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Han A, Jun W, Winges K. Case Report: Unilateral Cranial Nerve VI Palsy Secondary to Intracranial Hypotension. Optom Vis Sci 2023; 100:715-720. [PMID: 37639689 DOI: 10.1097/opx.0000000000002063] [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: 08/31/2023] Open
Abstract
SIGNIFICANCE Intracranial hypotension is a condition that occurs from a cerebrospinal fluid leak. Various visual symptoms have been associated with this condition. Cranial nerve VI (CN VI) palsies are the most common ocular manifestation, as the abducens nerve is prone to injury because of its intracranial anatomical course. PURPOSE This case report presents a CN VI palsy secondary to intracranial hypotension from ventriculoperitoneal shunt overfiltration. Diagnosis, treatment, and management considerations are discussed. No identifiable health information was included in this case report. CASE REPORT A 70-year-old White man was referred to the eye clinic for evaluation of binocular horizontal diplopia. The patient had a recent history of a left ventriculoperitoneal shunt for a persistent cerebrospinal fluid leak after complex mastoid surgery. The patient was also symptomatic for positional headaches, which improved in a recumbent position. He was diagnosed with a left CN VI palsy secondary to intracranial hypotension from a ventriculoperitoneal shunt overfiltration. The patient was followed up by neurosurgery for shunt adjustments to resolve the overfiltration. Binocular horizontal diplopia was managed conservatively with Fresnel prism. CONCLUSIONS Intracranial hypotension should be considered in patients presenting with cranial nerve palsies and positional headaches. Obtaining neuroimaging and comanaging with neurology or neurosurgery are advised to make prompt diagnosis and treatment. Careful clinical monitoring and conservative diplopia therapy are recommended as visual symptoms improve upon resolution of the cerebrospinal fluid leak.
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Koka K, Alam MS, Halbe S, Jaisankar D, Mukherjee B. Intermittent Manual Carotid Compression as a Treatment Option for Indirect Low Flow Carotid Cavernous Fistula. Orbit 2023; 42:502-509. [PMID: 36285708 DOI: 10.1080/01676830.2022.2136203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/09/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE To evaluate the efficacy of intermittent manual carotid compression (IMCC) in the management of low-flow carotid cavernous fistulae (CCF). MATERIALS AND METHODS Patients diagnosed with low-flow CCF and treated with IMCC over a period of 13 years were retrospectively analyzed. Data analyzed included demographic details, clinical features, type of CCF, and response to therapy. Outcomes were categorized as complete cure, partial cure, and no cure or worsening. Patients with complete and partial cure were grouped as good outcome whereas those with no cure or worsening as poor outcome. RESULTS A total of 44 patients were advised IMCC for low-flow CCF, of whom five were lost to follow-up. Results of the remaining 39 patients were analyzed, of whom 21 (53.8%) were males. The mean age at presentation was 54.38 ± 14.54 years. The median duration between the onset of symptoms and presentation was 5.0 ± 4.10 months. The common presenting features were episcleral congestion and proptosis (89.7%), extraocular motility restriction (66.7%), and diplopia (48.7%). Most common CCF type was type D (34, 87.2%). All patients were advised to undergo IMCC. Good outcome was seen in 35 patients (89.7%, 95% CI: 80.2% to 99.2%), whereas poor outcome was seen in four (10.3%) patients. The mean duration of follow-up was 15.91 ± 21.87 months. CONCLUSION The present study found a good outcome with IMCC in 89.7% cases of indirect low-flow CCF with no major complications. It should be considered the management of choice in patients who are systemically unfit or cannot afford endovascular embolization.
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Wu Y, Yin W, Liu S, Wang S, Ding Y. Diagnosis and management of Neuro-Behçet disease with isolated intracranial hypertension: a case report and literature review. BMC Neurol 2023; 23:335. [PMID: 37749518 PMCID: PMC10518965 DOI: 10.1186/s12883-023-03392-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Neuro-Behçet's disease (NBD), characterized by isolated intracranial hypertension, is a rarely encountered condition, especially in children. In this study, we describe the treatment of a pediatric patient with NBD, who exhibited isolated intracranial pressure elevation as indicated by the initial manifestation of diplopia and physical examination finding of papilledema. CASE PRESENTATION An 8-year-old boy was admitted to the hospital with a confirmed diagnosis of Behçet's disease (BD) over eight months. The patient also presented with the symptom of diplopia for three days. The evaluation of the patient's nervous system did not reveal any apparent abnormalities. The measurement of cerebrospinal fluid pressure yielded a reading of 470 mm H2O. The examination of the fundus indicated papilledema, and imaging scans revealed evidence of focal demyelination. The symptoms of the child showed alleviation after the administration of mannitol, methylprednisolone, and azathioprine. Furthermore, this study involved a comprehensive analysis of 18 cases of NBD with isolated intracranial hypertension, comprising one case reported herein and 17 cases from the literature review. Three cases were children, and an equal distribution of males and females 9:9 was noted. The average age at the onset of symptoms was 24.7 years (8-38 years). Headache (90%) was the most commonly reported clinical manifestation, followed by blurred vision or diplopia (80%). The ocular manifestations included papilledema (100%), abducent nerve paralysis (20%) and local eye hemorrhages in the retina (30%). Notably, 88.9% of these ocular manifestations were relieved or cured after treatment. CONCLUSION This study presents the first reported case of NBD with isolated intracranial hypertension in the pediatric population of China. In a child with Bechet's disease presenting with features of raised intracranial pressure, it is important to be aware of neuro Bechet's presenting with intracranial hypertension without other neurological abnormalities. This will help make early diagnosis, institute treatment and prevent sequelae resulting from untreated raised intracranial pressure.
