Surgical management of oculomotor nerve palsy: a comparison of lateral rectus deactivation combined with either medial rectus resection or medial rectus fixation to the medial palpebral ligament

PURPOSE

To analyze and compare the outcome of two different surgical procedures in patients with complete oculomotor nerve palsy with large-angle exotropia.

METHODS

The medical records of patients with total oculomotor nerve palsy and large-angle exotropia operated on at a single center from January 2006 to June 2020 were reviewed retrospectively. One group underwent lateral rectus deactivation with medial rectus resection (resection group); the other group underwent lateral rectus deactivation with medial rectus fixation to the medial palpebral ligament (fixation group). Surgical outcomes on the first postoperative day and at 6 months postoperatively were analyzed, including alignment and postoperative complications. All statistical analyses were performed using STATA version 14. A P value of <0.05 was considered significant.

RESULTS

A total of 35 patients were included. There was a trend toward greater surgical success in the fixation group (93%) than in the resection group (65%), but these results were not statistically significant. Postoperative exotropic drifts were noted in both the procedures but tended to be more with patients in the resection group. Postoperative complications were noted only in the fixation group.

CONCLUSIONS

Lateral rectus deactivation with medial rectus fixation to the medial palpebral ligament requires more time and greater surgical expertise but appears to better prevent postoperative exotropic drift compared with lateral rectus deactivation combined with medial rectus resection.

Oculomotor nerve cavernous malformation: case report and operative video

BACKGROUND

Cavernous malformations (CMs) are clusters of thin-walled sinusoidal vessels without well-defined walls. Though they can occur anywhere in the neuroaxis, cranial nerve (CN) CMs are rare.

METHOD

We report a 47-year-old male with gradual CN III palsy. Initial imaging showed no significant findings, but a follow-up MRI revealed a growing lesion along CN III. Intraoperative findings confirmed a CN III CM. Diagnosing and treating CN III CM are complex. Radiological findings lack specificity, requiring consideration of various diagnoses for patients with isolated CN III palsy and abnormal radiological findings.

CONCLUSION

Surgery is the gold standard, aiming for complete lesion removal while minimizing neurological complications.

Extraocular muscle ductions following nasal transposition of the split lateral rectus muscle

OBJECTIVE

To quantify changes in ductions following nasal transposition of the split lateral rectus muscle (NTSLR) for treating third nerve palsy.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A single eye from each patient with third nerve palsy treated with NTSLR with ocular motility measurements.

METHODS

Observation of changes in pre- and postoperative ductions. Outcome measures including patient demographic and surgical factors associated with the ability to adduct beyond the midline after NTSLR were evaluated using multivariable logistic regression.

RESULTS

A total of 116 patients met the inclusion criteria for this study. The NTSLR significantly decreased abduction (median of 0 limitation [interquartile range (IQR), 0-0] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001), with a corresponding improvement in adduction (median, -5 [IQR, -5 to -4] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001). There was no change in median supraduction or infraduction after NTSLR (p > 0.05). The ability to adduct beyond the midline after NTSLR was demonstrated in 42% of patients. Although not statistically significant, a trend toward a postoperative ability to adduct beyond the midline was seen in patients who had concurrent superior oblique muscle tenotomy (odds ratio [OR] = 5.08; 95% CI, 0.91-40.9) or who were designated with partial rather than complete third nerve palsy (OR = 2.29; 95% CI, 0.82-6.70).

CONCLUSIONS

NTSLR improves the horizontal midline positioning of eyes with third nerve palsy. Most eyes lose the ability to abduct, but some regain a modest ability to adduct while vertical ductions remain unchanged.

Immediate effects of electroacupuncture in oculomotor nerve palsy following brainstem infarction: A case report

INTRODUCTION

Research has demonstrated that electroacupuncture (EA) stimulation of paralyzed muscles significantly improves nerve regeneration and functional recovery.

DESCRIPTION

An 81-year-old man with no history of diabetes mellitus or hypertension presented with a history of brainstem infarction. Initially, the patient had medial rectus palsy in the left eye and diplopia to the right in both eyes, which almost returned to normal after six sessions of EA.

METHODS

The CARE guidelines informed the case study report. The patient was diagnosed with oculomotor nerve palsy (ONP) and photographed to document ONP recovery after treatment. The selected acupuncture points and surgical methods are listed in the table.

DISCUSSION

Pharmacological treatment of oculomotor palsy is not ideal, and its long-term use has side effects. Although acupuncture is a promising treatment for ONP, existing treatments involve many acupuncture points and long cycles, resulting in poor patient compliance. We chose an innovative modality, electrical stimulation of paralyzed muscles, which may be an effective and safe complementary alternative therapy for ONP.

Glioblastoma multiforme with oculomotor nerve involvement: case report and literature review

Gliomas involving the cranial nerves III-XIII are rare. Even rarer are glioblastomas multiforme (GBMs) with only 10 cases previously reported. Oculomotor nerve involvement was described in only 2 patients. The mechanisms proposed so far include an origin from the nerve itself or an extension within the nerve of a midbrain tumor. We report the case of a 69-year-old man who presented with an isolated left oculomotor nerve palsy. He was found to have a left temporal GBM extended to the frontal lobe. Diagnostics and intraoperative and pathological findings clearly demonstrated a massive infiltration of the cisternal portion of the left oculomotor nerve. We suppose this could be the first case of direct oculomotor nerve invasion by exophytic spread of a supratentorial GBM or by subarachnoid seeding from a temporal tumor. Less probably, it could be the first case of an oculomotor nerve GBM with a temporal lobe invasion.

Risks for Oculomotor Nerve Palsy and Time to Recovery After Surgical Clipping of Posterior Communicating Artery Aneurysms: A Multicenter Retrospective Cohort Study

BACKGROUND

Aneurysms of the posterior communicating segment of carotid artery (PcomA) have a high risk of rupture; when these nonruptured aneurysms are associated with oculomotor nerve palsy (ONP), the risk of rupture increases compared with asymptomatic nonruptured PcomA.

