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Cranial nerve palsy as a complication of operative traction.

STUDY DESIGN: Case report. OBJECTIVE: This report documents one case of diplopia from abducens (sixth cranial) nerve palsy after spinal surgery using a Jackson table and cranial traction. SUMMARY OF BACKGROUND DATA: Cranial nerve deficits have frequently been described in the orthopedic literature after trauma, halo pelvic traction, and halo skeletal fixation. The theorized mechanism of injury to the abducens nerve involves stretch or traction force, which causes localized ischemia or a change in nerve position. An extensive literature search failed to show this type of injury using Gardner-Wells tongs in conjunction with the Jackson table. METHODS: This is a case report that included a chart review, examination of the patient, and a literature search. RESULTS: The patient had complete spontaneous resolution of abducens nerve dysfunction within 6 months. CONCLUSIONS: It is important for the surgeon to be aware of this potential complication and to inform patients who have diplopia that develops from abducens nerve palsy that most of these cranial nerve deficits spontaneously improve.

Abducens Nerve Injury↗

Presumed ocular myasthenia and micropsia. A case report.

A 68-year-old woman presented with diplopia. Fluctuations of dysfunction of lateral rectus muscles in both eyes were detected on consecutive examinations. The diagnosis of ocular myasthenia was proposed. After the initiation of therapy, the patient complained of disturbing micropsia. The micropsia and diplopia were relieved by occlusion of one eye or by a base-out prism over one of the patient's eyeglass lenses. Mechanisms of micropsia are discussed.

Aged↗

Orbital apex lesion as the presenting manifestation of sarcoidosis.

A 32-year-old black woman presented with progressive proptosis, diplopia, and optic disc edema of the right eye. A computed tomography scan of the orbit showed a right retroorbital mass. A gallium scan showed increased radiotracer activity in the right retroorbital region. Biopsy of the mass showed non-caseating granulomas that were compatible with sarcoidosis. The patient was treated with systemic steroids, and the proptosis and diplopia resolved. Seven months later, the patient presented with contralateral optic neuropathy. Neuroimaging showed enlargement of the left optic nerve. The patient again responded to systemic steroid treatment and experienced complete restoration of vision. An orbital apex lesion may be the presenting manifestation of sarcoidosis.

Adult↗

Symptomatic corneal topographic change induced by reading in downgaze.

OBJECTIVE: To elucidate the cause of monocular blur or diplopia after reading in downgaze. METHODS: Corneal topography was obtained before and after a 15-to 30-minute reading effort in downgaze in three symptomatic patients and in nine asymptomatic control subjects. RESULTS: Changes in corneal topographic color maps, corneal uniformity index, and predicted corneal acuity were found in the symptomatic patients but not in the control subjects before and after reading. CONCLUSION: Changes in corneal topography can occur after prolonged reading in downgaze and may produce symptoms of blur or monocular diplopia.

Aged↗

Orbital decompression: a comparison between trans-fornix/transcaruncular inferomedial and coronal inferomedial plus lateral approaches.

PURPOSE: To compare two techniques of orbital decompression for Graves orbitopathy, that is, the inferomedial transfornix/transcaruncular approach and the inferomedial plus lateral coronal approach. METHODS: Comparative interventional case series. A retrospective review of 53 patients (94 orbits) with Graves orbitopathy operated on over a 9-year period was performed. Forty-nine orbits were decompressed by the transfornix-transcaruncular approach and 45 by the coronal approach. Data obtained for all patients included computed tomography scans of the orbits, Snellen visual acuity measurements, visual fields, Hertel exophthalmometry, color vision testing, subjective testing for diplopia in the cardinal positions of gaze, and direct ophthalmoscopic or biomicroscopic examination of the optic disc. RESULTS: The mean proptosis reduction was 4.37 mm with the transfornix/transcaruncular approach and 5.76 mm with the 3-wall coronal approach. The rate of optic neuropathy reversal was similar with both techniques (90%). Induction of new diplopia occurred in 13.6% patients operated by the transfornix/transcaruncular approach and in 16.6% patients who underwent decompression by the coronal approach. CONCLUSIONS: The two techniques have similar effects on visual function and ocular motility. For the vast majority of patients with Graves who need orbital decompression, the coronal approach is unnecessary; the transconjunctival approach allows the same exposure to the medial, inferior, and lateral walls.

Adult↗

Anti-hu paraneoplastic syndrome presenting as bilateral sixth cranial nerve palsies.