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Farsavian AA, Mobinikhaledi M, Ghorbani P, Ghadirzadeh E. Transient lateral rectus palsy associated with acute coronary syndrome treated with percutaneous coronary intervention: a case report. J Med Case Rep 2023; 17:389. [PMID: 37700337 PMCID: PMC10498533 DOI: 10.1186/s13256-023-04124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Patients who experience angina and acute myocardial infarction often receive diagnostic coronary angiography and percutaneous coronary intervention. CASE PRESENTATION A 54-year-old Persian man with acute coronary syndrome was admitted to the hospital and underwent elective percutaneous coronary intervention. Two hours after the procedure, the patient experienced ophthalmoplegia and diplopia. The diagnosis was abducens nerve palsy resulting in transient lateral rectus palsy. The cause is presumed to have been an ischemic event affecting the unilateral abducens nerve. This could have occurred owing to the microembolism during the percutaneous coronary intervention, which resulted in left lateral rectus palsy. Within 1 month, the diplopia was relieved completely, and the physical examination was normal. CONCLUSION The occurrence of neuro-ophthalmic complications that may arise from percutaneous coronary intervention is extremely rare. To our knowledge, this is the second reported case of unilateral rectus palsy associated with percutaneous coronary intervention.
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Harrison A, Mudhar O, Yoo J, Rampal M. Diplopia in a patient presenting with "blurred vision": a case report. J Med Case Rep 2023; 17:402. [PMID: 37679826 PMCID: PMC10485954 DOI: 10.1186/s13256-023-04089-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Myasthenia gravis is an autoimmune condition affecting the neuromuscular junction and causing muscle weakness along with fatigue (myasthenia). When the clinical manifestations of myasthenia gravis are isolated to the eye muscles, only causing weak eye movements, it is referred to as ocular myasthenia gravis, which can mimic a 1 and ½ syndrome. CASE PRESENTATION An African-American female in her fifties with past medical history of hypertension presented to our outpatient clinic with complaints of blurred vision for two weeks. Her symptoms were associated with facial discomfort and a generalized headache. On physical examination upon her initial presentation, there was demonstratable swelling of the left upper eyelid with drooping. Her extraocular movements revealed defects with the abduction and adduction of the right eye, and the left eye would not adduct, although the outward movement was normal. The left eye failed to lift/elevate completely when looking upwards, a pseudo 1 and ½ syndrome. A positive Cogan lid twitch was also noticed. Imaging of the brain and orbit ruled out central causes. Diagnosis of ocular myasthenia gravis was made in accordance with positive anti-acetylcholine receptor antibodies. With 120 mg pyridostigmine oral dose, the patient experienced improvement subjectively and objectively, and the patient was discharged on oral pyridostigmine and prednisone. Six months later, with prednisone having been tapered off, the patient developed a myasthenic crisis and was treated with plasmapheresis and intravenous immunoglobulins. After recovering from the myasthenic crisis, efgartigimod infusions were instituted, which helped our patient restore normal life. CONCLUSION Our patient who presented with "blurred vision" was discovered to have binocular diplopia due to significant dysconjugate eye movements. After diligently ruling out central etiologies, we concluded that her presentation was due to a peripheral etiology. Her serologies and her presentation helped confirm a diagnosis of ocular myasthenia gravis. Also, as in most cases, our patient also progressed to develop generalized myasthenia gravis while on pyridostigmine. Efgartigimod infusions instituted after our patient recovered from a myasthenic crisis have helped her restore a normal life.
