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PubMed2004

[Radiotherapy for Graves' ophthalmopathy].

Graves' ophthalmopathy (GO) is the most frequent extrathyroidal manifestation of Graves' disease, an autoimmune disorder of the thyroid, whereas the precise pathogenesis still remains unclear. In Hashimoto's thyroiditis the occurrence of proptosis is an extremely rare event. The therapy for middle and severe courses of GO shows in partly disappointing results, although several therapy modalities are possible (glucocorticoid therapy, radiotherapy, antithyroid drug treatment, surgery). All these therapies lead in only 40 - 70 % to an improvement of the pathogenic symptoms. An intensive interdisciplinary cooperation is necessary to satisfy the requirements for the treatment of Graves' ophthalmopathy. As a consequence of the very different results of the few of clinical studies that were accomplished with reference to this topic, treatment by radiotherapy in the management of the disease is presently controversially discussed. In the German-speaking countries the radiotherapy is, however, firmly established as a therapy option in the treatment of the moderate disease classes (class 2-5 according to NO SPECS), especially if diplopia is present. This article describes the sequences, dosages and fractionation schemes as well as the risks and side effects of the radiotherapy. Altogether, radiotherapy is assessed as an effective and sure method. The administration of glucocorticoids can take place before the beginning of or during the radiotherapy. For the success of treatment the correct selection of patients who may possibly profit from a radiotherapy is absolutely essential. By realising that GO proceeds normally over a period of 2-5 years, which is followed by a period of fibrotic alteration, the application of the radiotherapy in the early, active phase is indispensable. A precise explanation for the effects of radiotherapy in treatment of the GO does not exist at present. The determination of the most effective irradiation doses was made from retrospectively evaluated collectives. Recently the results of a national survey of all German RT departments were published, initiated by the working group of the DEGRO (German Society of Radiooncology). In the most of the German radiooncology departments irradiation with 8 to 10 x 1.8-2.0 Gy 5 x weekly to 16 or 20 Gy is standard. Two recently published prospective German studies pointed out the equivalence of the effectiveness of a short therapy in low dose ranges up to 2.4 Gy as well as of a low proportioned irradiation during a longer period in relation to a standard therapy with 20 Gy. That is why at the moment it is not possible to give a definite recommendation with reference to dosages or the fractionation schemes. In 2003 the first European group (European Group on Graves ' Orbitopathy Experience -- EUGOGO) was founded for pursuing investigations of GO in multi-centric studies, mainly to improve therapy results.

Diplopia↗
PubMed2005

[Treatment of a complication after surgical removal of an aneurysmal cyst of the ethmoid].

INTRODUCTION: An aneurysmal cyst (AC) is a rare benign bony tumor with a possible aggressive extension. We present a complication following the surgical ablation of an ethmoidal AC. CLINICAL HISTORY AND FINDINGS: A 40-year-old man with a left ethmoidal AC extending to the orbital roof underwent 2 surgeries. After the second one involving a neuro-surgical approach, a bilateral palsy of the superior oblique muscles (SO) appeared. The diplopia did not improve following a bilateral asymmetrical recession of the inferior recti muscles done elsewhere. There was an excyclotorsion up to 20 degrees in down gaze and a vertical deviation of 10 degrees in primary position. THERAPY AND OUTCOME: We performed a bilateral tucking of the anterior SO fibres with, on the left, an advancement of the inferior rectus and a resection of the medial rectus muscles. Two weeks after surgery the absence of cyclotorsional deviation allowed a binocular vision. CONCLUSION: The double vision due to the excyclotorsion, which was the main complaint, could be alleviated by an anterior strengthening of the SO. A precise measurement of the cyclotorsion is required for the surgical procedure.

Adult↗
PubMed2006

[Ocular neuromyotonia].

