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Orbital myositis is a rare disorder considered as a subgroup of inflammatory orbital pseudotumors. The pathophysiology is still unknown. Patients typically present with orbital pain exacerbated by eye movement and diplopia. Response to steroids is dramatic. We report a case of idiopathic myositis of the right inferior muscle, which recovered after steroid therapy.
Cataract extraction performed under local anesthesia is not so safe. During a 2 years period, 8 patients have presented a complication: 3 patients are presented with diplopia, 4 patients are presented with eyeball perforation and 1 patient developed a central complication. All those complications are caused by the superior peribulbar injections of anesthetics. A survey of the different etiologies of the superior rectus muscle blow and of eyeball perforation is given.
The paper for the first time presents statistically processed data on the cyclofusion reserves of subjects with normal binocular vision (25) for different age groups: adolescents aged 12-14 and adults aged 18-35 years. Two types of tests for evaluating cyclofusion under conditions of haploscopy (sinoptophore) are offered. The results can be used as a criterion for evaluating cyclofusion in various oculomotor abnormalities: squint, diplopia, and cyclotropia.
Palsies of cranial nerves are well-known complications after lumbar puncture. Sixth nerve palsies are the most common. They normally occur 4 to 14 days after the lumbar puncture and spontaneously recover in a few weeks or months. The occurrence of a fourth nerve palsy following lumbar puncture however is extremely rare. We report on a patient who developed a combined contralateral fourth and sixth nerve palsy after lumbar puncture (Syndrome of Intracranial Hypotension), requiring surgical correction for secondary diplopia.
OBJECTIVE: To review the neurological manifestations of isolated sphenoiditis. METHODS: The symptoms, signs, imaging data, diagnoses and outcomes of 14 cases with sphenoiditis hospitalized in Peking Union Hospital June 1995-January 2001 were analyzed retrospectively. RESULTS: The chief complaints of this group included headache (12 cases), visual loss and/or diplopia (7 cases), blood in nasal discharge (3 cases), purulent nasal discharge (2 cases), exophthalmoptosis (1 case), fixation of eyeball (1 case), and pharyngodynia (1 case). Six patients presented deficits of the second and/or third, fourth, and sixth cranial nerves; one patient had hemiplegia and aphasia; no more presentation of nervous system was found in all patients. Only five patients showed signs of posterior sinusitis in rhinologic examination. CT and/or MRI revealed isolated sphenoiditis (11 cases) and sphenoiditis with posterior ethmoiditis (3 cases). The complications of this group were intracranial infection involving frontal, temporal, and parietal lobes and brainstem (1 case), aneurysm of cavernous carotid artery (1 case), nasal cerebrospinal fluid leakage (1 case), optic neuritis (5 eyes), abducent paralysis (2 cases), orbital cellulitis (1 case) and orbital apex syndrome (1 case). All of the patients underwent endoscopic sphenoid surgery. 13 patients were free of headache after surgery. One patient died because of hernia of brain. CONCLUSION: Headache can be the first or unique symptom of isolated sphenoiditis. Isolated sphenoiditis should be considered in diagnosis and differential diagnosis of headache. CT and MRI are the best tools in diagnosis of isolated sphenoiditis.