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Savino G, Gambini G, Scorcia G, Comi N, Fossataro C, Stanislao Rizzo. Orbital myositis and scleritis after anti-SARS-CoV-2 mRNA vaccines: A report of three cases. Eur J Ophthalmol 2023; 33:NP29-NP34. [PMID: 36062603 PMCID: PMC9444811 DOI: 10.1177/11206721221123780] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/05/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE To report three cases of ocular myositis and scleritis, bilateral scleritis and unilateral single muscle myositis after mRNA COVID-19 vaccination. METHODS Case series of three patients who presented to the Orbit Outpatient Service of Fondazione Policlinico Universitario A. Gemelli with a history of unilateral proptosis, diplopia and pain, bilateral red eye and pain during eye movements and unilateral proptosis and inconstant diplopia respectively with onset 5-10 days after m-RNA COVID-19 vaccine. A thorough hematologic work up and orbital contrast enhanced magnetic resonance imaging (MRI) in patients with proptosis was performed. RESULTS Patients were females, 64, 58 and 45 years old respectively. MRI showed enlargement of all right rectus muscles, with both muscle belly and insertion involvement in the first case associated to right scleritis. A bilateral scleritis was diagnosed in the second patient and a single muscle myositis in the third patient. Serological tests excluded thyroid diseases. The first and second patient were treated respectively with oral and topical glucorticoids with a complete clinical response. Two 2 cycles of oral non-steroidal anti-inflammatory drugs were administered to the third patient with a partial response. CONCLUSION As far as we know these are the first report of orbital myositis and scleritis presenting after mRNA BNT162b2 vaccine (Pfizer/BioNTech) and mRNA-1273-(Moderna) vaccine, an uncommon effect of a likely autoimmune reaction triggered by the virus antigen.
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Yeager LB, Grimes JM, Dal Col AK, Shah NV, Bogomolny D, Debelenko L, Marr BP. Ophthalmologic Findings in Pediatric Erdheim-Chester Disease: A Literature Review With a Novel Case Report. Ophthalmic Plast Reconstr Surg 2023; 39:419-426. [PMID: 36877575 DOI: 10.1097/iop.0000000000002356] [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: 03/07/2023]
Abstract
PURPOSE The authors aim to describe the ophthalmologic manifestations of pediatric Erdheim-Chester disease (ECD). METHODS The authors describe a novel case of ECD presenting as isolated bilateral proptosis in a child and provide a comprehensive review of the documented pediatric cases to observe overall trends and ophthalmic manifestations of disease. Twenty pediatric cases were identified in the literature. RESULTS The mean age at presentation was 9.6 years (1.8-17 years) with a mean time of symptom presentation to diagnosis of 1.6 years (0-6 years). Nine patients (45%) had ophthalmic involvement at diagnosis, 4 who presented with ophthalmic complaints: 3 with observable proptosis and 1 with diplopia. Other ophthalmic abnormalities included eyelid findings of a maculopapular rash with central atrophy on the eyelids and bilateral xanthelasmas, neuro-ophthalmologic findings of a right hemifacial palsy accompanied by bilateral optic atrophy and diplopia, and imaging findings of orbital bone and enhancing chiasmal lesions. No intraocular involvement was described, and visual acuity was not reported in most cases. CONCLUSIONS Ophthalmic involvement occurs in almost half of documented pediatric cases. Typically presenting with other symptoms, the case highlights that isolated exophthalmos may be the only clinical sign, and ECD should be included in the differential diagnosis of bilateral exophthalmos in children. Ophthalmologists may be the first to evaluate these patients, and a high index of suspicion and an understanding of the varied clinical, radiographic, pathologic, and molecular findings are critical for prompt diagnosis and treatment of this unusual disease.
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Lin SC, Giang A, Liu GT, Avery RA, Shindler KS, Hamedani AG, Ross AG, Tamhankar MA. Frequency and Etiologies of Visual Disturbance After Cataract Surgery Identified in Neuro-Ophthalmology Clinics. J Neuroophthalmol 2023; 43:359-363. [PMID: 36727709 DOI: 10.1097/wno.0000000000001792] [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: 02/03/2023]
Abstract
BACKGROUND To identify the frequency and etiologies of visual disturbances after cataract surgery in patients referred to Neuro-ophthalmology. METHODS This study is a retrospective chart review. Records of patients 18 years and older referred to neuro-ophthalmology clinics for new-onset visual disturbances within 6 months of cataract surgery were reviewed. Those with pre-existing neuro-ophthalmic disorders, combined intraocular procedures with cataract surgery, or inadequate follow-up were excluded. The main outcome measures were frequency and etiologies of visual disturbances after cataract surgery. Secondary analyses of a cohort of patients who had cataract surgery at our institution were performed to determine the frequency and etiology of visual disturbances after uneventful cataract surgery. RESULTS One hundred seventy-three patients met the inclusion criteria (internal referral: 36/173, from outside surgeons: 137/173). Sixty-one percent (106/173) were newly diagnosed with neuro-ophthalmic etiologies, including 21% (36/173) with afferent and 40% (70/173) with efferent disorders. Thirty-six percent (62/173) of patients had non neuro-ophthalmic causes and 3% (5/173) had systemic conditions responsible for visual disturbances postoperatively. Decompensated strabismus causing diplopia was the most common neuro-ophthalmic diagnosis after cataract surgery (50%, 53/106). Of the 13,715 patients who had cataract surgery performed at our institution over a 9-year period, 20 of 36 patients referred for visual disturbances were identified with neuro-ophthalmic etiologies of which 85% (17/20) had postoperative diplopia. CONCLUSIONS In our study, decompensated strabismus causing diplopia was the most common neuro-ophthalmic visual disturbance after cataract surgery. Detailed history and ocular alignment should be assessed before cataract surgery to identify patients with the risk.
