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PubMed1995

Anastomosis of occipital artery to posterior cerebral artery with interposition of superficial temporal artery using occipital interhemispheric transtentorial approach: case report.

BACKGROUND: Superficial temporal artery (STA)-superior cerebellar artery (SCA) anastomosis, and STA-posterior cerebral artery (PCA) anastomosis are considered suitable as surgical procedures for the treatment of patients with significant stenosis or occlusion in the rostral portion of the basilar artery and patients with significant stenosis or occlusion of the posterior cerebral artery, respectively. However, several authors have reported frequent and serious complications of these surgical procedures, including temporal lobe retraction edema and hematoma. In this study, we introduce a new surgical revascularization using an occipital interhemispheric transtentorial approach for the treatment of severe stenosis of the rostral portion of the basilar artery. CASE REPORT: A 47-year-old man with hypertension noted the sudden onset of nuchal pain followed by vertigo, diplopia, drunken gait, and motor weakness on his right side. Angiography performed on the day of the onset disclosed severe stenosis of the basilar artery. The stenotic portion extended just distal to the anterior-inferior cerebellar artery (AICA) to just proximal to the SCA, and in addition, a pseudolumen was visualized just distal to the left AICA. The patient underwent right occipital artery (OA) to left PCA anastomosis with interposition of the STA using an occipital interhemispheric transtentorial approach. Marked improvement in dysarthria, diplopia, ataxia gait, and visual disturbance were noted and he was able to walk without aid 3 days after operation. A postoperative angiogram of the right OA obtained 25 days after operation demonstrated visualization of the left PCA via the anastomosed OA and STA graft. CONCLUSIONS: OA-PCA anastomosis with interposition of STA graft using an occipital interhemispheric transtentorial approach can be substituted for STA-SCA anastomosis and STA-PCA anastomosis for treatment of stenosis/occlusion of the rostral portion of the basilar artery.

Anastomosis, Surgical↗
PubMedDate not supplied

Perilymph fistula: a cause of auditory, vestibular, neurological and psychiatric disorder.

It is suggested that damage by mild trauma, viruses or bone disease to the otic capsule or to the membranes between the cochlea and the middle ear is common, and involved in many syndromes of obscure etiology. The clinical perilymph fistula (PF) syndrome can consist of any combination of the following: tinnitus, deafness, phonophobia, vertigo, ataxia, otalgia, facial palsy, headache, diplopia, blackouts, psychological distress. The following testable hypotheses are proposed: otitis media is due to perilymph in the middle ear, with secondary changes resulting from infection or inflammation: otosclerosis results from a slow leak in the presence of enzymes promoting bone growth: Meniere's syndrome follows reduced perilymph support for the endolymphatic system: Bell's palsy results from a perilymph provoked oedema in the bony facial nerve canal: PFs may be responsible for progressive rubella deafness, and for some cases of migraine, epilepsy, anxiety neurosis and hysteria: psychiatric sequelae of the PF syndrome predominate in the post-concussional syndrome and infantile autism: organisms can pass from the throat into the spinal fluid, causing meningitis or encephalitis. The tinnitus and vertigo are caused by random labyrinthine fluid movements, the headache and diplopia by reduced spinal fluid pressure.

Deafness↗
PubMed2005

Effect of full tendon transposition augmented with posterior intermuscular suture for paralytic strabismus.

PURPOSE: To evaluate the results of the full rectus muscle transposition augmented with a posterior intermuscular suture for paralytic strabismus. DESIGN: Single-center, retrospective, interventional case series. METHODS: This study retrospectively reviewed the medical records from November 1994 to September 2004 of 16 patients who underwent the full tendon transposition that was augmented with posterior intermuscular suture for paralytic strabismus. This series evaluated the results of a single transposition surgery; five patients had previous nontransposition strabismus surgery. The following data were analyzed before and after the operation: (1) the angle of deviation in the primary position, (2) the presence of diplopia in the primary position, (3) the binocular single visual fields, (4) the presence of an abnormal head posture, (5) the motility of the affected eye, and (6) the procedure that was performed. RESULTS: The preoperative angle of deviation in the primary position was 59 +/- 22 prism diopter (prism diopter; range, 30 to 115 prism diopter) compared with 17 +/- 12 prism diopter (range, -10 to 40 prism diopter) after the operation. The preoperative binocular single visual fields improved from 0 degrees to 60 +/- 25 degrees (range, 0 to 90 degrees) after the operation. Diplopia in the primary position was resolved in 11 patients (69%) after the operation. There were no complications such as scleral perforation, unwanted vertical deviations, or anterior segment ischemia in any of the cases during the procedure and postoperative follow-up. CONCLUSION: Full tendon transposition that is augmented with a posterior intermuscular suture is an effective procedure that results in improved ocular alignment in patients with paralytic strabismus and has a favorable complication profile.

