groups. In the vascular group, the recovery periods were 107.4 ± 74.8 days in CN III palsy, 97.2 ± 51.9 days in CN IV palsy, and 159.3 ± 194.1 days in CN VI palsy. The recovery period was significantly longer in patients with CN VI palsy (p = 0.03). Hypertension was significantly influencing the recovery period in patients with vascular CN VI palsy (odds ratio = 2.54, p = 0.01).Conclusions: The recovery period was longer in patients with vascular paralytic strabismus than in patients with idiopathic paralytic strabismus. Recovery rates were not significantly different between groups. In patients with vascular CN VI palsy, a history of hypertension was significantly associated with the recovery period.

Disorders of the Fourth Cranial Nerve

ABSTRACT

This review of disorders of the fourth cranial nerve includes discussion on anatomy, examination techniques, congenital and acquired etiologies, differential diagnosis, and management options. The findings of the superior oblique muscle on orbital MRI in patients with fourth nerve palsy have had a major impact on our understanding of this cranial neuropathy. In addition, briefly reviewed are rare disorders of the fourth nerve: superior oblique myokymia, Brown syndrome, and ocular neuromyotonia. It behooves the clinician to have a clear understanding of the role that the fourth cranial nerve plays in a variety of neuro-ophthalmic conditions.

Multiple sclerosis presenting as acute acquired comitant esotropia in a pediatric patient

Acute acquired comitant esotropia (AACE) is a rare form of esotropia in the older pediatric population. Although the workup for pediatric AACE varies, patients often do not undergo lab testing and imaging, because the overwhelming majority of cases are idiopathic. We describe AACE as the presenting manifestation of multiple sclerosis in a pediatric patient. His only other finding was a horizontal jerk nystagmus isolated to end gaze. Magnetic resonance imaging revealed extensive demyelinating lesions, with a small thalamic lesion possibly accounting for his esotropia. Our case underscores the need for extensive diagnostic workup for any ophthalmic or neurologic findings or symptoms accompanying AACE.

The incidence and presumed aetiologies of fourth cranial nerve palsy in Korea: a 10-year nationwide cohort study

AIMS

To investigate the incidence and presumed aetiologies of fourth cranial nerve (CN4) palsy in Korea METHODS: Using the nationally representative dataset of the Korea National Health Insurance Service-National Sample Cohort from 2006 to 2015, newly developed CN4 palsy cases confirmed by a preceding disease-free period of ≥4 years were identified. The presumed aetiology of CN4 palsy was evaluated based on comorbidities around the CN4 palsy diagnosis.

RESULTS

Among the 1,108,292 cohort subjects, CN4 palsy newly developed in 390 patients during 10-year follow-up, and the overall incidence of CN4 palsy was 3.74 per 100,000 person-years (95% confidence interval, 3.38-4.12). The incidence of CN4 palsy showed a male preponderance in nearly all age groups, and the overall male-to-female ratio was 2.30. A bimodality by age-group was observed, with two peaks at 0-4 years and at 75-79 years. The most common presumed aetiologies were vascular (51.3%), congenital (20.0%), and idiopathic (18.5%). The incidence rate of a first peak for 0-4 years of age was 6.17 per 100,000 person-years, and cases in this group were congenital. The second peak incidence rate for 75-79 years of age was 11.81 per 100,000 person-years, and the main cause was vascular disease. Strabismus surgery was performed in 48 (12.3%) patients, most of whom (72.9%) were younger than 20 years.

CONCLUSION

The incidence of CN4 palsy has a male predominance in Koreans and shows bimodal peaks by age. The aetiology of CN4 palsy varies according to age-groups.

Clinical Practice Guidelines for Occupational Therapists in the Evaluation and Treatment of Oculomotor Impairment Following Traumatic Brain Injury

Purpose of review

Currently, a lack of guidelines exists regarding best practices for occupational therapists (OTs) in the treatment and evaluation of oculomotor dysfunction following traumatic brain injury (TBI). Furthermore, individuals with TBI would benefit significantly from collaboration between OTs and optometrists during inpatient rehab.

Recent findings

Although few articles examine interdisciplinary models of inpatient rehab care that include optometry, a recent pilot study is explored. Emerging evidence from the field of optometry supports the use of restorative approaches for oculomotor impairment in mild TBI; however, cases with moderate to severe TBI are not addressed.