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Brodsky MC. Temporal Slant Recession of the Inferior Rectus Muscle: A Simple Surgical Treatment for Diplopia Caused by Small Vertical Deviations. J Neuroophthalmol 2023; 43:406-409. [PMID: 35947106 DOI: 10.1097/wno.0000000000001677] [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: 11/26/2022]
Abstract
BACKGROUND To evaluate the therapeutic effect of temporal slant recession of the inferior rectus muscle (TSRIRM) for the treatment of small vertical deviations in patients with vertical diplopia, with consideration of the theoretical additive effects of this procedure on ocular torsion and horizontal incomitance. METHODS Retrospective review of 11 patients who were treated with TSRIRM. Eight patients with vertical diplopia and small hyperdeviations (up to 6 prism diopters (PDs)) were treated with isolated TSRIRMs. Three patients with vertical diplopia from unilateral superior oblique palsies with large hyperdeviations (>15 PDs) were treated with TSRIRMs in conjunction with contralateral inferior oblique recessions. RESULTS Six of the 8 patients with small vertical deviations had successful vertical realignment with elimination of symptomatic diplopia after an isolated TSRIRM. Two of the eight patients had residual hypertropia with symptomatic diplopia. Three additional patients with unilateral superior oblique palsy had successful vertical realignment with elimination of symptomatic diplopia after ipsilateral inferior oblique recession and contralateral TSRIRM. In total, 9 of 11 patients had successful surgical results after TSRIRM. CONCLUSIONS TSRIRM provides an effective and reliable treatment for small angle vertical strabismus. Its ease of surgical access renders it useful for implementation in an outpatient neuro-ophthalmology setting.
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Elvan-Tuz A, Kaya-Guner E, Sarioglu FC, Agrali-Eroz N, Baykan M, Karadag-Oncel E, Yilmaz D, Olgac-Dundar N. HSV-1 Encephalitis Presenting with Diplopia: Effects of Infection or Autoimmunity? Pediatr Infect Dis J 2023; 42:e348-e349. [PMID: 37257098 DOI: 10.1097/inf.0000000000003984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This report describes a case in which diplopia was developed as a finding of postinfectious anti- N -methyl- d -aspartate receptor encephalitis. Infectious encephalitis, especially herpes simplex virus, is essential as it is one of the triggers of autoimmune encephalitis. Even if the cases present unexpected clinical findings, we should be vigilant in terms of autoimmune processes, such as diplopia seen in our case.
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范 常, 黄 亚, 李 霞, 陈 芸, 李 真, 乔 淑. [Posterior inferior cerebellar artery infarction with episodic postural diplopia as the initial symptom: A case report]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2023; 55:762-765. [PMID: 37534665 PMCID: PMC10398753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Indexed: 08/04/2023]
Abstract
Accurate and timely diagnosis of posterior circulation ischemic stroke is a challenge for emergency neurology clinicians, even MRI scan which is believed to be sensitive to acute ischemic lesions may be negative. It is particularly important to obtain the typical or characteristic symptoms and signs of the patients through comprehensive physical examination. We report a case of posterior inferior cerebellar artery (PICA) territory infarction with "episodic postural diplopia" as the initial symptom, hoping that clinicians notice the vertical diplopia caused by the disfunction of otolith gravity conduction pathway, which is characterized by the degree of diplopia being affected by postural changes. A 44-year-old man was in hospital due to episodic postural diplopia for 4 months, dizziness and unstable walking for 5 days. In the past four months, the patient had endured episodic diplopia attack for 8 times when standing or walking, which could be relieved obviously while lying down and gradually disappeared within 5-10 minutes. He had not seen a doctor since the outbreak of the novel coronavirus. Five days before admission, diplopia worsened accompanying obvious vertigo, nausea and vomiting, left facial numbness, and hiccups. The diplopia could be relieved after taking the supine position, but not completely disappear as before. Physical examination showed a triad of ocular tilt response (OTR), namely static ocular rotation (SOT), skew deviation (SD) and head tilt (HT). And also subjective visual vertical (SVV) deviation was found. Those signs were considered for otolith gravity conduction system involvement. Combined with other clinical signs, such as Horner signs, crossed sensory disorders, ataxia, and MRI scan, it was easy to find the infarction was in the territory of the left PICA. The reasons for the patient's "episodic posi-tional diplopia" in the early stage of the disease were considered as follows: (1) the gravity was less affected in the supine position, the stimulation of the otolith gravity conduction pathway was reduced, so the degree of eye deviation was reduced in the supine position. (2) As an ischemic cerebrovascular disease, the patient experienced a process of transient ischemic attack (TIA) in the posterior circulation, the cerebral blood supply and the hypoperfusion of stenosis were increased after lying down, so the diplopia symptom disappeared. The upright-supine test was recommended for the patients with vertical diplopia. It was recommened to differentiate between otolith pathway involvement and diplopia caused by trochlear nerve palsy.
