Isolated fascicular oculomotor nerve palsy as the initial presentation of the antiphospholipid syndrome

Ophthalmologic manifestations in primary antiphospholipid syndrome patients: A cross-sectional analysis of a primary antiphospholipid syndrome cohort (APS-Rio) and systematic review of the literature

OBJECTIVE

There is a broad spectrum of eye involvement in antiphospholipid syndrome (APS). The majority of descriptions are presented as case reports that include mostly APS patients secondary to systemic lupus erythematosus (SLE), with no compelling evidence in primary APS (PAPS). This study aimed to describe ocular manifestations in our well-defined PAPS cohort (APS-Rio) and then perform a systematic literature review (SLR) of ocular manifestations in patients with APS or positivity to aPL without SLE.

METHODS

We retrospectively analyzed PAPS patients followed at our outpatient clinics. All patients fulfilled Sydney APS classification criteria (2006). We evaluated them for ocular symptoms and previous ocular diagnoses. Antiphospholipid antibodies and clinical APS manifestations were compared between patients with and without ocular manifestations. For the SLR, electronic databases were searched up to November 2019.

RESULTS

We studied 105 PAPS patients; 90.5% were female and 56.2% were Caucasian. We found ocular manifestations in 37.1% of our cohort. Thrombosis was the main criteria manifestation (95.2%) and lupus anticoagulant was the most prevalent antibody. Ophthalmologic diagnoses were present in 7 patients, with 5 having retinal vessels thromboses. Amaurosis fugax was the leading complaint, present in 30 patients. In the univariate analysis, amaurosis fugax was related to livedo (p = 0.005), Raynaud's phenomenon (p = 0.048) and the presence of anticardiolipin antibody (≥40 GPL/MPL) (p = 0.041). Hemianopia was associated with arterial hypertension (p = 0.049). In the multivariate analysis, the only association found was between livedo and amaurosis fugax (OR 4.09, 95%CI 1.5-11.11, p = 0.006). Our SLR incorporated 96 articles of ocular manifestations in patients with PAPS or positivity to aPL without SLE. Ocular findings varied from 5 to 88%, including anterior and posterior segments, orbital and neuro-ophthalmologic changes.

CONCLUSION

There is little evidence on ocular manifestations in PAPS. We described an association between livedo and amaurosis fugax. Prospective studies are needed to promote the best treatment and avoid blindness in PAPS patients.

Monocular Oculomotor Nerve Disorder Manifesting as Cranial Neuropathy in Systemic Lupus Erythematosus

We herein report the case of a patient who developed peripheral neuropathy of the bilateral lower legs that later became complicated with isolated oculomotor nerve disorder and was finally diagnosed as systemic lupus erythematosus (SLE). Based on the findings for oculomotor nerve paralysis and contrast-enhanced magnetic resonance imaging findings for the oculomotor nerve in the prepontine cistern, the isolated oculomotor nerve disorder was considered to be a manifestation of peripheral neuropathy. This oculomotor nerve disorder may contribute to the diagnosis of SLE and can be effectively treated with steroid pulse therapy. Reports of SLE manifesting as isolated oculomotor nerve paralysis are rare.

Ocular manifestations of systemic lupus erythematosus: a clinical review

Although the eye itself is regarded an ‘immune-privileged’ organ, systemic lupus erythematosus (SLE) can affect every ocular structure, leading, if left untreated, to significant visual loss or even blindness. Since ocular inflammation in SLE can antedate the diagnosis of the systemic disease and cause significant morbidity, prompt diagnosis and treatment of the underlying systemic autoimmune disease is imperative.

Isolated unilateral oculomotor paresis in pure midbrain stroke

BACKGROUND AND PURPOSE

Pure midbrain stroke can cause isolated unilateral oculomotor paresis. We attempted to determine whether there is a difference in the oculomotor paresis pattern between pure midbrain infarction and midbrain hemorrhage.

METHODS

Pure midbrain stroke patients who presented with isolated unilateral oculomotor paresis were identified from a group of 2447 consecutive patients hospitalized for acute cerebral infarction or hemorrhage during the period May 2008 through April 2014. Detailed oculomotor findings were evaluated in the identified patients per the cause of the stroke.

RESULTS

Five patients with infarct and 1 with hemorrhage became our study subjects. Lesions were located in the paramedian area of the midbrain involving the oculomotor fascicles. The pupillary sphincter and inferior rectus muscles were selectively spared in the infarct patients, whereas these muscles were selectively affected in the hemorrhage patient.

CONCLUSION

Fibers in the oculomotor fascicle that innervate the levator palpebrae, superior rectus, and inferior oblique muscles appear to be more susceptible to ischemic damage than those that innervate the pupillary sphincter and inferior rectus muscles. Isolated impairment of the pupillary sphincter and inferior rectus muscles may be suggestive of a non-ischemic process.

A case of inferolateral oculomotor fascicular infarction: a review of the clinicoradiological literature

We report a patient with partial oculomotor paresis due to midbrain infarction. A 69-year-old man noticed diplopia suddenly. Ptosis, and impaired adduction and supraduction were found in the right eye. The pupillary size and light reflexes were normal on both sides. Magnetic resonance imaging disclosed an acute lesion in the right inferolateral oculomotor fascicle. These clinicoradiological findings suggested that the inferolateral fascicular damage could cause palsy of the levator palpebrae, medial rectus, superior rectus and inferior oblique muscles. Physicians should pay more attention to oculomotor fascicular infarction in patients with incomplete oculomotor paresis, and spared pupil sphincter and inferior rectus muscles.

Nasal septal perforation and antiphospholipid syndrome (Hughes syndrome)

We present the case of a 19-year-old woman who developed a nasal septal perforation and atrophic rhinitis following septal surgery. During the subsequent five years, she also experienced intermittent episodes of swelling and ischaemia of the left foot, as well as livedo reticularis. Ultimately, haematological investigations revealed the presence of lupus anticoagulant and elevated antiphospholipid immunoglobulin M levels. A diagnosis of antiphospholipid syndrome (Hughes syndrome) was made.A search of the literature revealed that nasal septal perforation has been described in up to 0.8 per cent of patients with antiphospholipid syndrome. However, it is undescribed in the otorhinolaryngological literature. The impact of this syndrome on otorhinolaryngology practice is examined.

A case of multiple cranial nerve palsies as the initial ophthalmic presentation of antiphospholipid syndrome

Purpose

To report a case of third, fourth, and six cranial nerve palsies with antiphospholipid syndrome (APS).

Methods

Medical records of a 16 year old female diagnosed with idiopathic intracranial hypertension (IIH) in primary APS were reviewed.

Results

A 16 year old female presented with headache and diplopia. Ocular examinations revealed marked bilateral disc edema. She was unable to depress, adduct, and abduct in left eye and had limited abduction in the right eye. Cerebrospinal fluid had a normal composition and a pressure of 400 mmH₂O. Lupus anticoagulant and IgG anticardiolipin antibody were positive. There was no clinical evidence of other autoimmune disease. Brain magnetic resonance (MR) imaging, MR angiography, and conventional angiogram with venous phase were normal. She was diagnosed with bilateral sixth, and left third and fourth cranial nerve palsies secondary to idiopathic intracranial hypertension in primary APS.

Conclusions

To our knowledge this is the first reported case of concurrent third, fourth, and sixth cranial nerve palsies in a patient with primary APS.