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PubMedDate not supplied

Bumpy muscles.

A 63-year-old man developed bilateral conjunctival injection and irritation followed by periocular discomfort and diplopia. Within weeks left proptosis and intermittent fever were noted. Orbital CT scan showed bilateral nodular enlargement of multiple extraocular muscles. Fine needle aspiration biopsy of the extraocular muscles revealed neoplastic cells compatible with a renal cell carcinoma. The bilateral extraocular muscle metastases were the initial manifestations of the underlying malignancy.

Biopsy, Needle↗
PubMedDate not supplied

Gaze-induced strabismus.

A 20-year-old woman with a past history of a sinonasal undifferentiated carcinoma involving the skull base and cavernous sinus, previously treated with surgery and radiation therapy, presented with intermittent horizontal diplopia induced by gaze to the right side. The gaze in the direction of the action of the right VI nerve produced sustained contraction of the right lateral rectus and an exodeviation increasing on left gaze. Ocular neuromyotonia involving the right VI nerve was believed to be secondary to the patient's previous radiation therapy. The discussants review the prior literature regarding ocular neuromyotonia involving the III, IV and VI cranial nerves, its relationship to prior radiation therapy, and possible modes of therapy including the use of Carbamazepine.

Abducens Nerve↗
PubMedDate not supplied

Disk edema and peripheral neuropathy.

A 55-year-old woman presented with an eight-year history of progressive gait dysfunction and a 2-3 week history of horizontal diplopia. Examination of the patient revealed acute papilledema, intermittent esotropia, and upper and lower motor neuron findings in her lower extremities. CT scan of the head showed communicating hydrocephalus. A spinal cord tumor extending from T11 to L3 was visualized by MR imaging of the spine. All of her symptoms, except for a left foot drop, resolved with aggressive removal of the tumor, which was a myxopapillary ependymoma. Mechanisms of the neuro-ophthalmic picture and treatment of this syndrome are discussed.

Acute Disease↗
PubMed1984

Microvascular decompression for trigeminal neuralgia. A five-year follow-up study.

A series of 72 patients with typical trigeminal neuralgia who underwent microsurgical exploration of the trigeminal nerve in the posterior fossa is analyzed. The operations were performed between 1977 and 1980 with an average follow-up period of 4.94 years. Seventy-eight percent of the patients have remained free of pain after the operation. Of the 16 patients (22%) that were either not relieved of their pain or had a recurrence, two are well-controlled with medical treatment and the rest have required a variety of surgical procedures (mostly radiofrequency rhizotomy) for pain relief. Recurrences were significantly more common in females. There was no relationship between recurrence rate and the age of the patient or the duration of the symptoms before surgery. Definite compression of the trigeminal nerve at the root entry zone by an arterial loop singly or in combination with other arteries or a vein was found in 82% of the patients. The recurrence rate in this group was 19%. Definite compression by a vein was found in seven patients and the pain recurred in four (47%), a significant difference. There was no death or disabling stroke in this series, but persistent unilateral hearing loss occurred in a total of 14 patients (19%), with complete deafness in the ipsilateral ear in five patients (7%). In addition, two patients suffered mild but persistent ataxia of gait and two patients intermittent diplopia. These results are compared with the results of other reported series.

Adult↗
PubMed1996

A retrospective analysis of different modalities for treatment of primary orbital non-Hodgkin's lymphomas.

We have reviewed 37 patients with primary orbital lymphoma, using the Ann Arbor criteria and the Working Formulation and its modification. Thirty-one patients had stage I disease, four stage II, one stage III and one stage IV. The male to female ratio was 2.7:1. There were 34 low-grade tumours (including 24 mantle zone) and three intermediate-grade. Patients were divided into three groups according to their primary treatment. Group 1: radiotherapy (17 cases); Group 2: surgery alone (13 cases); Group 3: chemotherapy (seven cases). Patients were followed up from 5 months to 24.3 years, with a mean and median of 7.6 and 6.2 years, respectively. The BMDP software package was used for survival estimation (Kaplan-Meier) and determination of prognostic variable (univariate Cox regression). Local relapse-free survival at 10 years was 100% in Group 1, 0% in Group 2 and 42% in Group 3 with a statistically significant difference (p < 0.01) in favour of radiotherapy. Statistically significant good prognostic features were: complete remission (CR) in response to initial treatment, primary radiotherapy and older age. For stage I cases, there was no difference in distant relapse-free survival in the three groups. The overall cause-specific survival for stage I patients at 10 years was 100% for each group and at 20 years was 100, 67 and 0% for Groups 1, 2 and 3. The difference between the primary radiotherapy and chemotherapy-treated groups was significant at the p = 0.08 level. Statistically significant prognostic factors were early stage, low-grade histology and primary radiotherapy. In one patient, ptosis and diplopia appeared after surgery. One case of glaucoma required enucleation, one patient suffered severe dry eye syndrome. All patients (11/11) in whom the lens received direct radiation developed cataracts of different degrees if follow-up was long enough. Cataract formation was prevented by adequate lens shielding. One patient in CR from a stage I low-grade tumour died from chemotherapy-induced marrow aplasia. Primary orbital lymphoma is an indolent, usually stage I disease, showing low to intermediate-grade histology. After biopsy the best treatment is 30 (low-grade) to 40 Gy (intermediate-grade) carefully planned, lens-sparing megavoltage radiation without adjuvant chemotherapy.