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Ehlers M, Mauschitz MM, Wabbels B. Implementing strabismus-specific psychosocial questionnaires in everyday clinical practice: mental health and quality of life in the context of strabismus surgery. BMJ Open Ophthalmol 2023; 8:e001334. [PMID: 37558407 PMCID: PMC10414054 DOI: 10.1136/bmjophth-2023-001334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/21/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Strabismus can have a great negative impact on the quality of life and the well-being of affected patients. In the past, these aspects were often neglected and, compared with somatic functioning, placed in the background. The aim of our study is to elicit factors influencing satisfaction with strabismus surgery, quality of life and expectations of surgery in order to better predict who will benefit the most and who may need further support. METHODS We made a selection of suitable questionnaires to assess psychosocial aspects of strabismus and decided for Adult Strabismus 20 Questionnaire, Amblyopia and Strabismus Questionnaire, Diplopia Questionnaire, Expectations of Strabismus Surgery Questionnaire and Hospital Anxiety and Depression Scale. We then translated these measures (if not available in German). The patients filled out these forms as part of their preoperative orthoptic and ophthalmological assessment as well as approximately 3 months after strabismus surgery. RESULTS We enrolled 59 patients in this study. Postoperative strabismus-related quality of life was higher after surgery and anxiety and depression levels were lower. Satisfaction with surgery was lower with higher postoperative angle and diplopia; the latter was also a determinant of lower postoperative quality of life. Higher expectations of strabismus surgery were present with higher depression levels and higher preoperative strabismus angle. CONCLUSION Our data indicate that strabismus surgery may cause a significant improvement in several psychosocial domains. There is evidence that psychosocial factors can have significant impact on expectations with surgery. Hence, it is important to consider mental health aspects of this disease in order to treat patients in the best possible way.
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Giacobbe A, Ravishankar M, Doherty L. Clinical Reasoning: Woman With Acute Bilateral Ophthalmoplegia. Neurology 2023; 101:140-144. [PMID: 36977598 PMCID: PMC10382261 DOI: 10.1212/wnl.0000000000207173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/25/2023] [Indexed: 03/30/2023] Open
Abstract
This is a case of a 75-year-old woman who presented with severe headache, left eye ptosis, and binocular diplopia and was found to have multiple cranial neuropathies on examination. This case reviews the localization and workup of multiple cranial neuropathies and emphasizes the importance of not prematurely narrowing the differential diagnosis.
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Kim YJ, Moon SW, Park ,IK, Shin JH. Extramedullary plasmacytoma of the orbit with intracranial invasion: A case report. Medicine (Baltimore) 2023; 102:e33920. [PMID: 37327309 PMCID: PMC10270485 DOI: 10.1097/md.0000000000033920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/15/2023] [Indexed: 06/18/2023] Open
Abstract
RATIONALE Plasmacytoma is a disease caused by the proliferation of monoclonal immunoglobulin-producing plasma cells and divided into multiple myeloma, solitary bone plasmacytoma, and extramedullary plasmacytoma. We report a case of orbital extramedullary plasmacytoma invading the dura mater in a patient with exophthalmos and diplopia. PATIENT CONCERNS A 35-year-old female patient with exophthalmos in the right eye and diplopia visited the clinic. DIAGNOSES The thyroid function tests showed nonspecific results. Orbital computed tomography and magnetic resonance imaging revealed a homogeneously enhancing orbital mass infiltrating the right maxillary sinus and adjacent brain tissue in the middle cranial fossa through the superior orbital fissure. INTERVENTIONS To diagnose and alleviate the symptoms, an excisional biopsy was performed, which revealed a plasmacytoma. OUTCOMES One month after the surgery, the protruding symptoms and eye movement restriction in the right eye improved, and the visual acuity in the right eye was restored. LESSONS In this case report, we present a case of an extramedullary plasmacytoma that originated in the inferior wall of the orbit and invaded the cranial cavity. To our knowledge, no previous reports have described a solitary plasmacytoma that originated in the orbit, causing exophthalmos and invading the cranial cavity at the same time.
