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PubMed1998

High dose gabapentin in refractory partial epilepsy: clinical observations in 50 patients.

Fifty patients with refractory partial seizures took part in a prospective, observational study of adjuvant gabapentin (GBP) in increasing doses. Thirty-three were started on 400 mg GBP daily with further weekly increments of 400 mg until seizures came under control for at least 6 months or to the limit of tolerability. A further 17 patients, not fully controlled on low dose GBP, followed the same regimen. All patients took the drug three times daily. Comparisons were made with seizure numbers during a 3-month baseline during which antiepileptic medication remained unchanged. Overall, 24 of the 50 patients documented a seizure reduction of 50% or more. Fifteen did so at or below 2400 mg GBP daily. Three of these patients became seizure-free. The remaining nine appeared to respond to higher daily doses of GBP (1:2800 mg; 3:3600 mg; 1:4000 mg; 1:4800 mg; 3:6000 mg), with two becoming seizure-free. Side-effects most commonly reported included tiredness, dizziness, headache and diplopia. On GBP doses exceeding 3600 mg daily, three patients developed flatulence and diarrhoea and two more had myoclonic jerks. Mean circulating GBP concentrations (mg/l) at each 1200 mg dose level were as follows: 1200 mg-4.1; 2400 mg-8.6; 3600 mg 13.2; 4800 mg 15.5; 6000 mg-17.2. In six patients, including three taking 6000 mg daily, GBP concentrations continued to rise linearly at each dosage increment. Although limited, our results do not support the suggestion that GBP absorption is saturable. High dose GBP may be effective in controlling seizures in patients with refractory partial epilepsy.

Acetates↗
PubMed1988

Medial orbital wall fracture with enophthalmos.

An isolated blow-out fracture of the medial orbital wall is uncommon, whereas the incidence in conjunction with an orbital floor fracture is high. The most striking features of an isolated medial wall fracture are diplopia on medial and lateral gaze and/or enophthalmos. The cases of two patients with a fracture of the medial orbital wall with enophthalmos are presented. One patient had an isolated medial wall fracture, whereas the other had a combined medial and inferior orbital wall fracture. Treatment of the enophthalmos consisted of exposure of the medial wall fracture site using a bicoronal flap, freeing of the herniated soft tissues and reconstruction of the defect with an autogenous medial iliac bone graft. The incidence, aetiology, pathogenesis, signs and symptoms and surgical treatment of the isolated orbital medial blow-out fracture are discussed.

Adolescent↗
PubMed2004

The effect of antiepileptic drugs on visual performance.

Visual disturbances are a common side-effect of many antiepileptic drugs. Non-specific retino- and neurotoxic visual abnormalities, that are often reported with over-dosage and prolonged AED use, include diplopia, blurred vision and nystagmus. Some anticonvulsants are associated with specific visual problems that may be related to the mechanistic properties of the drug, and occur even when the drugs are administered within the recommended daily dose. Vigabatrin, a GABA-transaminase inhibitor, has been associated with bilateral concentric visual field loss, electrophysiological changes, central visual function deficits including reduced contrast sensitivity and abnormal colour perception, and morphological alterations of the fundus and retina. Topiramate, a drug that enhances GABAergic transmission, has been associated with cases of acute closed angle glaucoma, while tiagabine, a GABA uptake inhibitor, has been investigated for a potential GABAergic effect on the visual field. Only mild neurotoxic effects have been identified for patients treated with gabapentin, a drug designed as a cyclic analogue of GABA but exhibiting an unknown mechanism while carbamazepine, an inhibitor of voltage-dependent sodium channels, has been linked with abnormal colour perception and reduced contrast sensitivity. The following review outlines the visual disturbances associated with some of the most commonly prescribed anticonvulsants. For each drug, the ocular site of potential damage and the likely mechanism responsible for the adverse visual effects is described.

Anticonvulsants↗
PubMed2003

Clinical signs of orbital wall fractures as a function of anatomic location.

OBJECTIVE: The objective of this study was to see whether clinical signs of medial orbital wall fractures distinguished these fractures from fractures of the lateral orbital wall and the orbital floor. STUDY DESIGN: The orbital fractures of 424 patients were analyzed. The patients were divided into 2 groups: (1) patients with orbital fractures with a medial orbital wall component and (2) patients with orbital fractures without a medial orbital wall component. RESULTS: Orbital fractures with involvement of the medial orbital wall showed a significantly higher incidence (P =.001) of diplopia and exophthalmos (P =.039) than fractures without involvement of the medial wall. CONCLUSION: Posttraumatic orbital clinical signs are associated with a higher incidence of medial orbital wall component fracture. Apparent lack of involvement of the medial orbital wall should not be an exclusion criterion for a surgical intervention when clinical orbital signs exist.

