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PubMed2002

[Orbital neuroma developing in the ciliary nerve].

Orbital neuroma is a rare disease accounting for a certain percentage of all orbital tumors. However, because of the anatomical features of the orbit, the origin of the tumor has been diagnosed in only a few cases. The authors report a case of orbital neuroma arising from a short ciliary nerve that was confirmed during surgery. The patient was a 72-year-old female. She visited our hospital with complaints of left visual disturbance, exophthalmus and diplopia. Neurological examination on admission also revealed Marcus gunn pupil sign. CT scan and MRI imaging showed a left orbital tumor located along the superior surface of the optic nerve and adjacent to the posterior pole of the eye ball. She underwent superior orbitotomy through a transcranial approach. The tumor was encapsulated and adhered tightly to the sclera, short ciliary nerve, and optic nerve. For this reason, it was removed without a part of the adhered capsule. Since histological examination revealed neuroma, the tumor was diagnosed as short ciliary nerve neuroma. Postoperatively no additional deficits occurred. The exophthalmus, diplopia and Marcus gunn pupil sign disappeared and visual acuity was improved after the surgery. In such a case of short ciliary nerve neuroma, it is possible to remove the tumor without any neurological deficit, if careful consideration of microsurgical anatomy is made.

Aged↗
PubMed2002

[Atelectasis of the maxillary sinus: report of a case of acute onset].

INTRODUCTION: Maxillary sinus atelectasis is a rare pathology, characterized by a retraction of the maxillary sinus walls associated with tenacious mucus secretions filling the antrum. The disease usually develops in a chronic fashion, leading progressively to enophthalmos. This is sometimes associated with diplopia and midfacial depression. In these typical forms, maxillary sinus ventilation (via a middle meatal antrostomy) stops progression to retraction, but usually cannot reverse the phenomenon, resulting in a specific surgical procedure on the orbital floor or on the anterior wall of the sinus. MATERIALS & METHODS: We describe a case of maxillary sinus atelectasis with enophthalmos and midfacial depression, which appeared suddenly in one week, without nasal or sinus related symptoms. A middle meatal antrostomy performed rapidly enabled us to observe a reversal of the atelectatic process with recovery of the sinus volume, correction of the enophthalmos and disappearance of the associated diplopia, without the necessity for an additional surgical procedure. It is, to our knowledge, the first case described with such a rapid evolution.

Acute Disease↗
PubMed2002

[A case of spontaneous intracranial hypotension without any history of positional headache].

A 52-year-old woman was admitted to our hospital with sudden diplopia, right ophthalmalgia, and occipital pain. The nature of her headache was continuous, and changing her position provided no relief. Three weeks before her admission, she experienced continuous cough and rhinorrhea during a few days. On admission, her neurological examination revealed right abducens paralysis, and right lateral gaze aggravated diplopia. Brain magnetic resonance imaging scan demonstrated diffuse pachymeningeal enhancement by gadolinium. Radioisotope cisternography showed a leak of cerebrospinal fluid from near the third lumbar vertebra. The first lumbar puncture revealed an initial pressure of 0 mm H2O. She was given a diagnosis of spontaneous intracranial hypotension due to a leak of the cerebrospinal fluid. During her hospitalization, she complained of vertigo and nausea. We found horizontal gaze nystagmus to left side and sensorineural deafness in her left ear, which improved in a few days. After treatment by a lumbar epidural continuous infusion of saline and a lumbar epidural blood patch, her headache and abnormal MRI findings had improved. The continuous cough before her admission may be the cause of the leak of cerebrospinal fluid. We had difficulty in diagnosis only by the history and clinical examination, because she had no history of orthostatic headache.

Female↗
PubMed2000

[The lamina papyracea fracture reduction under nasal endoscope].