Seven patients of temporal arteritis with eye involvement have been presented. These cases represent a spectrum of disease from intermittent diplopia with minimal 6th nerve weakness through mild retinal ischemia with recovery to permanent bilateral blindness. Temporal arteritis should be suspected when any form of ocular ischemia is suspected by history or found on examination of an elderly person. An early diagnosis may protect the vision in both eyes if vision is normal at the time of diagnosis. If vision in one eye is decreased because of ischemia, the vision in the other eye can usually be retained if proper therapy is instituted. Furthermore, adequate therapy may even result in improvement in vision in the involved eye. Patients with biopsy proven temporal arteritis should be continued on steroid therapy until the active disease is quiescent. Inactivity should be determined by carefully monitoring the ESR while steroids are being tapered. If the ESR rises, it is indicative of continued inflammation and if steroids are not continued, the eyes remain at risk as seen in Case 5. If the ESR remains elevated for a year or more despite continuation of high steroid levels, consideration should be given to repeating the temporal artery biopsy. Temporal arteritis should be considered in the differential diagnosis of any multisystem disease in older patients. Even central nervous system involvement may occur concomitantly, since the intracranial vessels are not immune from the disease process. Tuberculosis, systemic syphilis and more recently the collagen vascular diseases have been dubbed the "great imitators" and "the protean diseases." We suggest that the same terminology can be applied to temporal arteritis. Temporal arteritis can affect any organ. Moreover, there is a wide spectrum of variation in the degree of involvement of any particular tissue as illustrated by these 7 cases of ocular involvement.
The zygomatic bone is important for the midfacial contour and for protection of the orbital contents. Zygomatic fractures frequently occur. Because they are hidden behind a simple black eye in many instances, there is a potential risk of missing the diagnosis. Fresh zygomatic fractures are relatively easy to treat, but late secondary corrections are difficult and often have dissatisfying results. The most important clinical signs of a zygomatic fracture are: flattening of the zygomatic contour, edema, haematoma, unilateral nose-bleeding, disturbed sensibility, diplopia, restricted mandibular movements, contour defects. In this paper the clinical signs of a zygomatic fracture are emphasized to enable the general practitioner to examine the patient with a simple black eye appropriately and be able to recognize a zygomatic fracture.
A Phase I clinical trial was performed on patients with solid tumors refractory to conventional therapy. Crotoxin was administered i.m. for 30 consecutive days at doses ranging from 0.03 to 0.22 mg/m(2). Patients entered the study after providing a written informed consent. Although 26 patients were entered only 23 were evaluated. Reversible, nonlimiting neuromuscular toxicity evidenced as diplopia because of pareses of the external ocular muscles was present in 13 patients. It started at doses of 0.18 mg/m(2) and lasted from 2 to 6 h. These episodes did not require dose adjustment and disappeared in 1-3 weeks of treatment. Three patients experienced palpebral ptosis, nystagmus (grade 2), and anxiety (grade 2-3) at the dose-limiting toxicity of 0.22 mg/m(2). Also at dose-limiting toxicity, 1 patient showed nystagmus (grade 2) and anxiety (grade 3) without evidence of palpebral ptosis. Transient increases (grades 1-3) in the levels of creatinine kinase, aspartate aminotransferase, and alanine transaminase attributed to crotoxin myotoxicity were observed but returned to normal by the last week of treatment. At 0.21 mg/m(2) there was a case of grade-3 anaphylactic reaction on day 31, which required treatment. Hypersensitivity was regarded as an adverse drug-related reaction, and the patient was removed from the protocol. Two patients at different doses (0.12 mg/m(2) and 0.22 mg/m(2)) had sialorrhea. Four patients had asymptomatic transient increase in blood pressure (up to 20 mm Hg) 12 h after the first injection, which lasted 24 h. No treatment was required and toxicity did not reappear. Six patients experienced slight eosinophilia during the first 2 weeks. The maximum tolerated dose was set at 0.21 mg/m(2). Objective measurable partial responses (>50% reduction of tumor mass) were noted in 2 patients treated at 0.21 mg/m(2) and 1 at 0.12 mg/m(2). One patient (at 0.21 mg/m(2)) presented a complete response on day 110. Crotoxin pharmacokinetics showed rapid absorption from the injection site to blood (t(1/2 A) = 5.2 +/- 0.6 min). Plasma concentration reached a peak (C(max) = 0.79 +/- 0.1 ng/ml) at tau(max) = 19 +/- 3 min. The half-life of the distribution (alpha) phase is 22 +/- 2 min. Starting at 1.5 h after injection, the decrease in plasma concentration becomes slower, reaching 14 +/- 3 pg/ml 24 h after injection. The profile is dominated by the elimination (beta) phase with a half-life of 5.2 +/- 0.6 h. Consequently, 24 h after the injection ( approximately 5 half-life) 97% of the product was eliminated. The area under plasma concentration versus time curve was 0.19 +/- 0.05 microg/min/ml. Assuming availability (F) approximately 1, the clearance is C(L) = 26.3 +/- 7 ml/min, and the apparent volume of distribution is V(d) = 12 +/- 3 liter/kg. The recommended dose for a Phase II study is 0.18 mg/m(2).