BACKGROUND: Ocular neuromyotonia is a rare ocular motility disorder characterized by involuntary contractions of one or several ocular motor muscles. In this report a typical case is presented. PATIENT AND METHODS: A 61-year-old female patient was referred with persistent diplopia despite previous surgical treatment for right 6 (th) nerve palsy. The palsy was caused by a meningeoma of the petrous bone, which had been incompletely resected. Subsequently, the patient had received radiation therapy. Strabismological and neuroophthalmological examinations were performed. The results coincide with data collected in our department from three other patients with ocular neuromyotonia (2 cranial nerve VI, 1 cranial nerve IV), over the past three years. RESULTS: The patient showed orthophoria at distance (5 m) and an exophoria of 6 degrees at near vision. The abduction and adduction of the right eye were restricted to 40 degrees and 35 degrees , respectively. After several seconds of eccentric gaze to the right, the right eye remained in an abducted position of approximately 25 degrees . The gaze to the left led to a retraction instead of an adduction of the right eye. The spasm of the lateral rectus muscle resolved after some seconds, returning to the aforementioned right eye motility. Under oral treatment with carbamazepine, initially 200 mg, later increasing to 400 mg per day, the symptoms improved significantly, did not resolve entirely, however. CONCLUSIONS: These typical findings permit the diagnosis of ocular neuromyotonia. The characteristic symptoms of ocular neuromyotonia and the typical history of a previous intracranial tumor, treated neurosurgically with adjuvant radiotherapy, lead to the hypothesis that ephaptic transmission in the cranial nerve is the underlying pathophysiological mechanism in the development of ocular neuromyotonia. Hereby, efferent impulses from non-twitch motoneurons could activate neighbouring axons, and spread both peripherally and centrally. Beside other mechanisms discussed, an involvement of proprioceptive elements and their reafference is also a possible cause for the prolonged muscle contraction.

Abducens Nerve Diseases↗
PubMed2006

Isolated IVth (trochlear) nerve palsy due to basilar artery dolichoectasia.

BACKGROUND: Dolichoectasia (elongation, dilatation and tortuosity) of the basilar artery can cause an isolated cranial neuropathy. The trigeminal nerve and facial nerve are most frequently affected. Dysfunction of one of the ocular motor cranial nerves due to basilar artery dolichoectasia is uncommon, and an isolated IVth (trochlear) nerve palsy has not been previously described in the literature. HISTORY AND SIGNS: Two men, ages 70 and 59 years, respectively, presented with vertical diplopia due to a IVth nerve palsy. In one patient, the onset of the IVth nerve palsy was painless and gradual and in the other patient, the onset was acute and associated with periorbital pain. Neuroimaging in both patients revealed pathological tortuosity of the basilar artery around the midbrain and displacement of the artery toward the side of the affected trochlear nerve. THERAPY AND OUTCOME: The patients were observed clinically. One patient had gradual worsening of his palsy for three and one-half years then suffered a stroke. The second patient whose IVth nerve palsy had an acute onset experienced spontaneous resolution of his palsy but later developed dysfunction of other cranial nerves. CONCLUSIONS: Basilar artery dolichoectasia should be considered in the differential diagnosis of an isolated IVth nerve palsy. The clinical course may be variable, and the prognosis is not always benign.

Aged↗
PubMed1993

[Isolated medial orbital wall fractures: results of minimally invasive endoscopically controlled endonasal surgical technique].

Between 1991 and 1993, 9 cases of isolated medial orbital wall fractures were diagnosed with 8 patients, 8 of them complaining of horizontal diplopia due to medial rectus muscle entrapment. An endoscopic-controlled endonasal surgical procedure was performed in 7 patients. The endonasal procedure provided adequate exposure for removal of the incarcerated tissue as well as covering the defect. All 7 patients had good results with no restriction of lateral gaze and There were no surgical complications observed. The first step of the endonasal technique is a partial resection of the middle turbinate. During the following partial ethmoidectomy, the fracture of the ethmoid and medial orbital wall are exposed. This must be done carefully while avoiding any trauma to the herniated orbital contents. After repositioning the orbital fatty tissue, lyodura is introduced and fixed with fibrin glue. For larger defects, free graft of mucosa is recommended. The nasal packing is done between two silicon sheets in order to simplify the removal after 8 days. All 7 patients proved to be free of motility disturbances after the intervention. The endonasal method is limited to isolated medial wall fractures; in all other cases of midfacial fractures combined techniques have to be used.