OBJECTIVE: To evaluate the clinical results of blow-out laminapapyracea fracture reduction under nasal endoscopy. METHODS: All 6 cases had endophthalmos and blepharophimosis. Four cases also complained of diplopia. The horizontal and coronal CT of orbit showed the lamina papyracea fracture clearly. The degree and range of the lamina papyracea displacement was measured on CT films. The reduction under nasal endoscope was performed with local and topical anesthesia. We selected the Meeserklinger's route of entry. The uncinate process, ethmoidal bulla, and ethmoidal cells were removed successively. Then, with the help of a tonsil dissector, the lamina papyracea was pushed outward and replaced and was supported with iodoform gauze. After 2 to 3 weeks, the gauze was removed. RESULTS: The endophthalmos and diplopia disappeared in all cases. No postoperative complications occurred. With 0.5-2 years follow-up, the degree of the endophthalmos was stable within 2 mm. CONCLUSION: The reduction under nasal endoscope has many advantages such as short route of entry, simple performance, and no facial scar. It is a good operative option to correct the lamina papyracea fracture.

Endoscopy↗
PubMed2003

[A case report of syphilitic meningitis with right oculomotor nerve palsy].

A 63-year-old man presented with acute-onset right ptosis and diplopia. The patient reported having engaged in unspecified sexual activities during his third decade and was found to have positive syphilitic serological findings at the age of 56 years. No clinical symptoms were noted at this time. On admission, he showed only right oculomotor nerve palsy. The patient's intelligence, gait and sensory functions were normal. Laboratory analysis revealed positive syphilitic serological findings and examination of the cerebrospinal fluid (CSF) further revealed pleocytosis, a higher IgG index and positive syphilitic reactions. A computed tomographic scan and other imaging studies were diagnostically nonspecific. We made a diagnosis of right oculomotor nerve palsy due to syphilitic meningitis. We treated the syphilitic meningitis with intravenous injections of penicillin G (24 million units per day for 21 days). Jarisch-Herxheimer reaction and other side effects were not apparent. We first made a thorough examination of the CSF to rule out diagnosis of meningitis, and pursued methylprednisolone pulse therapy (MPP, 1 g/day for 3 days) to treat the oculomotor nerve palsy. The ptosis and diplopia showed signs of improvement following the second MPP therapy session. The present case suggests that neurosyphilis is an important differential diagnosis for presentations of unspecific oculomotor nerve palsy and that MPP therapy may prove an effective treatment for it, even where there has been the long clinical onset.

Humans↗
PubMed2003

[Topographical evaluation on decentration of orthokeratology lenses].

OBJECTIVE: To evaluate the degree and correlative factors of decentration of orthokeratology lenses and its effect on the visual function. METHODS: Two different kinds of orthokeratology lenses were fitted to 270 eyes of 135 patients [initial mean refractive error: (-3.98 +/- 1.51) D]. Humphery Instruments ATLAS 8.0 was used for the computer-assisted analysis of corneal differential topographical maps. The examination of corneal topography was proceeded on the patients before the fitting of orthokeratology lenses and 6-month later. The distance from center of optic zone to apex of the cornea was measured as the value of decentration of orthokeratology lenses. The factors influenced the value of decentration were analyzed, including the initial refraction error, astigmatism, keratometry values, corneal eccentricity, and the diameter of the lens. The complaints of patients were recorded. Questionnaires, involving the symptoms of monocular diplopia and glare, were used to evaluate the effects of decentration of orthokeratology lenses on the visual function. RESULTS: The mean distance of decentration was (0.49 +/- 0.34) mm after one night fitting, the mean distance of decentration after follow-up for 1 month, 3 months and 6 months was (0.57 +/- 0.41) mm, (0.55 +/- 0.48) mm and (0.59 +/- 0.39) mm, respectively. After one month, the distance of decentration was less than 0.5 mm in 51.1% eyes, 0.5 - 1.0 mm in 35.6% eyes and more than 1.0 mm in 13.3% eyes. The direction of decentration in eyes with more than 0.50 mm decentration was mainly in the temporal side (48.5%). Patients with greater initial astigmatism and smaller diameter of lens showed greater distance of decentration (P < 0.05). There was no statistically significant difference in the distance of decentration between two groups with different corneal eccentricities and keratometry values (P > 0.05). The distance of decentration was greater in patients with monocular diplopia and glare. CONCLUSIONS: The degree of decentration of orthokeratology depends on the degree of initial refractive error, astigmatism and the design of orthokeratology lenses. The degree of decentration can influence the visual function.