Summary

We describe an interdisciplinary approach involving collaboration between optometry and occupational therapy, yielding a comprehensive model to effectively evaluate and treat oculomotor impairments in those with TBI and facilitate improved performance in daily activities. We also provide guidelines useful for OTs working in settings where collaboration with optometry is not feasible.

Analysis of Clinical Data from the Third, Fourth, or Sixth Cranial Nerve Palsy and Diplopia Patients Treated with Ijintanggagambang in a Korean Medicine Clinic: A Retrospective Observational Study

Objective: The clinical course of the third, fourth, and sixth cranial nerve palsies varies according to etiology and onset. The effects of Ijintanggagambang in Korean patients with cranial nerve palsy and paralytic diplopia were assessed. Design: This is a retrospective observational study. Settings: The study was conducted in a Korean Medicine clinic in Seoul, Korea. Subjects: Subjects were 569 patients with cranial nerve palsy and diplopia who received Ijintanggagambang in 2009-2018. Interventions: The patients received herbal decoction, Ijintanggagambang, for 4 weeks. Main outcome measures: The baseline characteristics, including onset, etiology, type of paralysis, and deviation angle, were collected. Patients whose diplopia resolved were classified as completely recovered. Potential factors affecting the clinical effectiveness of Ijintanggagambang for this condition were explored. The rate and duration of complete recovery were narratively analyzed and compared with previous reports. Results: Sixth cranial nerve palsy was the most common type of paralysis (n = 311, 55%) and undetermined origin was the most frequent etiology (n = 281, 49%). The complete recovery rate was higher in patients who started treatment within 12 weeks of onset (95%, 503/532) than in those who started treatment later (19%, 7/37). In 532 patients who started treatment within 12 weeks of onset, the complete recovery rate of patients with vascular origin (98%, 122/124), other diseases (97%, 94/97), and undetermined etiology (96%, 252/263) was statistically high compared with those of traumatic origin (73%, 35/48, p < 0.05). The average treatment duration in the complete recovery group (n = 510) was 9.3 weeks. The treatment duration was correlated with the increase of deviation angle in all three types of cranial nerve palsies. Conclusions: Sixth cranial nerve palsy and undetermined etiology were common. There is an association between recovery of diplopia and the administration of Ijintanggagambang when started within 12 weeks of onset. Results of the study need to be interpreted cautiously due to the limited nature of narrative retrospective analysis.

Superior cervical sympathetic ganglion block under ultrasound guidance promotes recovery of abducens nerve palsy caused by microvascular ischemia

The abducens nerve palsy is most likely caused by microvascular issue. Spontaneous recovery of vasculopathic abducens nerve palsies was common at 3-6 months. But recovery time was longer when many risk factors were present. Several patients had residual esotropia or abduction deficit. Cervical sympathetic block has an established use in treating patients with disorders related to cranial circulatory insufficiency. It causes a significant increase in cerebral blood flow. We report a case of a 67-year-old man with acute horizontal diplopia and right periocular pain. He had been diagnosed with right abducens nerve palsy caused by microvascular ischemia. We performed ultrasound-guided superior cervical sympathetic ganglion blocks. After 4 weeks, the symptoms had been completely resolved. We introduce ultrasound-guided superior cervical sympathetic ganglion blocks for management of abducens nerve palsy caused by microvascular ischemia, which could be an effective novel method to promote recovery from diplopia.

Differential Diagnosis of Acquired Esotropia in the Elderly

AIM

To provide an overview of the differential diagnoses of acquired esotropia that occur in the elderly and to facilitate their differentiation in everyday clinical practice.

METHODS

The data of all patients who presented in our outpatient university department for strabology and neuroophthalmology from March 2014 to October 2015 due to esotropia with diplopia with onset after age 50 were evaluated retrospectively. Exclusion criteria were a known strabismus before the age of 50 and/or vertical deviations in the primary position. Anamnestic characteristics, accompanying findings and orthoptic parameters, were analysed.

