Acupuncture combined tuina for oculomotor paralysis: A protocol for systematic review and meta-analysis

BACKGROUND

Oculomotor paralysis (OP) is a neurologic syndrome with multiple causes of oculomotor nerve and its dominant tissue and muscle dysfunction. Acupuncture combined with tuina is a wide-ranging used rehabilitation therapy, although there is short of supporting evidence for its efficacy and safety in patients with OP. The purpose of this systematic review was to estimate and synthesize evidence of the efficacy and safety of acupuncture combined with tuina in the treatment of OP.

METHODS

Electronic databases, including PubMed, Web of Science, Cochrane Library, EMBASE, Technology Journal and China Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang,adopt an appropriate search strategy. RevMan V.5.3.5 software will be used for data synthesis, bias risk, and subgroup analyses.

RESULTS

This study provides high-quality evidence to assess the effectiveness and safety of acupuncture combined with tuina for OP.

CONCLUSION

This systematic review explores whether acupuncture combined with tuina is an effective and safe intervention for OP.

ETHICS AND DISSEMINATION

Private information from individuals will not publish. This systematic review does not involve endangering participant rights. Ethical approval was not obtained. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42021266447.

Efficacy of adeno-associated virus gene therapy in a MNGIE murine model enhanced by chronic exposure to nucleosides

BACKGROUND

Preclinical studies have shown that gene therapy is a feasible approach to treat mitochondrial neurogastrointestinal encephalomyopathy (MNGIE). However, the genetic murine model of the disease (Tymp/Upp1 double knockout, dKO) has a limited functional phenotype beyond the metabolic imbalances, and so the studies showing efficacy of gene therapy have relied almost exclusively on demonstrating correction of the biochemical phenotype. Chronic oral administration of thymidine (dThd) and deoxyuridine (dUrd) to dKO mice deteriorates the phenotype of the animals, providing a better model to test therapy approaches.

METHODS

dKO mice were treated with both dThd and dUrd in drinking water from weaning until the end of the study. At 8 - 11 weeks of age, mice were treated with several doses of adeno-associated virus (AAV) serotype 8 vector carrying the human TYMP coding sequence under the control of different liver-specific promoters (TBG, AAT, or HLP). The biochemical profile and functional phenotype were studied over the life of the animals.

FINDINGS

Nucleoside exposure resulted in 30-fold higher plasma nucleoside levels in dKO mice compared with non-exposed wild type mice. AAV-treatment provided elevated TP activity in liver and lowered systemic nucleoside levels in exposed dKO mice. Exposed dKO mice had enlarged brain ventricles (assessed by magnetic resonance imaging) and motor impairment (rotarod test); both were prevented by AAV treatment. Among all promoters tested, AAT showed the best efficacy.

INTERPRETATION

Our results show that AAV-mediated gene therapy restores the biochemical homeostasis in the murine model of MNGIE and, for the first time, demonstrate that this treatment improves the functional phenotype.

FUNDING

This work was funded in part by the Spanish Instituto de Salud Carlos III, and the Generalitat de Catalunya. The disclosed funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The oculomotor neurovascular conflict: Literature review and proposal of management

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.

Acupuncture for ophthalmoplegia: Protocol for a systematic review

BACKGROUND

Ophthalmoplegia is a disease that affects many people every year and is caused by reasons, such as cavernous sinus lesion, intracranial aneurysm, diabetes, and trauma. Acupuncture has been widely used to treat ophthalmological diseases especially ophthalmoplegia in China. Many clinical trials indicate that acupuncture may promote the recovery of extraocular muscles in ophthalmoplegia patients. We aim to conduct a meta-analysis to evaluate the efficacy and safety of acupuncture for ophthalmoplegia.

METHODS

We will retrieve the literature from the following electronic databases, by March 31, 2018, such as PubMed, EMBASE, the Cochrane Library, Web of Science database, Chinese BioMedical Literature Database, China National Knowledge Infrastructure, China Science and Technology Journal database, and Wanfang Database. We will also collect clinical trial registries, dissertations, grey literature, reference lists of studies, systematic reviews, and conference abstracts. Two people will review these articles, extract the data information, and assess the quality of studies separately. Data will be synthesized by either fixed-effects or random-effects model regarding to a heterogeneity test. The eyeball movement distance, size of fissure palpebrae, and the reduced degree of strabismus will be assessed as the primary outcomes. The secondary outcomes will be the size of the pupil, main symptom scores, ocular localization analysis, and functional impairment extent and safety. We will use the specific software called RevMan (version 5.3) to perform the meta-analysis.

RESULTS

This study will provide a high-quality synthesis based on current evidence of acupuncture for ophthalmoplegia, especially its impacts on eyeball movement distance, size of fissure palpebrae, the reduced degree of strabismus, size of the pupil, main symptom scores, ocular localization analysis, and functional impairment extent and safety.

EXPECTED CONCLUSION

Our systematic review will provide evidence to determine whether acupuncture is an effective and safe intervention for ophthalmoplegia patients.