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Spiteri R, Barakat S, Vukicevic M. COVID-19 and sudden-onset ocular neurogenic palsy in prior healthy patients: a systematic review. Strabismus 2023; 31:145-151. [PMID: 37448224 DOI: 10.1080/09273972.2023.2232419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND The aim of this systematic review is to identify cases of neurogenic ocular palsy in the presence of COVID-19 and to document patient characteristics, type of palsy and possible aetiologies. METHODS A systematic search of PubMed, Medline and CINAHL databases was conducted on the 6th of January 2023 to identify cases of neurogenic ocular palsy in patients with current or previous COVID-19 infection. Data were pooled to summarise the neurogenic palsy, patient clinical characteristics and proposed palsy mechanisms. RESULTS The combined database search yielded 1197 articles. Of these, 23 publications consisting of 25 patients met the inclusion criteria. Most patients were male (68%) and ranged in age from 2 to 71 years (median=32.7, SD=21.4). Seven patients (28%) were children aged 2 to 10 years old. Abducens palsies were most common (68%) and the most common ocular presentation was diplopia (76%) with an average time of onset 15 days from testing positive to COVID-19 or having symptoms of the virus. Proposed mechanism of development of a neurogenic palsy secondary to COVID-19 infection was classified into one of three categories: vascular/thrombotic, a viral neuro-invasive or inflammatory virus-mediated immune response. DISCUSSION This study suggests that COVID-19 infection may be linked to oculomotor, trochlear and abducens nerve palsies and the underlying mechanisms may vary but are difficult to definitively establish. Further studies investigating the onset of neurogenic palsy secondary to COVID-19 infection is required.
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Stallworth JY, Hoffman WY, Vagefi MR, Indaram M. Superior oblique palsy after facial feminization surgery. J AAPOS 2023; 27:165-166. [PMID: 37031917 DOI: 10.1016/j.jaapos.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/18/2023] [Accepted: 03/05/2023] [Indexed: 04/11/2023]
Abstract
Facial feminization surgery (FFS), or gender-affirming facial surgery, is a common procedure for patients with gender dysphoria. One goal of FFS involves extensive contouring of the frontal and nasal bones to reduce supraorbital bossing. Ophthalmic complications after FFS have been rarely reported. We report 2 cases of superior oblique palsy after FFS producing persistent vertical and torsional diplopia. One case was successfully treated with prism spectacles; the other required surgical management. Both cases likely involved surgical trauma to or disinsertion of the trochlea during orbital bony reshaping.
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Yadegari S. Skew deviation and ocular tilt reaction as presenting feature of CACNA1A mutation. J AAPOS 2023; 27:166-169. [PMID: 37201628 DOI: 10.1016/j.jaapos.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 05/20/2023]
Abstract
We report the case of a 9-year-old girl with aggravation of childhood left head tilt without diplopia. She had right hypertropia and right incyclotorsion, which was compatible with skew deviation and ocular tilt reaction (OTR). She had ataxia, epilepsy, and cerebellar atrophy. Her OTR and neurologic dysfunctions were secondary to a channelopathy caused by CACNA1A mutation.
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Tsai PF, Chen YJ. Case Report: Multiple Sclerosis Presenting as Unilateral Gaze-evoked Nystagmus. Optom Vis Sci 2023; 100:419-421. [PMID: 37200199 DOI: 10.1097/opx.0000000000002027] [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: 05/20/2023] Open
Abstract
SIGNIFICANCE Unilateral gaze-evoked nystagmus is a rare neurologic finding that is largely diagnosed in connection with ischemic stroke. Gazed-evoked nystagmus is also a rare initial presentation of multiple sclerosis. PURPOSE This study aimed to report a rare presentation of gaze-evoked nystagmus in a patient with multiple sclerosis and review the mechanism underlying the gaze-evoked nystagmus. CASE REPORT A 32-year-old man presented with a 1-week history of diplopia. Neurologic examination revealed right-sided gaze-evoked nystagmus and right-sided ataxia. Laboratory test revealed a positive result for oligoclonal bands. Contrast brain MRI revealed multiple hyperintense T2 lesions including a hyperintense patch at the right inferior cerebellar peduncle. A diagnosis of multiple sclerosis was made. The patient received methylprednisolone 500 mg intravenously for 14 days. The diplopia and gaze-evoked nystagmus resolved and remained stable 2 months later. CONCLUSIONS Our case demonstrates that damage to the inferior cerebellar peduncle may result in ipsilesional gaze-evoked nystagmus and ipsilesional ataxia, in contrast to ipsilesional gaze-evoked nystagmus and contralesional ataxia.