Adolescent↗
PubMed1992

[Two cases of post-thymectomy myasthenia gravis].

The first patient was a 37-year-old man with an invasive and lymphoid cell dominant thymoma (stage III). He underwent extended total thymectomy and partial resection of the upper lobe of the left lung. Four years after the operation, he had ptosis and diplopia and was diagnosed as having myasthenia gravis (positive Tensilon test and raised antiacetylcholine receptor antibody titer). His symptoms improved with the steroid therapy. The second patient was a 37-year-old woman with an invasive and mixed type thymoma (stage III). Extended total thymectomy with combined resection of the mediastinal pleura and right phrenic nerve was performed, but the tumor recurred in the right thorax 2 years postoperatively. Subtotal resection of the parietal pleura and recurrent tumors was performed by right thoracotomy, and steroid therapy was given. She developed malaise, ptosis and diplopia three months later, and was diagnosed as having myasthenia gravis. Her symptoms disappeared after the steroid therapy was stopped. A review of the Japanese literature is presented and problems regarding the pathogenesis of this disease are discussed.

Adult↗
PubMed2003

[A case presenting with trochlear nerve palsy and segmental sensory disturbance due to circumscribed midbrain and upper pontine hemorrhage].

We describe a patient presenting with trochlear nerve palsy and segmental sensory disturbance due to circumscribed mesencephalic hemorrhage. A 36-year-old man with no past illness visited our hospital complaining of sudden onset of diplopia, dysesthesia of the left face and upper extremity, and acuphenes of the left ear. Neurological examination revealed left trochlear nerve palsy and segmental sensory disturbance of the left side almost above T11 level. Pain and temperature sensation were disturbed, but vibration, joint position, graphesthesia, kinesthesia, and discrimination sensation were spared. Magnetic resonance imaging of the head, performed 7 days after onset, revealed acute to subacute phase hemorrhage at the right inferior colliculus. No abnormalities were identified on cerebral angiography. Symptoms gradually improved with conservative therapy. After about ten weeks, diplopia disappeared and area of sensory disturbance was reduced (disturbance of pain sensation reduced to about T4 level, temperature sensation to about T9). Segmental sensory disturbance usually accompanies spinal cord lesion. However, several cases of similar symptoms following cerebrovascular disease of the brainstem have been reported. Conversely, some reports have indicated that trochlear nerve palsy due to midbrain hemorrhage accompanies sensory disturbance contralateral to the lesion. The nature of sensory disturbance is thus variable. The present case suggests that segmental sensory disturbance might accompany trochlear nerve palsy caused by hemorrhage of the inferior colliculus, as intramedullary fibers of the trochlear nerve and spinothalamic tract are located nearby and somatotopy of the spinothalamic tract is preserved even at the level of the midbrain.

Adult↗
PubMed1992

[Isolated abducens nerve palsy caused by pontine infarction].

An 82-year-old hypertensive man suddenly developed diplopia during right lateral gaze. Neurological examination revealed right isolated abducens nerve palsy without any other findings. By cranial CT scan, a low density area over the posterior limb of right internal capsule and tortuosity of basilar artery were noted. 3 months later, his symptom disappeared and then he was well in next 2 years til he felt diplopia during left lateral gaze. On this time he showed left isolated abducens nerve palsy. Though cranial CT scan failed to find out new abnormality, T2-weighted cranial MRI disclosed high intensity spot over left pontine base located between medial lemniscus and pyramidal tract, which was supposed to coincide to fascicle of left abducens nerve Three months later, he recovered in the same manner as 2 years before. Hemilateral isolated abducens nerve palsy may be caused by many origins, but pontine infarct was not detected so much in pre-MRI era. Being the long-term prognosis of the lacunar infarction not satisfactory, it is important for the cases of isolated abducens palsy to ascertain whether there is pontine small infarction or not. So in these cases, precise examination including MRI should be needed.

Abducens Nerve↗
PubMed2003

[Strabismus surgery of the myopic patient under topical anaesthesia].