OBJECTIVE

To retrospectively analyze the risk factors involved in ONP secondary to PcomA aneurysm and to study the factors involved in the recovery time of ONP once it is established.

METHODS

This was a retrospective study of patients from 10 neurosurgery centers from October 2008 to December 2020. We analyzed age at diagnosis, presence of compressive neuropathy of the oculomotor nerve, presence of aneurysm rupture, largest aneurysm diameter, aneurysm projection, smoking, hypertension, diabetes, time between diagnosis and surgical treatment, as well as the outcome.

RESULTS

Approximately 1 in 5 patients (119/511 23.3%) with a PcomA presented with ONP. We found that patients with aneurysms measuring greater than or equal to 7.5 mm were 1.6 times more likely to have ONP than those with aneurysms smaller than 7.5 mm. In our study, the prevalence of smoking in the PcomA + ONP group was 57.76%, and we also found that smokers were 2.51 times more likely to develop ONP. A total of 80.7% showed some degree of improvement, and 45.4% showed complete improvement with a median recovery time of 90 days.

CONCLUSION

This study showed that 80.7% of patients with PcomA aneurysms undergoing surgical treatment with aneurysm clipping showed some degree of improvement of the ONP, with a median time to recovery between 90 and 120 days.

Split-Tendon Medial Transposition of Lateral Rectus for Pediatric Complete Oculomotor Palsy

BACKGROUND

Split-tendon medial transposition of lateral rectus (STMTLR) for complete oculomotor palsy can correct large angles of exotropia in adults, but outcomes are variable, and complications are frequent. Only a few pediatric cases have been reported, and further insight is needed to assess the child's alignment outcomes and ability for postsurgical gain of function. The aim of our study is to report the outcomes of this surgical procedure in pediatric cases of complete oculomotor palsy.

METHODS

A retrospective review of outcomes was conducted on 5 consecutive patients with complete oculomotor palsy treated with STMTLR by a single surgeon (V.S.S.) between 2015 and 2021 at tertiary referral centers. Primary outcome was postoperative horizontal alignment, and secondary outcome was demonstration of gain-of-function activity in the field of action of the paretic medial rectus muscle.

RESULTS

Five cases of pediatric complete oculomotor palsy underwent surgical treatment with STMTLR. Subjects averaged 5.3 years old (range 10 months-16 years). Two were female. Etiologies were heterogeneous, and all presented with unilateral (n = 2) or bilateral complete oculomotor palsy with exodeviations ranging from 45 to >120 prism diopters. Two subjects had bilateral disease secondary to military tuberculosis with CNS involvement. A third subject presented iatrogenically with complete bilateral third nerve palsies secondary to removal of a nongerminomatous germ cell tumor (NGGCT) of the pineal gland. The 2 remaining subjects had monocular involvement in their right eye, 1 from compressive neuropathy after a cavernoma midbrain hemorrhage, and 1 from a congenital right oculomotor palsy. All patients were observed to have stable ocular alignment for a period of at least 6 months before surgery. Unilateral STMTLR was performed in all cases except the subject with NGGCT, in which bilateral STMTLR was performed. Measurement of alignment permanence out to 1-3 years postop resulted in an average correction of 40.83 prism diopters (range 37.5-45 prism diopters) per operated eye. Four of 5 subjects regained limited but active adduction eye movements, and the 2 unilateral cases demonstrated improved convergence. None of the subjects experienced significant complications.

CONCLUSIONS

STMTLR was a safe and effective approach for the surgical correction of complete pediatric oculomotor palsy in our case series. In addition, pediatric patients may benefit from STMTLR with immediate gain-of-function activity in the transposed lateral rectus muscle, which supports the hypothesis that children have a dynamic and adaptive neuroplasticity of visual target selection that predominates established agonist/antagonist neural signaling.

Surgical approach for traumatic chiasmal syndrome and complete third nerve palsy following severe head trauma

Traumatic chiasmal syndrome and traumatic third nerve palsies are rare entities usually caused by severe, high-speed, closed-head road accidents that require a thorough diagnostic work-up and complex medical and surgical management. This report presents the case of a young adult who was involved in a motorcycle accident and sustained blunt frontal head trauma, resulting in optical chiasmal syndrome and complete unilateral third nerve palsy. Ophthalmological examination demonstrated a right complete ptosis, a downward and outward position of the right eye with a fixed and dilated pupil, and bitemporal hemianopsia. In addition, funduscopy revealed bilateral optical nerve atrophy. After stabilisation and during follow-up, strabismus surgery was performed with improvement of ocular alignment in the primary position. Subsequently, eyelid surgery was carried out with good amplification of the visual field, particularly on the left side. Although challenging, surgical intervention in these cases should be considered for both functional and cosmetic reasons.

Efficacy and long-term results of endovascular embolization and surgical clipping for posterior communicating artery unruptured aneurysms complicated with oculomotor nerve palsy

to investigate the efficacy and long-term outcomes of endovascular embolization and surgical clipping for patients with posterior communicating artery unruptured aneurysms (PcomAs) concomitant with oculomotor nerve palsy (ONP). No significant (P > .05) difference existed in the age, gender, proportion of complete ONP, and size of eye fissure and pupil before treatment between 2 groups. After compared with before treatment, the eye fissure was widened significantly (P < .05) and the pupil narrowed significantly (P < .05), but no significant (P > .05) differences existed between the 2 groups. Complete ONP recovery was observed in 32 (80%) patients in the embolization group and 31 (77.5%) in the microsurgical group, partial ONP recovery occurred in 6 (15%) in the embolization group and 8 (20%) in the microsurgical group. The recovery rate was 95% in the embolization group and 97.5% in the microsurgical group, with no significant (P > .05) difference between 2 groups. The recovery rate of the ONP was significantly (P < .01) greater in the microsurgical group than that in the embolization group at follow-up of 1 month, 3 months, six and 12 months, respectively. At 18 months, the ONP recovery rate was not significantly different between 2 groups (95% vs 97.5%) Surgical clipping may have a faster effect on the recovery of oculomotor nerve palsy than endovascular embolization for patients with posterior communicating artery unruptured aneurysms complicated with oculomotor nerve palsy, but both approaches may result in a similar effect on the nerve recovery in the long run.Eighty patients treated with endovascular embolization or surgical clipping were retrospectively enrolled into the endovascular embolization group or surgical clipping and analyzed.