RESULTS

85 patients were included in the study, 42 of them female and 43 male. The following diagnoses were made: abducens nerve palsy (n = 34, 3 of them both sides), esotropia due to myopia magna (n = 12), esotropia with accompanying neurological symptoms (n = 6) and other etiology (n = 5). In 4 cases, the diagnosis was still unclear at the end of the study. In 24 patients, none of the above diagnoses existed and the diagnosis of "sagging eye syndrome" (ETSAG) was made. The abducens nerve palsy typically showed a sudden onset of double vision, slowed abduction saccades and asymmetrical abduction ability. With unilateral abducens nerve palsy, the esotropia increased continuously from the view to the unaffected side through the primary position to the view to the affected side. Patients with ETSAG and myopia-associated esotropia, on the other hand, reported a gradual onset of double vision, showed normal abduction saccades and a slightly reduced abduction ability. The squint angle often increased slightly to both sides. Esotropia with accompanying neurological symptoms was rare and was seen in various underlying diseases.

CONCLUSIONS

The kind of onset of the double vision, the quality of the saccades, the incomitance pattern and the ability to abduct are important parameters for the etiological assignment of an esotropia in the elderly. The characteristics of the individual diagnoses are described and differential diagnostic aspects are discussed.

Outcomes of Extraocular Muscle Surgery for Diplopia or Abnormal Head Posture After Treatment of Brain Disease

Purpose

To report the characteristics and outcomes of extraocular muscle (EOM) surgery for diplopia and abnormal head posture (AHP) after treatment of severe brain diseases such as brain tumor, severe cerebral bleeding and cerebral infarction.

Patients and Methods

Sixty-four patients (mean age 53.7 ± 16.0 years) who underwent EOM surgery to eliminate diplopia or AHP after treatment for brain disease at Hyogo College of Medicine Hospital from March 2006 through February 2018 were included. We divided the patients into two groups: a severe cerebrovascular disorder (SCVD) group and a brain tumor (BT) group. Backgrounds, surgical outcomes and satisfaction with treatment outcomes were examined retrospectively and compared between the two groups. The NEI-VFQ 25, Japanese version, was used to quantify postoperative satisfaction.

Results

There were 26 patients in the SCVD group and 38 patients in the BT group. The average age for the BT group was significantly younger than that for the SCVD group (P = 0.0236). The period from the onset of diplopia to EOM surgery was approximately 4 years for both groups. Abducens palsy was the most frequent disturbance (27% in the SCVD group and 52.6% in the BT group), and the numbers of operations were similar between the 2 groups (1.3 ± 0.7 and 1.3 ± 0.5 operations, respectively). In total, diplopia was eliminated in 82.8% of cases and AHP improved in 81.6% of cases. The BT group scored significantly higher than the SCVD group on 8 out of the 11 items on the VFQ 25.

Conclusion

EOM surgery was effective in eliminating diplopia and AHP. Therefore, we recommend that these patients visit an ophthalmologist as soon as possible and undergo EOM surgery.

Acute binocular diplopia: peripheral or central?

Objectives

Acute diplopia is a diagnostic challenge for clinicians, in particular in the emergency department. The most common cause of acute diplopia are ocular motor nerve palsies (OMP). In this prospective study, we focused on identifying the most crucial signs and symptoms for differentiating between peripheral and central OMP.

Methods

We prospectively evaluated 56 non-consecutive patients who presented at our emergency department with acute binocular diplopia (≤ 10 days). The patient history was taken using a standardized questionnaire and patients underwent a neurological, neuro-ophthalmological and neuro-otological examination, including measurement of the subjective visual vertical (SVV), Harms tangent screen test, and cranial MRI.

Results

Forty-six out of 56 patients were diagnosed with an ocular motor cranial nerve palsy (OMP), 21 of peripheral and 23 of central origin; in two patients, the etiology remained unknown. The following features were different in peripheral and central OMP: (1) the presence of vertigo/dizziness was more frequent in central (43.5%) than in peripheral (9.5%) OMP. (2) Central ocular motor signs, such as saccadic smooth pursuit, additional internuclear ophthalmoplegia, skew deviation, and saccade palsies, were also found more frequently in the central than in the peripheral group (86.7% vs. 33.3%). (3) Further, a pathological SVV deviation by monocular testing of the non-affected eye was also more common in central (77.3%) than in peripheral OMP (38.9%). The presence of all three factors has a positive predictive value of 100% (CI 50–100%) for the presence of a central lesion.

Conclusions

In acute diplopia due to central OMP, the most important accompanying symptom is vertigo/dizziness, and the most important clinical signs are central ocular motor disorders (which require examination of the non-paretic eye) and an SVV deviation in the non-paretic eye.

The Incidence and Etiologies of Third Cranial Nerve Palsy in Koreans: A 10-year Nationwide Cohort Study

PURPOSE

This study aimed to determine the incidence, prevalence, and etiologies of third cranial nerve (CN3) palsy in Koreans.