PURPOSE: To study the epidemiological characteristics and the results of strabismus surgery of high myopic patients under topical anaesthesia. METHOD: Retrospective study of nine high myopic patients with restrictive myopic myopathy (RMM) that underwent surgery in the last year and with a minimum follow-up of at least 6 months following surgery. Clinical findings, alteration of the extrinsic ocular motility (EOM) and response to surgical treatment were evaluated in each case. RESULTS: RMM was more frequent in women, average age was 46 years and average refractive error was 14 diopters. Diplopia was the most frequent reason for consultation, followed by the wish to undergo surgery because of an aesthetically unacceptable strabismus. High myopia was the most frequent etiology. One case was secondary to decompensated fourth cranial nerve palsy. The alteration of the EOM more frequently observed was endotropia associated with hypotropia. The recurrence rate of the deviation was 44%, occurring generally in the immediate postoperative period. In these cases botulinum toxin is a valid treatment option. CONCLUSIONS: Topical anaesthesia offers undoubted advantages for a better adjustment of diplopia in RMM surgery. During the intraoperative adjustment it is convenient to overcorrect the horizontal deviation and to undercorrect the vertical deviation.

Adult↗
PubMed2003

Three-wall decompression technique using transpalpebral and endonasal approach in patients with Graves' ophthalmopathy.

PURPOSE: To evaluate the effects of the three-wall decompression technique using transpalpebral and endonasal approach in patients suffering from Graves' ophthalmopathy. METHODS: In this prospective study, we present a consecutive series of 15 subjects (17 eyes) who were submitted to orbital decompression by removing the inferior and lateral walls using transpalpebral incision combined with a transnasal endoscopic resection of the medial wall. The surgical technique involved the preservation of the bone structure between the lamina papyracea of the ethmoid and the maxillary orbital floor. MAIN RESULTS: The mean ocular recession based on Hertel measurements was 6.00 mm (range, 4-9 mm). None of the patients presented pre-operation diplopia, and one developed post-operation diplopia. Visual acuity was preserved in all cases. CONCLUSION: It is safe and efficient to perform three-wall decompression, combining transpalpebral and endoscopic transnasal approach, with preservation of the bone structure and the bone lateral to the infraorbital canal with fixation by two titanium plates on the lateral edge and removal of intraorbital fat, which results in significant proptosis reduction and minimal complications.

Adult↗
PubMed1992

[A case of benign intracranial hypertension with fluctuated symptoms and CSF pressure synchronized with menstrual cycle].

A 39-year-old woman presented with a 2-month history of repeated severe headache, nausea and diplopia. On admission she was obese with bilateral papilledma and abducens weakness. Mass lesion and sinus thrombosis were ruled out by brain CT and angiography. CSF pressure was normal initially. CSF pressure fluctuated with menstrual cycle, sometimes showing over 600 mmH2O with worsening of the symptoms. She was diagnosed as benign intracranial hypertension (BIH). Diuretics did not improve the symptoms, and visual disturbances ensued and deteriorated. A spinal subarachnoid space-peritoneal shunt was inserted to control CSF pressure, showing rapid improvement of headache and diplopia but visual disturbances remained almost unchanged. Optic nerve sheath fenestration was performed without improvement of visual deterioration. We postulated multiple factors such as obesity, menstrual abnormality, iron deficiency anemia and analgesic drugs played important roles to produce BIH in this case. Careful quantitative perimetry should be done to decide a suitable time for surgical treatment in BIH.

Adult↗
PubMed2002

[The classification and treatment of lamina papyracea blow-out fracture].

