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PubMedDate not supplied

Superior oblique and inferior rectus muscle injury following frontal and intranasal sinus surgery.

Chronic inflammatory sinus disease is a common process, sometimes requiring nasal and paranasal sinus surgery. Extraocular muscle dysfunction is a rare surgical complication of sinus surgery, but has been reported. Previous studies have been concerned with trauma to the medial rectus muscle resulting in severe paralysis or restriction. This study reports five patients with acquired strabismus and symptomatic vertical diplopia secondary to sinus surgery. In all patients, the resultant diplopia was disabling. Four patients had frontal sinus window surgery performed, with incisions placed in the supero-nasal quadrant of the orbit, below the eyebrow (a modified Lynch incision). Three patients acquired a superior oblique paresis and the fourth developed a Brown's syndrome. The location of the skin incision was critical to injury in the trochlear area. The fifth patient underwent a nasal polypectomy and antrostomy with secondary orbital hemorrhage and proptosis. A mild inferior rectus paresis was the result.

Adolescent↗

PubMedDate not supplied

Acquired Brown's syndrome caused by frontal sinus osteoma.

A 32-year-old man had a history of acquired Brown's syndrome associated with diplopia, proptosis, downward displacement of the globe, and lid edema. A CT scan of the orbit revealed an osteoma arising from the left frontal sinus and extending into the left orbit. After surgical extirpation the proptosis and diplopia disappeared and the globe returned to normal. To our knowledge, such a case has not been reported previously.

Adult↗

PubMedDate not supplied

Exercise induced esotropia.

A case of unusual intermittent esotropia and diplopia is reported. A 13-year-old boy experienced diplopia during vigorous exercise that resolved within 30 minutes after stopping the exercise. The symptoms had been present unchanged since age 6. Examination revealed orthophoria. After vigorous exercise an esotropia of 14 prism diopters in the distance developed, which gradually resolved over 30 minutes. Neurologic evaluation, CT scan, and magnetic resonance imaging scan have been normal. The symptoms have continued unchanged for 11 years. To my knowledge, no other similar case of exercise induced esotropia has been reported.

Adolescent↗

PubMedDate not supplied

Motility disturbances after Molteno implants.

Molteno implants are gaining wide acceptance for refractory glaucoma in both children and adults. Such surgery led to vertical strabismus in three patients. Two children developed an inability to elevate the globe after Molteno implants were placed superiorly. One adult, whose Molteno implant was placed inferiorly, could not fully depress the globe postoperatively, and experienced vertical diplopia. This complication of Molteno implants was explored using forced duction testing and surgery. We feel a likely explanation for this is a Faden or posterior fixation suture effect induced by scarring under the rectus muscle. Patients undergoing this surgery should be counseled about possible postoperative diplopia, an especially devastating complication when the implant is placed inferiorly.

Aged↗

PubMedDate not supplied

Canine tooth syndrome due to superior oblique myocysticercosis.

A 13-year-old boy had right periocular pain, upgaze vertical diplopia, and lid swelling. Right extorsion and hypodense cystic swelling in the right superior oblique involving the muscle and tendon behind the trochlea existed. Oral treatment was prescribed. MRI revealed a collapsed cyst. Ocular motility improved, but levoelevation diplopia persisted.

Adolescent↗

PubMed2004

[Bilateral superior oblique palsy and botulinum toxin].

PURPOSE: To study the effectiveness of botulinum toxin in the treatment of bilateral acquired oblique superior palsy. MATERIAL AND METHOD: Five patients with bilateral asymmetrical acquired superior oblique palsy were treated with periodical injections of botulinum toxin in the inferior oblique and rectus muscles (2.5-5 U). The average age of the sample was 37.4 years. A trauma etiology was present in four cases. Treatment was applied at two months after the beginning of the illness in two cases, at four months in another two cases, and at one year in the other patient. RESULTS: A good result was achieved in three of the cases with botulinum toxin. Two patients required surgery. All of the patients were injected in the inferior obliques, and two cases were also injected in the inferior rectus. The number of injections ranged between four and six applications. It was considered to be a good result when diplopia was corrected in reading and primary position, and torticollis disappeared. Diplopia was not corrected in extreme lateral gazes and supraversion in two cases. CONCLUSIONS: Periodical botulinum toxin injections represent an alternative management to surgery in the treatment of bilateral acquired oblique palsy. In some cases botulinum toxin injections can prevent or decrease the number of surgical interventions

Adult↗

PubMed1979

Cyclophosphamide in the management of advanced Graves' ophthalmopathy. A preliminary report.

