Acquired Ocular Motor Palsy: Current Demographic and Etiological Profile

Outcomes and Factors Associated with Successful Strabismus Surgery for Abducens Nerve Palsies: A Retrospective Study and Literature Review

Purpose

Several studies reported surgical outcomes for abducens nerve palsy, but information on factors that affect treatment success remains lacking. These factors are crucial for developing a treatment plan and providing disease counseling. This study aimed to investigate the outcomes of strabismus surgery for abducens nerve palsy and determine the factors that influence its success, including a review of relevant literature.

Methods

This retrospective analysis included abducens nerve palsy cases, focusing on surgical interventions and relevant patient data, at the outpatient clinics of Phramongkutklao Hospital from April 1, 2012, to April 30, 2022. A relevant literature review included the surgical success rate and factors that influence surgical outcomes.

Results

This study enrolled 32 patients, including 19 with partial and 13 with complete abducens nerve palsy. The overall success rate of strabismus surgery was 78.1%. Trauma was the leading cause of abducens nerve palsy in this population (28.13%). Fisher's exact and Mann-Whitney U-tests revealed that shorter abducens nerve palsy onset and smaller preoperative angle were significantly associated with successful surgical outcomes of strabismus surgery among the groups. In contrast, subgroup analysis revealed that only preoperative smaller angles were significantly associated with good surgical outcomes in horizontal strabismus surgery. However, the vertical rectus muscle transposition group demonstrated no significant factors. The literature review revealed that the success rate of surgery in abducens nerve palsy was 25%-82.6% for horizontal rectus muscle surgery and 46.2%-91% for rectus muscle transposition.

Conclusion

The surgical success rate for abducens nerve palsy reached 78.1%, including 78.95% for partial and 76.92% for complete abducens nerve palsy. Notably, a shorter onset preceding surgery and a smaller preoperative angle significantly correlated with successful surgical outcomes one year postoperatively.

Clinical spectrum and its association with recovery patterns in patients with acquired isolated ocular motor nerve palsies - an observational study

Purpose: To study the clinical spectrum and recovery patterns in patients of acquired isolated ocular motor nerve palsies (OMNPs). Methods: Patients above 5 years of age with various etiologies of OMNPs were included. Demographic and ocular details were recorded, and a squint assessment was performed. Recovery patterns at 3 and 6 months were noted. Results: OMNP was more common in adults, in the order VI > III > IV nerve. Ischemic cause (35%) was followed by idiopathic (26.3%). III nerve palsies were all unilateral, of which all ischemic palsies were pupil-sparing. By 6 months, >50 patients showing complete recovery had ischemic and idiopathic palsies. Smaller baseline deviation correlated with better recovery. Conclusion: Acquired isolated OMNPs are mostly ischemia-related, with >80% of cases fully recovering by 6 months. VI nerve palsy of ischemic or idiopathic etiology and small baseline deviation were associated with self-recovery.

Pituitary Adenoma Masquerading as Diabetic Third Nerve Palsy

A 46-year-old uncontrolled diabetic female visited the ophthalmology outpatient department with a sudden onset of drooping of the upper lid and restriction of movements in adduction, depression, and elevation in the right eye, suggestive of third nerve palsy. Initially, it was thought to be due to a vasculogenic cause due to uncontrolled diabetes, but visual fields revealed bitemporal hemianopia, characteristic of a pituitary adenoma. The diagnosis was confirmed by a CT scan. The patient then underwent a trans-nasal endoscopic removal of the pituitary macroadenoma, followed by a partial recovery of vision.

Oculomotor Cranial Neuropathies: Diagnosis and Management

Ocular nerve palsies are among the most common cranial neuropathies in neurological practice. Nerves can get affected anywhere along their path from the brainstem to the orbit. There can be isolated involvement of multiple cranial nerves together. The etiologies differ according to the type of presentation. The steps toward the diagnosis need to be strategically planned and must be based on clinical localization. It is crucial to make proper localization to plan further investigations and thus treatment of the etiology. This review covers the approach toward the diagnosis, etiologies involved, and management of ocular cranial neuropathies.

Trends in Etiologies, Demographics, and Neuroimaging in New-Onset Adult Strabismus at an Ophthalmic Emergency Department

PURPOSE

To evaluate new-onset strabismus in adults presenting to an ophthalmic emergency department, and to identify which patients require neuroimaging.

METHODS

This was a retrospective review of electronic medical records of patients 18 years and older who presented to an ophthalmic emergency department between January 1, 2019 and December 31, 2020 with new-onset strabismus. Data regarding demographics, causes, neuroimaging, and resolution were recorded and analyzed.

RESULTS

Of the 557 patients in the current study, 54.8% were men and the mean age was 57.3 ± 16.7 years (range: 18 to 92 years). Most patients (72.4%) presented with diplopia. Esotropia was the most common ocular misalignment (43.6%) and was more common in women than men (51.6% vs 37.0%, respectively) (P = .001). The most common diagnoses were cranial nerve palsies (66.8%) for both sexes and all age groups, with the most common etiology being microvascular (48.1%) for patients 50 years and older and idiopathic (20.1%) for patients between 18 and 49 years old. The incidence of cranial nerve palsies was significantly higher in older patients (P < .001). Neuroimaging was performed in 58% of patients (n = 323), of whom 37.2% (n = 120) had abnormal findings. The most common abnormal neuroimaging finding was mass for all age groups and sexes (19.2%). Patients with cranial nerve palsy and microvascular etiology had a significantly lower proportion of abnormal neuroimaging findings (P < .001).