Chi-Square Distribution↗
PubMed2003

Restoration of binocular single vision after long-term fusion disruption.

BACKGROUND: One of the most difficult situations faced by orthoptists and pediatric ophthalmologists is attempting to restore binocular single vision to a patient who has experienced a long-term disruption of fusion. Initial poor results with standard treatment modalities, including prisms and strabismus surgery, may lead to a diagnosis of intractable diplopia. METHODS: We examined, treated, and followed up 5 patients with strabismus after an extended period of monocular vision loss. All patients were diplopic after the restoration of visual acuity in the affected eye. RESULTS: All 5 patients experienced a period of uncomfortable intermittent fusion with the initial prismatic correction. After many months of close follow-up with prism and orthoptic therapy, comfortable fusion was restored for 3 patients. Convergence amplitudes improved with the orthoptic exercises, and we were eventually able to eliminate most or all of the horizontal prism in the 3 patients who regained binocular single vision; however vertical fusion was less responsive and most often required permanent prismatic correction. CONCLUSIONS: A combination of prism therapy, orthoptic treatment, and follow-up during a period of many months to years can restore fusion in some patients who have experienced a long-term disruption of fusion.

Adolescent↗
PubMed1998

The natural history of acute traumatic sixth nerve palsy or paresis.

BACKGROUND: Spontaneous resolution of traumatic sixth nerve palsy or paresis has been reported to range between 12% and 54%. However, previous studies have been based in tertiary referral centers, have been retrospective in nature, have included a heterogeneous group of patients, and have included patients with long-standing palsies. To provide a more accurate estimate of the true recovery rate, we performed a prospective natural history study. METHODS: All members of the American Association for Pediatric Ophthalmology and Strabismus and the North American Neuro-Ophthalmology Society were invited to enroll patients with acute traumatic sixth nerve palsy or paresis between March 1996-February 1997. Recovery at 6 months after injury was defined as absence of diplopia in primary position and less than or equal to 10 PD distance esotropia in primary position. Patients who had been treated with botulinum toxin (n = 8) within 6 months after injury and patients with <6 months of follow-up (n = 3) were excluded. RESULTS: Thirty-three eligible patients were enrolled by 27 investigators. Twenty-five (76%) of the palsies were unilateral and 8 (24%) were bilateral. The overall spontaneous recovery rate was higher than previously reported (73%, 95% CI 54%-87%). Spontaneous recovery was more frequent in unilateral cases (84%, 95% CI 64%-95%) than in bilateral cases (38%, CI 9%-76%; P = .02). CONCLUSIONS: In this prospective multicenter study of acute traumatic sixth nerve palsy or paresis, the overall spontaneous recovery rate, particularly in unilateral cases, was much higher than previously reported. Our results have important sample size implications for the planning of any randomized treatment trial and may help guide early treatment decisions.

Abducens Nerve Diseases↗
PubMed1998

Superior oblique damage from the traction suture at cataract surgery.

A 41-year-old woman underwent uneventful phacoemulsification and posterior chamber lens implantation in the right eye. Approximately a month later similar surgery was performed in the left eye. The surgery was performed with the patient under retro-bulbar anesthesia with a combination of bupivacaine (Marcaine) 0.75% and lidocaine (Xylocaine) 4% administered through a lower lid injection. Immediately after the patch was removed, the patient was aware of constant vertical diplopia. Over the ensuing 6 months the symptom worsened. Orbital computed tomography showed no abnormalities.

Adult↗
PubMed1999

Bilateral inferior rectus muscle recession for correction of hypotropia in dysthyroid ophthalmopathy.

PURPOSE: The restrictive myopathy of dysthyroid ophthalmopathy frequently results in strabismus and diplopia. The most common deviation is hypotropia. Ipsilateral inferior rectus muscle recession, the generally accepted treatment, may lead to a progressive marked overcorrection. The purpose of this study is to evaluate the results of bilateral asymmetric inferior rectus muscle operations with regard to late progressive overcorrection. METHODS: A retrospective review of all patients undergoing bilateral inferior rectus muscle recession for dysthyroid ophthalmopathy between 1993 and 1997 found 8 patients with hypotropia resulting from dysthyroid ophthalmopathy. Alignment and motility were assessed preoperatively and postoperatively in all patients. Bilateral asymmetric inferior rectus muscle recession was performed on all patients with an adjustable suture performed on the hypotropic eye. A successful, long-term, postoperative result was defined as orthophoria or a vertical misalignment of less than or equal to 5 PD in primary gaze. RESULTS: Data were collected from 8 patients at 4 to 6 weeks postoperatively. Six patients had successful alignment, and 2 patients remained undercorrected. Seven patients were successfully aligned, and 1 patient was undercorrected at the latest postoperative examination (mean, 18 months). CONCLUSION: In our series, bilateral asymmetric inferior rectus muscle recession resulted in successful correction of hypotropia without late postoperative overcorrections in patients with dysthyroid ophthalmopathy.