Adult↗
PubMed1994

Unusual visual stimulation in dynamic balance conditions: proposal for a space motion sickness test.

We previously demonstrated the efficiency of normal vision/unusual vestibular cues conflict to induce motion sickness. In the present study, we investigate whether, inversely, unusual visual information/normal vestibular function conflict also elicited motion sickness. The experiments were again carried out in dynamic balance conditions to increase proprioceptive input. Circular translation of the visual field with diplopia were produced by rotating Fresnel prismatic glasses. The stimulation triggered SMS-like symptoms and dynamic balance disturbance. A positive relationship was found between discomfort and balance disturbance. Unusual visual information should therefore be included in Space Motion Sickness susceptibility testing.

Adult↗
PubMed1985

Emergency department presentation of type A botulism.

In October 1983, 28 people became ill with type A botulism in a common-source, food-borne outbreak. Thirteen of these patients presented to an emergency department for initial medical evaluation. The records of these thirteen patients were examined retrospectively in an attempt to characterize the initial presenting symptoms. All patients complained of at least three of four symptoms (generalized weakness, diplopia, dry mouth, and difficulty speaking). Emergency physicians can play a pivotal role in limiting the extent of common-source botulism outbreaks by early recognition of the disease and immediate mobilization of community public health resources.

Botulism↗
PubMed1985

Lumbar puncture.

Lumbar puncture has been in widespread clinical use for nearly a century. It is used in emergency medicine primarily as a tool for the diagnosis of meningoencephalitis and subarachnoid hemorrhage. The development of computed tomography has changed the position that lumbar puncture has held in the diagnostic sequence of a number of clinical entities. The procedure is contraindicated if there is soft-tissue infection adjacent to the puncture site and if there are findings of increased intracranial pressure due to a mass lesion. Performance in the setting of a coagulopathy may also be hazardous. The most serious potential complication is cerebral herniation. The commonest complication is postlumbar puncture headache, which is due to CSF hypotension resulting from persistent spinal fluid leakage through the meningeal puncture site. Spinal hematoma, diplopia, and intraspinal dermoid tumor formation are less common complications. Meningitis has been found to follow lumbar puncture in children with bacteremia. The lumbar puncture is a useful test for providing information regarding the cellular, chemical, and microbiologic composition of the CSF. Fluid obtained should be evaluated for cell count, Gram's stain, bacterial culture, glucose and protein levels, and other tests as clinically indicated.

Cerebrospinal Fluid↗
PubMed2005

Sixth and tenth nerve palsy secondary to pseudomonas infection of the skull base.

PURPOSE: To describe skull base osteomyelitis, an uncommon complication of chronic otitis media in the post-antibiotic era, as a cause for diplopia. DESIGN: Case report. METHODS: The records of a patient with skull base osteomyelitis were reviewed. RESULTS: A patient presented with a sixth nerve palsy and tenth nerve palsy. Magnetic resonance imaging, bone scan, and gallium scan were helpful in establishing the diagnosis. Cultures grew Pseudomonas. The treatment required long-term intravenous antibiotics. CONCLUSIONS: Pseudomonas skull-based osteomyelitis can produce a sixth nerve palsy as a result of the involvement of the clivus. Although uncommon in the post-antibiotic era, early recognition, appropriate diagnostic testing, and aggressive systemic antibiotic treatment might prevent permanent neurologic sequel.

Abducens Nerve Diseases↗
PubMed2005

Downbeating nystagmus and muscle spasms in a patient with glutamic-acid decarboxylase antibodies.

PURPOSE: To report the ophthalmic findings and response to treatment in a patient with glutamic-acid decarboxylase antibodies. DESIGN: Case report. METHODS: A 55-year-old woman developed progressive, painful, low back muscle spasms, vertical diplopia, downbeating nystagmus, and asymmetric appendicular ataxia. RESULTS: Downbeating nystagmus was present in primary gaze with an alternating skew deviation in lateral gaze. Serum and cerebrospinal fluid GAD antibodies were detected. Treatment with diazepam led to resolution of spasticity, whereas repeated courses of intravenous immunoglobulin improved cerebellar function, including appendicular ataxia and downbeating nystagmus. CONCLUSIONS: Patients with GAD antibodies may have elements of both Stiff-person syndrome (muscle rigidity and spasms) and prominent cerebellar dysfunction. Treatment with diazepam rapidly improved Stiff-person symptoms, whereas IVIg was partially effective at the early stage of cerebellar dysfunction.