Three patients with advanced Graves' ophthalmopathy were treated with cyclophosphamide. All had proptosis and diplopia. One patient had disabling iatrogenic Cushing's syndrome from steroid treatment of the ophthalmopathy and had undergone bilateral orbital decompression before cyclophosphamide therapy; steroids could not subsequently be withdrawn. When cyclophosphamide was administered to the cushingoid patient, withdrawal of glucocorticoid therapy was then possible. Diplopia completely resolved in two patients and improved in the third coincident with administration of cyclophosphamide. Deteriorating visual acuity resolved in one patient. Chemosis improved in the two affected patients. Proptosis was unchanged in all three patients. Cyclophosphamide deserves further study as a therapeutic agent in Graves' disease.

Administration, Oral↗

PubMed1999

Cerebral polyopia with extrastriate quadrantanopia: report of a case with magnetic resonance documentation of V2/V3 cortical infarction.

This is a case report of the occurrence of cerebral diplopia with right-side superior homonymous quadrantanopia in a young woman after chiropractic neck manipulation. Magnetic resonance imaging confirmed an infarct in the left inferior V2/V3 (extrastriate) cortex. The characteristics of the diplopia are illustrated with the patient's drawings, and persisting abnormalities in perception are described in the area of the initial field defect after static (computed) visual field testing yielded normal results.

Adult↗

PubMed1999

Neuro-ophthalmic complication after maxillary surgery.

We report an unusual case of ophthalmoplegia after maxillofacial surgery. A thirteen year old girl with unilateral left cleft lip and palate underwent maxillary advancement by distraction osteogenesis. Postoperatively she developed diplopia. The diplopia was not due to orbital lesions, most often seen after maxillofacial surgery, but to a haemorrhage posterior to the cavernous sinus.

Adolescent↗

PubMed1999

Divergence paralysis & intracranial hypertension due to neurobrucellosis. A case report.

CASE REPORT: A 22 year old female presented with sudden onset of uncrossed diplopia at distance, intracranial hypertension, esotropia and was evaluated. Microbiological tests of CSF and sera showed for brucellosis and the patient received therapy for this and her intracranial hypertension. The papilledema, headache, esotropia and diplopia all disappeared after therapy. CONCLUSIONS: Diagnostic tests for brucella must be considered for patients who have divergence palsy and papilledema, especially those living in endemic areas.

Acetazolamide↗

PubMed1999

[Prismatic treatment for heterophoric decompensation after onset of presbyopia].

This study presents the results of the prescription of small prisms in horizontally (N = 11) and vertically (N = 5) heterophoric patients after the onset of presbyopia. There was a high incidence of diplopia (69%) at an age where fusionnal adaptation capacities are limited. Prismatic treatment released the diplopia and asthenopic complaints in 100% of the cases. The prisms were easily included in prescriptions for progressive lenses in half of the cases. Their strength was eventually decreased in 12.5% of the cases, and they were totally eliminated in 12.5%. The prescription had to be increased in only one case. The mean follow-up was 2.8 years (with a range from 1 to 7.5 years).

Adaptation, Physiological↗

PubMedDate not supplied

[Spontaneous intracranial hypotension].