Adult↗
PubMed2006

Clinical perspectives of thyroid eye disease.

Thyroid eye disease is a noninfectious, inflammatory disorder of the orbit mostly associated with hyperthyroidism. Thyroid eye disease affects women approximately 6 times more than men. The most common clinical sign is eyelid retraction. Compressive optic neuropathy and excessive proptosis can lead to vision loss. Restrictive myopathy can result in diplopia. Vision loss and diplopia should he referred to an ophthalmologist for further management. Herein, we present a representative case presentation of thyroid eye disease.

Female↗
PubMedDate not supplied

Carcinomatous meningitis arising from primary nasopharyngeal carcinoma.

Carcinomatous meningitis, also known as leptomeningeal metastasis and meningeal carcinomatosis, is the invasion of neoplastic cells into the leptomeninges. Head and neck cancers, especially nasopharyngeal carcinoma, give rise to carcinomatous meningitis very infrequently. In this case report, we present a rare case of carcinomatous meningitis with nasopharyngeal carcinoma as the primary source. In 1987, a 45-year-old white female presented with a few year history of chronic bilateral serous otitis media. She also complained of intermittent diplopia, right facial pain, right-sided headache, and, finally, right facial palsy. The patient was subsequently diagnosed with nasopharyngeal carcinoma by biopsy and treated with radiation as well as chemotherapy. Her neurological symptoms improved, and she did fairly well for several years. However, various neurologic symptoms started to recur, including right facial weakness, right facial numbness in the distribution of all 3 divisions of cranial nerve (CN) V, loss of taste as well as smell, and diplopia. In 1993, magnetic resonance imaging scan of the head revealed recurrence of nasopharyngeal carcinoma with involvement of the ethmoid sinuses as well as extension of the tumor into the frontotemporal leptomeninges. Over the course of the next 3 years, the patient experienced a very gradual decline with involvement of almost all of the CNs (CN I, II, III, V, VI, VII, VIII, IX, X, XII). This case report of carcinomatous meningitis from primary nasopharyngeal carcinoma is one of the few reported in the literature. Although very rare, nasopharyngeal carcinoma can give rise to carcinomatous meningitis, probably by direct invasion of malignant cells. We also review the literature with respect to the diagnosis and treatment of carcinomatosis meningitis.

Adult↗
PubMed2004

Ocular motility disturbances after episcleral plaque brachytherapy for uveal melanoma.

OBJECTIVE: To evaluate contributions of various factors in the development of strabismus after iodine-125 brachytherapy for uveal melanoma. METHODS: Twenty consecutive patients who underwent episcleral plaque brachytherapy for uveal melanoma underwent a full orthoptic examination before and after the surgery. Iodine-125 seeds at 5-mCi strengths were used with a mean total dose of 10.400 cGy toward the tumor apex. RESULTS: Average follow-up time was 25.4 months (range, 14 to 40). At 12 months all tumors showed regression, 9 patients had visual acuity of 20/200 or better, and 4 patients had ambulatory vision. After tumor treatment, 8 patients were orthophoric, 9 patients developed exotropia, 1 patient became hypertropic, 2 patients developed exotropia and hypertropia. Of 2 patients who developed significant diplopia, 1 received 10 U botulinum-toxin A injection (Botox, Allergan, Irvine, CA) for exotropia, and the other was managed with superior rectus advancement and superior oblique tenectomy for surgery-induced iatrogenic Brown's syndrome and slipped superior rectus muscle. CONCLUSION: Extensive mechanical injury, possible ionizing radiation of the plaques, and low visual acuity may cause strabismus after episcleral plaque brachytherapy. Diplopia and cosmesis could be improved with Botox injection or strabismus surgery.

