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Affiliation(s)
- Subahari Raviskanthan
- Neuro-Ophthalmology Fellow, Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Peter W Mortensen
- Neuro-Ophthalmology Fellow, Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Andrew Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York, Department of Ophthalmology, University of Texas Medical Branch, Galveston, Texas, University of Texas MD Anderson Cancer Center, Houston, Texas, Texas A and M College of Medicine, Bryan, Texas, Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Microvascular Decompression for Oculomotor Nerve Palsy due to Nonaneurysmal Vascular Compression. World Neurosurg 2020; 145:102-106. [PMID: 32891836 DOI: 10.1016/j.wneu.2020.08.215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Diabetes mellitus and aneurysmal compression are well-known causes of oculomotor nerve palsy (ONP), but nonaneurysmal vascular compression of the oculomotor nerve has rarely been reported. CASE DESCRIPTION A 70-year-old nondiabetic man presented with left ONP for the past 2 days. Magnetic resonance imaging revealed the left posterior communicating artery to be compressing the left oculomotor nerve. Microvascular decompression of the offending artery from the nerve via a left frontotemporal craniotomy was performed; the nerve showed a color change suggestive of degenerative alteration. ONP was fully resolved within 1 month of surgery. CONCLUSIONS Whether nonaneurysmal vascular compression of the oculomotor nerve is a true cause of ONP is sometimes controversial. However, recent developments in magnetic resonance imaging can clearly demonstrate the spatial relationship between the oculomotor nerve and vessels. Detailed magnetic resonance imaging should be used to diagnose compression of the oculomotor nerve by blood vessels. Microvascular decompression is the treatment of choice in this situation.
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William F. Hoyt and the Neuro-Ophthalmology of Superior Oblique Myokymia and Ocular Neuromyotonia. J Neuroophthalmol 2020; 40 Suppl 1:S29-S34. [DOI: 10.1097/wno.0000000000001004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Giannantoni N, Bonasia S, Bertulli L, Staedler C, Robert T. Rare neurovascular conflict between oculomotor nerve and posterior communicating artery. Neuroradiology 2020; 62:1717-1720. [PMID: 32632512 DOI: 10.1007/s00234-020-02489-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
Paroxysmal diplopia could be the expression of a multitude of clinical or anatomical conditions. Both ophthalmological and neurological pathologies could be responsible of this symptom. Rarely, a neurovascular conflict involving the oculomotor nerve is the etiology. We present the case of a 75-year-old man who presented for a 20-year history of transient vertical diplopia. The radiological exams demonstrated the presence of a neurovascular conflict between the right oculomotor nerve and a fetal-type posterior communicating artery. This fetal posterior communicating artery had an aberrant downward course that compressed the third cranial nerve. Few cases of neurovascular conflict interesting the third cranial nerve were described in the literature whom the responsible artery was generally the superior cerebellar artery. No case of oculomotor nerve compression by the posterior communicating artery was published. Authors have reviewed the literature and discuss the embryology of the posterior communicating artery, pathophysiology, radiological findings, and therapeutic possibility.
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Affiliation(s)
- Nadia Giannantoni
- Department of Neurology, Neurocenter of the Southern Switzerland, Lugano, Switzerland
| | - Sara Bonasia
- Department of Neurosurgery, Neurocenter of the Southern Switzerland, Lugano, Switzerland
| | - Lorenzo Bertulli
- Department of Neurosurgery, Neurocenter of the Southern Switzerland, Lugano, Switzerland
| | - Claudio Staedler
- Department of Neurology, Neurocenter of the Southern Switzerland, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Neurocenter of the Southern Switzerland, Lugano, Switzerland. .,Ospedale Regionale Civico di Lugano, University of the Southern Switzerland, USI, Lugano, Switzerland.
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Belotti F, Zanin L, Fontanella MM, Panciani PP. The oculomotor neurovascular conflict: Literature review and proposal of management. Clin Neurol Neurosurg 2020; 195:105920. [PMID: 32474258 DOI: 10.1016/j.clineuro.2020.105920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Oculomotor nerve (OCN) lies in a close relationship with large arteries inside the basal cisterns. Therefore, it may be compressed by vascular malformations or aneurysms. Nevertheless, the compression is not always related to pathologic conditions. Indeed, some cases of neurovascular conflicts of the OCN have been described in the literature. METHODS A case of neurovascular conflict of the OCN resolved after steroid treatment is reported. Additionally, a systematic literature review of those cases was performed. RESULTS OCN palsy due to a neurovascular conflict has been described as acute or chronic persistent palsy, or with an intermittent presentation. Symptoms result from compression, although asymptomatic compression is not uncommon. Surgical treatment, pharmacological treatment, and observation have been reported as options in the literature. Microvascular decompression was employed effectively in some cases of OCN neurovascular conflict. Nevertheless, other cases were treated successfully with steroids (persistent presentation) and carbamazepine (intermittent presentation). A management algorithm based on the results of the literature review is proposed. CONCLUSIONS Treatment options for OCN neurovascular conflicts and their results are heterogeneous. Based on the literature review, the pharmacological treatment seems to be the most appropriate first-line approach, reserving surgery for refractory cases. Collecting clinical information about new cases will allow defining treatment standards for this rare condition.