INTRODUCTION AND CLINICAL CASE: A 38 year old woman, with no previous history of trauma, presented complaining of interscapular pain followed by pulsating headache clearly related to posture, alleviated on lying down and worse on standing up. Subsequently, she also complained of diplopia. On examination there was paresia of the left sixth cranial nerve. Low opening pressure on lumbar puncture confirmed the presence of intracranial hypotension. The protein level of the cerebrospinal fluid was slightly raised. On CT the cortical sulci and small ventricles had disappeared. Cerebral MR (without gadolinium) showed marked diffuse meningeal hyper-intensity and apparent absence of the basal cisterni. Isotopic cisternography showed a pattern compatible with hypotension, without signs of fistulas. On spinal MR no spinal meningeal defects were seen. With conservative treatment the patient improved in a few days and the headache and diplopia disappeared. The absence of traumatism or spinal operations mean that the hypotension may be considered to be spontaneous. We discuss the CSF, neuroimaging and cisternography findings characteristic of the spontaneous intracranial hypotension syndrome. CONCLUSION: Unawareness of this syndrome, the particular neuroimaging changes and the usual CSF anomalies may lead to confusion over diagnosis, leading to the use of invasive techniques unsuitable for a condition which often has a good prognosis and in which the symptoms resolve in a few days or weeks with conservative treatment.

Abducens Nerve↗

PubMed2000

Superior oblique palsy in a patient with a history of perineural spread from a periorbital squamous cell carcinoma.

A 74-year-old man experienced vertical diplopia. Two years earlier, he was diagnosed with a squamous cell carcinoma of the periorbital frontal skin, with perineural spread involving the ophthalmic division of the right trigeminal nerve and the right facial nerve. The clinical findings were consistent with a right fourth cranial nerve palsy. Computerized tomography and magnetic resonance imaging demonstrated a discrete mass involving the belly of the right superior oblique muscle. An anterior orbitotomy and biopsy demonstrated a mass extending into the belly of the superior oblique muscle. Histology revealed an infiltrating squamous cell carcinoma. The possibility of perineural, direct, or metastatic spread to the superior oblique muscle should be considered in a patient with a history of squamous cell carcinoma of the head and neck. The authors believe this case to be the first report of superior oblique underaction due to involvement of the muscle by squamous cell carcinoma, presumably because of perineural spread. Diagnosis was made possible by neuroimaging and histopathology. There was good short-term resolution of the patient's diplopia after radiotherapy.

Aged↗

PubMed2001

Surgical correction of blepharoptosis in patients with myasthenia gravis.

PURPOSE: To describe the results of surgical correction of blepharoptosis in a series of patients with myasthenia gravis (MG). METHODS: In this retrospective case series, we reviewed the medical records of all patients with MG who did not respond to medical therapy and underwent surgical correction for blepharoptosis at the Mayo Clinic between 1985 and 1999. The primary outcome measure was change in interpalpebral eyelid fissure height. RESULTS: Sixteen blepharoptosis procedures were performed on 10 patients with MG. Eight of the 10 patients had ocular MG. Two of the 10 patients had systemic MG. Of the 16 procedures performed, 9 were external levator advancements (ELA), six were frontalis slings, and one was a tarsomyectomy. Patients were followed postoperatively for an average of 34 months (range, 14-126 months). The amount of ptosis was quantified pre- and postoperatively for seven of the nine eyelids that underwent ELA. For these seven eyelids (five patients), there was a statistically significant improvement in the mean interpalpebral eyelid fissure height from 3.7 mm preoperatively to 7.8 mm postoperatively, with a mean difference of 4.1 mm (95% confidence interval 1.9 mm to 6.25 mm, p = 0.0038). Postoperative complications included worsened diplopia in one patient with ELA and exposure keratopathy in one patient with frontalis sling. Two of the ELA eyelids developed recurrent ptosis requiring additional surgery more than 2 years after the initial procedure. CONCLUSIONS: Blepharoptosis surgery can achieve eyelid elevation in patients who have failed to respond to medical therapy for MG. Potential complications include worsened diplopia and exposure keratopathy.

Adult↗

PubMed2001

Palsies of the third, fourth, and sixth cranial nerves.

Diplopia is one of the most vexing problems to confront a physician. When diplopia is binocular, it commonly results from dysfunction of one or more of the ocular motor nerves. Ocular motor dysfunction may result from injury anywhere along the neuraxis, from the ocular motor nucleus to the myoneural junction. Identifying the location of the lesion is important for determining the etiology and prognosis of third-, fourth-, and sixth-nerve injuries. In this article, an anatomic approach is presented for the diagnosis and treatment of ocular motor nerve lesions. Emphasis is placed on the identification of associated neurologic and ophthalmologic findings that are critical for management of patients with acquired and congenital ocular motor palsies.