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94
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Rizzo SA, Flanagan EP, Trejo-Lopez JA, Toledano M, Chia NH. Clinical Reasoning: New-Onset Diplopia and Headache in a Patient With Metastatic Breast Cancer. Neurology 2023; 100:927-931. [PMID: 36805434 PMCID: PMC10186217 DOI: 10.1212/wnl.0000000000206856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 12/07/2022] [Indexed: 02/22/2023] Open
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95
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Amer MM, Cestari DM, Yoon MK, Armstrong GW. Traumatic rupture of the inferior rectus muscle: case report and review of the literature. Digit J Ophthalmol 2023; 29:45-49. [PMID: 37727467 PMCID: PMC10506612 DOI: 10.5693/djo.02.2022.11.002] [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: 09/21/2023]
Abstract
Traumatic inferior rectus muscle rupture secondary to blunt injury in the absence of associated orbital or ocular fractures or injury is rarely encountered, and there are limited published reports on subsequent surgical repair. We present the case of a 74-year-old man with complete inferior rectus transection following a fall with facial strike. A computed tomography scan of the face was unremarkable. Surgical exploration and repair of the muscle was performed by hooking the inferior oblique muscle to identify the inferior rectus muscle. Subsequent strabismus surgery was performed for residual binocular diplopia, resulting in excellent anatomic and visual outcomes and postoperative ocular alignment.
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96
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Sarkis Y, Worden A, Schreiber T, Lapitz A. High index of suspicion: diagnosing a carotid-cavernous fistula. BMJ Case Rep 2023; 16:e253473. [PMID: 36863755 PMCID: PMC9990649 DOI: 10.1136/bcr-2022-253473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
A woman in her 70s presented with acute bilateral retro-orbital headache, diplopia, chemosis and eye swelling. Ophthalmology and neurology were consulted after detailed physical examination and diagnostic workup including laboratory analysis, imaging and lumbar puncture. The patient was diagnosed with non-specific orbital inflammation and was started on methylprednisolone and dorzolamide-timolol for intraocular hypertension. The patient's condition improved slightly, but a week later, she developed subconjunctival haemorrhage in the right eye, which prompted investigation for a low-flow carotid-cavernous fistula. Digital subtraction angiography showed bilateral indirect carotid-cavernous fistula (Barrow type D). The patient underwent bilateral carotid-cavernous fistula embolisation. Her swelling improved considerably on day 1 after the procedure and her diplopia improved over the following weeks.
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97
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Motose Y, Terasaki H, Ichiki M, Okawa M, Mihara N, Yoshinaga N, Sakamoto T. Simultaneous Occurrence of Buckle Infection and Migration: A Case Report. Medicina (B Aires) 2023; 59:medicina59030449. [PMID: 36984450 PMCID: PMC10054413 DOI: 10.3390/medicina59030449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
Background: When scleral buckling is performed using a #240 encircling band anterior to the equator for rhegmatogenous retinal detachment, buckle migration may occur anteriorly, eroding the rectus muscle. There are few cases of buckle migration occurring simultaneously with buckle infection. Notably, most previous reports included inadequate data on the pathophysiology of buckle migration and did not include the Hess test and perioperative images. Case presentation: A 36-year-old man with a history of atopic dermatitis underwent scleral buckling for rhegmatogenous retinal detachment of the left eye with #287 and #240 encircling bands at Kagoshima University Hospital. Four years later, he developed discharge, redness, and diplopia of the left eye. He was then referred to our hospital because buckle infection was suspected. The buckle was partially visible on the lower nasal side. Optical coherence tomography of the anterior chamber revealed the buckle to be on the nasal side and overlying the medial rectus muscle. Buckle migration and infection in the left eye was diagnosed, and early buckle removal was recommended. Two weeks later, on the day before surgery, conjunctival melting progressed in the nasal and inferior areas, and the buckle was exposed to a greater extent. In the surgical video at the initial surgery, the silicone band was confirmed to pass under the four rectus muscles, specifically the inferior and medial rectus muscles. At the beginning of the second surgery, we confirmed that the buckles were over the inferior and medial rectus muscles. As far as could be observed after buckle removal, the inferior and medial rectus muscles were not present at the normal location. Postoperatively, ocular pain and discharge quickly resolved. The subjective symptoms of diplopia also improved, and the postoperative Hess chart showed an improved ocular movement in the upward and lateral directions. Conclusions: Buckle migration is a rare postoperative complication of scleral buckling; however, patients at risk of buckle migration, such as those with encircling scleral buckle anterior to the eyeball, should be monitored with caution. If a buckle infection develops, buckle migration may occur within a short period, and early buckle removal should be considered.
