Synkinesis of upper lid elevation occurring in horizontal eye movements

Oculomotor neuromyotonia with lid ptosis on abduction

Ocular neuromyotonia is an episodic involuntary contraction of one or more of the extraocular muscles resulting from spontaneous neural discharges of the oculomotor nerve. It is characterized by symptomatic diplopia for the duration of the contraction and occurs either spontaneously or after a sustained eccentric gaze. Although the mechanism of ocular neuromyotonia is not fully understood, primary or secondary aberrant regeneration and consequent ephaptic transmission generally are held to be involved. We report the case of a patient with right oculomotor neuromyotonia accompanied by lid ptosis on abduction of the left eye who was successfully treated with oral carbamazepine.

Correction of congenital blepharoptosis in oculomotor-abducens synkinesis

A 4-year-old boy was referred for blepharoptosis. Examination revealed the presence of oculomotor-abducens synkinesis (right upper eyelid elevation with right gaze). Reports of congenital oculomotor-abducens synkinesis syndromes are rare. Two surgeries required more levator resection than anticipated to obtain the first, to our knowledge, reported successful result in this condition.

Paradoxical eyelid movement in trisomy 2p

Paradoxical eyelid movement was reported in a 12-year-old female with 46,XX,dup(2)(p25.3p22.2). Alternating seesaw-like movement of the eyelids during lateral gazing had been observed at 5 months of age when she was first referred to our neuropediatric outpatient department, and the abnormal lid movement persisted without any change for 11 years. The differentiation of the features of the paradoxical lid movements in our patient from those of Duane syndrome were discussed, and a possible pathogenesis is discussed as well. Besides ophthalmologic abnormalities, the patient demonstrated severe psychomotor retardation, marked growth failure, symptomatic generalized epilepsy, and multiple anomalies. The dysmorphism consisted of a cleft lip, a narrow high-arched palate, malalignment, lowset ears, and kyphoscoliosis caused by fused thoracic vertebrae.

The differential diagnosis and classification of eyelid retraction

BACKGROUND

Classification schemes are useful in the formulation of differential diagnoses. Thoughtful commentary has been devoted to the classification of blepharoptosis, but the causes of eyelid retraction have received less attention in published reports. Although eyelid retraction most frequently is associated with Graves ophthalmopathy, numerous other entities may cause the sign. This study was undertaken to provide a more comprehensive differential diagnosis and classification of eyelid retraction.

METHODS

A series of patients with eyelid retraction was studied, and pertinent published reports were reviewed.

RESULTS

Forty-four patients with different causes for eyelid retraction are described. Normal thyroid function and regulation were confirmed in all patients in whom Graves ophthalmopathy could not be excluded by clinical, biochemical, or historical criteria.

CONCLUSION

Based on a series of patients and reported cases, a differential diagnosis for eyelid retraction is proposed using a classification system compromising three categories (neurogenic, myogenic, and mechanistic).

Prevalence of palpebral fissure asymmetry in white persons

PURPOSE

Because palpebral fissure asymmetry in horizontal gaze is reportedly common in otherwise normal persons, we determined the prevalence of physiologic palpebral fissure asymmetry for primary and horizontal gazes.

METHODS

We measured the palpebral fissure height of both eyes of 88 healthy white subjects. Measurements were obtained with high-resolution videography, with the eyes in primary position, in 45-degree right gaze, and in 45-degree left gaze.

RESULTS

Of the 88 subjects, 36 (41%) were male and 52 (59%) were female. The ages ranged from 12 to 50 years, with a mean of 32.5 +/- 9.0 years. When a criterion of equal to or greater than 1 mm was used, the prevalence of physiologic palpebral fissure asymmetry was 5.7% (five of 88) in primary gaze, 18.2% (16 of 88) in right gaze, and 14.8% (13 of 88) in left gaze. The largest observed palpebral fissure asymmetry was 2.1 mm. After correcting for any existing fissure asymmetry in primary gaze, two-tailed trivariate analysis of variance showed that the fissure of the adducting eye tended to be wider. The mean increase in the palpebral fissure of the adducting eye was 0.12 mm for right gaze (P = .052) and 0.13 mm for left gaze (P = .034). Additionally, a chi 2 test indicated that the occurrence of wider adducting eye in both right and left gazes was highly significant (P = .0023).

CONCLUSIONS

In this sample of white subjects, palpebral fissure height asymmetry increased in horizontal gaze to the right and to the left, which is in part because of a tendency of the adducting eye to widen slightly. In contrast to previous reports, the prevalence of palpebral fissure asymmetry was low, and the abducting eye did not widen significantly.

Benign encephalitis: electro-oculographic analysis of opsoclonus

Two cases of benign encephalitis are described, which showed opsoclonus associated with myoclonic jerks of the body and face, and with cerebellar dystaxia in one case. EOG and EEG analysis during the course of these cases showed: 1. opsoclonic eye movements were triggered by saccadic and non-saccadic eye movements, 2. decrease of luminancy and loss of fixation were releasing, but not triggering opsoclonic bursts during the initial stages, 3. eye closure had the strongest trigger effect, which lasted very long and allowed an objective description of the (benign) course of the illness, 4. besides conjugate, mostly horizontal, spontaneous eye movements oblique and vertical ones were also obtained. Monocular and disconjugate eye movements were seen only during the initial stages, 5. statistical analysis of the frequency of single eye movements during periods of opsoclonic bursts showed that, in the course of the disease the variability of frequencies decreased and the degree of fast frequencies increased, particularly with open eyes, 6. the frequent coincidence of opsoclonus and lesions of the cerebellum or of the cerebellar pathways is striking, but the initially distinct EEG changes, the very different trigger modes and certain pathoanatomically described cases without any cerebellar lesion indicate the more general character of the disturbance. 7. the entity of opsoclonus, body tremulousness, and benign encephalitis has to be differentiated from other syndromes including the sign opsoclonus by recording the EEG and EOG during the course of the disease; this might lead to very useful diagnostic and prognostic information.

Gaze-evoked blepharoclonus

Painful bilateral orbicularis clonus on eccentric gaze developed in 2 patients with demyelinating disease. This unusual phenomenon was of variable intensity but persisted for years and did not respond to phenytoin or carbamazepine therapy.

Clinical observations in 101 consecutive patients with Duane's retraction syndrome

We retrospectively studied 101 consecutive patients with Duane's retraction syndrome. Eighty-five percent were unilaterally affected and 15% were bilaterally affected. More patients had straight eyes in primary position than esotropia or exotropia. On lateral version reflex testing the amount of underaction of the lateral and medial rectus muscles could be determined, and could be used to predict whether the patients' eyes were esotropic, exotropic, or straight in primary position. Almost all the patients showed an esotropia when looking to one side and either an exotropia or no deviation to the other side. The degree of the exotropia and the esotropia on opposite sides determined whether a head turn would be present and in what direction. On adduction, the palpebral fissure in the affected eye narrowed in one half the patients because of motion of both upper and lower eyelids, and in 40% because of motion of only one eyelid. When the lower eyelid elevated, it usually assumed a straight horizontal contour with peaking of the punctum lacrimalis (appearing as a small pyramid). The statistical predominance of females and left eyes was more significant among patients whose eyes were straight in primary position. All patients tested demonstrated stereopsis. Most of the amblyopic patients had anisometropia.