OBJECTIVE: To investigate the classification criterion and the treatment of lamina papyracea blow-out fracture. METHOD: A clinic analysis was made on 108 case with lamina papyracea blow-out fracture. According to the classification, different treatments were taken differently. RESULT: The classification of 108 cases were reported as follows: 71 cases were classified as level 1, 33 cases as level 2, 4 cases as level 3. There was no special treat-ment for 43 cases (level 1) who had no diplopia. 28 cases (level 1) who had symptom of diplopia were treated conservatively. Its cure rate was 92. 9% (26/28). Other 34 cases were operated. Among them, 33 cases were classified as at least level 2, 1 case who had no satisfactory curative effect with conservative therapy was classified as level 1. The cure rate was 88. 2% (30/34). The other 4 cases classified as level 2 or 3 who didn't accept operation were treated conservatively, the cure rate was 25% (1/4). CONCLUSION: The classification of lamina papyracea blowout fracture facilitates the judgement of patient's condition and the selection of treatment. The transnasal endoscopic operation on serious lamina papyracea blow-out fracture cases produces a good curative effect.

Adolescent↗
PubMed2004

Surgical management of strabismus for dysthyroid ophthalmopathy.

BACKGROUND: The study reports our 8-year experience in the surgical treatment of restrictive myopathy resulting from dysthyroid ophthalmopathy. We tried to determine the factors that contributed to favorable surgical outcomes. METHODS: The charts of patients who had surgical treatment for strabismus related to dysthyroid ophthalmopathy at Chang Gung Memorial Hospital between January 1995 and December 2002 (n=25) were retrospectively reviewed, and factors that possibly influenced the outcome were statistically analyzed for significance. RESULTS: The mean pre-operative vertical deviation of the 25 patients was 23.3 prism diopters and the pre-operative horizontal deviation was 11.3 prism diopters. The mean follow-up time was 29.7 months. Each patient had strabismus surgery an average of 1.5 times. The majority of patients (84%) were satisfied with the result. No significant difference in the success rate was evident between patients who waited less than 3 months before the surgery and those who waited for a longer period. The repeat surgery rate was significantly higher in the latter group. A shorter duration of diplopia and smaller angle of pre-operative horizontal deviation were contributors towards a favorable outcome. CONCLUSIONS: A waiting time of less than 3 months prior to treatment of strabismus associated with dysthyroid ophthalmopathy produced a favorable outcome. The duration of diplopia and the pre-operative angle of horizontal deviation were the most important prognostic factors.

Adult↗
PubMed2005

[Ocular surface reconstruction for severe symblepharon resulting from eye burns].

OBJECTIVE: To evaluate the efficacy of lamellar keratoplasty (LKP) using fresh graft with limbus, combined with conjunctival limbal autograft transplantation (CLAT) and amniotic membrane transplantation (AMT), in treating severe symblepharon resulting from eye burns. METHODS: Patients with severe symblepharon visited our hospital between February 1998 and February 2003 were divided into 4 degrees based on impairment of visual function. Pseudopterygium was partially dissected after separation of conjunctival adhesion, the corneal lesion was covered with partial (17 eyes) or total (9 eyes) lamellar corneal graft. Autologous limbal graft was placed onto the most seriously damaged limbus. Then the preserved pseudopterygium was receded with AMT to reconstruct fornix. All cases were followed up for 8 months to 3 years. Eye movement, diplopia, development of corneal grafts, preserved pseudopterygium and transplanted amniotic membrane were observed. RESULTS: 25 eyes, except that 1 eye because of irreformable lagophthalmos, got considerable improvement. Conjunctival adhesion was completely relieved and diplopia disappeared in 17 eyes. Adhesion recurred in the area covered only with amniotic membrane in 8 eyes, and 5 of them were completely relieved after one or two adhesion excisions combined with autologous conjunctival transplantation. Mild adhesion still remained in 3 eyes. Amniotic membrane began autolyzing at 1 week and completely disappeared 3 months after operation. Pseudopterygium began thinning at 1 to 3 months. Immune rejection occurred in 6 eyes, and 2 of them had second LKP. CONCLUSIONS: LKP using fresh graft with limbus, combined with CLAT and AMT, is an ideal treatment for severe symblepharon resulting from eye burns. Pseudopterygium can partly substitute conjunctiva to reconstruct fornix. Amniotic membrane facilitates ocular surface reconstruction by temporary protection of lesions.

Adolescent↗
PubMed2005

Cerebral tuberculosis mimicking intracranial tumour.