METHODS

Data were collected from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database of South Korea and analyzed. Incident CN3 palsy subjects in the cohort population were defined as cases occurring after the initial 4-year or longer washout period. The incidence and prevalence were analyzed by sex, age group, and year. The etiologies of CN3 palsy were evaluated using comorbidities.

RESULTS

Of 1,108,253 subjects, 387 patients were newly diagnosed with CN3 palsy between 2006 and 2015. The incidence of CN3 palsy was 3.71 per 100,000 person-years (95% confidence interval, 3.35-4.09). The incidence of CN3 palsy increased with age and accelerated after the age of 60 years. The mean male-to-female incidence ratio was 1.16. The main cause was presumed to be vascular disease (52.7%), followed by idiopathic causes (25.8%), intracranial neoplasm (7.8%), unruptured cerebral aneurysm (5.4%), and trauma (5.2%).

CONCLUSIONS

The incidence of CN3 palsy in Koreans increased with age and peaked between 75 and 79 years. The main cause of CN3 palsy was vascular disease.

Nonvitreoretinal Eye Injuries in 2 Infants Due to Nonaccidental Trauma

Intraocular findings are well known and well documented in child abuse cases. However, eye deviation on physical examination can also be just as important in evaluating a child for maltreatment. We present 2 cases of infants younger than 6 months who presented to the emergency department with new-onset abnormal eye deviation, and further evaluation revealed other findings consistent with nonaccidental trauma. These cases were ruled as abusive head trauma and demonstrate the importance of conducting a thorough evaluation for any acute-onset ophthalmological and neurological finding.

Clinical outcomes and aetiology of fourth cranial nerve palsy with acute vertical diplopia in adults

Background

We investigated the clinical outcomes of fourth cranial nerve (CN4) palsy with acute vertical diplopia in adults.

Methods

A total of 80 patients with acute CN4 palsy who underwent at least 3 months of follow-up were included in this study. We retrospectively investigated the aetiology, rate of recovery, and factors associated with recovery between March 2016 and January 2019.

Results

The average age of patients with CN4 palsy was about 60 years, and the duration of recovery was 1.5 months: 48 (60.0%) patients had a vascular aetiology and 17 (21.3%) patients had a trauma history. Brain lesions were found in four (5.0%) patients and decompensated cause accounted for four (5.0%) cases. Among the total of 80 patients, 13 (16.3%) failed to completely recover. Non-isolated CN4 palsy with other cranial nerve palsies were recorded in seven cases. The comparison between recovery and non-recovery groups showed that initial deviation angle, aetiology, fundus extorsion, and head tilt status were significantly different factors.

Conclusion

The recovery rate of acute CN4 palsy was about 80% and duration of recovery was 1.5 months. However, the varying rates and duration of recovery was presented according to aetiology thus we should consider the prognosis by aetiology.

Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia

PURPOSE

Sagging eye syndrome (SES), horizontal and/or vertical strabismus caused by orbital connective tissue degeneration, was first defined 10 years ago. This study investigated SES and other causes of acquired binocular diplopia in adults presenting to a single institution since the description of SES.

DESIGN

Retrospective observational case series.

METHODS

Medical records were reviewed of all new patients over the age of 40 who presented to the Stein Eye Institute with binocular diplopia between January 2015 and December 2018. Clinical causes of diplopia were tabulated in patients grouped by age and sex. In patients with SES, we tabulated binocular alignment, types of treatment, and surgical outcomes.

RESULTS

There were 945 patients of mean age 66.5 years, of whom 514 (54.4%) were female. The most common cause of diplopia was SES (31.4%). The 297 patients with SES were older at 71.2 years (P < 0.0001) and more predominantly female at 59.9% than other patients (52.0%; P = 0.023). The relative proportion of SES patients among all diplopic patients increased with age from 4.7% under age 50 years to 60.9% over the age of 90. Age-related distance esotropia was present in 35% and cyclovertical strabismus in 65% of cases of SES. Strabismus surgery was performed in 50% of cases of SES. Mean esotropia at distance decreased from 6.9 ± 0.7Δ preoperatively to 0.3 ± 0.3Δ postoperatively. Preoperative hypertropia decreased from 3.0 ± 0.3Δ to 0.7 ± 0.2Δ postoperatively. Surgery resolved diplopia in all cases.

