Acute abducens nerve palsy after COVID-19 vaccination in a young adult

We present the case of a 23-year-old young man with left-eye abducens nerve palsy following the COVID-19 vaccination. Given the temporal relationship between vaccination and the onset of symptoms, the lack of systemic history, and unremarkable magnetic resonance imaging, the patient’s abducens nerve palsy was related to his vaccination. The ophthalmologist should be aware of this neurotropic sequela of COVID-19 vaccination in young adults.     

COVID-19 asociada a nistagmo

This case reports a 20-year-old female patient who was in northern Italy when the state of emergency was declared on the 31st of January 2020, developing 15 days after return to Spain upper respiratory symptoms characterized by fever, headache and anosmia that was treated as sinusitis. Three weeks later presented with dizziness and an intermittent horizontal nystagmus with rotatory component. Otorhinolaryngology and neurological examination including MRI were normal. COVID-19 IgG antibodies where positive. In the context of the ongoing pandemic, and associating the symptoms with positive IgG antibodies, we can consider the infection of SARS-CoV-2 as a probable cause of the acquired nystagmus.     

Isolated abducens nerve palsy associated with retinoic acid therapy: a case report

Isolated abducens nerve palsy is a rare complication of treatment with various drugs. Here, the authors report the case of a 23-year-old female with isolated left abducens nerve palsy after long-term retinoic acid therapy. The association is based on the temporal relationship and the exclusion of other possible etiologic factors following extensive laboratory and imaging diagnostics. The authors suggest that isolated abducens nerve palsy may be a presenting sign of a toxic neuropathy associated with retinoic acid therapy. After the exclusion of other organic lesions, especially idiopathic intracranial hypertension, and an assessment of the risk-benefit ratio, discontinuation of treatment must be considered in such cases.     

Acute Abducens Nerve Palsy in a Patient who Sustained Mechanical Trauma to the Orbit

Background:Abducens nerve (Cranial Nerve VI) innervates the lateral rectus (LR) muscle. Head trauma is one of the most common causes of abducens nerve palsy. Orbital and/or facial injuries could also affect the LR muscle directly or the orbital course of abducens nerve and lead to palsy. We present a case of a young man with multiple orbital fractures and an impingement of the LR muscle resulting in a complete loss of abduction.Case Report:A 29-year-old male reported falling 15 feet. He presented with diplopia and had complete abduction deficit of the left eye. Orbital CT imaging revealed a bony spur from his left zygomatic bone impinging on the lateral rectus muscle. In view of –4 abduction deficit, he was operated upon to remove the bony spur. This led to a gradual, but complete recovery of his abduction.Discussion:The abducens nerve has a tortuous course and as a result is commonly injured during head trauma, in particular due to its vulnerability as it passes into Dorello’s canal, or its journey through the cavernous sinus. The case report highlights orbital causes such as direct muscle avulsion or injury to the orbital portion of the abducens nerve, as reasons for how LR weakness could be easily overlooked, unless specifically examined with high-resolution orbital imaging.Conclusion:Orbital mechanical causes can be overlooked in LR palsy. We emphasise the role of orbital imaging in any patient with abducens nerve or LR Palsy and reaffirm that not all cases are associated with an intracranial cause.     

Neuro-ophthalmological manifestations of diabetes mellitus during COVID-19-related lockdown in India

Purpose:The coronavirus disease 19 (COVID-19) pandemic has resulted in a huge impact on the health care system. Diversion of health care workforce toward management of a high number of COVID-19 cases and lockdown restrictions have affected the follow-up of patients. The objective of this study was to analyze the impact of this situation on the control of diabetes, eventually resulting in related neuro-ophthalmological complications.Methods:This retrospective case series included diabetic patients visiting the neuro-ophthalmology clinic at a tertiary care eye center in India from 25 March 2020 to 25 September 2020 during the lockdown. The incidence of diabetes-related neuro-ophthalmological complications, including third, fourth, sixth nerve palsies and non-arteritic anterior ischemic optic neuropathy (NAION) was evaluated and compared with that of the same period during 2019.Results:Overall disease incidence rate was significantly higher in the year 2020 (60.2%) compared to the previous year of 2019 (29.8%). The proportion of third nerve palsy (4.8% vs 16.3%, P < 0.001) and NAION (0.3% vs 14.3%, P < 0.001) had increased. Even though the percentage of sixth nerve palsy was 25% in 2020, this was not significantly different from 2019. There was a reduction in the percentage of fourth nerve palsy cases from the year 2019 to 2020.Conclusion:There was a significant increase in diabetes-related neuro-ophthalmic complications during the COVID-19 lockdown. This can possibly be attributed to worsening of glycemic control in diabetic patients.     

