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PubMed1997

Visual responses of neurons from areas V1 and MT in a monkey with late onset strabismus: a case study.

One adult monkey (Macaca fascicularis) was investigated psychophysically and electrophysiologically after at least 5 years of late onset esotropic macrostrabismus (squint angle 52 deg). Behavioural tests revealed normal monocular visual and visuomotor functions. No indications of deep amblyopia or oculomotor asymmetry were found. The monkey used the left or right eye alternately at about equal frequencies. Single unit recordings from area VI disclosed a normal ocular dominance distribution. Most VI neurons from both hemispheres received binocular input. Thus, discordant visual information from corresponding retinal locations of the two eyes converged onto the cortical neurons. No evidence for anomalous retinal correspondence was found. Diplopia and confusion must therefore be avoided by suppression of vision through one eye to allow stable, unambiguous perception. Possible suppression was investigated by stimulating a neuron through the same eye when it was actively used for fixation in one set of trials, and when it was not used for fixation in another set of trials. Significant differences in these two stimulus conditions were found in 20/39 neurons from area VI and in 11/34 motion sensitive neurons recorded in the middle superior temporal area (MT). The normalized population activity in VI and MT was higher if cells were stimulated through the fixating eye. The data are discussed with respect to possible suppressive mechanisms helping to prevent double vision in strabismus and in binocular rivalry.

Action Potentials↗

PubMed2004

[Imaging of neuro-ophthalmological emergencies].

MRI often is mandatory in the diagnostic work-up of visual loss, visual field alterations and oculomotor problems. It is performed emergently in patients with painful diplopia associated to mydriasis, to exclude aneurysm, or in patients with painful Horner syndrome to exclude dissection of the internal carotid artery. CT scan in emergency remains useful in case of acute lateral hemianopsia or acute post traumatic visual loss. Progressive neuro-ophthalmological symptoms may require imaging examination in a short delay to define the therapeutic strategy: monocular transient blindness (dissection or carotid stenosis), progressive visual loss (optic nerve compression), bitemporal hemianopsia (optic chiasm lesion), painful visual loss (optic neuritis). A very precise clinical indication is helpful for the choice of imaging protocol and to improve its diagnosis value.

Acute Disease↗

PubMed2001

Predictors of nonrecovery in acute traumatic sixth nerve palsy and paresis.

PURPOSE: To evaluate whether nonrecovery from acute traumatic sixth nerve palsy could be predicted from demographic factors or palsy characteristics. DESIGN: Prospective, observational case series SETTING: Multicenter (academic and private practices). OUTCOME MEASURE: Nonrecovery, defined as the presence of diplopia in primary position or more than 10 prism diopters of distance esotropia in primary position at 6 months after onset. METHODS: Using data from a previously described cohort of 84 eligible patients with acute traumatic sixth nerve palsy, we performed multivariate analyses of demographic factors and palsy characteristics. RESULTS: Nonrecovery at 6 months after onset was associated with a complete palsy (adjusted risk ratio, 9.11; 95% confidence interval [CI], 2.77-14.84) and with a bilateral palsy or paresis (adjusted risk ratio, 2.53; 95% CI, 0.98-4.29). The choice of conservative management (observation, prism, or patch) versus acute injection of Botulinum toxin (within 3 months of injury) did not influence final recovery. CONCLUSIONS: In acute traumatic sixth nerve palsy or paresis, failure to recover by 6 months after onset was associated independently with inability to abduct past midline at presentation and bilaterality. Although the overall recovery rate is high in acute traumatic sixth nerve palsy or paresis, a complete or bilateral case has a poor prognosis and is more likely to need strabismus surgery.

Abducens Nerve Diseases↗

PubMed1981

Meningioma and the ophthalmologist. A review of 80 cases.

We reviewed the charts of all patients with pathologically proven meningiomas who were admitted to the Montreal General Hospital between 1960 and 1977. Of the 80 patients reviewed, we found approximately one third of them had ophthalmological symptoms of which visual loss, field defect, and diplopia were the most common. Most of these patients also had neurological symptoms, but they were often nonspecific. One half of the patients presented with chronic symptomatology such as headache, mental change, and visual loss. One third of the patients presented acutely with seizures, hemiplegia, or dysphasia. Of the investigations done, the angiogram and brain scan were most often diagnostic, while the skull x-ray and EEG were often normal. Meningioma of the sphenoidal ridge, parasellar area, and occiput most often produced visual deficits. In almost one half of these patients, the visual deficit was initially misdiagnosed.

Adolescent↗

PubMed1982

Orbital abscess. Presentation, diagnosis, therapy, and sequelae.