CONCLUSIONS

It is important to recognize that SES is a very common cause of adult binocular diplopia.

Acquired Ocular Motor Palsy: Current Demographic and Etiological Profile

PURPOSE

To describe the clinical, demographic, and etiological profile of patients of acquired ocular motor palsy presenting in a tertiary eye care center.

DESIGN

A retrospective hospital record-based study was conducted in patients of paralytic strabismus presenting from April 2016 to December 2017.

METHODS

Data included demographic and clinical details, diagnosis, underlying etiology, imaging, laboratory reports, and the outcome.

RESULTS

Mean age of presentation of 345 patients included in the study was 38.2 ± 19.5 years (range = 365 years). Pediatric patients (age: ≤16 years) constituted 9.5% of the entire cohort. Mean duration of complaints was 5.87 ± 2 months. Of the 372 eyes of 345 cases, 42.7% were sixth nerve palsy, 34.7% were third nerve palsy, 17.7% were fourth nerve palsy, and 4.8% had multiple ocular motor nerve involvement. Third and sixth nerve palsies were mostly due to ischemic event (58.1% and 69.8% cases, respectively), whereas fourth nerve palsies were commonly caused by trauma (63.6%). Amongst traumatic cases, road traffic accident was the most common mode of trauma. Systemic risk factors were preexistent in 18.2% cases (n = 63); in the remaining (40.8%; n = 141), they were diagnosed after presentation. Complete or partial recovery was noted in 69.7% cases in third nerve palsy, 67.9% cases in sixth nerve palsy, and 45% cases in fourth nerve palsy.

CONCLUSIONS

Acquired cranial nerve palsy has younger onset in Indian scenario. Ischemia is the most common etiology raising concerns about the health issues of young Indians. Sixth nerve is most commonly involved in all age groups. Low recovery rate in fourth nerve palsy can be attributed to traumatic etiology.

The incidence and etiology of sixth cranial nerve palsy in Koreans: A 10-year nationwide cohort study

We aimed to investigate the incidence, prevalence, and etiology of sixth cranial nerve (CN6) palsy in the general Korean population. The nationally representative dataset of the Korea National Health Insurance Service–National Sample Cohort from 2006 through 2015 was analyzed. The incidence and prevalence of CN6 palsy were estimated in the cohort population, confirming that incident cases of CN6 palsy involved a preceding disease-free period of ≥4 years. The etiologies of CN6 palsy were presumed using comorbidity conditions. Among the 1,108,256 cohort subjects, CN6 palsy developed in 486 patients during the 10-year follow-up. The overall incidence of CN6 palsy was estimated to be 4.66 per 100,000 person-years (95% confidence interval [CI], 4.26–5.08) in the general population. This incidence increased with age, accelerating after 60 years of age and peaking at 70–74 years of age. The mean male-to-female incidence ratio was estimated as 1.41 in the whole population, and the incidence and prevalence of CN6 palsy showed an increasing trend over time in the study period. Surgical incidence for CN6 palsy was only 0.19 per 100,000 person-years (95% CI, 0.12–0.29). The etiologies were presumed to be vascular (56.6%), idiopathic (27.2%), neoplastic (5.6%), and traumatic (4.9%). In conclusion, the incidence of CN6 palsy increases with age, peaking at around 70 years, and shows a mild male predominance in Koreans.

Acute onset binocular diplopia: a retrospective observational study of 100 consecutive cases managed at a tertiary eye centre in Saudi Arabia

OBJECTIVE

To evaluate the demography, aetiology and clinical course of acute onset binocular diplopia (AOBD) in patients presented as emergency and managed at the neuroophthalmology clinic of a tertiary eye care centre in Saudi Arabia.

PATIENTS AND METHODS

A retrospective review of the medical records of 100 consecutive patients who attended the emergency department of Dhahran Eye Specialist Hospital with isolated, AOBD. The exclusion criteria were: (a) monocular diplopia, (b) binocular diplopia accompanied with neurological deficits other than ocular muscles dysfunction and (c) thyroid eye disease. All patients were followed until resolution of the diplopia or onward referral to another specialty for further management.

RESULTS

Male:female ratio was 2:1. Median age of the cohort was 56 years (range 18-90 years). Associated nerve palsy included: abducens nerve (n = 57 patients), oculomotor (n = 32 patients) and trochlear nerve (n = 3 patients). Microvascular ischaemia and ocular myasthenia gravis were two most common pathogenic mechanisms. AOBD resolved spontaneously in 98% of patients.