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Affiliation(s)
- Francesco Belotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
| | - Luca Zanin
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Marco Maria Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Pier Paolo Panciani
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
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Thompson B, Kerr N, Bell A, Graves E, McGregor A. Congenital Ocular Neuromyotonia with Partial Third Nerve Palsy. J Binocul Vis Ocul Motil 2019; 69:13-17. [PMID: 30806169 DOI: 10.1080/2576117x.2018.1563451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE We report the first case of congenital ocular neuromyotonia (ONM) and the results of strabismus surgery for this patient's co-existing cranial nerve (CN) III palsy. PATIENTS AND METHOD The patient presented at 18 months with strabismus that had reportedly been present since the time of birth. On exam, she had persistent exotropia (RXT) and hypertropia (RHT) with episodes of esotropia in the right eye that could be evoked by sustained left gaze. A diagnosis of ONM with partial CN III palsy was made. T1-weighted, T2-weighted, and fluid-attenuated inversion recovery magnetic resonance imaging failed to reveal intracranial pathology. RESULTS Gaze induced intermittent esotropia resolved with carbamazepine. Surgery was performed to improve the patient's RXT and RHT. Post-operatively, the patient's RXT had improved from 12 to 15 prism diopters (∆) at near and 20∆ at a distance to 10∆ RXT at near with no horizontal deviation at distance. Her deviation has remained stable for 13 years, as has her neurological exam and good state of health. CONCLUSION This case demonstrates that ONM may present congenitally and adds to the body of knowledge regarding surgical outcomes on concurrent CN palsies in these patients.
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Affiliation(s)
- Barrett Thompson
- a College of Medicine , University of Tennessee Health Science Center , Memphis , Tennessee
| | - Natalie Kerr
- a College of Medicine , University of Tennessee Health Science Center , Memphis , Tennessee.,b Hamilton Eye Institute , University of Tennessee Health Science Center , Memphis , Tennessee.,c University of Tennessee Le Bonheur Pediatric Specialists , Memphis , Tennessee
| | - Austin Bell
- d BoozmanHof Regional Eye Clinic , Rogers , Arkansas
| | | | - Amy McGregor
- a College of Medicine , University of Tennessee Health Science Center , Memphis , Tennessee.,c University of Tennessee Le Bonheur Pediatric Specialists , Memphis , Tennessee
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Blanc C, Bidot S, Héran F, Tournaire-Marques É, Vignal-Clermont C. A Puzzling Ocular Motility Disorder: Apparent Up-Gaze Fatigability in a Patient With Oculomotor Nerve Compression. Neuroophthalmology 2018; 42:242-245. [PMID: 30042796 DOI: 10.1080/01658107.2017.1374416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/23/2017] [Accepted: 08/29/2017] [Indexed: 10/18/2022] Open
Abstract
We report the case of a woman who developed right third nerve dysfunction with synkinesis and ocular neuromyotonia secondary to a compressive arterial aneurysm. Surprisingly, our examination showed a downward drift of the right eye in sustained up-gaze resulting in transient hypotropia, suggesting either fatigability of the superior rectus or contraction of the inferior rectus. We believe this ocular motility pattern is secondary to a co-contraction of the inferior rectus in up-gaze caused by synkinesis (explaining the downward drift), followed by failure of the inferior rectus to relax upon return to primary position caused by ocular neuromyotonia (explaining the hypotropia).