Adolescent↗
PubMed1991

[Unusual perceptions with the Pola Test in a case of esotropia with anomalous correspondence].

That the Pola test figures of heterophoric subjects with fixation disparities are described as deformed at times, was published by H. J. Haase two decades ago. The main subject in this publication is a 13-year-old boy with early childhood convergent strabismus, in which the "squint therapy" which was used at that time, did not change the angle of squint and the anomalous correspondence to any extent. The corrected visual acuity was the same bilaterally, 1.0 to 1.1. If the esotropic eye position was corrected as well as possible with prisms to the objective angle, a change between diplopia and binocular fusion occurred; occasionally even to "normal corresponding" fusion with correct stereopsis. In the transition phases the test level appeared to be more or less drawn out in width, and the half figures underwent all kinds of "somersaults". Binocular macropsia and monocular micropsia and macropsia, and also polyopia and unusual depth effects were described. Confusion did not occur; all pictures had form. These rare phenomena were interpreted as a competition between established anomalous and latent normal correspondence. This communication should stimulate further observations of this type and, should the occasion arise, lead to experimental research.

Adolescent↗
PubMed1987

[Light phenomena in the dislocation of artificial lenses in a model trial].

Light phenomena evoked by a Kratz elliptical posterior chamber lens, a Mark Choyce IX anterior chamber lens, and a four-loop Binkhorst anterior chamber lens were investigated in a model with pupils of various sizes. Besides monocular diplopia, the edge of the lens produces scattered light phenomena which vary according to the type of lens as well as the size of the pupil. It makes little difference whether the beam of light strikes the surface of the lens perpendicularly or at an angle of 30 degrees. Of the three lenses tested, the four-loop Binkhorst lens caused the most intense scattered light, due to the fixation of its haptic near its center.

Diplopia↗
PubMed1985

[Monocular polyopia in nuclear cataract].

Only patients with primary nuclear cataracts perceive multiplied images caused by the lens. All of them see these images in a lambda-shaped arrangement. This is not a diplopia caused by the two focal points of a 'Linse mit doppeltem Brennpunkt' (double-focus lens). The monocular polyopia can be explained by a prismatic effect of the sectors of the lens nucleus.

Cataract↗
PubMed1982

[Long-term indomethacin treatment of ophthalmopathies after Basedow disease in general practice].

Seven patients with Basedow' disease were treated with 100 mg of indomethacin (rectal suppository) before going to bed and showed moderate improvement of various ocular disturbances. In two there was conspicuous regression of edema of the upper eyelid. In these patients a double eyelid hidden by the edema reappeared and the bloated sensation in the eyelid decreased. In two other patients, the edema and the bloated sensation in the eyelid decreased slightly. In two patients exophthalmus decreased by 1-2 mm. Diplopia disappeared in two patients and was improved in 1. Two patients failed to continue treatment with indomethacin suppositories, due to exacerbation of hemorrhoids. Indomethacin was moderately effective in treating Basedow's ophthalmopathy. The author believes that indomethacin is as efficacions as or more so than drugs tried so far for Basedow's ophthalmopathy.

Adult↗
PubMed2000

Ophthalmologic complications after intraoral local anesthesia with articaine.

A series of 14 cases of ophthalmologic complications after intraoral anesthesia of the posterior superior alveolar nerve is presented. The most commonly encountered symptoms were diplopia, mydriasis, palpebral ptosis, and abduction difficulties of the affected eye. In all cases, these effects occurred a few minutes after injection of the anesthetic, followed by complete resolution without sequelae on cessation of the anesthetic effect. The pathogenic mechanism underlying such ophthalmologic disorders is discussed in terms of a possible diffusion of the anesthetic solution toward the orbital region.