BACKGROUND AND OBJECTIVES: Posttraumatic carotid-cavernous sinus fistula is a rare complication of maxillofacial trauma and is seldom discussed in the literature. Motor vehicle accidents, falls, and other crush injuries contribute to the incidence of basilar skull fractures and the formation of fistulae. When injuries occur in the vessel wall, the carotid artery has the potential to fill the low-pressure cavernous sinus. The symptoms include chemosis, proptosis, pulsating exophthalmos, diplopia, ophthalmoplegia, orbital pain, audible bruits, and blindness. METHODS AND MATERIALS: The conventional treatments include carotid ligation and embolization. These techniques have often proved to be ineffective. A new method--the occlusive balloon technique--has been developed and is described in this article. A clinical case is used to illustrate the procedure. RESULTS AND/OR CONCLUSIONS: Utilization of balloon catheters provides a minimally invasive technique to treat patients, without significant morbidity or mortality. The procedure is found to be successful and predictable.
The utilization of the bicoronal scalp flap in craniofacial trauma has proved indispensable in the management of severe craniofacial injuries. It provides vast exposure of such critical structures as the cranium, frontal sinus, orbit and upper midface, compared with that for previous techniques of facial fracture reduction. Although the flap has great utility, severe complications, such as facial nerve injury, diplopia, telecanthus, and scalp necrosis, can occur. This article reviews the surgical anatomy, technique, and indications for the safe utilization of the bicoronal scalp flap approach in the management of craniofacial trauma.
Carotid-cavernous sinus fistulae (CCF) represent pathological communications between the intracavernous internal carotid artery and the cavernous venous sinus. Although trauma is the most common cause of high flow carotid cavernous fistulae, they are relatively uncommon in patients sustaining craniofacial trauma. Nevertheless, CCF require early diagnosis and rapid and effective treatment in order to prevent severe and significant morbidity. Clinical presentation may include pulsatile proptosis, ocular and orbital erythema, chemosis, diplopia, headaches, and visual loss. Cerebral angiography is currently the definitive diagnostic study. Obliteration of the fistula by endovascular techniques is the current mainstay treatment, and direct surgery is reserved for cases that have failed endovascular therapy. This article reviews clinical features, pertinent anatomy, and therapeutic approaches to carotid-cavernous sinus fistulae.
Devastating complications can occur following an uncomplicated resection of a fronto-ethmoid mucocele, namely, total blepharoptosis, diplopia, and vertical-horizontal extraocular muscle abnormalities. Four stages of reconstructive surgery were required over a two-year period of time to arrive at an acceptable appearance and useful binocular vision. Maximum care must be exercised when resecting a fronto-ethmoid mucocele. Inadvertent trauma to the orbital anatomy may result in a multitude of serious ocular complications.
Blunt trauma can lead to intra-orbital haemorrhage, which cause motility and sensibility disturbances typically found also in orbit-floor fracture. When there is also a fracture present, it can be problematic to give the function deficiencies their right causes. Spontaneous improvement of the defiencies can be expected in a reasonable percentage of cases. Operative revision therefore should not be performed in cases of doubt, or in any case not earlier than 14 days after the injury. In a severe stove-in orbit with enophthalmos and double vision the operation should be preformed within the first week. In some cases, however, residual diplopia can be expected in spite of optimal early therapy.