A 62-year-old woman presented with diplopia caused by bilateral sixth cranial nerve palsies. Two weeks later, she had bulbar weakness and ataxia. Brain magnetic resonance imaging showed non-specific abnormalities and spinal fluid was acellular but contained an elevated protein and oligoclonal bands. A paraneoplastic screen showed anti-Hu antibodies. Her clinical condition improved with immunoglobulin and systemic corticosteroid treatment. Breast cancer was diagnosed 21 months later by mammography but there were no metastases detected. Four and half years after the onset of her diplopia, she died of diffuse metastatic breast cancer. This is the first reported case of anti-Hu paraneoplastic brain stem encephalitis presenting with sixth cranial nerve palsies.

Abducens Nerve Diseases↗

Visual complaints and binocular function in bilaterally aphakic persons with cataract glasses.

Seventy-one consecutive patients who underwent operation for senile cataract in both eyes during the period 1969-1973 were examined and questioned about visual complaints an average of 18 months after being fitted with cataract spectacles. In the distance situation none had complaints, either reported spontaneously or after questioning. Except for a few immobile patients, all could manage on their own in the street and on stairs. In the near situation 16 of the 71 patients had permanent alternating or intermittent exotropia which, however, gave rise to diplopic complaints in only two. The diplopia in these two patients disappeared after the glasses had been decentered. On questioning, complaints of diplopia could be elicited in another 5 patients. Investigation of sensory binocular function using Titmus' sterotest showed that 35 of the 71 patients could manage the test at the level 40 inches/arc. Division of the material into two groups by duration of monocular visual function during the development of the cataract and during the period between the operations on the two eyes, disclosed that this factor was of no importance to the postoperative motor and sensory binocular function.

Aged↗

Bupivacaine injection of eye muscles to treat strabismus.

BACKGROUND: Bupivacaine injected into animal muscles induces a cycle of myotoxicity, degeneration, regeneration and hypertrophy of muscle fibres, without adverse effects on other tissues. This induced hypertrophy can be harnessed to treat strabismus. METHODS: Bupivacaine, 4.5 ml of a 0.75% solution, was injected into the right lateral rectus (RLR) muscle of a patient who had diplopia and who showed 14-prism-dioptres oesotropia. RESULTS: RLR paresis persisted for 7 days. Then, the RLR regained its abducting ability, and progressive improvement of alignment to 4-prism-dioptres oesophoria occurred over the next 33 days, with the elimination of diplopia. Alignment remained the same at 54 days after injection. Magnetic resonance imaging showed a focal increase in the size of the injected RLR of 58% in the posterior area, with reduced change in anterior portions of the RLR. CONCLUSION: Injection of bupivacaine to induce hypertrophy of the injected muscle and thus alter eye alignment was effective in our patient. This approach can be a useful addition to the treatment of strabismus.

Aged↗

Late reoperations for squint.

Ten patients in the age range 2 to 22 years are described who had operations initially for squint in childhood. Nine had had concomitant convergent strabismus and one divergent. All presented again in adult life with a cosmetic complaint, but two also had diplopia. Reoperations were done, age range 14 to 43. These ten were all the "late reoperations" for squint which were done during the four year period 1972 to 1976 by one consultant (C.I.P.). Technically these late reoperations were not difficult, through the amount of change predictable in position of the eyeball could be only approximate. Recession +/- advancement +/- resection of horizontal recti were done in all cases. In one case no medial rectus was identified attached to the eyeball; a mass of tissue behind the caruncle was mobilised and sutured to the globe with resultant good movement. To avoid tethering of the eye by scarred conjunctiva, vertical conjunctival incisions were often converted at suturing to (see article) shaped wounds. The absence of any new cases of diplopia (the two who had it preoperatively retained it without aggravation) is attributed to the fact that all cases were under-corrected, i.e., no convergent or divergent squint was converted into a divergent or convergent squint respectively, so that the non-corresponding image remained within the area of suppression, which probably extends only to the vertical meridian in a squinting eye.

Adolescent↗

Bilateral superior oblique palsies.

Eighteen consecutive cases of bilateral superior oblique palsy have been studied retrospectively. The patients were typically adults with a history of severe head trauma. All patients complained of diplopia, either vertical, torsional, or both. Other neurological sequelae were common. Central disruption of fusion was seen in three patients. Eight patients underwent surgery for torsional or vertical diplopia, and the results are briefly discussed.

Adult↗

Acute acquired comitant esotropia.

Acute acquired comitant esotropia has been used to describe a dramatic onset of a relatively large angle of esotropia with diplopia and minimal refractive error. We describe six children aged 5 to 11 years who developed an acute non-accommodative esotropia with diplopia. Neurological examination, including CT scan, in each of these children gave negative results. We suggest that this is an unusual presentation of esotropia of undetermined aetiology. The diagnosis, clinical characteristics, and management are discussed.