Adult↗
PubMedDate not supplied

Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device.

BACKGROUND AND OBJECTIVES: Complications related to cerebrospinal fluid (CSF) leak and low CSF pressure can occur following placement of an intrathecal drug delivery device. METHODS: A 58-year-old man with chronic, intractable lower back pain underwent implantation of an intrathecal drug delivery device. On the fourth postoperative day, he developed a postural headache and diplopia with findings compatible with left sixth cranial nerve palsy. The headache subsequently became constant and nonpostural. Cranial magnetic resonance imaging was obtained that showed the presence of a posterior subdural intracranial hematoma. Conservative treatment for postdural puncture headache did not improve the symptomatology. Therefore, an epidural blood patch was performed that produced rapid improvement and eventual resolution of symptoms. CONCLUSIONS: Intrathecal catheter implantation can result in CSF loss that might not resolve promptly with conservative therapy. In this case, epidural blood patch proved to be a safe and effective form of treatment.

Analgesics, Opioid↗
PubMedDate not supplied

Lack of efficacy of an epidural blood patch in treating abducens nerve palsy after an unintentional dura puncture.

BACKGROUND AND OBJECTIVES: Unintentional dural puncture with a Tuohy epidural needle during the course of an epidural anesthetic may lead to a postdural puncture headache and double vision. We describe a parturient that developed left abducens nerve palsy after an epidural anesthetic for labor. METHODS: A 32-year-old female developed a postdural puncture headache 1 day after an epidural anesthetic for labor. Over the next several days she began to complain of diplopia. Subsequent to this, she developed lateral rectus muscle palsy. RESULTS: The lateral rectus palsy resolved spontaneously 8 weeks after the epidural anesthetic. CONCLUSIONS: We believe that a dural puncture during an attempted epidural anesthetic resulted in cerebrospinal fluid (CSF) leakage with a consequent headache. The CSF leak caused traction on the sixth cranial nerve resulting in lateral rectus muscle palsy. An epidural blood patch performed after the onset of symptoms did not acutely resolve the abducens nerve palsy.

Abducens Nerve Diseases↗
PubMed2001

Accommodative esotropia: an unrecognized cause of hemifacial spasm in children.

Pediatric hemifacial spasm can be a sign of an intracranial tumor. We examined two females, ages 2 and 6 years, who presented with hemifacial spasm as an early sign of accommodative esotropia. Initial ophthalmologic examination disclosed high hyperopia without detectable esotropia. Both children developed an intermittent esotropia over the following month. In the first child, the hemifacial spasm resolved concurrent with the onset of amblyopia. In the second child, spectacle correction produced immediate cessation of the spasms. In both children, squinting to avoid diplopia produced an overflow facial movement that manifested as hemifacial spasm. Accommodative esotropia should be considered in the differential diagnosis of pediatric hemifacial spasm.

Amblyopia↗
PubMed2006

Isolated inflammatory sphenoiditis with multiple unilateral cranial nerve palsies.

Isolated sphenoidits is a rare entity that often presents with vague, non-specific symptoms. We present the case of a 36-year-old Middle Eastern man, who developed headache and a painful right eye. A diagnosis of acute sphenoiditis was made. Shortly afterwards, he developed diplopia due to isolated abducent nerve involvement. Within two months, the extent of cranial nerve involvement had increased to include cranial nerves II, III, and V. Subsequently, this was treated by functional endoscopic sinus surgical drainage and biopsy. Histology revealed inflammatory changes. The patient made a dramatic recovery post-operatively, with resolution in all symptoms.

Adult↗
PubMed1999

The ophthalmology of internal carotid artery dissection.

PURPOSE: Carotid dissection is an important cause of cerebral and retinal ischemic symptoms, especially in young adults. This article presents a patient material and also includes a review of the ophthalmologic signs and symptoms of carotid dissection. MATERIAL AND METHODS: Twenty-eight patients with spontaneous dissection of the extracranial internal carotid artery dissection underwent a neuro-ophthalmological examination. RESULTS: Twenty-three patients had oculosympathetic paresis. Two experienced transient monocular blindness; in one the episodes were provoked by sitting up from a supine position. One patient presented with a monocular visual field defect, due to posterior ischemic neuropathy, and two others with homonym hemianopia. Diplopia, caused by an incomplete VIth cranial nerve palsy was recognised in one. CONCLUSION: All but one patient presented with detectable ophthalmologic symptoms or signs. Very often the ophthalmologist is the first medical contact for patients with internal carotid artery dissection. The condition is serious, and a prompt evaluation and treatment is indicated to prevent irreversible sequelae.