Adult↗
PubMed2005

Lateral rectus resections in divergence palsy: results of long-term follow-up.

INTRODUCTION: Lateral rectus resections have been previously advocated as surgical options to treat patients with divergence palsy who do not respond well to prisms. This study was undertaken to review the results and long-term follow-up of patients with divergence palsy who underwent lateral rectus resections at our institution. METHODS: Retrospective review of 29 patients (age 35-83 years) with divergence palsy. Five subjects underwent unilateral lateral rectus resection between 4.5 and 5.5 mm on adjustable suture and 24 subjects underwent bilateral lateral rectus resection between 3 and 7 mm on adjustable sutures. RESULTS: Preoperatively, all patients had diplopia at distance and an esodeviation, which was greater at distance (mean 14.7 +/- 5.1Delta) than at near (mean 4.7 +/- 3.5Delta). Twenty-five subjects had previously been treated with prisms. Postoperative follow-up period ranged from 6 to 96 months (mean 38.7 +/- 27.3 months). The angle of deviation at distance was significantly reduced to -0.1 +/- 3.2Delta postoperatively ( P < 0.0001). The angle of deviation at near reduced significantly to -2.2 +/- 3.3Delta postoperatively ( P < 0.0001). No patient was overcorrected for near. Two patients experienced recurrent postoperative diplopia at distance subsequently at 1 and 4 years, which was corrected with prism glasses and lateral rectus re-resection. CONCLUSION: Lateral rectus resection in patients with divergence palsy is an effective and stable procedure in patients with divergence palsy over long-term follow-up periods, with minimal risk of overcorrections at near.

Adult↗
PubMed2001

Visual function after foveal translocation with 360-degree retinotomy and simultaneous torsional muscle surgery in patients with myopic neovascular maculopathy.

PURPOSE: To assess functional and anatomical outcomes after foveal translocation with 360-degree retinotomy and simultaneous torsional muscle surgery in patients with myopic neovascular maculopathy. METHODS: Foveal translocation with 360-degree retinotomy was performed in 11 eyes of 11 patients with myopic neovascular maculopathy. Ten eyes had simultaneous torsional muscle surgery with recession of the superior oblique muscle and tucking of the inferior oblique muscle. Silicone oil removal with or without intraocular lens implantation was performed 2 to 8 weeks after the primary procedure. Visual acuity, binocular function, and degree of cyclotorsion were assessed preoperatively and postoperatively. Angles of retinal and globe rotation, distance of foveal shift, and surgical complications were also investigated. RESULTS: With a mean postoperative follow-up of 6.2 months (range, 3 to 13 months), vision improved (greater than 0.2 logarithm of minimal angle of resolution [logMAR] units) in eight eyes, was unchanged in two eyes, and worsened (greater than 0.2 logMAR units) in 1 eye. Seven of 11 eyes (64%) had a final visual acuity of 20/50 or better. Five patients developed or maintained binocular fusion, four patients continued to have suppression, and two patients developed diplopia that was managed by spectacles with Fresnel prisms. Subjective cyclotorsion was less than 8 degrees in 10 eyes. Mean retinal and globe rotations were 23.4 degrees and 19.8 degrees, respectively. Average size of the choroidal neovascular membrane was 0.8 disk diameter, whereas the average distance of foveal shift was 1.5 disk diameter. After the primary procedure, three eyes developed retinal detachment, one eye macular hole, and one eye proliferative vitreoretinopathy. These complications were successfully managed by additional surgery. CONCLUSION: Foveal translocation with 360-degree retinotomy is effective in restoring vision in some patients with myopic neovascular maculopathy. Although the development of torsional diplopia is generally obviated by simultaneous extraocular muscle surgery, a relatively high incidence of surgical complications should be taken into account with this procedure.

Aged↗
PubMed2001

Extraocular muscle cysticercosis presenting as Brown syndrome.