CONCLUSION

AOBD, though an alarming and distressing condition, carries reassuringly good prognosis in majority of patients. High risk factors for vascular disease in Middle-Eastern population are reflected in microvascular aetiology as the major cause.

Sudden-onset trochlear nerve palsy: clinical characteristics and treatment implications

PURPOSE

To identify clinical characteristics, etiologies, and treatment implications of sudden-onset, acquired cases of superior oblique palsy.

METHODS

The medical records of patients diagnosed with trochlear nerve palsy between January 2010 and January 2018 were reviewed retrospectively to identify cases of acquired trochlear nerve palsy with a specific date of onset of acute symptoms or specific causative incident. Patients with congenital palsies or an uncertain date of onset, history of other strabismus, concomitant oculomotor or abducens nerve palsies, or history of strabismus surgery were excluded.

RESULTS

Of 214 patients with superior oblique palsy, 23 had sudden-onset, acquired palsies. There were 14 cases of unilateral palsy and 9 cases of bilateral palsy. Patients with unilateral palsy presented with vertical diplopia, while those with bilateral palsy complained of either torsional (4/9 patients) or vertical (5/9 patients) diplopia. The most common etiologies were severe trauma associated with traumatic brain injury, followed by central nervous system neoplasm and stroke. Fifteen patients underwent surgical intervention, 3 of whom required more than one surgery.

CONCLUSIONS

Patients with acute superior oblique palsy invariably complain of vertical and/or torsional diplopia. Neuroimaging should be considered in cases of acquired superior oblique palsy without a known traumatic cause. Bilateral cases of acquired superior oblique palsy are more challenging to manage surgically because of symptomatic torsional diplopia.

Ocular Motor Cranial Nerve Palsy as an Indicator of Neglected Systemic Disease in Nigeria: Perspective from a Neuro-Ophthalmology Clinic

The aim of this article from Nigeria is to draw attention to public health issues in medical care using ocular motor cranial nerve palsy (OMCNP) presenting to a neuro-ophthalmology clinic as a case study. All patients presenting with OMCNP between November 2007 and October 2016 were retrospectively reviewed. Demographic details as well as information regarding the clinical presentation, clinical course, investigation, and treatment outcomes were extracted from case records. Phone calls were made to the contact numbers of patients who had been lost to follow-up. Data were analysed using SPSS version 22 (IBM, Corp. Armonk, NY, USA). Cranial nerve palsies other than oculomotor, trochlear, and abducens palsies were excluded. Fifty-nine patients, comprising 28 males and 31 females, were identified. Age range was 1-84 years (median 43.0 ± 19.7 years). Fifty-one cases (93.2%) were mono neuropathies, while four (6.8%) affected multiple nerves. Oculomotor nerve palsy was most common, accounting for 57.6% of cases. Microvascular angiopathy was the commonest identifiable cause (25.6%). Aetiology was not identified in 16 cases. There were three (5.1%) deaths. Undiagnosed systemic disease appears to be a major risk factor for this patient group in this African setting. Patient investigation was problematic. Poor patient compliance and follow-up resulted in preventable deaths. Neuro-ophthalmologists practicing in low resource settings should be aware of these risks.

Acquired Ocular Motor Nerve Palsy in Neurology Clinics: A Prospective Multicenter Study

BACKGROUND AND PURPOSE

This study aimed to determine the patterns and etiologies of acquired ocular motor nerve palsy (OMNP) diagnosed in neurology clinics. We also investigated the clinical features that may predict the causes other than microvascular ischemia in isolated OMNP.

METHODS

We performed a prospective multicenter study that had recruited 298 patients with acquired OMNP from the neurology clinics of referral-based 9 university hospitals in Korea. We finally selected 235 patients with isolated OMNP and divided them into older (age ≥50 years, n=188) and younger (age <50 years, n=47) groups. We investigated the underlying etiologies of acquired OMNP. We also estimated the frequency of microvascular ischemia and other causes in isolated OMNP, and sought to determine the clinical features that can predict the causes other than microvascular ischemia.