[Bridle operation for incomplete oculomotor nerve paralysis (superior rectus and lateral rectus nasal inferior transposition)]

PURPOSE

To demonstrate the technique and effectiveness of the bridle operation for oculomotor nerve paralysis with maintained elevation.

METHOD

The bridle operation includes transposition of the lateral rectus muscle (passing behind inferior oblique and rectus muscles) and the superior rectus muscle (behind superior oblique tendon and medial rectus muscle) to the nasal inferior surface of the globe.

RESULTS

In the reported case, this procedure corrected exo-hypertropia of 30-40°/20-30° without inducing cyclotropia.

CONCLUSION

The bridle operation expands the surgical arsenal for paralytic strabismus.

Complication and Management of Optic Nerve Edema Resulting From Nasal Transposition of the Split Lateral Rectus Muscle

A 9-year-old boy with partial third nerve palsy underwent medial transposition of the left lateral rectus muscle and left inferior oblique myectomy. He developed optic nerve compression, which improved after a superior oblique tenotomy. A primary superior oblique tenotomy or a maximum lateral rectus muscle split may help avoid this complication. [J Pediatr Ophthalmol Strabismus. 2021;58(3):e12-e15.].

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.

Long term outcomes of strabismus surgery for third nerve palsy

PURPOSE

To report long-term outcomes of strabismus surgery for treatment of third nerve palsy.

METHODS

We performed a 15-year retrospective study of patients who had undergone surgery. We analyzed preoperative mean deviation (at 6 months, 1 year after surgery, and at the end of follow-up), type of surgery, and factors predicting outcomes. A final deviation <10 prism diopters (pd) was considered a good esthetic outcome, and no diplopia in the primary position at the end of follow-up was considered a good functional outcome.

RESULTS

Surgery was performed in 31 cases. Mean age was 36.27 years (women, 51.6%). Total and complete third nerve palsy was recorded in 22.6% and acquired palsy in 80.6%. Mean preoperative horizontal deviation (HD) in primary position was 40.24pd (near) and 44.29 (distance) and 14.33pd in vertical deviation (VD). Mean final HD was 8.94pd (near) and 11.35pd (distance), and mean final VD was 6.13. One surgery was performed in 68.9%. A favorable esthetic outcome was obtained in 64.5% and a successful functional outcome in 72.2%. Statistically significant differences were found between near HD (p=0.019) and distance HD (p=0.035) at 1 year compared with the end of follow-up and between VD at 6 months and 1 year after surgery (p=0.03). Mean follow-up was 6.05 years. No specific factors predicted a successful outcome.

CONCLUSIONS

Esthetic and functional results were similar. No predictors of successful outcome were identified. HD was better 1 year after surgery, and VD improved during follow-up.

Lateral Rectus-Medial Rectus Union: A New Surgical Technique for Treatment of Complete Third Nerve Palsy

PURPOSE

To describe a new surgical technique for the treatment of complete third nerve palsy.

METHODS

This study included patients with chronic complete third nerve palsy. The lateral rectus muscle was split, followed by disinsertion of the superior and inferior halves, which were passed between the sclera and superior and inferior rectus muscles, respectively. Then the medial rectus muscle was sutured as posteriorly as possible from its insertion and cut. Next, the distal stump of the medial rectus muscle was split into two halves and united with the superior and inferior halves of the lateral rectus muscle. Finally, the proximal portion of the medial rectus muscle was sutured back to its original insertion. In cases with hypotropia and a functional superior oblique muscle, superior oblique tenectomy was also performed. Success was defined as postoperative horizontal deviation of 10 prism diopters (PD) or less and vertical deviation of 5 PD or less.

RESULTS

Ten patients with a mean age of 32.4 ± 18.4 years had surgery using this technique; 2 of them had a history of strabismus surgery. Mean exotropia was 84 ± 14.9 PD, which reduced to 6.5 ± 8.2 PD. Mean vertical deviation was 16.5 ± 10 PD, which reduced to 2.5 ± 3.5 PD. Mean follow-up was 13.2 ± 7.9 months, and the success rate was 70% and 90% for horizontal and vertical deviations, respectively.

CONCLUSIONS

The lateral rectus-medial rectus union technique is an effective and long-lasting procedure to overcome large-angle exotropia associated with complete third nerve palsy. This method can also be employed as a reoperation procedure. [J Pediatr Ophthalmol Strabismus. 2019;56(1):10-18.].

Efficacy of endovascular intervention in patients with unruptured posterior communicating artery aneurysm-related oculomotor nerve palsy

OBJECTIVES

Oculomotor nerve palsy (ONP) is commonly encountered in daily neurosurgical activities. The ONP secondary to un-ruptured PComA aneurysm might be a unique entity that was different in diagnosis, treatment and prognosis from its ruptured counterparts. Perhaps as a result of the limitation in sample size, studies that solely focused on factors affecting recovery of ONP in patients with unruptured corresponding PComA aneurysms were scarce.

METHODS

In this study, we would like to report a relatively larger case series of patients with un-ruptured PComA aneurysm-related ONP. A retrospective review of medical records of 39 patients with un-ruptured PComA aneurysm-related ONP was performed with endovascular coiling.