ETHICS AND DISSEMINATION

It is not necessary for this systematic review to acquire an ethical approval. This review will be disseminated in a peer-reviewed journal or conference presentation.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018091536.

A case of bilateral ophthalmoplegia while diving

This case report presents a military diver who became dysphoric and lost consciousness during a routine surface-supplied dive. The patient regained consciousness spontaneously, but the physical exam was notable for bilateral ophthalmoplegia. Full eye movement was regained during hyperbaric oxygen (HBO2) therapy, and the patient subsequently made a full recovery. Equipment and dive profile analysis led to the conclusion of hypercapnia and arterial gas embolism as the probable causes of the diver's symptoms. This is a unique case of isolated bilateral ophthalmoplegia presenting in a diving injury.

Recurrent ocular involvement in pediatric atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (HUS) is a subtype of thrombotic microangiopathy associated with complement alternative pathway dysregulation. It is clinically characterized by a relapsing course and a poor prognosis. Multiple organ systems are commonly affected by thrombotic microangiopathy in pediatric atypical HUS; however, ocular involvement is rarely reported. The case of an 11-year-old girl diagnosed as having atypical HUS who presented with bilateral central retinal vein occlusions with macular subhyaloid hemorrhage during her initial onset and ophthalmoplegia, diplopia, and optic disc edema during her relapsing episode 1 year later is described. All ocular manifestations occurred in the convalescence phase of atypical HUS. No other extrarenal complications were found and full recovery was achieved following typical treatment for atypical HUS (ie, plasma infusion, steroid, and supportive therapy). This is thought to be the first reported case of recurrent ocular involvement in pediatric atypical HUS.

[Proptosis and ophthalmoplegia after cataract surgery]

We report a case of a 57 years old female presenting with proptosis, periorbital swelling and ophthalmoplegia, 4 days after an uneventful phacoemucification surgery. Visual acuity was 20/200, biomicroscopy showed mild corneal edema and anterior chamber cells with normal posterior segment. The patient was febrile with leukocytosis and elevated Levels of C-reactive protein. A head computed tomography venography scan showed left eye proptosis, bilateral paranasal sinus hyper-density with massive sinus vein thrombosis extending from the left ophthalmic vein to the left cavernous, transversal and sigmoidal sinuses, the right cavernous and sigmoidal sinuses and internal jugular veins bilaterally. Very mild infiltration was seen around the Left ophthalmic vein, with no other signs of orbital inflammation. Emergency endoscopic sinus surgery was performed followed by anticoagulation and antibiotic treatment, blood and sinus culture later grew streptococci. The therapeutic measures resulted in complete resolution of the ocular and systemic findings.

Inferior rectus palsy as an isolated ocular motor sign: acquired etiologies and outcome

The aim of this work is to elucidate underlying etiologies, lesion locations, and outcomes of inferior rectus (IR) palsy of acquired origin. Retrospective search identified 44 patients with acquired IR palsy between April 2006 and May 2011 from four Neurology and two Ophthalmology Clinics in Korea. We analyzed clinical features, the results of radiological and laboratory evaluation, and prognosis. The most common causes were vascular (n = 16, 36 %) and trauma (n = 12, 27 %). Vascular disorders included microvascular ischemia (n = 10, 23 %), cerebral infarction (n = 5, 11 %), and dural arterio-venous fistula (n = 1, 2 %). Other causes were inflammation (n = 7, 16 %), myasthenia gravis (n = 5, 11 %), and thyroid ophthalmopathy (n = 1, 2 %). We were unable to determine the etiology in the remaining three patients (7 %). Most patients (95 %) showed a complete recovery with or without treatment. Acquired IR palsy mostly occurs with brainstem or orbital lesions, and has an excellent prognosis.

[Progress of treatment on oculomotor paralysis with electroacupuncture]

Collecting information from the database of China National Knowledge Information (CNKI) and VIP database of Chinese Journals, an overall analysis and review on treatment of oculomotor paralysis with electroacupuncture in recently years are made in the paper. The electroacupuncture, which can provide constant stimulation and reinforce the effect of acupuncture, is the major therapy to treat oculomotor paralysis. However, the best stimulate threshold of electroacupuncture on oculorotary muscles has not been reported yet. The parameters of electroacupuncture adopted in clinic are not standardized, which lead to unfavorable therapeutic effect as well as unclear mechanism of treatment. Therefore, it is suggested that the study should focus on enhancing the research level and broadening researcher's mind to explore the best parameter for the electroacupuncture stimulation on the oculorotary muscles, to make clear the mechanism of treatment and to search for valuable observation indicators in the future.

Recovery of ophthalmoplegia after endovascular treatment of intracranial aneurysms

BACKGROUND AND PURPOSE

Recovery of aneurysm induced CNP after endosaccular coiling has been reported in the literature. The aim of this study was to assess in detail the parameters that affect the outcome after endovascular treatment of ophthalmoplegic aneurysms due CNP.