RESULTS

Abducens nerve palsy was the most common (40%) of the acquired OMNPs, followed by oculomotor nerve palsy (27%), trochlear nerve palsy (23%), and multiple OMNPs (10%). The etiologies included microvascular ischemia (47%), inflammatory (21%), stroke (5%), trauma (5%), neoplasm (3%), and others (2%), with the cause not being determined in 13% of the patients. Microvascular ischemia was the most common cause (83%) in patients aged ≥50 years with isolated OMNP, followed by inflammation (6%), stroke (6%), neoplasm (3%), and aneurysm (1%). Microvascular ischemia was more common in the older than the younger group (83% vs. 49%, p<0.001). The intensity of headache was the only risk factor for causes other than microvascular ischemia in isolated OMNP.

CONCLUSIONS

Vascular and inflammatory disorders are the most common causes of acquired OMNP diagnosed in neurology clinics. Microvascular ischemia was the predominant cause of isolated OMNP. Severe headache indicates causes other than microvascular ischemia in isolated OMNP.

Ocular motor cranial nerve palsy and increased risk of stroke in the general population

Purpose

To determine whether ocular motor cranial nerve (CN) palsy raises the risk of subsequent stroke in the general population.

Methods

We investigated the association between ocular motor CN palsy and occurrence of stroke using the National Health Insurance Service-National Sample Cohort database from 2002 to 2013. We included individuals aged ≥ 20 years on January 1^st, 2004, and excluded those having any paralytic strabismus, disorders in binocular movement, diplopia and any cerebrovascular diseases before entering the cohort. Incident ocular motor CN palsy was identified by diagnostic codes for third, fourth, and sixth nerve palsies. To determine the effect of incident ocular motor CN palsy on the occurrence of subsequent stroke, we used time-varying covariate Cox regression models. Model 1 included only incident third, fourth, and sixth nerve palsies as a time-varying covariate. Model 2 included Model 1 and defined demographic information. Model 3 included Model 2, comorbidity, co-medication, and the Charlson index score.

Results

Among 727,689 individuals in the cohort, 1,633 patients developed ocular motor CN palsy and 17,657 patients suffered stroke. Cox regression models showed that development of ocular motor CN palsy was associated with an increased risk of subsequent stroke (hazard ratio [HR] = 4.65; 95% confidence intervals [CIs], 3.74–5.80 in Model 1), and the results were consistent even after adjusting for demographic factors and confounders in Model 2 and 3. Men, older age, and individuals not living in Seoul/Incheon area were associated with an increased risk of stroke, while individuals with higher income were associated with decreased risk of stroke in both Model 2 and 3. Sensitivity analyses using propensity score-based matching produced similar results in all three Models (HR = 1.95; 95% CI, 1.55–2.46 in Model 1, HR = 1.91; 95% CI, 1.52–2.41 in Model 2, and HR = 1.63; 95% CI, 1.29–2.06 in Model 3).

Conclusions

The occurrence of ocular motor CN palsy is a significant risk factor of subsequent stroke even after adjusting for demographic factors and confounders in the general population. Physicians may need to educate patients with ocular motor CN palsy regarding the higher risk of future stroke.

Isolated Ocular Motor Nerve Palsies

Isolated cranial nerve (CN) palsies are frequently encountered by strabismologists. Management decisions for patients with isolated ocular motor nerve palsies must take into account multiple factors, including patient age, historical features, the specific CN affected, examination findings, and coexistent medical diagnoses. In general, isolated ocular motor nerve palsies in children are assessed and managed differently than adults. Furthermore, older adults with vascular risk factors may be managed differently than younger adults and children. The need for urgent neuroimaging in older adults with microvascular risk factors is under debate and requires the physician to weigh the risks and benefits of close observation with immediate testing. The presence of multiple cranial neuropathies should also raise the level of concern and indicate the need for a more urgent work-up. The following manuscript aims to provide information on common etiologies of isolated ocular motor nerve palsies and to suggest algorithms for the management of these CN palsies in children and adult.

Incidence and Etiology of Presumed Fourth Cranial Nerve Palsy: A Population-based Study

PURPOSE

To determine the incidence of isolated, presumed fourth nerve palsy in a defined population, and to report the frequency of each cause.

DESIGN

Retrospective, population-based case series.

METHODS

A population-based database was used to identify all cases of isolated fourth nerve palsy in Olmsted County, Minnesota, USA diagnosed over a 15-year period (January 1, 1978 to December 31, 1992). The most likely etiology was determined by review of the entire medical record by 2 ophthalmologists. A priori definitions were applied for assigning cause. The incidence of fourth nerve palsy and the frequency of each etiology were calculated. Decade of life at presentation was recorded.