PURPOSE: Report of a case of acquired Brown syndrome caused by infestation of the superior oblique muscle by Cysticercus cellulosae. METHOD: Case seen in a referral practice. A 20-year-old man presented with recurrent attacks of conjunctivitis and diplopia in upgaze. Clinical examination of ocular motility established a diagnosis of acquired Brown syndrome of the right eye. Computed tomography of the right orbit unequivocally established the diagnosis of superior oblique muscle cysticercosis. The patient was started on systemic steroids and albendazole in the prescribed doses for a month. RESULT: Serial computed tomography scans of the orbit revealed resolution of the cystic lesion after a month. Clinically, although there was restoration of ocular motility in upgaze, mild restriction of movement of the right eye in levoelevation persisted. However, the patient was symptomatically better with amelioration of the recurrent conjunctivitis and diplopia in primary gaze. CONCLUSION: Extraocular muscle cysticercosis should be considered in the differential diagnosis of acquired motility disorder. The presentation of extraocular muscle cysticercosis as an acquired Brown syndrome is unusual. Response to medical therapy was satisfactory.

Adult↗
PubMed1997

Ophthalmologic findings in patients with ataxia.

PURPOSE: To determine the frequency and spectrum of ophthalmologic findings in a large, heterogeneous group of patients with ataxia. METHODS: Medical records of 184 patients from a university-based ataxia clinic were retrospectively reviewed. Patients were classified as having Friedreich's ataxia, spinocerebellar degeneration, cerebellar degeneration, familial or sporadic olivo-pontocerebellar atrophy, multisystem atrophy, spastic ataxia, myoclonic ataxia, or other diagnoses such as mitochondrial myopathy. All had complete ophthalmologic examinations, and 107 underwent electro-oculography. RESULTS: Among 184 patients with ataxia, diplopia was present in 52 (28%), best-corrected visual acuity was decreased in 29 (16%), and oscillopsia was present in 10 (5%). Diplopia was usually caused by an intermittent, small-angle heterotropia. The reduction in best-corrected visual acuity varied from mild to profound and was caused by optic atrophy, retinal degeneration, or both. Optic atrophy was present most frequently in spastic ataxia (five of 22 patients) and myoclonic ataxia (two of eight patients), followed by Friedreich's ataxia (three of 26 patients). Retinal degeneration and ophthalmoplegia were most characteristically associated with familial olivopontocerebellar atrophy and mitochondrial myopathy. Laboratory testing of ocular motility showed frequent abnormalities in all groups. Fixation instability was most characteristic of Friedreich's ataxia, whereas saccadic slowing was noticeably absent from patients with purely cerebellar degenerations. CONCLUSIONS: The ataxias may be associated with visual dysfunction caused by retinal degeneration, optic atrophy, oculomotor disturbance, or a combination of these.

Adolescent↗
PubMed1993

Results of transantral orbital decompression in 428 patients with severe Graves' ophthalmopathy.

We reviewed records from 428 consecutive patients with severe Graves' ophthalmopathy to determine early and late results after transantral orbital decompression. Optic neuropathy was present in 217 (50.7%) patients. Post-operatively, 402 (89%) of 453 eyes with preoperative visual acuity worse than 20/20 improved or remained the same. Visual field scotomas improved or resolved in 245 (91%) of 269 eyes tested pre- and postoperatively. Preoperative papilledema resolved or improved in 99 (94%) of 105 eyes, and preoperative exposure keratitis improved or resolved in 178 (92%) of 195 eyes. Average proptosis reduction was 4.7 mm. Postoperatively, new diplopia developed in 74 (64%) of 116 patients who had no diplopia before orbital decompression, although 300 patients ultimately had strabismus surgery. At late follow-up (N = 293 patients), 226 (77%) had single vision and 44 (15%) had correction with prism. Complications included sinusitis (18 patients), lower eyelid entropion (38 patients), numb lip (23 patients), cerebrospinal fluid leaks (15 patients), and one frontal lobe hematoma (one patient). The average duration of follow-up was 8.7 years. Transantral orbital decompression effectively reduces proptosis and usually corrects optic neuropathy. In other circumstances, the benefits achieved and the side effects incurred must be carefully balanced for each patient before transantral orbital decompression is considered.

Adolescent↗
PubMed1992

Massive epithelium-lined inclusion cysts after scleral buckling.