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Affiliation(s)
- Christelle Blanc
- Department of Neurology, University Hospital of Dijon, Dijon, France
| | - Samuel Bidot
- Department of Ophthalmology, The Rothschild Foundation, Paris, France
| | - Françoise Héran
- Department of Radiology and Imaging Sciences, The Rothschild Foundation, Paris, France
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Therapy of Vestibular Paroxysmia, Superior Oblique Myokymia, and Ocular Neuromyotonia. Curr Treat Options Neurol 2016; 18:34. [PMID: 27306762 DOI: 10.1007/s11940-016-0417-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OPINION STATEMENT Neurovascular compression syndromes are characterized by recurrent attacks of neurological symptoms and clinical signs depending on the cranial nerve affected. It is assumed that pulsatile compression of the nerve is caused mainly by an artery. The result is segmental demyelination of the transition zone or the central part of the cranial nerve, which is covered by oligodendrocytes, and subsequent ephaptic axonal transmission. Compression of the vestibular nerve can cause attacks of spinning or non-spinning vertigo: vestibular paroxysmia. Compression of the trochlear nerve is characterized by attacks of monocular oscillopsia: superior oblique myokymia. Damage to ocular motor nerves due to local radiation or rarely neurovascular compression can also lead to oscillopsia and double vision precipitated by sustained excentric gaze: ocular neuromyotonia. It is important to note that controlled trials have so far not been performed for any of these three syndromes, mainly because of their low prevalence. Therefore, treatment recommendations are based on single cases or small case series and thus have the lowest level of evidence. The sodium channel blockers carbamazepine (50 to 200 mg tid) or oxcarbazepine (100 to 300 mg tid) are evidently effective in most of the patients who have these three syndromes. However, one should always keep in mind the contraindications, side effects, and interactions with other drugs of carbamazepine ( http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682237.html ) All patients require regular laboratory examinations. Alternatives are other sodium channel blockers such as phenytoin (100 to 300 mg tid), gabapentin (100 to 600 mg tid), or valproic acid (100 to 300 mg tid). Furthermore, there are also few reports on the effects of beta blockers, which may be explained by their reduction of the amplitude of blood pressure. Patients who do not respond to pharmacotherapy require further diagnostics to determine the possibility of other etiologies. Some of these patients benefit from surgical decompression of the affected nerve.
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A case of ocular neuromyotonia caused by neurovascular compression of the oculomotor nerve by the elongated superior cerebellar artery. J Neurol 2016; 263:1236-8. [DOI: 10.1007/s00415-016-8117-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
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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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Golnik KC. Neuro-Ophthalmology Annual Review. Asia Pac J Ophthalmol (Phila) 2015; 4:307-15. [PMID: 26417928 DOI: 10.1097/apo.0000000000000147] [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: 11/25/2022] Open
Abstract
PURPOSE The purpose of this review was to update the practicing ophthalmologist on the English language neuro-ophthalmology literature from the past year. DESIGN A review of English language literature from August 1, 2013, to August 1, 2014, was conducted. METHODS The author searched PubMed from August 1, 2013, to August 1, 2014, limited to English language publications including original articles, review articles, and case reports and excluding letters to the editor, unpublished work, and abstracts. The following topics were searched: pupillary abnormalities, eye movement dysfunction, neuromuscular diseases, optic neuropathies, optic neuritis, demyelinating diseases including multiple sclerosis, lesions of the optic chiasm and posterior primary visual pathways, elevated intracranial pressure, tumors and aneurysms affecting the visual pathways, vascular diseases, higher visual function, and neuroimaging advances. The focus of this review is on clinically relevant literature in the past year for the practicing ophthalmologist. The aim was to highlight remarkable and interesting literature rather than exhaustively including all new neuro-ophthalmological publications of the year. RESULTS Initially, more than 11,000 articles were identified. One hundred were selected that met criteria specified above. CONCLUSIONS This review updates the comprehensive ophthalmologist on neuro-ophthalmic topics.
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Affiliation(s)
- Karl C Golnik
- From the Department of Ophthalmology, University of Cincinnati and the Cincinnati Eye Institute, Cincinnati, OH
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Menon D, Sreedharan SE, Gupta M, Nair MD. A novel association of ocular neuromyotonia with brainstem demyelination: two case reports. Mult Scler 2014; 20:1409-12. [PMID: 25160126 DOI: 10.1177/1352458514536481] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ocular neuromyotonia (ONM) is a rare disorder of ocular mal-alignment in which painless, transient spontaneous or gaze-induced abnormal deviation of the eye manifests as episodic diplopia. With only a few cases reported in the literature, ONM mostly follows months to years after cranial irradiation for sellar or suprasellar lesions. Here we present two patients with this rare ocular condition, secondary to brainstem demyelination, the association of which is hitherto unreported in the literature. Both patients were 15-year-old girls who presented to us with episodic forced-eye deviation with diplopia. Examination during these attacks revealed ONM involving the superior rectus and medial rectus in the first and second patient, respectively. There was clinical evidence of intrinsic brainstem involvement with downbeat nystagmus and skew deviation in one patient without any other cerebellar or long tract signs. MRI showed evidence of demyelination involving the brainstem in both, with CSF showing positive immunological markers and with positive aquaporin-4 antibody in one patient. Both patients responded remarkably to immunomodulatory therapy and are asymptomatic at follow-up. That ONM can occur with brainstem demyelination has not been reported in the literature. This association may help in explaining the pathophysiology of ONM as secondary to segmental demyelination.
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Affiliation(s)
- Deepak Menon
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | | | - Maneesh Gupta
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
| | - M D Nair
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, India
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