MATERIALS AND METHODS

Between November 1999 and March 2008, 30 consecutive patients (8 men, 22 women; mean age, 54.9 years) presenting with CNP underwent endosaccular coiling with or without additional use of stents in the parent artery. Subarachnoid hemorrhage was present in 10 patients, whereas 20 patients had unruptured aneurysms. The mean size of the aneurysms was 10 mm. Initial CNP was complete in 11 patients and partial in 19. Mean follow-up after coiling was 19 months.

RESULTS

The mean interval between the onset of CNP and aneurysm embolization was 48 days. Fifteen patients (50%) had complete recovery of oculomotor function, 12 had incomplete recovery (40%), and 3 (10%) remained unchanged after treatment. In 4 aneurysms (13.3%), 1 additional embolization was performed, whereas in 4 other aneurysms, 2 additional embolization procedures were necessary. Procedure-related permanent morbidity occurred in 2 patients (6.6%).

CONCLUSIONS

Endosaccular coiling is an effective and safe method for the treatment of ophthalmoplegic aneurysms. Age, neck size, and time of treatment do not seem to constitute prognostic factors with respect to CNP recovery, though patients with small aneurysms, unruptured status, and/or location in the posterior circulation showed a tendency for better outcome. The degree of initial CNP was the only statistically significant prognostic factor concerning the final outcome, resulting in better recovery, in case of incomplete initial CNP.

[Study on acupuncture for treatment of oculomotor paralysis according to syndrome differentiation of meridians]

The authors compared and analyzed the correlated meridians in Internal Classic and Study on the Eight Extra-Channels and Vessels by clinical observation on acupuncture for treatment of oculomotor paralysis and reorganization research on ancient related literature, and course of meridians and collaterals, manifestations of disease and function were used as indexes. The present symptoms of oculomotor paralysis (paralytic strabismus) are well consistent with the delineation in Internal Classic such as inability to open eyes, blurring of vision and pain of outer canthus. The results indicate that it is important to regulate the Qiao Meridian function for acupuncture treatment of oculomotor paralysis; the method of the twelve regular meridians and the eight extra-meridians is different for treatment of this disease, for the twelve regular meridians treating the superficiality and the eight extra-meridians treating the origin, and the combinativue use of the two methods can display the TCM theory thought and the characteristic of simultaneous treatment of principal and subordinate symptoms; there is closely relation between musculature diseases and pathological change of oculomotor paralysis and it is helpful in perfecting therapeutic principles and research methods.

Isolated ptosis as acute ophthalmoplegia without ataxia, positive for anti-GQ1b immunoglobulin G

Anti-GQ1b IgG antibody syndrome comprises a wide range of diseases presenting with ophthalmoplegia and ataxia. Anti-GQ1b antibodies have been strongly associated in the literature with Miller Fisher Syndrome, with acute ophthalmoplegia associated with Guillain-Barré syndrome, and with isolated ophthalmoplegia. Acute ophthalmoplegia presents as various combinations of external and internal ophthalmoplegia. Reported here is a novel case of isolated ptosis as a manifestation of ophthalmoplegia. The present finding of bilateral ptosis and areflexia with anti-GQ1b IgG antibody positivity helps confirm the existence of the syndrome. Further research is needed on diagnosis and treatment.

Miller-Fisher syndrome at King Chulalongkorn Memorial Hospital

BACKGROUND

Miller-Fisher syndrome (MFS), a variant of Guillain-Barré syndrome (GBS) is a self-limiting demyelinating disease of the peripheral nervous system. Clinical spectrum, natural history, prognosis, and pathogenesis of MFS are not fully documented.

OBJECTIVE

Probe the clinical features of MFS in a tertiary center in Thailand and compare its pattern with other Asian countries.

MATERIAL AND METHOD

The clinical recordings were searched from databases at King Chulalongkorn Memorial Hospital (KCMH) between 2002 and 2007. Keywords were "Miller-Fisher syndrome" and "Guillain-Barré syndrome". Cases with MFS were recruited The data regarding clinical features, course, treatments, and investigations were reviewed. Comparisons with other large Asian series were demonstrated.

RESULTS

Six patients (male:female; 3:3) with MFS were analyzed The incident rate is 7.7% that of GBS. The median age was 54.3 years (range 28 to 73 years). MFS frequently started with diplopia followed by ophthalmoplegia and ataxia. Other clinical symptoms included limb dysesthesia and weakness, dysphagia, dysarthria, and diffuse headache. Spontaneous recovery occurred in three patients while two patients received plasmapheresis and one received intravenous immunoglobulin (IVIG). Six months after neurological deficits, all patients were almost free of symptoms and had returned to their normal activities.

CONCLUSION

The incidence, clinical features, and prognosis of MFS in KCMH were comparable with the previous studies in other Asian countries. High percentage of limb dysesthesia and optic neuropathy were detected in the present series. Headache was also common among Thai MFS. Immuno-pathogenesis of MFS is well documented but immunomodulatory therapy should be considered only in some cases.