RESULTS

All 39 consecutive patients underwent endovascular coiling. Eighteen (46%) patients had a complete resolution of ONP, 14 (36%) patients had a partial resolution. Time interval from onset of ONP to endovascular intervention (P=0.004), degree of ONP (P=0.015) and age (P=0.016) were predictors of ONP recovery with statistical significance. Sex, aneurysm size and risk factor exposure (smoking, alcohol abuse and hypertension) were not associated with ONP outcomes.

CONCLUSION

ONP secondary to un-ruptured aneurysm should be treated as a unique entity from its ruptured counterparts. A prospective study that contains surgical clipping and endovascular coiling, and comparison between two treatment modalities would be more convincing and is anticipated.

Third nerve decompression by anterior petroclinoid ligament opening after clipping of posterior communicating artery aneurysm-How I do it

BACKGROUND

Posterior communicating artery aneurysms sometimes present with partial or complete oculomotor nerve palsy, due to direct oculomotor nerve compression, irritation by subarachnoid blood, or both. Superiority of surgical clipping over endovascular coiling in terms of postoperative outcome is still controversial.

METHOD

Direct oculomotor nerve decompression by opening of the anterior petroclinoid ligament during aneurysm clipping is performed as a simple and feasible surgical maneuver which allows to improve the decompression effect obtained by aneurysm exclusion.

CONCLUSION

Anterior petroclinoid ligament opening permits to achieve a better oculomotor nerve decompression. Its efficiency on the recovery of the deficit needs to be proved by larger series.

Indications and outcome of vertical rectus partial recessions

OBJECTIVE

To assess the indications and results obtained with partial vertical recti recessions in patients with diplopia and small-angle vertical strabismus (≤10 dp).

MATERIAL AND METHODS

A retrospective study was conducted on 9 patients that were operated on with partial temporal or nasal recession of the superior (SR) or inferior rectus (IR), during 2017. A good outcome was considered when diplopia was resolved in primary position and infraversion, at the end of follow-up.

RESULTS

A total of 9 cases were included, with a mean age 66.3 years (55.5% women), diagnosed with sixth nerve palsy (3), incomplete third nerve palsy (2), sagging eye (2), age related strabismus (1), and restrictive strabismus post-retinal surgery (1). Mean preoperative vertical deviation was 8.2 dp in primary position and the post-operative vertical deviation was 0.8 dp (mean difference was statistically significant, P=.007). In 4 cases, the SR was operated on (temporal pole in 3 and nasal in 1). The IR was operated on in 5 patients (temporal pole in 4 and nasal in 1). Mean recession was 3.77mm. In 55.5% of case diplopia was eliminated, and in a 33.3% a well-tolerated, intermittent diplopia persisted. A good outcome was obtained in 88.8% of the cases at the end of follow-up (mean: 7. 1 months), with no over-corrections.

CONCLUSIONS

Partial SR or IR recessions obtained good results in most of the cases with small angle vertical strabismus and diplopia. Although post-operative torsion or modification of the pre-operative torsion was not observed, a prior study should be made of torsion.

Isolated Hypertrophic Neuropathy of the Oculomotor Nerve

BACKGROUND

Hypertrophic neuropathy is a rare entity commonly associated with peripheral nerve, characterized by onion bulb formations. Its cranial nerve involvement is very rare; only 7 cases have been found in the literature.

CASE DESCRIPTION

A 32-year-old white man with a 5-year history of intermittent right retro-orbital headache and mild right ptosis presented to the Neurosurgery Clinic. A magnetic resonance imaging of his brain demonstrated an enhancing lesion associated with the right third nerve. He underwent biopsy of the lesion, and its pathology report confirmed the diagnosis of hypertrophic neuropathy. Within 4 months, his third nerve palsy had completely resolved and was functioning fully.

CONCLUSIONS

Here, we report a first case of isolated hypertrophic neuropathy involving the oculomotor nerve.

Comparison of the efficacy of surgical clipping and embolization for oculomotor nerve palsy due to a posterior communicating artery aneurysm

OBJECTIVE

To aim at the efficacies of surgical clipping and endovascular embolization for oculomotor nerve palsy (ONP) as treatments for posterior communicating artery aneurysm (PcoAA), and the comparison and various influencing factors of the treatments.

PATIENTS AND METHODS

An analysis of the clinical data of 52 enrolled PcoAA patients with ONP who had treatment in the Department of Neurosurgery in Anhui Provincial Hospital from January 2011 to June 2015 was conducted. There were 23 patients among a total underwent surgical clippings and others 29 patients received endovascular embolization treatment. Then, the age, gender, aneurysm size and rupture status, onset duration, preoperative ONP severity and postoperative recovery degree of ONP of patients in the two groups were compared.

RESULTS

The final ONP outcomes of the 52 PcoAA patients consisted of 27 full recovery patients (51.9%), 21 partial recovery patients (40.4%), and 4 no recovery patients (7.7%). (1) Within the 23 patients in the surgical clipping group, subarachnoid hemorrhage (SAH) occurred in 16 patients, and no SAH occurrence in the other 7 patients; the final ONP evaluation showed 18 patients fully recovered (78.3%) and 5 patients partially recovered (21.7%). Within the 29 patients in the endovascular embolization group, SAH occurred in 18 patients, and no SAH occurrence in the other 11 patients; the final ONP evaluation showed 9 patients fully recovered (31%), 16 patients partially recovered in 16 patients (55.2%) and 4 no recovery patients (13.8%). (2) The postoperative ONP recovery was analyzed with multivariate logistic regression, and the treatment method was an independent factor for ONP recovery (OR = 0.041, 95% CI: 0.007-0.261, p < 0.01).

CONCLUSIONS

When compared with the endovascular embolization, the surgical clipping showed a better efficacy in the recovery from PcoAA related ONP.