Autoantibodies↗
PubMed2005

Accommodative intraocular lens tilting.

PURPOSE: To report an unusual complication of accommodative intraocular lens (IOL) implantation after clear lens extraction for hyperopia correction. DESIGN: Observational case report. METHOD: A 48-year-old woman underwent clear lens exchange for the correction of moderate hyperopia. A Crystalens Model AT-45 Accommodating Posterior Chamber IOL (AT-45 IOL) was implanted to allow optimal distance and near vision. At the 3-week follow-up appointment, she complained of monocular diplopia. Ocular examination showed an increased astigmatism, causing decreased visual acuity. Scheimpflug Pentacam Image and Wave Front Analysis supported the diagnosis of IOL tilting. RESULTS: IOL repositioning was unsuccessful because of fibrosis of the haptics. It was necessary to replace AT 45 IOL with a monofocal acrylic sulcus-fixated IOL. CONCLUSION: Control of capsular fibrosis should be a major concern, especially in this type of IOL. Accommodating IOL exchange appears to be a safe alternative to manage this complication.

Accommodation, Ocular↗
PubMed2006

Ophthalmoparesis in idiopathic intracranial hypertension.

PURPOSE: To report unusual ocular motility disturbances in the setting of idiopathic intracranial hypertension (IIH). DESIGN: Interventional case series. METHODS: Two cases with IIH and unusual ophthalmopareses are reported. RESULTS: Two patients with confirmed IIH presented with headache, diplopia, and papilledema. The first patient had bilateral sixth nerve palsies and a partial right third nerve palsy, which resolved rapidly after a cerebro spinal fluid (CSF) shunting procedure; the second patient had alternating skew deviation and upbeat nystagmus. Both cases had normal brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) and normal CSF contents, ruling out a secondary cause of intracranial hypertension. CONCLUSIONS: These exceptional vertical and horizontal ophthalmopareses in the setting of IIH may be related directly to very elevated CSF pressures and may be secondary to altered CSF flow in the posterior fossa.

Adult↗
PubMed2004

Eye patching biases spatial attention after thalamic hemorrhage in a patient without spatial neglect: a case report.

Monocular patching has been advocated as a treatment for spatial neglect. Eye patching, however, is also reported to increase spatial bias. Thus, patching brain injury patients for ocular conditions may also impair their attention. To learn if an eye patch may induce asymmetric attention in a patient without spatial neglect, we tested a woman with diplopia after a left thalamic-intraventricular hemorrhage. She had no spatial neglect on bedside attention tasks. Using a laser pointer, she bisected a blank space at near (279 mm) and far (914 mm) distances under 3 conditions: unpatched and wearing a right or left eye patch. Unpatched, she showed no bias. She erred further leftward with right patching at both distances. Right eye patching appeared to induce neglect of right space when the patient performed this task. With left patching, leftward error tended to increase in near space only. Clinicians prescribing eye patches to patients with brain injury even for purely ocular indications, should evaluate them for spatial neglect once the patch is in place.

Adult↗
PubMed2006

Anterior cranial fossa dermoid cyst: case report.

We report a case of an intracranial mass that presented with proptosis and diplopia, and proved to be a dermoid cyst. Resection was successful and there had been no recurrence after 5 years.

Cranial Fossa, Anterior↗
PubMed2006

Evaluation of the clinical presentations in neurobrucellosis.

BACKGROUND: Brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations and complications. Neurobrucellosis is one of the complications. METHODS: In this study, we describe our experience in the diagnosis, treatment, and the final outcomes of 20 patients with neurobrucellosis out of 305 patients with brucellosis, within a five-year period between January 1999 and June 2004. RESULTS: The rate of neurobrucellosis was 6.6%. Twelve males and eight females with a mean age of 37.4 years were investigated. Fever, headache, confusion, and gait disorders were the main complaints. The duration of their complaints varied between one week and six months. On physical examination, 13 patients had fever, six had neck stiffness and confusion, three had motor deficit on either their upper or lower extremities, and four of them had diplopia. The Rose-Bengal test and standard tube agglutination tests were positive in all of the patients. Brucella melitensis was isolated from the blood of six of the 20 (30%) patients. Cerebrospinal fluid (CSF) was analyzed in 18 patients. Pleocytosis with a mean value of 244x10(6)cells/L, and high protein levels were detected in all. A low glucose level in the CSF was detected in ten patients. Patients were treated medically and a complete resolution was achieved in all. CONCLUSION: Patients with a Brucella infection occasionally manifest central nervous system involvement. Clinicians, especially serving in endemic areas or serving patients coming from endemic areas should consider the likelihood of neurobrucellosis in the patients with unexplained neurological and psychiatric symptoms, and should perform the necessary tests on blood and CSF.