[Internuclear ophthalmoplegia--causes, symptoms and management]

Internuclear ophthalmoplegia (INO) is a disorder of eye movements caused by a lesion in an area of the brain called the medial longitudinal fasciculus (MLF). The most common causes of INO are multiple sclerosis and brainstem infarction. Other causes include head trauma, brainstem and fourth ventricular tumors, Arnold-Chiari malformation, infection, hydrocephalus, and lupus erythematosus. Internuclear ophthalmoplegia is clinically characterized by total or partial failure to adduct one eye in lateral gaze and a monocular nystagmus of the abducting eye. It may be unilateral and bilateral. The method of choice for diagnostic imaging of MLF lesion in patients with INO is magnetic resonance. In this article authors present current opinion about pathogenesis, clinical symptoms, and management in patients with inter nuclear ophthalmoplegia.

Ophthalmoplegic migraine: still a diagnostic dilemma?

The term ophthalmoplegic migraine (OM) was first coined by Charcot in 1890. This condition was included as a migraine variant in the first Headache Classification of the International Headache Society in 1988. Based on postcontrast enhancement seen on MRI in some patients who were diagnosed with OM, there was a suggestion that this could be an inflammatory/demyelinating disorder; therefore, it was moved out of the "migraine" group and repositioned as a "neuralgia" in the revised 2004 classification. However, there have been subsequent reports in the literature in which there was no enhancement on postcontrast MRI. Based on a survey of literature on OM in the post-imaging era, this article highlights the fact that enhancement on magnetic resonance is not a sine qua non for the diagnosis of OM. Some diagnostic dilemmas are discussed, and a protocol is included for documentation of clinical findings in future case reports on a prospective basis. Hopefully, this will help in modification of the criteria, better understanding the etiology, correct diagnosis, and determining appropriate treatment for OM.

[Comparative observation on electroacupuncture combined with acupoint-injection for treatment of oculomotor paralysis induced by aneurysm of cerebral posterior communicating artery]

OBJECTIVE

To compare clinical therapeutic effects of electroacupuncture (EA) combined with acupoint-injection and simple acupuncture on oculomotor paralysis induced by aneurysm of cerebral posterior communicating artery.

METHODS

Seventy-eight cases were randomly divided into an acupuncture group and an EA plus acupoint-injection group. In the acupuncture group, Jingming (BL 1), Qiuhou (EX-HN 7), Chengqi (ST 1), etc., were selected and the EA plus acupoint-injection group were treated by the same method as in the acupuncture group, in combination with EA and local acupoint injection of adenosine cobaltamine. After treatment of 3 months, their therapeutic effects were compared.

RESULTS

The total effective rate was 41.7% in the acupuncture group and 77.8% in the EA plus acupoint-injection group, with a very significant difference between the two groups (P<0.01). The therapeutic effect in the patients who received the operation within 2 weeks after attack was better than that in those who received the operation over 2 weeks after attack (P<0.01); the therapeutic effect in the patients who received acupuncture treatment within 1 month after the operation was better than that over 1 month after the operation(P<0.01).

CONCLUSION

EA plus acupoint-injection is an effective method for oculomotor paralysis induced by aneurysm of cerebral posterior communicating artery, with a better therapeutic effect than that of simple acupuncture, and early diagnosis, surgery and timely acupuncture treatment are closely related with its prognosis.

[Clinical observation on Chinese drug acupoint-injection for treatment of acquired abducent paralysis]

OBJECTIVE

To seek for an effective therapy for abducent paralysis.

METHODS

Seventy-six cases of abducent paralysis were randomly divided into an acupoint-injection group and a western medicine group. The acupoint-injection group were treated by point-injection therapy, with Jingming (BL 1), Yangbai (GB 14), Sibai (ST 2), Tongziliao (GB 1) on the affected side, and bilateral Ganshu (BL 18) used as basic points and compound Danggui Injection as the principal injected medicine, and in combination with corresponding acupoints and injected medicine according to different syndrome types. The western medicine group were treated with routine western medicine therapy. After treatment for 36 days, the therapeutic effects were recorded and analyzed statistically.

RESULTS

The total effective rate was 94.7% in the acupoint-injection group and 76.3% in the western medicine group with a significant difference between the two groups (P < 0.05); there was a significant difference between the two groups in eyeball moving rate and restoration of cateral rectus (P < 0.05).

CONCLUSION

Chinese drug acupoint-injection therapy has a definite therapeutic effect on acquired abducent paralysis, which is better than that of routine western medicine.

Chronic ataxic neuropathy mimicking dorsal midbrain syndrome

We describe the clinical course, with special attention to the disturbance of eye movements, of a 29-year-old man with chronic ataxic neuropathy with ophthalmoplegia, IgM paraprotein, cold agglutinins and anti-GD1b disialosyl antibodies (CANOMAD). Using the magnetic search coil technique, we documented convergence during upward saccades and other features suggestive of dorsal midbrain syndrome. Thus, in common with Miller Fisher syndrome, CANOMAD may present with clinical findings implicating involvement of the central nervous system, which contains ganglioside antigens to anti-GD1b antibodies.