A New Surgical Treatment Option for Chronic Total Oculomotor Nerve Palsy: A Modified Technique for Medial Transposition of Split Lateral Rectus Muscle

PURPOSE

To describe a new surgical modified procedure in patients with chronic total oculomotor nerve palsy and to evaluate the results of this procedure.

METHODS

Eight eyes of 6 consecutive patients who underwent strabismus surgery due to chronic total oculomotor nerve palsy were enrolled in the study. The lateral rectus muscle was split into two halves and disinserted from the sclera. The upper half of the muscle was passed under the superior rectus muscle and the inferior half of the muscle was passed under the inferior rectus muscle. The two halves of the muscle were moved to the medial rectus muscle insertion area and were sutured to sclera near the insertion. Additional medial rectus resections were made in the undercorrected patients.

RESULTS

The mean age was 21.8 ± 12.1 years (range: 11 to 42 years). Postoperatively, 4 of 6 patients had stable horizontal deviations; 1 had orthophoria, 2 had 10 prism diopters (PD) of exotropia, and 1 had 10 PD of esotropia. However, 2 cases had 25 and 30 PD of undercorrection. Additional medial rectus resections were made in these undercorrected patients and horizontal deviations reduced to 15 and 20 PD of exotropia, respectively. The mean primary position horizontal deviation, which was 74.1 ± 10.2 PD before the surgeries, reduced to 10.8 ± 6.6 PD after the surgeries (P < .001).

CONCLUSIONS

The authors described a new and relatively simple modified surgical procedure for the treatment of chronic total ocular nerve palsy and reached satisfactory outcomes. Further studies with larger sample sizes are warranted. [J Pediatr Ophthalmol Strabismus. 2016;53(3):150-154.].

[Detection of oculomotor nerve compression by 3D-FIESTA MRI in a patient with pituitary apoplexy and diabetes mellitus]

We report the usefulness of 3D-FIESTA magnetic resonance imaging(MRI)for the detection of oculomotor nerve palsy in a case of pituitary apoplexy. A 69-year-old man with diabetes mellitus presented with complete left-side blepharoptosis. Computed tomography of the brain showed an intrasellar mass with hemorrhage. MRI demonstrated a pituitary adenoma with a cyst toward the left cavernous sinus, which was diagnosed as pituitary apoplexy. 3D-FIESTA revealed that the left oculomotor nerve was compressed by the cyst. He underwent trans-sphenoid tumor resection at 5 days after his hospitalization. Post-operative 3D-FIESTA MRI revealed decrease in compression of the left oculomotor nerve by the cyst. His left oculomotor palsy recovered completely within a few months. Oculomotor nerve palsy can occur due to various diseases, and 3D-FIESTA MRI is useful for detection of oculomotor nerve compression, especially in the field of parasellar lesions.

Pituitary adenoma apoplexy presenting with bilateral third nerve palsy and bilateral proptosis: a case report

OBJECTIVE

To report a case of pituitary adenoma apoplexy presenting with bilateral proptosis and bilateral third nerve palsy that developed after cardiovascular surgery.

CLINICAL PRESENTATION AND INTERVENTION

A 45-year-old man developed bilateral proptosis and bilateral third nerve palsy after a coronary artery bypass grafting operation. A pituitary macroadenoma with extension into the sphenoid sinus and cavernous sinus with bilateral involvement was resected on computed tomography scan by microscopic transsphenoidal procedure. Third nerve palsy improved partially on the first postoperative day and completely improved in the fourth month after the operation.

CONCLUSION

This is a rare case of pituitary adenoma apoplexy that presented with bilateral third cranial nerve palsy.

Neuronavigation used for the transsphenoidal resection of a pituitary adenoma accompanied by a concha sphenoid sinus

A concha non-pneumatized sphenoid is considered to be a contraindication for the transsphenoidal resection of a pituitary adenoma. Specifically, this anatomical variation makes it difficult to approach the sella turcica. However, in this report, an intra-operative navigational system was used as a guide to access the sella through the sphenoid sinus. This procedure was found to be both reasonable and safe.

Oculomotor nerve schwannoma: a case report and review of the literature

BACKGROUND

Oculomotor nerve schwannomas are extremely rare tumors. There are only 40 cases reported in the literature. There is no standard treatment for these rare tumors.

CASE REPORT

The authors have reported a case of a 41-year-old Thai man presenting with progressive visual loss of the left eye for 6 months without diplopia. Visual acuity was 20/70 in the right and 20/400 in the left. There was no limitation of eye movement. MRI showed a 42.5 ml mass in the suprasellar region compatible with a schwannoma. The patient underwent a leftpterional craniotomy with partial tumor removal. The pathological section confirmed a diagnosis of schwannoma and the patient received postoperative stereotactic radiotherapy

CONCLUSION

Options for treating these rare tumors include clinical observation, surgical resection or stereotactic radiation. High incidence of complete third nerve palsy following surgery has been reported in the literature. Therefore, a subtotal removal of large oculomotor schwannoma followed by stereotactic radiotherapy could provide a safer alternative compared to radical surgery.

[Paralysis of the oculomotor nerve caused by aneurysm--general facts and a case report]

One of the most frequent etiology of oculomotor nerve palsy are intracerebral aneurysms. Due to anatomical facts (its course and main relations with vascular structures of the brain) lesions of the oculomotor nerve often occur. In this paper there are presented essential issues concerning neuroanatomy of the III-rd cranial nerve pair main locations of the cerebral aneurysms in order to investigate the effect of nerve compression, clinical data regarding the palsy of the oculomotor nerve due to a cerebral aneurysm, the treatment and post surgery recovery followed by a clinical report.

"Interdural" oculomotor neurinoma: report of two surgically treated cases

BACKGROUND

Dural relationships and their possible implications on surgical treatment of oculomotor nerve neurinomas are discussed on the basis of surgical experience with two cases.