Cerebral tuberculoma is a rare entity and is one of the causes of intracerebral mass lesions. A rapid diagnosis based on pathological findings improves its prognosis. We describe two cases where the tuberculoma was located in the cavernous sinus and prepontine cistern, respectively. The first case was a 36-year-old man who was admitted with progressive headache, left ptosis and diplopia. Computed tomography showed a solid enhancing mass in the left cavernous sinus. Diagnosis of meningioma was proposed and a left pterional craniotomy was performed. Histopathological examination revealed granulomatous inflammation with areas of caseation necrosis. The second case was a 20-year-old man who presented with headache, new-onset strabismus, diplopia, malaise, weight loss and low-grade fever. The lesion mimicked an aggressive meningioma on imaging. The patient was operated for primary diagnosis of cerebral tumour. The histopathological examination of the excised lesion revealed a tuberculoma. Although the incidence of tuberculosis is decreasing, a high index of suspicion must be maintained for the diagnosis of intracranial masses in the presence of risk factors for tuberculosis.

Adult↗
PubMed2005

[Modified transcranial orbitotomy for treating exophthalmic intraorbital tumor].

OBJECTIVE: To study the feasibility of the modified osteotomy of transcranial orbitotomy in the treatment of intraorbital tumor. METHODS: We treated 8 patients with intraorbital tumor during six years. By the bicoronary incision, all cases underwent double bone flap osteotomy on the frontal bone: the superior orbital rim bone flap and roof flap instead of single fronto-orbital bone flap in the conventional transcranial orbitotomy. After removal of bone flaps, intracranial and intraorbital operation was performed. Then, two bone flaps were reduced respectively and fixated with titanic micro-plates and nails. At last, the scalp flap was sutured. RESULTS: The operative field was very well exposed. It was found that the retrobulbar tumor was located at the superolateral, median and superonasal area respectively, which was coincided with the preoperative CT and MRI. The tumor included adenocarcinoma of the lacrimal gland, neurinoma, meningioma, and cavernous hemangioma. Four patients had blood transfusion during the operation. No other postoperative complications happened except 3 cases of diplopia and one case of blindness. After 3 to 6 months follow up, diplopia of the 3 cases gradually disappeared. Of the 8 cases, 6 reached the same visual acuity as the preoperative state. One decreased visual acuity and one lost light perception. There was well-balanced fronto-orbital appearance and eyeball position compared with the healthy side in all cases. CONCLUSIONS: This surgical method for the treatment of intraorbital tumor is safe with well-exposed operative field. It has advantages not only in simpleness and less trauma, but also in keeping orbital roof and anterior fossa intact and decreasing complications.

Adult↗
PubMed2005

Eye problem following foot surgery--abducens palsy as a complication of spinal anesthesia.

BACKGROUND: Paralysis of abducens nerve is a very rare complication of lumbar puncture, which is a common procedure most often used for diagnostic and anesthetic purposes. CASE REPORT: A 38-year-old man underwent surgery for a left hallux valgus while he was under spinal anesthesia. On the first postoperative day, the patient experienced a severe headache that did not respond to standard nonsteroidal anti-inflammatory medication and hydration. During the second postoperative day, nausea and vomiting occurred. On the fourth postoperative day, nausea ceased completely but the patient complained of diplopia. Examination revealed bilateral strabismus with bilateral abducens nerve palsy. His diplopia resolved completely after 9 weeks and strabismus after 6 months. CONCLUSION: Abducens palsy following spinal anesthesia is a rare and reversible complication. Spinal anesthesia is still a feasible procedure for both the orthopaedic surgeon and the patient. Other types of anesthesia or performing spinal anesthesia with smaller diameter or atraumatic spinal needles may help decrease the incidence of abducens palsy. Informing the patient about the reversibility of the complication is essential during the follow-up because the palsy may last for as long as 6 months. Special attention must be paid to patient positioning following the operation. Recumbency and lying flat should be accomplished as soon as possible to prevent cerebrospinal fluid leakage and resultant intracranial hypotension. This becomes much more important if the patient has postdural puncture headache.

Abducens Nerve Diseases↗