An approach to the patient with painful ophthalmoplegia, with a focus on Tolosa-Hunt syndrome

The differential diagnosis of painful ophthalmoplegia is extensive and consists of numerous sinister etiologies, including neoplasms (ie, primary intracranial tumors, local or distant metastases), vascular (eg, aneurysm, carotid dissection, and carotid-cavernous fistula), inflammatory (ie, orbital pseudotumor, giant cell arteritis, sarcoidosis, and Tolosa-Hunt syndrome), and infectious etiologies (ie, fungal and mycobacterial), as well as other miscellaneous conditions (ie, ophthalmoplegic migraine and microvascular infarcts secondary to diabetes). A systematic approach to the evaluation of painful ophthalmoplegia can lead to prompt recognition of serious disorders that can be associated with significant morbidity or mortality if left untreated. Inflammatory conditions such as Tolosa-Hunt syndrome and orbital pseudotumor are highly responsive to corticosteroids but should be diagnoses of exclusion.

Atypical botulism sparing palsy of extraocular muscles

Recent studies of patients with botulism found ophthalmoplegia as a characteristic clinical sign. Here we illustrate a very rare case of atypical foodborne botulism with multiple bilateral cranial nerve palsies sparing palsy of extraocular muscles. Therefore, the classical diagnostic pentad of botulism (dry mouth, nausea, vomiting, dysphagia, diplopia, fixed dilated pupils) may be of limited sensitivity in single cases.

The aetiology and management of long-lasting sixth nerve palsy in ophthalmoplegic migraine

The features and management of two adult patients with ophthalmoplegic migraine and longlasting sixth nerve palsies are described. Both had had previous shorter episodes of diplopia following migraine-like headaches. One recovered following an injection of botulinum toxin to the medial rectus of her affected eye 11 months after the onset of diplopia. The other patient had previously had surgery for a consecutive divergent squint and required further squint surgery to realign his eyes 1 year after the onset of his sixth nerve palsy. Both botulinum toxin and squint surgery may be useful in the management of longstanding sixth nerve palsy in patients with ophthalmoplegic migraine. The aetiology of ophthalmoplegic migraine is discussed.

[Observation on therapeutic effect of eye-needling combined with medication for treatment of ophthalmoplegia]

OBJECTIVE

To observe the therapeutic effect of eye-needling combined with medication for treatment of ophthalmoplegia and explore the possible mechanism.

METHODS

One hundred and twenty cases were randomly divided into a treatment group and a control group. According to etiological factors, the control group were treated with medication and the treatment group with the medication plus eye-acupuncture at main point ocular muscles. Changes of the rima oculi, the range of ocular movement and the dialopia angle after treatment were recorded and statistically analyzed in the two groups.

RESULTS

The total effective rate was 93.4% and the cured rate was 54.1% in the treatment group, and 74.6% and 18.6% in the control group, with significant difference between the two groups (P < 0. 01).

CONCLUSION

Eye-needling combined with medication has an obvious therapeutic effect which is better than simple medication for ophthalmoplegia.

[Painful ophthalmoplegias]

Painful ophthalmoplegias have numerous etiologies and are often the presenting sign of a severe disease. Anatomic localization of the lesion is essential in interpreting neuroimaging.

Binocular diplopia. A practical approach

BACKGROUND

Diplopia is a common complaint in both inpatient and outpatient neurologic practice. Its causes are many, and special historical and examination features are important to localization and accurate diagnosis.

REVIEW SUMMARY

This review is divided into 2 sections: the first related to diagnosis and the second to treatment of binocular diplopia. In the diagnostic section, emphasis is placed on identification of historical and examination features that can help to differentiate diplopia caused by dysfunction of cranial nerves versus neuromuscular junction, or orbital extraocular muscle. Techniques available to the neurologist for examining ocular motility and ocular misalignment and focused laboratory testing to evaluate diplopia are discussed in detail. The final section covers the various treatments for binocular diplopia, with recommendations regarding the utility of each treatment for different types of diplopia.

CONCLUSIONS

A logical step-by-step approach applied to each patient with diplopia will help prevent misdiagnosis and improve patient care.

[Effectiveness of plasma exchange in Miller Fisher syndrome--a case report]

BACKGROUND

We report a successful treatment by plasma exchange(PE) in the case of Miller Fisher syndrome.

CASE

A 71-year-old woman rapidly developed diplopia and unsteady gait, and was admitted to Minami-matsuyama Hospital on day 3 of her illness. Ophthalmological and neurological examination on admission revealed bilateral complete external ophthalmoplegia with moderate mydriasis, cerebellar ataxia, and weakness of biceps reflexs, but her consciousness was intact. Protein concentration in the cerebrospinal-fluid was slightly increased and serum anti-GQlb IgG antibody was positive. With the diagnosis of Miller Fisher syndrome, PE was carried out on days 12, 14, and 16. After PE, ophthalmoplegia and cerebellar ataxia improved markedly. The ocular symptoms resolved after a month.