MATERIALS AND METHODS

We describe two cases with large oculomotor neurinomas that probably arose from the precavernous sinus segment of the nerve. Both tumors were located entirely within the confines of dura or were "interdural." Operating within the limits set and protection afforded by the dura, the tumors could be excised relatively easily and safely. While the third nerve function recovered completely in one patient, the other continued to have complete third nerve palsy. The duration of follow-up in two cases was 52 and 24 months.

RESULTS AND CONCLUSIONS

Even the intracranial component of large oculomotor neurinoma can be covered entirely by dura. Understanding of the dural relationship can assist in planning and conduct of surgery.

Isolated oculomotor nerve palsy in interventional neuroradiology

BACKGROUND

Isolated oculomotor nerve palsy (IOP) can be annoying for a patient and can also be the only clue to a potentially devastating and life-threatening disease. In order to understand its clinical spectrum and management better we analyzed the files of 13 patients seen at our institution over a 3-year period.

METHODS

Thirteen consecutive patients with IOP between January 2005 and August 2008 presented to our hospital. Magnetic resonance imaging and angiography were employed as investigations tailored to the individual patient. A vascular disorder [i.e. arteriovenous fistula, aneurysm of the posterior communicating artery (Pcoma)] was found in 7 patients (63%), most commonly a dural carotid-cavernous sinus fistula (DCCF) or a Pcoma aneurysm.

RESULTS

In 7 patients with a vascular abnormality (4 DCCFs; 3 Pcoma aneurysms), IOP was the presenting symptom. Pcoma aneurysms were coiled endovascularly and DCCFs were managed transvenously. Of the patients with more than 1 year (6 months to 2 years) of follow-up, all 7 endovascular patients recovered completely. Time to complete resolution of ONP was 6 months.

CONCLUSION

Patients with IOP should be investigated with noninvasive techniques (MRI and MRA). If these are negative or to clarify abnormal findings of noninvasive techniques, selective angiography is needed for diagnosis and to guide treatment.

Precaruncular approach for medial orbital wall periosteal anchoring of the globe in oculomotor nerve palsy

PURPOSE

To evaluate a precaruncular approach for fixation of the globe to the medial orbital wall periosteum for management of complete third (oculomotor) nerve palsy.

METHODS

Consecutive patients with severe unilateral oculomotor nerve palsy present for at least 2 years were prospectively treated and evaluated. In all patients, a 12-16 mm recession of the lateral rectus muscle was performed along with the precaruncular anchoring procedure. Follow-up evaluations were performed at 1 week, and at 1, 2, and 3 months after surgery, with ongoing follow-up at 3 month intervals.

RESULTS

Fourteen eyes of 14 patients with complete oculomotor nerve palsy were included in the series. The median horizontal preoperative deviation of -90(Delta) +/- 4.8(Delta) reduced to -10(Delta) +/- 8.3(Delta). The vertical deviation reduced from 24(Delta) +/- 7.4(Delta) to 12.8(Delta) +/- 6.0(Delta). Mean follow-up was 8.9 +/- 5.5 months (range, 6-21 months). A slight exotropic drift was observed over 4 to 6 weeks following surgery in all cases. Satisfactory alignment was observed in 13 of the 14 cases (92.85%) over the duration of the follow-up period.

CONCLUSIONS

Anchoring the globe to the medial orbital wall using a precaruncular approach is a viable option in the management of complete external oculomotor nerve palsy.

Predictive factors of surgical outcome in oculomotor nerve palsy

PURPOSE

To investigate the outcomes and predictive factors of surgical treatment of oculomotor nerve palsy.

METHODS

Records of patients requiring eye muscle surgery for oculomotor nerve palsy in our institution were retrospectively reviewed. Age, sex, etiology, deviation, completeness of involvement, time between onset and surgery, botulinum toxin treatment, and number of surgical procedures were recorded as potential predictive factors. Muscle function, presence of diplopia, and torticollis were also recorded. The main outcome measure was motor function. Secondary outcome measures were presence of diplopia, torticollis, and limitation of muscle function.

RESULTS

Surgery was required in 22 patients, of whom motor success was obtained in 14 (63.6%). Frequency of diplopia and torticollis were significantly reduced by surgery. After multivariate regression analysis, longer time between onset and surgery (p = 0.03) and larger initial deviation (p = 0.05) were significantly associated with poorer postsurgical results in terms of motor function.

CONCLUSIONS

Longer time from onset to surgery and larger eye deviation are negative prognostic factors of postsurgical motor success for oculomotor nerve palsy.

Effects of innervational strabismus surgery on a patient with hypotropic strabismus and pseudoblepharoptosis

PURPOSE

We seek to analyze the results of the innervational surgery in a case of hypotropia with peudoptosis with vidiooculography (3D-VOG).

CASE REPORT

We present the clinical case of a 35 year old male suffereing from acquired ptosis of the left eyelid, present since the age of 10 and who was interested in cosmetic surgery. The preoperative 3D-VOG shows hypotropia of the left eye (22.5 degrees), minimum exotropia and intorsion together with limitation in the elevation of the left eye with positive passive duction test and pseudoptosis.

RESULTS

Surgery was carried out in three stages: 1. Recession of the superior rectus of the right eye (RE) resulting in an improvement in the elevation and the pseudoptosis; 2. Recession of the inferior rectus of the left eye (LE), with improvement in the elevation of the LE but deterioration of the pseudoptosis; 3. Resection of the inferior rectus of the RE which improves both the elevation as well as the pseudoptosis of the LE.

CONCLUSIONS

We consider the usefulness of the innervational techniques in the incomplete third nerve paralysis with important affectation in the elevation, making it necessary to check and in this case eliminate the restrictive effects although this may influence the effect on the pseudoptosis.

Cavernous hemangioma of the third cranial nerve: case report

OBJECTIVE

The authors report a rare case of a cavernous hemangioma (CH) involving the third cranial nerve.