Abducens Nerve↗
PubMed2000

Extramedullary plasmacytoma of the orbit.

PURPOSE: To report a case of extramedullary plasmacytoma of the orbit. METHODS: A 71-year-old patient presented with diplopia eyelid fullness and limitation of ocular motility in the left eye. Visual acuity was counting fingers, intraocular pressure 34 mmHg and fundus eye examination showed choroidal folds in the involved eye. RESULTS: CT scan showed a mass filling the superior and external left orbit without bone destruction. A biopsy was performed revealing that the tumour was composed of plasmacytoid cells positive with immunohistochemical stains for Kappa light chains and epithelial membrane antigen. Systemic work up was negative. The diagnosis of extramedullary orbital plasmacytoma was made. The patient was treated with external beam radiotherapy (40 Gy) and has remained disease free for four years (49 months). CONCLUSION: Extramedullary plasmacytomas of the orbit are extremely rare tumours. Accurate and early diagnosis is essential for the therapeutic approach. Extensive medical work up to rule out multiple myeloma or other malignant lymphoproliferative conditions involving the orbit is needed when the diagnosis of orbital extramedullary plasmacytoma is suspected because treatment and prognosis are very different.

Aged↗
PubMed2002

Primary palpebral and orbital ossification in pseudo-pseudohypoparathyroidism.

PURPOSE: To present a case of ossification of the eyelid, episclera and orbit in a patient with pseudo-pseudohypoparathyroidism (pPHP). METHODS: A 20-year-old woman diagnosed with pseudo-pseudohypoparathyroidism underwent clinical and histopathological examination of calcified plaques of the right eyelid and orbit. The patient presented with a round face, tousled short hair and retarded speech. She had been diagnosed with pPHP at 3 years of age. During her first decade, calcified plaques developed in the right eyelid and orbit. Gradually, she developed horizontal diplopia, pseudo-ptosis and periorbital pain. Vertical eye movements were reduced to 10 mm, although levator function remained intact. Computer tomography scans of the orbit showed three separate dense structures. Radiographic findings also showed bilateral shortening of the fourth metacarpus and a calcified subcutaneous plaque in the left thigh. The patient's blood status revealed an elevated level of thyroid stimulating hormone, but was otherwise normal. The patient was treated with eltroxin and shortly afterwards regained normal hair and normal speech function. RESULTS: The calcified structures were removed surgically and almost normal eye movements were re-established. Histological examination of the excised tissue demonstrated bone formation. CONCLUSION: This is the first reported case of ossification of the eyelid and orbit in a patient with pseudo-pseudohypoparathyroidism.

Adult↗
PubMed1991

Early botulinum toxin treatment of acute sixth nerve palsy.

Eight patients with total sixth nerve palsy were treated with botulinum toxin injection to the antagonist non-paretic medical rectus, within eight weeks of the onset of the palsy. Within a few days seven of the eight gained fusion without the necessity of a marked head turn, and none complained of confusing reversal of diplopia. The same seven recovered full function. The mean follow-up period after the last injection was 20 months. Seven palsies were the result of head trauma and one was due to cerebro-vascular disease. This preliminary report suggests that early botulinum toxin injection of patients with recent onset sixth nerve palsy is beneficial. Although all of the patients may possibly have recovered full lateral rectus function without treatment, the aetiologies of their palsies were of the type that frequently do no resolve. A randomised double-blind study is necessary more precisely to determine the effectiveness of this form of therapy.

Abducens Nerve↗
PubMed1994

Extraocular muscle problems in thyroid eye disease.

In this paper methods of visualisation of the extraocular muscle changes in thyroid eye disease are discussed. The histopathology of extraocular muscle biopsies has been studied by both light and electron microscopy to show the type of cellular infiltration and the amorphous material in the extracellular matrix. A series of questions to which answers have not yet been found concerning thyroid eye disease are posed which may help to direct new research projects. Finally, in the last part of the paper, the surgical results in a series of 41 patients having ocular muscle surgery for diplopia and/or compensatory head postures due to thyroid eye disease are described. The conclusions drawn from these results are that one should maintain the patient euthyroid, establish by orthoptic measurements that the ocular movements have been stable for at least 6 months, treat by recessing tight muscles using adjustable sutures, and aim to undercorrect the vertical deviation at the time of adjustment.

Diplopia↗