Fifteen cases of orbital abscess were reviewed. Significant morbidity occurred despite treatment with intravenous antibiotics and surgical drainage. The complications included visual loss to less than 20/200 (four patients), residual proptosis (two patients), residual diplopia (two patients), osteomyelitis (one patient), and death (one patient). Seven patients reported no pain. Fever was absent in eight patients. Four patients had normal white blood cell counts. Many of these patients had received inappropriate or inadequate doses of oral antibiotics before referral. Partially treated cases of orbital abscess may not manifest the expected clinical findings of orbital infection. Four patients presented in an insidious fashion with symptoms evolving over weeks to months. Their subacute presentations in the absence of fever, pain, or elevated white blood cell count mimicked the onset of orbital tumors. CT scan failed to detect an abscess in two cases. Conjunctival and nasal cultures were not helpful in determining the bacteriologic etiology of these infections. Surgical drainage and appropriate antibiotic therapy is the definitive treatment of orbital abscess.

Abscess↗

PubMed1982

Surgery of bilateral superior oblique palsy.

Following head trauma, because the patient has no overt vertical or horizontal tropia to account for the complaint of diplopia, the symptoms are dismissed, when in fact cyclodiplopia resulting from the excyclotropic feature of bilateral superior oblique palsy is the cause. A prospective study of nine patients with bilateral superior oblique muscle palsy caused by head trauma and managed by an identical surgical regimen are presented. All patients had symptomatic cyclodiplopia that increased in downgaze. Cover testing performed in various gaze positions and in left and right head tilt positions plus the double Maddox rod tests confirmed the diagnosis. The four expected findings are left hypertropia (LHT) in right gaze and right hypertropia (RHT) in left gaze, RHT on right head tilt and LHT in left tilt, V pattern, and excyclodeviation. All patients received symmetrical bilateral superior oblique tendon surgery, using a modified technique originally described by Harada and Ito, which consisted of advancing the anterior tendon half along the equator of the globe toward the superior border of the lateral rectus muscle. Elimination of the cyclodiplopia symptom was achieved in all cases by reducing the quantity of excyclotropia.

Adult↗

PubMed1982

Ocular motility problems after orbital decompression for dysthyroid ophthalmopathy.

Ocular motility problems of 50 consecutive patients following orbital decompression for dysthyroid (Graves') ophthalmopathy were analyzed retrospectively. No significant relationship to the development of postoperative diplopia was seen in the amount of retrodisplacement of the globe, the anatomical approach for orbital decompression, or the indication for decompression. Several clinical observations were made. Patients whose indication for orbital decompression was a vision-threatening ophthalmopathy were more likely (although not statistically significantly) to develop postoperative strabismus. Patients who developed changes in preoperative strabismus were more likely to develop increased esotropia and/or restrictive hypertropia. Of 32 patients who were orthotropic in the primary position before operation, 11 developed postoperative strabismus in the primary position. Only five patients had normal versions and ductions before operation. All five of these patients had normal versions and ductions after operation.

Adult↗

PubMed1985

Orbital blowout fractures. The prognostic significance of computed tomography.

Nineteen patients with orbital floor fractures were examined and underwent computed tomography of both orbits. By evaluating the amount of orbital expansion and soft tissue herniation, we were able to identify a group of patients at high risk for developing enophthalmos (3/7 in the group with the largest amount vs. 0/7 and 0/5 in the two other groups). By studying the appearance of the inferior rectus muscle, we were also able to identify a group of patients at high risk for developing persistent diplopia (5/5 with entrapped muscles, 0/2 with hooked muscles and 0/12 of patients with free inferior rectus positions).

Diplopia↗

PubMed1986

Optical problems following refractive surgery.

All of the refractive surgical procedures share the common optical complications of glare and photophobia, undercorrection and overcorrection, regular and irregular astigmatism, loss of best corrected acuity, fluctuation in visual acuity, loss of progression of effect, and monocular diplopia. This review presents the different clinical settings under which these various complications can occur. Many of the complications are associated with technical problems at the time of surgery and abnormalities in the resurfacing of the cornea after surgery. Many of these complications can be corrected by glasses, contact lenses, or repeat refractive surgical procedures.

Adult↗

PubMed1988

Long-term results and complications of botulinum A toxin in the treatment of blepharospasm.