CLINICAL PRESENTATION

A 25-year-old Caucasian woman presented with neuralgic facial pain that responded to pharmacological management. She had no neurological deficit. Magnetic resonance imaging scans revealed a space-occupying lesion in the interpeduncular cistern with no evidence of hemorrhagic event. Preoperative cerebrospinal fluid and blood samples were negative for cytology and tumor markers.

INTERVENTION

The patient underwent craniotomy and exploration of the interpeduncular cistern. A lesion with the raspberry-like appearance characteristic of a CH was found emerging from between the fibers and completely encircling Cranial Nerve III. The surgeon decided to leave the lesion in place to avoid creation of a new neurological deficit in the young patient. The patient is asymptomatic with a stable radiological picture 18 months after surgery.

CONCLUSION

CH should be considered as a possible differential diagnosis of extra-axial space-occupying lesions along the course of the cranial nerves. Resection with resulting deficit may not be indicated in patients presenting with normal neurological function. Further research and longer follow-up periods are required to better understand the natural history of CH involving the cranial nerves.

Sporadic malignant nerve sheath tumour of the oculomotor nerve

Malignant peripheral nerve sheath tumours (MPNST) are exceedingly rare in an intracranial location. In this report clinical and pathological evidence for the diagnosis of a MPNST arising from of the oclumotor nerve is presented. To our knowledge this is the first such case reported in the medical literature.

NEUROMUSCULAR CHORISTOMA OF THE OCULOMOTOR NERVE

OBJECTIVE

Neuromuscular choristomas (NMC) are rare benign tumors of the peripheral nerves. We report an NMC affecting the oculomotor nerve.

CLINICAL PRESENTATION

An 18-year-old girl presented with long-standing intermittent retro-orbital pain and oculomotor paresis. Magnetic resonance imaging scans demonstrated a small nodular lesion on the left oculomotor nerve, similar to the findings for a schwannoma.

INTERVENTION

The tumor was resected with the parental oculomotor nerve, which was reconstructed using a peroneal nerve graft. Postoperatively, the patient became pain-free, and her oculomotor function partially recovered. Histologically, the lesion consisted of well-differentiated smooth muscle fibers intermingled with mature nerve elements consistent with the diagnosis of an NMC, although the possibility of leiomyoma in this rare location was not excluded completely.

CONCLUSION

NMC may need histological confirmation for diagnosis if they occur in the intracranial space. The resection is feasible, and the function of the affected nerve can be at least partially restored with the nerve reconstruction.

Asymmetrical bilateral paresis of the superior oblique muscle

BACKGROUND

To review the preoperative signs of bilateral superior oblique paresis and to analyze their presence.

METHODS

The proposed preoperative signs of bilateral superior oblique (SO) muscle paresis were separated into "certain signs" and "suspicious signs." The signs were analyzed for accuracy using case examples and statistics.

RESULTS

A strong preoperative sign of bilateral SO muscle paresis was reversal of the hypertropia in the ipsilateral (and/or ipsi-supralateral) position and/or in the contralateral head tilt position. In such cases, the addition of a light contralateral weakening procedure to the operation aimed at the elimination of the hypertropia caused by the more affected SO muscle prevented development of the clinical picture of a contralateral SO muscle paresis. A suggestive preoperative sign of bilateral SO muscle weakness was marked reduction of the hypertropia in the ipsilateral (and ipsi-supralateral) position, as well as in the contralateral head tilt position. In these cases, a contralateral inferior oblique muscle weakening was deferred until after motility could be reassessed postoperatively. An additional sign of possible bilateral SO muscle weakness was the presence of a large V pattern.

CONCLUSIONS

When planning surgery for apparent unilateral SO muscle paresis, the surgeon should be aware of the often subtle preoperative signs of bilateral SO muscle paresis. Early diagnosis allows the surgeon to avoid the reversal of the clinical picture or to advise the patient of the possibility of a bilateral problem.

Treatment strategy for giant aneurysms in the cavernous portion of the internal carotid artery

BACKGROUND

As direct surgery to treat giant aneurysms of the ICA is difficult, ICA occlusion is the conventional treatment in patients with BTO tolerance. To determine whether bypass surgery should be performed after carotid occlusion by trapping or proximal occlusion, we developed a treatment strategy that includes BTO and SPECT.

METHODS

We report 19 patients with symptomatic giant aneurysms in the cavernous portion of ICA. The appropriate type of bypass surgery was determined by the results of BTO and SPECT. The type of ICA occlusion selected was based on the evaluation of retrograde filling of the aneurysm during BTO.

RESULTS

In all 19 patients, the ICA was sacrificed; 10 patients also underwent bypass surgery (low-flow bypass with STA-MCA anastomosis, n = 7; medium-flow bypass with radial artery graft, n = 2; high-flow bypass with vein graft, n = 1). Coil trapping was performed in 11 patients; proximal occlusion in 8. In 18 patients, there were no ischemic complications after treatment; 1 patient who had been treated by proximal ICA occlusion developed transient ischemia due to an intra-aneurysmal thrombus. Cranial nerve palsies were improved in 16 patients.

CONCLUSIONS

Based on our experience, we recommend that patients with giant aneurysms in the cavernous portion of the ICA be evaluated by BTO and SPECT. In conjunction with bypass surgery, ICA trapping or proximal occlusion constitutes an effective treatment strategy.

The surgical innervational effect: utilizing it to treat monocular elevation deficiency strabismus

BACKGROUND

Horta-Barbosa proposed, in 1978, what he named "innervational surgery" which means the weakening of a muscle of the sound eye in order to increase the innervation to its paretic yoke muscle. He proposed it for the paralysis of the third cranial nerve in which the medial rectus has some residual force. The method can be accomplished also by means of prisms, like Guibor's method for lateral rectus paresis or botulinum toxin.