Two patients with massive epithelium-lined inclusion cysts of the orbit became symptomatic five and 16 years after scleral buckling. Each patient described diplopia and displacement of the previously treated eye. An orbitotomy in the first patient disclosed a loculated epithelium-lined inclusion cyst that extended posteriorly from the insertion of the inferior rectus muscle nearly to the apex of the orbit. In the second patient, a loculated epithelium-lined inclusion cyst extended into the superior nasal portion of the orbit from its origin near the insertions of the superior and medial recti muscles. We speculated that epithelial cells of the conjunctiva were shed at the time of scleral buckling and became lodged in the exposed sulcus created by the surgical retraction of Tenon's capsule. Here they proliferated and formed the large epithelium-lined cysts. In each patient, removal of the cyst was followed by a decrease in diplopia as the displaced globe returned toward its normal position.

Aged↗
PubMed1998

Human leukocyte antigens associated with hyperthyroid Graves ophthalmology in Japanese patients.

PURPOSE: To evaluate the association of human leukocyte antigen (HLA) types in Japanese patients with Graves ophthalmopathy. METHODS: Japanese patients with severe ophthalmopathy (48 patients) and patients without ophthalmopathy (46 patients) were selected prospectively from 234 consecutive patients with hyperthyroid Graves disease. The criteria for severe ophthalmopathy were proptosis of 19 mm or more, or a 3-mm difference in exophthalmometry measurement between the two eyes, or diplopia at the primary eye position. The criteria for the absence of ophthalmopathy were proptosis of 16 mm or less, no diplopia, no lid retraction, and no thickening of extraocular muscles. Serologic HLA typing of class I and II antigens was performed in the two patient groups. The frequency of each HLA antigen in the two patient groups was compared to that in 767 unrelated normal healthy Japanese controls. RESULTS: The frequencies of HLA-DR14 and DQ1 were significantly higher in the patient group with severe ophthalmopathy (35% and 75%, respectively) than in healthy controls (4% and 43%, respectively; corrected P < .05), and also greater than in the patient group without ophthalmopathy (13% and 55%, respectively; P < .01). On the other hand, the frequencies of HLA-B35, B54, DR4, and DQ4 were significantly higher in the patient group without ophthalmopathy (23%, 23%, 43%, and 30%, respectively) than in the patient group with severe ophthalmopathy (13%, 15%, 25%, and 19%, respectively; P < .01). CONCLUSIONS: HLA-DR14 and DQ1 antigens may be genetic markers of predisposition to the development of severe ophthalmopathy. In addition, HLA-B35, B54, DR4, and DQ4 may be genetic markers of resistance to severe ophthalmopathy. Variation in the severity of ophthalmopathy associated with Graves disease may depend, in part, on the presence or absence of particular HLA antigens.

Adolescent↗
PubMed1993

Palsies of the trochlear nerve: diagnosis and localization--recent concepts.

In this review, the anatomy of the trochlear nerve, the diagnosis of palsies of the trochlear nerve, and the localization of lesions of the trochlear nerve are discussed. Paresis of the superior oblique muscle is often not evident on duction testing; therefore, subjective diplopia testing with use of a Maddox rod is often necessary. The torsional component of the deviation may be evaluated by double Maddox rod testing. Palsies of the trochlear nerve must be distinguished from other causes of vertical diplopia, such as oculomotor palsy, skew deviation, myasthenia gravis, and Graves' ophthalmopathy. Trauma is the most common cause of isolated, unilateral or bilateral, acquired palsies of the trochlear nerve when a cause can be determined. The localization of lesions of the trochlear nerve to the nucleus or fascicles (or both), subarachnoid space, cavernous sinus and superior orbital fissure, or orbit depends on the associated damage to neighboring neurologic structures. Myokymia of the superior oblique muscle is usually idiopathic and benign but may rarely be an isolated manifestation of tectal disease.

Cranial Nerve Diseases↗
PubMed1994

Predictors of response to transantral orbital decompression in severe Graves' ophthalmopathy.