Abducens Nerve Diseases↗

PubMed1975

Orbital corrections with the use of alloplastic material.

After a severe trauma of the face, e.g. fractures involving the zygoma, the upper jaw or other orbital bone alteraions and deviations of the bony orbital contours and also of the orbital contents can subsist, even after primary operative correction. The patients have functional as well as cosmetic complaints. In consequence of eyeball dislocation and incarceration or fibrosis of the external eye muscles, the patients also complain of diplopia in one or more directions. Due to the bony orbit enlargement and reduction of the orbtial contents, the eye is moved inferiorly and backwards, also causing diplopia, ptosis and a deep sulcus of the upper lid. The treatment consists in closing and sufficient raising of the orbital floor correction of the enophthalmos. To cover the floor fracture, we apply 1-8 perforated Teflon implants which are placed under the periost of the orbital floor. To correct the enophthalmos, we use 30-50 Teflon beads with a diameter of 5 mm, and placed them in a sub-periorbital pocket laterally above and behind the eyeball, thus ensuring that the eye will be forced forwards in the cone-shaped orbit and so diminish or eliminate the enophthalmos. The operation is performed in close cooperation between an ophthalmologist and a plastic surgeon. Most of our cases also needed operative muscle correction. Although not all deviations could be totally corrected, we always achieved a clear improvement, and all 36 patients obtained a useful field of binocular single view. Until now we have had no implant infections or rejections. We should like to consider that this method of correction will have its own place in the treatment of orbital deformities.

Diplopia↗

PubMed1997

Refection of orbital floor blow-out fractures with silicone implant.

In a retrospective study, the authors present the results of the surgical treatment of 6 cases of orbital floor blow-out fractures with silicone implant. The diagnosis was based on history, clinical ground and coronal tomography. The surgical procedure was the same in all patients, using silicone implant. The mean follow-up time after surgery was 3 months. The mean interval time between injury and diagnosis was 34.8 days while that between injury and surgery was 55.3 days. The fractures occurred during brawls in 3 patients, car accidents in 2 patients and child's play in 1 patient. Limitation of vertical eye movements was presents in all patients, diplopia in 4 patients, enophthalmos in 3 patients and hypesthesia in the distribution of infraorbital nerve in 1 patient. Five patients hale late repairs (> 14 days) after surgery. Postoperatively, good results were obtained with regards to limitation of vertical eye movements, diplopia, enophthalmos and hypesthesia. Only one patient had a persistent and partially reduced enophthalmos. Silicone implant was well tolerated in all cases since complications such as infection, tissue reaction and extrusion were not observed. Excellent results may be obtained after late repair of orbital floor blow-out fractures. Silicone implant has the potential to be used successfully in orbital floor fractures.

Accidents, Traffic↗

PubMed2002

Spontaneous intracranial hypotension with unique strabismus due to third and fourth cranial neuropathies.

PURPOSE: To report an atypical case of Spontaneous Intracranial Hypotension (SIH) with bilateral trochlear nerve palsies and an oculomotor nerve palsy. DESIGN & METHOD: Case report and literature review. RESULTS (CASE REPORT): A 42 year old man was treated for SIH. His neurological symptoms resolved following neurosurgical treatment with the exception of diplopia due to bilateral trochlear nerve palsies and a pupil-sparing oculomotor nerve palsy. The cranial nerve palsies are believed to be secondary to brainstem ischemia and compression occurring during the acute phase of events. They did not spontaneously improve, but were treated successfully with eye muscle surgery. CONCLUSION: SIH is a rare disease that has been associated with a variety of symptoms and signs including cranial neuropathies. A diagnosis of SIH should be considered in a patient presenting with headache, diplopia secondary to cranial neuropathy and typical radiologic features. This is the first reported case in which bilateral trochlear nerve paresis has been reported in association with this condition.

Adult↗