Adolescent↗
PubMed2006

Recovery from orbital floor fractures: a prospective study of patients' and doctors' experiences.

This study aimed at investigating the extent to which remaining symptoms and signs troubled patients in the year after suffering from zygomatico-orbital fractures, and whether there was any discrepancy between patients' and doctors' opinions as to the presence of symptoms and signs. Over the course of 1 year, 46 patients were included. Symptoms and clinical findings were registered in a 'doctor's protocol', and patients described self-reported symptoms and signs using a visual analogue scales (VAS) in a questionnaire administered 5 times during the year after injury. The VAS proved to be a useful instrument for evaluating patient discomfort and indicating differences between patients' and doctors' opinions regarding the presence of symptoms and signs. Agreement between the two was good regarding the presence of objective and measurable signs, such as facial asymmetry and diplopia. When it came to sensibility and mouth-opening ability, however, discrepancies were evident. It is desirable that reliable methods for measuring sensibility and evaluating mouth opening are included in follow-up routines. This would increase our knowledge of the course of healing, prognosis and possibilities for the prevention and active treatment of these problems.

Adolescent↗
PubMed2005

Results of stereotactic radiosurgery for patients with imaging defined cavernous sinus meningiomas.

INTRODUCTION: The purpose of this study was to evaluate the efficacy and safety of stereotactic radiosurgery as primary management for patients with imaging defined cavernous sinus meningiomas. METHODS: Between 1992 and 2001, 49 patients had radiosurgery for dural-based masses of the cavernous sinus presumed to be meningiomas. The mean patient age was 55.5 years. The mean tumor volume was 10.2 mL; the mean tumor margin dose was 15.9 Gy. The mean follow-up was 58 months (range, 16-144 months). RESULTS: No tumor enlarged after radiosurgery. Twelve of 38 patients (26%) with preexisting diplopia or facial numbness/pain had improvement in cranial nerve function. Five patients (10%) had new (n = 3) or worsened (n = 2) trigeminal dysfunction; 2 of these patients (4%) underwent surgery at 20 and 25 months after radiosurgery despite no evidence of tumor progression. Neither patient improved after partial tumor resection. One patient (2%) developed an oculomotor nerve injury. One patient (2%) had an ischemic stroke related to occlusion of the cavernous segment of the internal carotid artery. Event-free survival was 98%, 85%, and 80% at 1, 3, and 7 years after radiosurgery, respectively. Univariate analysis of patient and dosimetric factors found no analyzed factor correlated with postradiosurgical morbidity. CONCLUSIONS: Radiosurgery was an effective primary management strategy for patients with an imaging defined cavernous sinus meningioma. Except in situations of symptomatic mass effect, unusual clinical presentation, or atypical imaging features, surgery to confirm the histologic diagnosis is unlikely to provide clinical benefit.

Adult↗
PubMed2004

Orbital imaging demonstrates occult blow out fracture in complex strabismus.

BACKGROUND: While strabismologists are familiar with diagnostic evaluation of suspected blow out fractures, unsuspected blow out fractures may further complicate difficult cases of strabismus not clinically supposed to be related to orbital trauma. METHODS: According to a prospective protocol, we studied five adults presenting with diplopia, and one with convergence-related asthenopia. No patient recalled or had any clinical suspicion of orbital fracture at initial evaluation. Surface coil magnetic resonance imaging of the orbits was performed at 312 microm resolution, slice thickness 2 mm. Quasicoronal images in central gaze were supplemented with eccentric gaze positions, and sagittal and axial images as indicated. RESULTS: Five patients had incomitant hypertropia, and one had abducens paralysis. Magnetic resonance imaging disclosed previously unsuspected blow out fractures in all six patients. Three patients had medial wall fracture, one bilaterally. Two patients had inferior wall fractures, and one inferomedial. Although only one patient had an extraocular muscle displaced into a sinus, all had evidence of orbital connective tissue distortion in the region of the rectus extraocular muscle pulleys influencing muscle paths. These effects altered the presentations of more familiar pathologies such as superior oblique palsy. After learning of the MRI findings, most patients then recalled orbital trauma from as early as childhood. CONCLUSION: Unsuspected blow out fractures occur and may confound the usual findings in complex strabismus. High-resolution orbital imaging can detect blow out fractures and clarify the pathophysiology, enabling appropriate surgical management.

Adult↗