RESULTS

Seventy-three patients (74 episodes, 70 [95%] unilateral) were identified. Mean age at presentation was 41.8 (range 3.3-81.6) years. The age- and sex-adjusted annual incidence rate was 5.73 per 100 000 per year (95% confidence interval [CI] 4.31-7.14). The most common etiology was presumed congenital (49%), followed by hypertension (18%) and trauma (18%). One patient (1%) had fourth nerve palsy owing to a known intracranial neoplasm. For 3 patients (4%) the cause of fourth nerve palsy was undetermined. The most common decade of presentation overall was the fourth decade, including for presumed congenital cases.

CONCLUSIONS

In this population-based study, the majority of isolated fourth nerve palsies were presumed congenital, even though they presented throughout adulthood. Other etiologies such as hypertension and trauma were less frequent, and in no case was an isolated fourth nerve palsy the presenting sign of an intracranial tumor.

Stroke risk among adult patients with third, fourth or sixth cranial nerve palsy: a Nationwide Cohort Study

PURPOSE

This study sought to determine whether isolated third, fourth and sixth cranial nerve palsies (NPs) are associated with increased short- and long-term risk of a subsequent stroke.

METHODS

This was a nationwide retrospective propensity score-matched cohort study. A cohort of patients with NP (n = 466) and a randomly selected, propensity-matched control cohort (n = 2281) were extracted from the Korean national insurance claim database. Subjects were tracked for 5 years total, subdivided into periods of 0-1 years, 1-3 years and 3-5 years. We assessed the risk of stroke using hazard ratios (HRs) and confidence intervals (CIs) after adjustments using Cox regression at different time intervals.

RESULTS

The median follow-up was 3.1 years. Stroke developed in 18.9% of the NP cohort and 7.5% of the control cohort. Stroke risk after NP was highest in the first year [14.7 per 100 person-year at 0-1 years (HR = 6.6), 3.1 per 100 person-year at 1-3 years (HR = 1.6) and 4.3 per 100 person-year at 3-5 years (HR = 2.8)]. Each type of NP was also associated with stroke risk: within 0-1 years, stroke risk was increased in third (HR = 7.6), fourth (HR = 6.0) and sixth (HR = 5. 84) NPs. In the 3- to 5-year period, risk was increased in sixth (HR = 4.7) and fourth (HR = 3.3) NPs, but not third (HR = 0.6) NPs.

CONCLUSION

Patients in the NP cohort were more likely to have a stroke than those in the matched control cohort; the increased risk was both time- and cranial nerve-dependent.

Delayed Onset of Isolated Unilateral Oculomotor Nerve Palsy Caused by Post-Traumatic Pituitary Apoplexy: A Case Report

Post-traumatic pituitary apoplexy is uncommon, most of which present with a sudden onset of severe headache and visual impairments associated with a dumbbell-shaped pituitary tumor. We experienced an unusual case of post-traumatic pituitary apoplexy with atypical clinical features. A 66-year-old man presented with mild cerebral contusion and an incidentally diagnosed intrasellar tumor after a fall accident with no loss of consciousness. The patients denied any symptoms before the accident. After 4 days, the left oculomotor nerve palsy developed and deteriorated associated with no severe headache. Repeated neuroimages suggested that pituitary apoplexy had occurred at admission and showed that the tumor compressed the left cavernous sinus. The patient underwent endonasal transsphenoidal surgery at 6 days after head injury, and the mass reduction improved the oculomotor nerve palsy completely within the following 14 days. The pathologic diagnosis was nonfunctioning pituitary adenoma with hemorrhage and necrosis.

An Incidental Finding of Ecchordosis Physaliphora in a Case of Abducens Nerve Palsy: Case Report

Ecchordosis physaliphora (EP) is a rare non-malignant mass that originates from remains of the notochord and is typically asymptomatic. A 42-year-old man presented with sudden onset of painless horizontal diplopia and his neurological exam showed sixth cranial nerve palsy. Magnetic resonance imaging (MRI) identified a non-enhanced retroclival mass (EP) with increased signal intensity on T2 and decreased signal intensity on T1-weighted sequences. He was treated with methylprednisolone, completely recovered in four weeks and has remained symptom free. Conservative management should be attempted before surgery in all cases since symptoms can resolve spontaneously and EP could be an incidental finding.