Acute Disease↗

Persistent superior oblique paresis as a manifestation of familial periodic cerebellar ataxia.

A brother and sister complained of persistent diplopia due to superior oblique palsies. The cause of their symptoms became apparent when they were diagnosed as having familial periodic cerebellar ataxia (FPCA), a rare autosomal dominant condition. Oral acetazolamide (250 mg twice daily) not only prevented all the periodic symptoms but also relieved their diplopia, which had been present between attacks.

Acetazolamide↗

Choroidal involvement in lymphomatoid granulomatosis.

A 13-year-old boy with evidence of pulmonary lymphomatoid granulomatosis developed monocular diplopia. Fluorescein angiography revealed bilateral choroidal involvement. Following treatment with vincristine, cyclophosphamide, and prednisone his diplopia resolved and the angiographic appearances returned to normal.

Adolescent↗

Coronal approach for rehabilitative orbital decompression in Graves' ophthalmopathy.

AIMS: To determine the effectiveness and safety of three wall orbital decompression by the coronal approach in Graves' ophthalmopathy. METHODS: The records of 125 patients with Graves' ophthalmopathy, who had undergone three wall orbital decompression by coronal approach between April 1984 and October 1993, were studied retrospectively. Special attention was paid to proptosis reduction, changes in ocular motility, and complications. RESULTS: The preoperative Hertel values ranged from 15 to 30 mm (mean 22.43 mm). The mean proptosis reduction was 4.34 mm (range 0-10 mm). Proptosis reduction in patients with preoperative Hertel values higher than 27 mm was significantly more than in patients with preoperative values between 25 and 27 mm (p < 0.05). This last group showed significantly more proptosis reduction than patients with preoperative Hertel values of 23 and 24 mm (p < 0.01). Postoperatively, 3.2% of the patients showed new diplopia in primary and/or reading position. In 4% of the patients with normal ocular motility preoperatively, diplopia in the extreme directions of gaze developed. In 4% of the patients, preoperative motility disturbances decreased or disappeared postoperatively. CONCLUSION: Three wall orbital decompression by coronal approach is a safe and effective technique, to achieve proptosis reduction in patients with Graves' ophthalmopathy, with fewer complications than other techniques thus far described.

Adolescent↗

Acute comitant esotropia in a boy with head trauma and convulsions receiving carbamazepine.

We examined an 11-year-old boy who complained of acute onset of diplopia. The patient had head trauma and postsurgical convulsions and had been treated with carbamazepine. Diplopia developed after the dose of carbamazepine was increased to 700 mg/day. On examination, comitant esotropia and lateral gaze nystagmus were found. These disorders disappeared after carbamazepine was decreased to 400 mg/day. We believe that acute comitant esotropia and lateral gaze nystagmus may have been precipitated by head trauma and carbamazepine in our patient.

Acute Disease↗

Fronto-orbitonasal intradiploic meningioma in a child.

Intradiploic meningioma, which may be classified as a subgroup of intraosseous meningioma, is a rarely encountered disorder. To date, less than 10 cases have been reported. Here, we report a case of fronto-orbitonasal intradiploic meningioma. A 12-year-old female with exophthalmos and diplopia was operated on for a cranial intradiploic mass lesion. Histopathological evaluation of the specimen confirmed the diagnosis of intradiploic psammomatous meningioma. Her exophthalmos did not change, but the diplopia disappeared. This case is unique in that it is an extensive case of intradiploic meningioma of the orbital roof and frontal base in a child. Intradiploic meningiomas generally are of psammomatous type. Especially tumors adjacent to the orbita cause exophthalmos; cases located on the other side of the calvarium may not cause any symptom or sign other than headache or sometimes a mass on the scalp. Treatment, as with meningiomas located in the intracranial cavity, is total resection of the lesion.

Biopsy↗

Saccadic eye movement disorder in cephalic tetanus.

A 64-year-old woman presented with complaints about facial spasms, difficulty in opening her mouth and intermittent short episodes of horizontal diplopia. The diagnosis of a purely cephalic tetanus was made. While her eye movements appeared normal on clinical examination, infrared reflection oculography revealed a saccadic abnormality which could explain her diplopia. In view of today's pathophysiological concepts on tetanus an attempt is made to explain the eye movement disorder by disturbed inhibitory mechanisms in the brainstem.

Brain Stem↗

Oculomotor anomalies in sellar and parasellar pathology.

The authors report 19 cases where diplopia was the initial symptom of sellar pathology, Additionally, 5 cases with doubtful, diagnosis are discussed. Considering a series of 134 adenomata, the onset in 7 cases was intermittent diplopia with involvement of the third nerve.

Abducens Nerve↗