CONCLUSION

The findings indicate that PE is a beneficial treatment in Miller Fisher syndrome during the acute phase of the disease.

A noisy zygoma fracture—complication of carotid-cavernous sinus fistula: total recovery of monocular blindness and frozen-eye after endoarterial coil embolization

A case of a patient with a zygoma fracture in combination with a carotid-cavernous sinus fistula--an arterio-venous fistula between the internal carotid artery and the cavernous sinus--is presented. The most frequent cause is trauma, but the carotid-cavernous sinus fistula itself may have been the cause of trauma. The patient showed complete loss of ocular motility and total monocular blindness. Treatment of the fistula with endoarterial coil embolization was followed by improvement of vision and ocular motility, until finally complete recovery of ocular functions, which is exceptional. In this case, careful analysis of the MRA's showed that the CCSF most likely developed in the posttraumatic phase.

Paralytic strabismus as a manifestation of lyme borreliosis

Lyme disease is a multi-system organ disorder caused by Borrelia burgdorferi. Although ocular manifestations have been reported, these remain a rare feature of the disease. This report shows a 49-years old patient that has been bitten by a tick and as consequence of which developed symptoms of the Lyme disease. In 1998 the patient was hospitalized in our Eye Clinic due to operating treatment of the paralytic strabismus (abductal nerve paralysis), as a rare feature of the Lyme disease. Postoperative squint angle was significantly reduced, but without any temporal movement. Diplopia was still present, though slightly reduced with the use of prism eyeglasses. The improvement of the quality of life was achieved, as well as the patient's satisfaction.

Orbital apex syndrome

PURPOSE OF REVIEW

Visual loss from optic neuropathy and ophthalmoplegia involving multiple cranial nerves are the hallmarks of an orbital apex syndrome. Historically, the terms superior orbital fissure, orbital apex, and cavernous sinus have been used to define the anatomic locations of a disease process. However, the diagnostic evaluation and management is similar for each of these entities. The authors reviewed the literature on the diagnosis and evaluation of disorders involving the orbital apex.

RECENT FINDINGS

High-resolution MRI is the preferred modality for evaluating most lesions involving the orbital apex. CT is a useful tool in the setting of trauma, to evaluate bone involvement, or when MRI is contraindicated. Although laboratory studies may be useful adjuncts in the diagnostic evaluation of lesions involving the orbital apex, surgical biopsy is often required for definitive diagnosis.

SUMMARY

Orbital apex syndromes may result from a variety of inflammatory, infectious, neoplastic, iatrogenic/traumatic, and vascular conditions. A detailed history with review of systems is important in narrowing the differential diagnosis. Management is directed at the underlying cause and may be guided by surgical biopsy. Corticosteroids may be useful if an inflammatory etiology is suspected, but should be used with caution.

Painful ophthalmoplegia: Overview with a focus on tolosa-hunt syndrome

Painful ophthalmoplegia is an important presenting complaint to emergency departments, ophthalmologists, and neurologists. The etiological differential diagnosis of painful ophthalmoplegia is extensive and consists of numerous sinister etiologies including vascular (eg, aneurysm, carotid dissection, carotid-cavernous fistula), neoplasms (eg, primary intracranial tumors, local or distant metastases), inflammatory conditions (eg, orbital pseudotumor, sarcoidosis, Tolosa-Hunt syndrome), infectious etiologies (eg, fungal, mycobacterial), and other conditions (eg, microvascular infarcts secondary to diabetes, ophthalmoplegic migraine, giant cell arteritis). A systematic approach to the evaluation of painful ophthalmoplegia can lead to prompt recognition of serious disorders that if left untreated, can be associated with significant morbidity or mortality. Inflammatory conditions such as Tolosa-Hunt syndrome and orbital pseudotumor are highly responsive to corticosteroids, but should be diagnoses of exclusion.

Ophthalmoplegic migraine

Ophthalmoplegic migraine is a rare condition, previously thought to represent a variant of migraine. Recent observations regarding its usual clinical presentation and common magnetic resonance imaging findings have given rise to speculation that this illness is more likely to represent an inflammatory cranial neuropathy. The recent revision of the International Headache Classification has reclassified ophthalmoplegic migraine from a subtype of migraine to the category of neuralgia. In this article, potential pathophysiological mechanisms are discussed. The typical clinical presentation of ophthalmoplegic migraine generally involves transient migraine-like headache accompanied by often long-lasting oculomotor, abducens or, rarely, trochlear neuropathy with diplopia and (if oculomotor nerve is involved) pupillary abnormalities and ptosis. Ophthalmoplegic migraine generally occurs in children, but a number of adult cases have been reported. Prognosis is good because symptoms almost always resolve, but, after several episodes, some deficits may persist. Differential diagnosis is rather large, although most other possible causes of ophthalmoplegia and headache have distinctive presentations or can be excluded with fairly straightforward diagnostic testing. Optimal prophylactic and acute treatment is still unclear, but migraine prophylactic medications such as b blockers and calcium channel blockers have been proposed. Steroids have been used with mixed results.