PURPOSE

To present 5 cases of oculomotor muscle paresis with monocular elevation deficiency in which the 'innervation surgery' was used and to discuss its indications and results.

CASE REPORTS

Five cases, a third nerve paresis and four idiopathic monocular elevation deficiency are presented with their indications, kind of surgery, results and comments.

CONCLUSIONS

The authors conclude that in moderate cases of monocular elevation deficiency, using this simple and easier operation one can achieve a good restoration of normal appearance.

Oculomotor nerve schwannoma located in the oculomotor cistern

BACKGROUND

OSs are extremely rare tumors, most often located in the interpeduncular cistern or the CS. We report an OS located predominantly within the oculomotor cistern, the arachnoid sac that surrounds the nerve for a short distance in the roof of the CS. We discuss a possible growth pattern for cavernous OSs.

CASE DESCRIPTION

We report the case of a 34-year-old woman presenting with a right oculomotor nerve palsy. Magnetic resonance imaging revealed a mass within the borders of the roof of the CS extending forward toward the superior orbital fissure. A right pterional approach was undertaken, and the roof of the CS was opened just above the oculomotor nerve toward the superior orbital fissure. Although the part of the OS inside the oculomotor cistern was excised completely while preserving the anatomical continuity of the nerve, a subtotal removal was performed for the more anterior part of the tumor toward the superior orbital fissure. At 5 months follow-up, her third nerve paresis had improved dramatically.

CONCLUSIONS

Resection of cavernous OSs within the oculomotor cistern, where the third nerve is clearly separated from the adjacent neurovascular structures, is feasible with functional preservation of the nerve. The chance of occurrence of the nerve palsy may increase as the resection proceeds more anteriorly toward the superior orbital fissure.

[Therapeutic options in III. nerve paralysis]

The treatment of ocular motility disorders, which occur in paralytic strabismus, presents a therapeutic challenge. The goal of treatment is to create an area of single binocular vision that is centered around the primary-gaze position. Careful analysis of the ocular motility deficit is crucial in selecting the appropriate surgical procedure. Paralytic strabismus is difficult to treat because of the incomitance of the deviation depending on the direction of gaze, respectively an increase of the deviation in the gaze with limited motility. Moreover, the possibility that horizontal and vertical components may be present, like in third nerve palsies, is another obstacle. Finally, in patients with long-stand paralysis, the ocular motility defect may have a restrictive component due to contracture of the antagonist muscle. Recognition of this phenomenon is important because any planned surgical procedure must deal with the induced restriction.

The effect of graded recession and anteriorization on unilateral superior oblique palsy

PURPOSE

We wanted to examine the effect of graded recession and anteriorization of the inferior oblique muscle on patients suffering from unilateral superior oblique palsy.

METHODS

Inferior oblique muscle graded recession and anteriorization were performed on twenty-two patients (22 eyes) with unilateral superior oblique palsy. The recession and anteriorization were matched to the degree of inferior oblique overaction and hypertropia. The inferior oblique muscle was attached 4 mm posterior to the temporal border of the inferior rectus muscle in six eyes, 3 mm posterior in five eyes, 2 mm posterior in five eyes, 1 mm posterior in five eyes, and parallel to the temporal border in one eye.

RESULTS

The average angle of vertical deviation prior to surgery was 11.3 +/- 3.9 prism diopters (PD). The total average correction in the angle of vertical deviation after surgery was 10.8 +/- 3.8 PD. In the parallel group, the average reduction was 14 PD. After surgery, normal inferior oblique muscle action was seen in eighteen of twenty-two eyes (81.8%).

CONCLUSIONS

Graded recession and anteriorization of the inferior oblique muscle is thought to be an effective surgical method to treat unilateral superior oblique palsy of less than 15 PD.

Precaruncular periosteal anchor of medial rectus, a new technique in the management of complete external third nerve palsy

Management of complete external third nerve palsy is a challenge to a strabismologist; as four of six extra-ocular muscles are affected, it leaves eye in fixed hypotropic and exotropic position (Srivastava et al., 2004). Although numerous surgical procedures have been described, none has been found to be ideal for all cases. Horizontal supramaximal recession-resection procedure may work in cases having some function of medial rectus (Harley, 1980). In cases of complete external palsy, anchoring of globe to periosteum of medial orbital wall using different structures has been described (Villasenor Solares et al., 2000; Bicas, 1991; Salazar-Leon et al., 1998), as recession-resection may result in large residual deviation and/or eye drifts back to abducted position due to unopposed lateral rectus action (Von Noorder, 1996). These anchoring procedures are with associated problems of skin incision, thigh surgery or loss of superior oblique function (Villasenor Solares et al., 2000; Bicas, 1991; Salazar-Leon et al., 1998). We describe a new and safe technique for management of complete external third nerve palsy by anchoring insertion of medial rectus to medial wall periosteum, posterior to posterior lacrimal crest, along with supra maximal recession of lateral rectus.

Periosteal fixation in third-nerve palsy

PURPOSE

We present a new technique of anchoring the eyeball to the nasal periosteum using a nonabsorbable suture in acquired isolated third-nerve paresis.

METHODS

This was a case series of 4 consecutive adult subjects with isolated third-nerve paresis. After a 12-mm lateral rectus muscle recession in all 4 subjects, we passed 5-O double-armed polyester (NW683 Ethibond; Ethicon, Division of Johnson and Johnson Ltd., Aurangabad, India) on spatulated needles through the periosteum overlying the anterior lacrimal crest (exposed as in a Dacryocystorhinostomy procedure) at its superior part. The needles were brought anterior to the medial rectus muscle insertion and tightened enough to align the eye in 8-10 prism diopters adducted position.

RESULTS

Ocular alignment in the primary gaze was satisfactory at 6-12 months of follow up.

CONCLUSIONS

The use of a nonabsorbable polyester suture to anchor the globe to the nasal periosteum is an additional technique that holds promise to align the eyes in the primary gaze.