The authors review their long-term results and complications with the use of botulinum A toxin in the treatment of facial dystonias. Two hundred thirty-two patients in three diagnostic groups--essential blepharospasm, hemifacial spasm, and Meige's syndrome--were treated with botulinum A toxin. A total of 1044 treatments were given over a 4-year period. A reduction in orbicularis spasm intensity was noted in 1012 (96.9%) treatments (mean duration, 13.3 weeks). There was no clear relationship between toxin dose and the amount of spasm reduction or duration of response, and average duration of beneficial effect remained constant from the first through the twelfth injections. Complications occurred in 236 (22.6%) treatments. In most cases, these were local and transient. Symptomatic dry eye was the most common side effect, noted in 7.5% of cases. Ptosis was reported in 7.3% of treatments and photophobia in 2.5%. Diplopia involving the inferior oblique or lateral rectus muscles was seen in less than 1% of cases. There were no differences in degree of response or in complications among the three diagnostic groups, although there was a slight difference in duration of effect. Patients who had undergone previous eyelid surgery for blepharospasm did not respond differently from those without prior surgery.

Adult↗

PubMed1988

Visual symptoms associated with the presence of a lupus anticoagulant.

The lupus anticoagulant is an acquired serum immunoglobulin that prolongs several coagulation parameters, most notably the partial thromboplastin time (PTT). Most commonly, this condition is found in association with systemic lupus erythematosus (SLE) but may be seen with other collagen-vascular diseases and in otherwise healthy individuals. Despite the laboratory tests suggesting impaired coagulation, clinically the lupus anticoagulant has been associated with thrombosis. The authors present five patients with the lupus anticoagulant who came to medical attention because of branch retinal artery occlusion, ischemic optic neuropathy, transient visual loss, transient diplopia, or vertebrobasilar insufficiency. Eleven previously reported patients with the lupus anticoagulant and disturbed vision are also reviewed with additional findings of retinal venous occlusive disease and homonymous visual field loss. The relationship of these findings to retinopathy in SLE is discussed. Patients with the lupus anticoagulant (with or without SLE) may develop disturbances in vision due to thrombosis from a hypercoagulable state. We recommended obtaining a PTT, VDRL, and the more sensitive anticardiolipin antibody in patients with unexplained visual symptoms.

Adult↗

PubMed1989

Subjective and objective findings after radial keratotomy.

Monocular diplopia secondary to radial keratotomy was investigated in a 42-year-old ophthalmologist. Under certain conditions, the patient observed a ghost image, loss of contrast, and variability in the subjective refraction. The objective findings were scissoring of the retinoscopic reflex, a prominent iron line, and localized flattening of the cornea.

Adult↗

PubMed1989

Hyperdeviation associated with isolated unilateral abducens palsy.

Sixteen patients with isolated unilateral abducens palsy were found to have an associated hyperdeviation (HD) in peripheral gaze on Maddox rod examination. In four patients, the chief complaint was vertical as well as horizontal diplopia. Vertical ductions were normal in each case and the maximal HD ranged from 8 to 16 prism diopters (PD) in 10 of 16 patients (62.5%) and from 4 to 7 PD in 6 of 16 patients (37.5%). In ten cases, an HD in primary as well as peripheral gaze was detected. The magnitude of HD did not correlate with the degree of abduction defect, and the HD was maximal to the side of the paretic lateral rectus muscle in 14 of 16 cases, with 2 cases greatest on direct lateral gaze; 6 cases, lateral upgaze; and 6 cases, lateral downgaze. The Bielschowsky head tilt test was positive in 1 of 14 cases, and the double Maddox rod test showed the absence of cyclodeviation in 10 of 12 cases tested. A variable HD was present in six cases. In two cases, up and downshooting of the paretic eye, respectively, was noted on attempted abduction. The HD diminished in synchrony with abduction improvement. Mechanical factors and vertical substitution movements may explain the HD.

Abducens Nerve↗

PubMed1989

Primary liposarcoma of the orbit. Problems in the diagnosis and management of five cases.

The clinicopathologic features and the results of diagnostic studies were reviewed in five patients with primary orbital liposarcoma. The major clinical complaints were diplopia and proptosis; visual function was typically well maintained. In three cases, computed tomographic (CT) scans displayed lesions with a central fat density rimmed by a variably radiodense pseudocapsule, leading to the erroneous clinical impression that the lesions were cystic in character. Ultrasonography ruled out a truly cystic tumor by demonstrating internal acoustic interfaces. Magnetic resonance imaging (MRI) in one case showed hyperintense signals in T-1-weighted images, suggesting the presence of fat within the lesional tissue. In the other two cases, CT scans showed reticulated densities accentuating the septa of the orbital fat in the absence of clear-cut circumscription. A potentially useful feature pointing to a neoplasm was bowing of an involved extraocular muscle, which is usually straightened and splinted in either Graves' disease or inflammatory pseudotumor. Histopathologically, two lesions were well-differentiated liposarcomas and three were myxoid liposarcomas, all featuring univacuolar signet ring lipoblasts. Scattered bizarre hyperchromatic mesenchymal cells without prominent lipidization were present in the lesions. None of the patients has experienced regional or distant metastases with follow-ups from onset of 1 to 7 years (mean, 5.2 years); three required orbital exenteration after local recurrence; and two who refused exenteration received only orbital radiotherapy.