[Painful ophthalmoplegia secondary to larynx carcinoma]

CASE REPORT

We present a case of metastatic larynx cancer in the cavernous sinus. It presented itself as a right sixth cranial nerve palsy which progressed into a painful ophthalmoplegia with normal CT and RNM in its early stages.

DISCUSSION

We must suspect a cavernous sinus invasion in patients with cranial nerve palsies and with a history of malignancy, despite negative radiologic findings. Tumoral invasion of the skull base has been described in pharyngeal neoplasms but it is exceptional in larynx carcinomas.

Major review: the clinical spectrum of pediatric myasthenia gravis: blepharoptosis, ophthalmoplegia and strabismus. A report of 14 cases

BACKGROUND

Myasthenia gravis is infrequently encountered in pediatric ophthalmology practice. The purpose of this study is to evaluate the clinical spectrum of this condition in children and to identify factors that may aid the clinician in its diagnosis and management.

SUBJECTS AND METHODS

A retrospective chart review was performed on all pediatric patients presenting with myasthenia gravis to the Departments of Pediatric Ophthalmology and Neuro- ophthalmology at the Texas Children's Hospital from 1989-1999. Information regarding mode of presentation, myasthenic classification, ocular and systemic involvement, diagnostic investigations, therapy and outcome was collected and evaluated.

RESULTS

Fourteen patients were included in the study whose ages ranged from 1-17 years at presentation. One patient had congenital myasthenia gravis and 13 had juvenile myasthenia gravis. Thirteen of 14 (93%) patients presented with ocular findings; two of whom had associated systemic disease at presentation. Six of 14 (43%) patients had systemic involvement during the course of their illness, of whom three (21%) had respiratory compromise requiring assisted ventilation. Thirteen of 14 (93%) patients received pyridostigmine as first line treatment. Ten of 14 (71%) patients had a favorable response. A favorable response was defined as improvement in the extraocular motility to within 10 prism diopters of orthotropia with resolution of the blepharoptosis. Three of 14 patients (21%) received a combination of pyridostigmine and steroids, all of whom had a favorable response. Seven of 14 patients (50%) underwent thymectomy; all had a favorable response. Two of 14 patients (14%) required both blepharoptosis and strabismus surgery.

CONCLUSION

Pediatric myasthenia gravis may present initially to the ophthalmologist and should be considered in any pediatric patients with blepharoptosis and an ocular motility disturbance. Prompt diagnosis may be associated with significant reduction in morbidity. A favorable response to medical and surgery therapy was noted in most of our patients.

Unusual presentation of central nervous system relapse with oculomotor nerve palsy in a case of CD56-positive acute myeloid leukemia following allogeneic stem cell transplantation

Allogeneic stem cell transplantation (allo-SCT) plays an important role in the treatment of infants and children with acute myelogenous leukemia (AML). Leukemic relapse after allo-SCT is responsible for a high rate of treatment failure. Extra-medullary relapse (EMR), without involvement of bone marrow, is rare compared to medullary relapse. CD56, the neural cell adhesion molecule, may contribute to the higher frequency of CNS relapse in CD56-positive AML. We observed an isolated EMR on the oculomotor nerve of a 17-month-old girl 12 weeks after cord blood transplantation (CBT), who was transplanted because of CD56-positive AML. Diagnosis of relapse was suspected clinically and confirmed by magnetic resonance imaging (MRI), and fluorescence-activated cell sorter (FACS) and chimerism analysis of cerebrospinal fluid (CSF). Therapy consisted of intra-thecal chemotherapy, CNS irradiation, and systemic immunomodulation by cyclosporin A (CsA) and basiliximab withdrawal. Twenty-one months after relapse, the patient shows full remission of symptoms and previously described oculomotor nerve infiltration.

Abrupt-onset oculomotor paralysis: an endocrine emergency

Pituitary apoplexy is a severe and potentially life-threatening condition that may be highly variable in its clinical presentation. We report a 37-year-old man presenting to the emergency department with diplopia that abruptly developed while he was eating canned and bottled food prepared at home. A computed tomography scanning revealed an isodense mass within the sellar region and, subsequently, a magnetic resonance imaging showed a pituitary apoplexy causing a compression of the right III and VI oculomotor nerves. There was no improvement with hydrocortisone therapy and the patient underwent a transsphenoidal excision of the mass with an uneventful course. Pituitary apoplexy may raise in the appropriate setting the suspicion of botulism. The abrupt-onset paralysis of oculomotor nerves has been described as the chief presenting sign of pituitary apoplexy in only few cases including this. A pathophysiology, differential diagnosis with botulism and other causes of multiple cranial nerve paralysis, and treatment are described.