OBJECTIVE: To identify factors that may help predict the outcome after transantral orbital decompression in Graves' ophthalmopathy. DESIGN: A retrospective study was conducted of 428 patients who had undergone an initial transantral orbital decompression for severe Graves' ophthalmopathy at the Mayo Clinic between November 1969 and May 1989. MATERIAL AND METHODS: With use of logistic regression analysis, we assessed the preoperative characteristics, the early postoperative results, and the follow-up questionnaire data (obtained a median of 9.5 years postoperatively) from 304 female and 124 male patients with Graves' ophthalmopathy who had undergone transantral orbital decompression at a median age of 53 years. RESULTS: On multivariate stepwise regression analysis, young age, male sex, and long duration of eye symptoms were predictors of severe initial proptosis (P < 0.001). The only independent predictors of greater postoperative recession of proptosis were severity of initial proptosis and longer interval between operation and postoperative examination (P < 0.001). Patients with the most reduction of proptosis had the greatest improvement in visual acuity but more chance for postoperative development of continuous diplopia. Failure of prior corticosteroid or orbital radiation therapy did not affect the degree of recession of proptosis or improvement in visual acuity. On multivariate analysis for predictors of long-term overall patient satisfaction, only young age of the patient was of borderline significance (P = 0.05), and the only significant predictor of satisfaction with the postoperative eye appearance was an operation done primarily for cosmetic purposes (P = 0.012). CONCLUSION: Although various factors may influence the outcome of orbital decompression in patients with Graves' ophthalmopathy, this study showed that the more pronounced the initial proptosis, the greater the degree of recession postoperatively. A higher degree of reduction of proptosis is associated with better visual acuity but also a greater likelihood of development of continuous diplopia.

Adolescent↗
PubMed1998

Comparison of fixation disparities obtained by objective and subjective methods.

Fixation disparities (FD) were measured as a function of forced vergence using binocular scleral search coils and simultaneously with nonius lines. The slope of the objective FD curve was significantly greater than the subjective FD curve for three of five subjects. This indicates an alteration in retinal correspondence of up to one degree, that shifts Panum's area to avoid the diplopia normally present with large disparities. This process allows for fusion in the presence of large objective fixation disparities which would normally cause diplopia. The shift in correspondence enhances the range of forced vergence, since the larger objective FDs serve as more effective stimuli to fusional vergence. The remaining subjects who lacked this effect had "flat" FD curves indicative of high vergence adaptation.

Adult↗
PubMed1997

Cavernoma of the cavernous sinus: case report.

BACKGROUND: The authors report a case of extra-axial cerebral cavernoma localized at the level of the cavernous sinus. This pathology is extremely rare, therefore, differential diagnosis with tumors such as meningioma is often difficult. During recent years, surgical indications for these lesions, congenital and rarely hereditary, have become more definite due to the considerable progress made in neuroradiologic and microsurgic techniques as well as better anatomic knowledge of this region. METHODS: This 49-year-old man was admitted with a 1-year history of diplopia. Cranial computed tomography (CT) scan with contrast medium, performed prior to admission, showed an expansive lesion at the level of the right cavernous sinus. Preoperative neuroradiologic diagnosis, after cerebral magnetic resonance imaging (MRI) with gadolinium enhancement and cerebral panangiography, was probable cavernoma. The lesion was totally removed via a fronto-orbito-temporo-zygomatic craniotomy. RESULTS: Postoperatively, the patient had a right oculomotor nerve palsy. This spontaneously resolved 8 months after surgery; diplopia also completely disappeared. Early postoperative control MRI scans with gadolinium on the 2nd postoperative day and 3 months after operation confirmed total removal of the lesion. CONCLUSIONS: The clinical onset and neuroradiologic aspect of these lesions and the fact that they rarely involve the cavernous sinus, may sometimes make preoperative diagnosis of cavernous sinus cavernoma difficult. Nevertheless, given the routine use of microsurgical techniques and improved anatomic knowledge of this delicate region, the treatment of choice is surgery. However, when doubts exist regarding achievement of total removal, radiosurgery is still a valid therapeutic tool.

Brain Neoplasms↗
PubMed1984

Eyelid and orbital treatment following radical maxillectomy.

Malignant lesions of the nasopharynx and paranasal sinuses often encroach upon the orbit. A series of nineteen patients who underwent partial or radical maxillectomy is presented to summarize the eyelid and orbital findings that required further treatment. Fifteen of these patients were left with an intact globe and a visually useful eye, but the defects of epiphora, eyelid malposition, dacryocystitis, and diplopia were visually threatening and required treatment. The cosmetic deformities and diplopia following maxillectomy and radiation are partially amenable to treatment with late bone grafting. Lacrimal outflow deficiencies were successfully treated with dacryocystorhinostomy. Only patients with ocular complications following maxillectomy are included in this series; therefore, the range of problems and their treatment confronting the ophthalmologist is summarized.

Adenocarcinoma↗