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98
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Kim DH, Roh HC, Oh SY. Ophthalmologic clinical features of ocular myasthenia gravis. Medicine (Baltimore) 2023; 102:e31972. [PMID: 36637960 PMCID: PMC9839294 DOI: 10.1097/md.0000000000031972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
To investigate the clinical features of ocular myasthenia gravis (OMG) in ophthalmology. A total of 28 patients with ptosis or diplopia who were followed for at least 6 months between March 2016 and February 2022 were included in this study. The clinical symptoms of the patients and test results were analyzed. According to the positivity of serologic or electrophysiologic test, these patients were divided into 2 groups (positive and negative OMG results) and according to the clinical symptoms of diplopia or ptosis for comparison. Ptosis, diplopia, and both ptosis and diplopia were present in 6 (21.43%), 14 (50.0%), and 8 (28.57%) patients, respectively. Acetylcholine receptor auto-antibody (AchR Ab) was positive in 16 (57.14%) of 28 patients and the ice test was positive in 13 (92.86%) of 14 patients with ptosis. Abnormal thymic lesions were presented in 7 (25.0%) patients, and a definite improvement in response to pyridostigmine was observed in 27 (100.0%) patients. Both ptosis and diplopia were significantly higher in the group with positive results than that in the negative results group (P = .025). In addition, both horizontal and vertical diplopia was significantly higher in the group with AchR Ab titer > 5.0 than that in the group with AchR Ab titer < 5.0 (P = .041). After excluding cranial nerve palsy, if there is ptosis and diplopia, especially vertical diplopia, the possibility of OMG should be considered.
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Nazari H, Emerson G, Tang PH. INTRACTABLE PAIN AND DIPLOPIA AFTER SCLERAL BUCKLE SURGERY. Retin Cases Brief Rep 2023; 17:41-43. [PMID: 33323898 PMCID: PMC9750093 DOI: 10.1097/icb.0000000000001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report a case of early postoperative scleral buckle slippage because of the dehiscence of scleral belt loop tunnels. METHOD Case report. RESULTS A 54-year-old woman presented with painful diplopia after a combination pars plana vitrectomy and scleral buckling procedure. Ocular movements were limited. Forced duction testing was restricted in all directions. Anterior slippage of the silicone band was suggested on computed tomography (CT) scans and was confirmed with surgical exploration. During surgery, it was found that thin-roofed scleral belt loop tunnels were dehisced in three quadrants leading to anterior slippage of the buckle. The displaced buckle was removed. Diplopia and pain resolved, and ocular motility improved immediately afterward. The retina remained attached at six months follow-up. A supplemental video summarizes the surgical findings and postoperative results. CONCLUSION Spontaneous dehiscence of scleral belt loops may occur in thinly dissected scleral tunnels. Painful eye movement, diplopia, and a positive forced duction test should raise suspicion about a displaced scleral buckle. A CT scan may help with the diagnosis. Early diagnosis and immediate surgical intervention are needed to minimize patient discomfort and to improve long-term ocular motility.
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100
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Meshref M, Shaheen N, Swed S, Ibrahim M, Mostafa MR, Algazar MO, Dobs M, Elsayed SI, Amro Y, Afsa A, Morra ME. An overview of third, fourth and sixth cranial nerve palsies in the setting of COVID-19: A case report and systematic review. Medicine (Baltimore) 2022; 101:e32023. [PMID: 36626529 PMCID: PMC9750665 DOI: 10.1097/md.0000000000032023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Covid-19 has serious sequelae that may be poorly understood, underreported, and, as a result, not diagnosed promptly, such as variations in clinical manifestations of hyperinflammation among people infected with SARS-CoV-2. ophthalmoplegia can be one of these manifestations. METHODS We are reporting a 55-year-old male patient with unilateral diplopia considering it as a case of multisystem inflammatory syndrome in adults. We also reviewed the literature systematically for the previously reported studies/cases with third, fourth and sixth cranial nerve palsies due to or after Covid-19. RESULTS The literature search yielded 17 studies reporting 29 patients. 71.4% of the patients were males with a mean age of 42.23 years. Ophthalmological symptoms took 9.7 days to appear after the respiratory involvement. All patients had diplopia as part of their visual symptoms. 41.4% of the patients had unilateral sixth nerve palsy, 24% had bilateral sixth nerve involvement, 17% had fourth nerve involvement, and 27.6% had third nerve involvement. CONCLUSION Ophthalmoplegia is considered presenting symptom of Covid-19. Further research is needed to detect all neuro-ophthalmological manifestations of Covid-19.
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