CONCLUSIONS

Most cases of new-onset strabismus in adults presenting to the emergency department were due to cranial nerve palsy, particularly in older patients. Despite high rates of neuroimaging, patients with cranial nerve palsy had mostly normal findings. The current study supports the belief that neuroimaging may be deferred in patients older than 50 years with micro-vascular risk factors. [J Pediatr Ophthalmol Strabismus. 2022;59(4):269-273.].

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.

Neuro-Visual and Vestibular Manifestations of Concussion and Mild TBI

PURPOSE OF REVIEW

Mild traumatic brain injury, or concussion, is a major cause of disability. Vestibular and visual dysfunction following concussion is common and can negatively affect patients' well-being and prolong recovery. Etiologies of visual and vestibular symptoms are numerous, including ocular, neuro-ophthalmic, otologic, and neuro-vestibular conditions. Some etiologies are benign and may be treatable, while others are potentially vision or life-threatening, making a focused history and examination essential. This review offers an approach to the evaluation and treatment of the most common neuro-visual and vestibular impairments that may result from concussion.

RECENT FINDINGS

Treatment of concussion including exercise, computerized programs, transcranial magnetic stimulation, gene therapy, stem cell therapy, and nanoparticles has shown promise. Many novel therapies are in the pipework for visual and vestibular recovery after concussion; however, the treatment mainstay remains therapy and evaluation for co-existing diseases.

Frontalis Sling Using a Silicone Rod for Ptosis in Third Nerve Palsy: Cosmesis Versus Safety

Purpose

To evaluate the results of the frontalis sling operation using a silicone rod for the correction of ptosis in patients with third nerve palsy with a focus on corneal safety.

Methods

Patients with third nerve palsy who underwent the frontalis sling operation using a silicone rod between 2008 and 2019 were included in this study. The medical records of all patients were reviewed, and their clinical characteristics and postoperative outcomes were analyzed. In this retrospective, interventional case series, the main outcome measures were eyelid contour, eyelid height by margin reflex distance, and corneal status.

Results

Twenty-four eyes of 18 patients (12 male and six female patients) were included. The mean age at the time of surgery was 35.1 years (range, 5–64 years). Twelve patients underwent a unilateral ptosis operation, and six patients received a bilateral ptosis operation. The mean follow-up period was 32.1 months (range, 2–87 months). Most patients (21 of 24 eyes, 88%) showed poor Bell’s phenomenon on preoperative examination. Satisfactory eyelid height and eyelid contour were achieved in almost all patients (mean postoperative margin reflex distance, +1.2 mm) postoperatively. Although corneal erosions were detected for several months in eight of 24 eyes after surgery, these findings were well controlled medically with artificial tear eye drops and ointments.

Conclusions

Frontalis sling surgery using a silicone rod can safely and effectively correct ptosis without severe corneal complications in patients with third nerve palsy. Our study outlines a new method to define the postoperative safety outcome by specifically focusing on categorized corneal status.

Pediatric ocular motor cranial nerve palsy: Demographics and etiological profile

Purpose:

The aim of this study was to describe epidemiological and clinical characteristics of pediatric ocular motor cranial nerve palsy.

Methods:

This was a retrospective record-based study, carried out at a tertiary eye care hospital in India, between January 2011 and January 2015 and included patients up to 16 years of age at the time of presentation, diagnosed with third, fourth, sixth nerve palsy or a combination of these with other cranial nerve palsy. Data analyzed included demographic details, etiologies, presence or absence of amblyopia, relevant investigations, and management.

Results:

A total of 90 cases were included in the study. Eighty patients (88.88%) presented with isolated nerve palsy. Forty-three patients (47.77%) had congenital nerve palsy. The most common nerve involved was third (n = 35, 38.88%) followed by sixth (n = 23, 25.55%) and fourth nerve (n = 22, 24.44%). Most common cause of third and fourth cranial nerve palsy was congenital (n = 18, 51.42% and n = 17, 77.30%, respectively), while it was trauma for the sixth nerve (n = 7, 30.40%). Amblyopia was most frequently associated with third cranial nerve palsy (n = 27, 77.14%). The radio-imaging yield was maximum (n = 7, 70%) for combined cranial nerve palsy. Overall 44 (48.88%) patients were managed conservatively, while 46 (51.11%) patients needed squint with or without ptosis surgery.

Conclusion:

The most common ocular motor cranial nerve involved in the pediatric population was the third cranial nerve, and it was found to be the most amblyogenic in this age group. The neuroimaging yield was maximum for combined cranial nerve palsy. The most common conservatively managed nerve palsy in this study group was the fourth nerve palsy.

Idiopathic unilateral oculomotor nerve palsy: A case report

Cranial nerve III palsy, also known as oculomotor nerve palsy, may result from various causes; however, the etiology remains unknown in some instances. The aim of this case report is to present the authors' experience with two cases of idiopathic cranial nerve III palsy, together with a review of the literature. Case 1 is a 78-year-old woman and case 2 is a 75-year-old man, both having no history of trauma and no vascular risk factors. They presented to the authors' hospital with diplopia and palpebral ptosis and were diagnosed with idiopathic unilateral cranial nerve III palsy. They received oral steroids for treatment. One patient recovered completely within 3 months, while the other patient did not recover regardless of long-term follow-up. Idiopathic cranial nerve III palsy can occur in otherwise healthy individuals and often recover in several months. Careful examinations to rule out other causes and then steroid treatment should be considered after early diagnosis.