[Diagnostic and therapeutic approaches in oculomotor paralyses]

OBJECTIVES

We wish to unify current criteria regarding oculomotor paralysis (POM). Based on our experience, we have designed a diagnostic-therapeutic protocol which permits an early approach, especially since botulinum toxin has been used for treatment.

DEVELOPMENT

To make things easier to understand, we start with the concept of POM, including the physiopathogenic description of phenomena secondary to eye movements. Then we consider the aetiological-topographical incidence and assess the overall causes of POM and the relative frequency of the involvement of the different cranial oculomotor nerves. Finally, we consider each cranial nerve more fully from two different angles: the aetiologic-topographic diagnosis and therapeutic attitudes.

CONCLUSIONS

The current approach to POM should include a systematic study to classify the disorder as isolated, associated with other neurological causes or of some other type (metabolic, auto-immune, etc). Satisfactory early treatment should include consideration of infilbration with botulinum toxin in all paresis or paralysis presenting with contractures. In cases of total paralysis the contractures may occur within a week of onset of the condition. In partial paralyses close follow-up of three parameters evolution of the degree of ocular deviation, limitation of movement and exploration of passive movements makes it possible to determine the best moment to treat the contracture by injection of botulinum toxin: This treatment resolves or improves the diplopia, with recovery of oculomotor equilibrium, when it is given during the acute phase.

Acute onset of a bilateral areflexical mydriasis in Miller-Fisher syndrome: a rare neuro-ophthalmologic disease

Miller-Fisher syndrome (MFS) is characterized by variable ophthalmoplegia, ataxia, and tendon areflexia. It seems to be a variant of Guillain-Barré syndrome (GBS), but unlike in GBS, there is a primitive involvement of the ocular motor nerves, and in some cases there is brainstem or cerebellum direct damage. The unusual case of MFS in the current study started with a bilateral areflexical mydriasis and a slight failure of accommodative-convergence. Ocular-movement abnormalities developed progressively with a palsy of the upward gaze and a bilateral internuclear ophthalmoplegia to a complete ophthalmoplegia. In the serum of this patient, high titers of an IgG anti-GQ1b ganglioside and IgG anti-cerebellum. anti-Purkinje cells in particular, were found. The former autoantibody has been connected to cases of MFS, of GBS with associated ophthalmoplegia, and with other acute ocular nerve palsies. The anti-cerebellum autoantibody could explain central nervous system involvement in MFS. The role of these findings and clinical implications in MFS and in other neuro-ophthalmologic diseases are discussed.

Progressive visual loss and ophthalmoplegia

A 51-year-old woman with hyperthyroidism presented with a 4-week history of bilateral progressive visual loss despite treatment with oral prednisone. Her visual function improved after bilateral orbital decompression. The indications for and advantages and disadvantages of radiation therapy and orbital decompression in TAO are discussed. The management of intraocular pressure, strabismus, and lid abnormalities in TAO is also addressed.

Eye muscle paralysis after Vipera aspis envenomation

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Cerebral B-cell lymphoma following treatment for Tolosa-Hunt syndrome

We herein report a unique case of cerebral lymphoma which occurred after lymphocytic neuritis of cranial nerves causing Tolosa-Hunt syndrome and demonstrate the histological difference between these two diseases. A 70-year-old woman developed a sensory disturbance in the first and third divisions of the left trigeminal nerve and a left ocular movement disturbance five years before death. Although she was clinically diagnosed to have a schwannoma in the left cavernous sinus, a histologic examination verified a diffuse infiltration of T lymphocytes in the left trigeminal ganglion. Corticosteroid therapy was effective. Thereafter she demonstrated a disturbance of consciousness and dysphasia four years after surgery. A T1-weighted magnetic resonance image (MRI) disclosed high intensity lesions in both the basal ganglia and corpus callosum. She also showed progressive spastic paralysis. At autopsy a diagnosis of primary intracranial B-cell lymphoma was made. Although there was no invasion of the lymphoma cells into the left trigeminal nerves, a mild inflammatory infiltration of T cells still remained.

Fourth cranial nerve palsy in pediatric patients with pseudotumor cerebri

PURPOSE

To describe three children with acute fourth cranial nerve palsy secondary to pseudotumor cerebri.

METHODS

We reviewed the medical records of children younger than 18 years who were diagnosed with pseudotumor cerebri between 1977 and 1997. Pseudotumor cerebri was defined by normal neuro-imaging, elevated intracranial pressure measured by lumbar puncture, and normal cerebrospinal fluid composition.

RESULTS

Three children with pseudotumor cerebri presented with vertical diplopia and clinical signs of fourth cranial nerve palsy including a hypertropia of the affected eye, which increased with adduction and ipsilateral head tilt. The fourth cranial nerve palsy resolved after reduction of the intracranial pressure in all three children.

CONCLUSIONS

Fourth cranial nerve palsy may occur in children with pseudotumor cerebri and may be a nonspecific sign of elevated intracranial pressure.