Adult↗

PubMed1990

Orbital varix thrombosis.

Venous disease of the orbit is a rare occurrence which can become manifest in a variety of ways including an arteriovenous aneurysm or fistula, a cavernous sinus or superior ophthalmic vein thrombosis, and an orbital varix, with and without thrombosis. Three patients had proptosis due to orbital varix thrombosis. The onset, degree of pain, and presence of diplopia were all variable. In two of three patients, computed tomographic (CT) scans showed lesions reminiscent of cavernous hemangiomas. The clinical, radiographic, surgical, and histopathologic features of this entity are described and discussed and a hypothesis is proposed to explain the pathophysiology of orbital varix thrombosis.

Adult↗

PubMed1993

Early clinical experience with the Baerveldt 350-mm2 glaucoma implant and associated extraocular muscle imbalance.

PURPOSE: The Baerveldt glaucoma implant is a new commercially available aqueous drainage device. Clinical data on the performance of the implant are relatively limited. The purpose of this investigation is to explore potential advantages and disadvantages of this implant over the more widely used Molteno implant. METHODS: Retrospective analysis was performed on 37 eyes of 36 patients with refractory glaucoma who underwent placement of a mid-sized Baerveldt 350-mm2 implant. Patient selection was based on previous failure of conventional medical, laser, and surgical management, with poor prognosis for further glaucoma surgery and adjunctive antifibrosis therapy. RESULTS: Significant postoperative extraocular motility restriction and heterotropia were found in the operated eyes. Twenty-three (77%) of 30 eyes measured have significant heterotropia in primary gaze and restriction of gaze into the quadrant of the implant. As a result, 11 (65%) of 17 functionally binocular patients have diplopia in primary gaze. CONCLUSIONS: Pending further study, the authors are avoiding placement of the Baerveldt 350-mm2 implant in both binocular and monocular patients due to the high frequency of induced heterotropia and motility restriction.

Adolescent↗

PubMed1994

Diagnostic management by gatekeepers is not cost effective for neuro-ophthalmology.

PURPOSE: To determine whether the "gatekeeper physician system" for evaluating neuro-ophthalmologic problems is cost effective. METHODS: The authors retrospectively reviewed the records of 588 patients referred for neuro-ophthalmologic evaluation between July and December 1989 to determine the frequency and cost of unnecessary diagnostic testing ordered by "gatekeeper physicians." Pre-referral diagnostic testing costs were compared with the cost of neurophthalmologic consultation for four common problems: (1) optic neuropathy; (2) diplopia; (3) ptosis; and (4) proptosis. RESULTS: Between 16% and 26% of patients in the first three diagnostic categories were subjected to overtesting, resulting in $57,900 of excessive costs, a 724% overcharge. Although the evaluation of proptosis was performed correctly, the quality of 10 of the 18 neuro-imaging procedures was substandard. CONCLUSIONS: The gatekeeper system managed by primary care physicians for these four neuro-ophthalmologic problems not only did not conserve healthcare dollars but also had a negative impact on cost control. For neuro-ophthalmologic disorders, prompt subspecialty evaluation and examination appear to be a cost-effective strategy.

Blepharoptosis↗

PubMed1994

Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy.

BACKGROUND: Progressive exophthalmos from dysthyroid orbitopathy may result in marked disfigurement. Commonly affecting middle-aged women, it can be a significant social and psychologic handicap. Cosmesis is increasingly recognized as an indication for orbital decompression. Many argue, however, that decompression carries risks of operative complications which are only warranted where vision is threatened. METHODS: Between 1984 and 1990, the authors performed orbital decompression for cosmetic indications on 34 patients (65 orbits) with thyroid orbitopathy. The charts of these patients were reviewed to assess the results of surgery and the nature and incidence of complications. RESULTS: The mean retroplacement achieved was 4 mm (range, -1.0 to 10 mm). In 29 (85%) of the 34 patients, there was a difference of 1 mm or less in the proptosis of the two eyes postoperatively. Diplopia arose de novo in five (18%) previously asymptomatic patients. Postdecompression strabismus was managed successfully with adjustable surgery (mean, 1.3 operations per patient). With the exception of transient infra-orbital nerve hypoesthesia, there were no surgical complications. CONCLUSION: Decompression surgery is effective in reducing exophthalmos in dysthyroid orbitopathy. In this series of operations, complications were rare and treatable. Decompression is often the first of a series of operations that may be necessary to correct the cosmetic sequelae of this condition. It should be considered by experienced surgeons in carefully selected and counseled patients who have disfiguring thyroid orbitopathy.

Adult↗