Adult↗
PubMed2001

Initial treatment outcomes in chronic sixth nerve palsy.

INTRODUCTION: We conducted a prospective multi-center, nonrandomized, data-collection study of patients with chronic sixth cranial nerve palsy. We evaluated success rates with conservative nonsurgical management, botulinum toxin (botox) treatment, strabismus surgery, and a combination of botox treatment and surgery. 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 sixth nerve palsy or paresis of more than 6 months duration over a 2-year period (between March 1998 and February 2000). The botox and surgical groups received intervention within 3 months of enrollment. Success at 6 months from enrollment was defined as absence of diplopia in primary position and no more than 10 prism diopters (pd) distance esotropia in primary position. Patients with no follow-up were excluded. RESULTS: Fifty-six eligible patients were enrolled by 33 investigators. Eighteen (32%) were traumatic in etiology, 15 (27%) were unknown (including presumed hypertensive), 14 (25%) were neoplastic, 2 (4%) were diabetic, and 7 (13%) were other. Twenty (35%) were managed conservatively without surgery, 10 (18%) with botox treatment, 19 (33%) with surgery, and 8 (14%) with a combination of botox treatment and surgery. Success at 6 months from enrollment was 15% in the conservatively managed cases, 10% with botox alone, 39% with surgery alone, and 25% with a combination of botox and surgery. CONCLUSIONS: This study demonstrates that management of chronic sixth nerve palsy and paresis remains challenging. Spontaneous recovery occurs but is uncommon. Botox treatment alone was rarely successful, and a single surgical procedure had a lower-than-expected success rate. Care should be taken in directly comparing success rates between treatment groups because of bias in patient selection.

Abducens Nerve Diseases↗
PubMed2002

Strabological results in patients with macular translocation surgery and counterrotation of the globe as a secondary procedure.

INTRODUCTION: Age-related macular degeneration is the most common cause of irreversible loss of visual acuity, including the ability to read, in elderly patients. One of the surgical treatment options is macular translocation with 360 degrees retinotomy. The orthoptic results of torsional muscle surgery as a second procedure are demonstrated. MATERIALS AND METHODS: Between January 1999 and December 2000, the macula was rotated upward by 12-45 degrees in 10 eyes following complete artificial detachment and a 360 degrees retinotomy. In these patients, torsional surgery was carried out as a second procedure. Depending on the resulting cyclotorsion, we performed surgery on the oblique muscles only in four patients with a cyclotropia of 12-20 degrees and a combination of oblique muscle surgery with surgery of two or four rectus muscles in the remaining six eyes (cyclotropia over 21 degrees ). The pre- and postoperative diagnostic techniques included visual acuity, reading vision and the orthoptic status. RESULTS: Due to the unilateral ectopia of the macula, all patients presented postoperative strabismus with a vertical deviation of 2-10 degrees and a subjective cyclotropia between 12 degrees and 40 degrees. After surgery on the oblique muscles, the patients showed a residual cyclotropia of 0-6 degrees. In patients in whom surgery on the oblique muscles was accompanied by rectus muscle surgery, the remaining cyclotorsion was 5-13 degrees. Four patients excluded the non-operated fellow eye, six patients experienced double vision under binocular conditions and thus required prescription of additional prism glasses. CONCLUSION: Macular translocation causes diplopia under binocular conditions because of the unilateral ectopia of the macular region with cyclotropia and vertical deviation. These problems can be resolved or reduced by oblique muscle surgery or in combination with additional surgery on the rectus muscles, depending on the range of the cyclotorsion. Performing the torsional surgery as a second procedure after macular rotation with an exact preoperative measurement of the subjective cyclodeviation appears to be useful.