All antiepileptic medications have potential side-effects. Some are rather specific like diplopia for carbamazepin or lamotrigin, whereas others are not, like fatigue or unsteadiness. Most are dose-related and can therefore be alleviated by dose reduction (e.g. somnolence or tremor) but a few are idiosyncratic (e.g. rash) and require cessation of the causative agent. Some can be detected and followed-up on a clinical basis but others necessitate specific examinations.
We report the case of a 60-year old woman presenting, 3 days after arterial embolization of a dural arteriovenous fistula, with diplopia and gait disturbance in relation with right oculomotor nerve palsy and cerebellar dysfunction. On T2 weighted MR images, several hyperintense areas appeared in the pons and the midbrain. After one month, clinical symptoms and diffuse hyperintense areas resolved spontaneously, as the patient was treated by anti-vitamin K. This complication probably corresponds to reversible pontine venous congestion caused by poor venous drainage of the dural arteriovenous fistula.
THE AIM OF THE STUDY: To evaluate demographic and clinical features of the patients with myasthenia gravis. MATERIAL AND METHODS: Retrospective analysis of medical data on 82 patients with myasthenia gravis, referred to the University Hospital of Kaunas during 1992 to 2001. RESULTS AND CONCLUSIONS: More than a half of all patients with myasthenia gravis were female, and almost four fifths fell ill before the age of 50 years. The most common first sign of myasthenia gravis was unilateral or bilateral ptosis and diplopia. The Osserman-Genkins grade at onset was I in 34.1%, IIA in 35.4% and IIB in 30.5% of cases. Among thymectomised patients, the percentage of thymomas in late-onset group (> or = 50 years) was higher than in the early-onset group (< 50 years). Mortality rate was 7.3%. Myasthenic crisis was the main cause of death in all cases. Overall, 99% of patients were treated with acethylcholinesterase inhibitors and 92% with prednisolone at some time. Pharmacological remission was observed in more than 40% of patients. Prospective design of the study is recommended for the research of chronic noncommunicable diseases since it allows to evaluate the course and progression of the disease, effectiveness and side-effects of the treatment in more precise way. We used retrospective data in this study, therefore the results should be considered keeping in mind the possibility of bias and as the basis of prospective autoimmune myasthenia gravis studies in future.
BACKGROUND: Pseudotumor cerebri (PT) is a disease characterized by elevated intracranial pressure with no apparent etiology. A majority of cases of PTC occur in adults, with a distinct predilection for obese women of childbearing age. On rare occasions, PTC will affect children and is associated with different patient characteristics. CASE REPORT: A slender 10-year-old boy was brought to clinic with a one-day history of intermittent horizontal diplopia and a two-week history of severe headaches on awakening. Visual acuity, pupil function, and color vision were all normal. Cover test revealed an intermittent esotropia at distance, with full ocular motilities. Fundus examination revealed swelling of the optic disks OU. Further diagnostic testing, treatment, and followup are discussed. CONCLUSIONS: Pseudotumor cerebri in children is rare. When present, PTC in children often manifests different characteristics than adults. First, no clear sexual predilection exists for PTC in children. Second, the role of associated illnesses and medications is stronger in children than in adults. Third, the extent of neurologic deficit present in children with PTC is broader than in adults. All children with swollen optic disks warrant a thorough diagnostic evaluation. In the absence of obvious neuropathology, knowledge of the differences between adult and pediatric PTC can help avoid a diagnostic dilemma.
Papilledema and raised intracranial pressure have been reported in association with Guillain-Barre syndrome. Papilledema is usually asympotomatic or associated with mild visual field defects, without any visual loss. The cerebrospinal fluid protein is usually reported to be high. A case of a 35 year old lady is reported, who presented with headache, diplopia and progressive visual loss in both eyes and limb weakness with hyporeflexia. Optic fundus examination showed bilateral papilledema. She had features of pseudotumor cerebri. Nerve conduction studies were suggestive of polyradiculopathy. The unusual things in this case, were the profound visual loss normal cerebrospinal fluid profiles and the presentation of papilledema before the limb weakness.