Aged↗
PubMed2002

Ocular neuromyotonia: a case report.

Ocular neuromyotonia is a rare motility disorder occurring after tumor irradiation near the skull base or as a consequence of vascular abnormalities. Ocular myasthenia, convergence spasm and a cyclic third nerve palsy must be considered as differential diagnoses. The case of a 32-year-old woman suffering from intermittent diplopia six months after radiation therapy of a recurrent pituary gland adenoma is presented.

Adenoma↗
PubMed2005

Primary tuberculous petrositis.

Tuberculous osteomyelitis of the temporal bone is a rare and dangerous entity that should be included in the differential diagnosis of infectious processes of the base of the skull. We present the case of an 11-year-old child who presented with diplopia, ear discharge and hearing loss. The radiological and histopathological findings revealed tuberculous otitis with osteomyelitis and an abscess in the petrous apex. The child responded to anti-tuberculous chemotherapy. The diagnosis and management of tuberculous osteomyelitis are discussed and a brief review of the literature is presented.

Antitubercular Agents↗
PubMed2004

Extraocular muscle cysticercosis - a clinical challenge to the ophthalmologists.

PURPOSE: To report our experience with extraocular myocysticercosis, to highlight the role of ultrasound and orbital computerized tomography (CT) scan in these cases and to discuss the management. METHODS: This is retrospective study of 35 cases of orbital myocysticercosis confirmed on ultrasound and CT scan of the orbit. RESULTS: There were 18 males and 17 females. The average age of these patients was 19.6 years. The most common presenting feature was restricted ocular motility with diplopia and recurrent pain and redness. Ultrasound examination and CT scan of the orbit done for all these patients identified the cyst and the affected muscle. All extraocular muscles were noted to be involved in myocysticercosis. However the lateral rectus, medial rectus and the superior oblique were affected to a greater extent. All cases dramatically improved on treatment with albendazole and oral steroids. Surgical excision of cyst was done in 6 cases. CONCLUSION: A high index of suspicion should be entertained for extraocular muscle cysticercosis, especially in cases of acquired ocular motility disorder with recurrent ocular congestion. Ultrasound and CT scans of orbit play a vital role in diagnosis. Medical therapy with albendazole under cover of steroids is effective in most of the cases.

Adolescent↗
PubMed2001

Pontine glioma and cerebellopontine angle epidermoid tumour occurring as collision tumours.

A 36-year-old male was admitted with a 10-year history of gradually progressive left ear hearing loss, diplopia and right hemiparesis. Magnetic resonance imaging showed a left lateral pontine enhancing tumour and an additional cerebellopontine angle epidermoid tumour in close proximity forming a collision tumour. On exploration, the epidermoid tumour and the intraaxial pontine glioma were completely resected. The literature on collision tumours is reviewed.

Adult↗
PubMed2005

Acquired retraction of the eye as the first sign of myositis.

The authors report a patient who was diagnosed with idiopathic orbital myositis based on the findings of diplopia, worse on right gaze, globe retraction on adduction and injection at the lateral muscle tendon insertion of the left eye. Although orbital myositis as a cause of acquired retraction of the eye is rare, they wish to emphasize the importance of globe retraction with injection over the recti as an important clue for the diagnosis of orbital myositis.

Adrenal Cortex Hormones↗
PubMed2000

Subarachnoid cyst and ascent to high altitude--a problem?

A 31-year-old man suffered diplopia and ataxia on two occasions when he ascended from sea level to 4,000 m. Evaluation revealed a moderate-sized subarachnoid cyst in the left frontal region, which did not communicate with the cerebral ventricles. The cyst might have acted as a space-occupying lesion, and caused symptoms on ascent due to hypoxic brain swelling, brain compression against the cyst, and elevated intracranial pressure. Subarachnoid cysts are common, and they should be considered in the differential diagnosis of neurological problems at high altitude.

Adult↗