Abducens Nerve Palsy Following Expansion Cranioplasty with Distraction Osteogenesis

Abstract

Childhood abducens nerve palsy can occur as a result of trauma, tumour, vasculopathic disease, elevated intracranial pressure, infection, inflammation, and congenital or idiopathic causes. The authors present two cases of unilateral abduction deficit secondary to a recent trans-sutural distraction osteogenesis (TSuDO) operation for craniosynostosis. After distractor removal, the problem resolved spontaneously over 2–4 months in both cases. This is a first reported case of sixth nerve palsy as a complication of TSuDO operation.     

Neurological Imaging in Acquired Cranial Nerve Palsy: Ophthalmologists vs. Neurologists

ABSTRACT

Purpose: Cranial nerve palsies often require neurological imaging by MRI. Guidelines on whether or not to utilize MRI have been absent or lack clarity. In daily practice, both neurologists and ophthalmologists treat patients with cranial nerve palsy and determine whether neuro-imaging is required. There appear to be differences in policy with respect to neuro-imaging. The question, which will be answered in this study, is the following: to what extent do differences in policy exist between ophthalmologists and neurologists regarding imaging by MRI of patients with acquired ocular cranial nerve palsy?

Method: PubMed database was searched for literature on acquired cranial nerve palsy and MRI scanning performed by ophthalmologists and neurologists. Case series published between 2000 and 2015 were included. The first author screened the literature on eligibility, profession of the authors, and conducted data abstraction.

Result: Ten case series were found eligible for analysis. A total of 889 cranial nerve palsies were described, 770 by ophthalmologists and 119 by neurologists. The age range of patients in all case series was 2 to 96 years of age. The oculomotor nerve was investigated in 162 patients, the trochlear nerve in 131 patients, and the abducens nerve in 486 patients. All neurologists (n=3) and 2 out of 7 investigated ophthalmologists recommended performing MRI scanning in every patient who presented with an ocular cranial nerve palsy, while 5 ophthalmologists (5/7) opted to triage patients for risk factors associated with cranial nerve palsies prior to ordering MRI imaging. When different groups of patients were viewed separately, it became apparent that almost all specialists agreed that every patient with a third nerve palsy and patients under 50 years of age should undergo MRI scanning. In patients with fourth nerve palsy, MRI scanning was not indicated.

Conclusion: The neurologists in this study were more likely to perform MRI scanning in every patient presenting with ocular cranial nerve palsy. Ophthalmologists were more likely to determine risk factors associated with cranial nerve palsy, which they took into account when deciding whether or not to perform neurological imaging in patients aged more than 50 years or presenting with abducens nerve palsy.     

Neuromyelitis optica spectrum disorder post-COVID-19 infection: A rare case report from Northeast India

Multiple sclerosis and neuromyelitis optica spectrum disorder may be seen in the acute setting of coronavirus disease 2019 (COVID-19) infection or even post-recovery. Such patients may present with optic neuropathy along with weakness in the back and lower limbs. Ascending paralysis can present with respiratory distress in acute COVID-19 infection and may even prove to be fatal. We report a unique case of a 16-year-old female with past history of COVID-19 infection having optic neuropathy, and radioimaging showing demyelinating plaques in the central nervous system with spinal cord edema. Serology showed positivity for rheumatoid arthritis, and the patient was managed with steroids and rituximab.     

Preoperative COVID-19 testing for elective vitreoretinal surgeries: Experience from a major tertiary care institute in South India

Purpose:To study the prevalence of asymptomatic SARS-CoV-2 virus infection (COVID-19) among patients undergoing elective vitreoretinal surgeries at a tertiary care eye hospital.Methods:This cross-sectional, observational study was performed between July 16, 2020 and August 31, 2020, in the retina clinic of a tertiary care eye hospital in south India. All patients undergoing elective retinal surgical procedures underwent RT-PCR testing for SARS-CoV-2 before being posted for surgery and after obtaining informed consent. Patients planned for surgery under general anesthesia underwent additional computed tomography of the chest. Testing strategies and outcomes were documented.Results:Out of a total of 413 patients who were given appointments for surgery during this period, nine patients (2.2%) were found to have positive RT-PCR for SARS-CoV-2, and their surgeries were postponed. The test positivity (prevalence) rate of asymptomatic COVID-19 infection among all elective vitreoretinal surgical patients in our hospital was 2.2%. None of the patients were symptomatic for COVID-19.Conclusion:Our results showed that among patients visiting high volume ophthalmic centers in the near future, approximately 1 in 45 patients may be asymptomatic, SARS-CoV-2 RT-PCR positive. Asymptomatic COVID-19 patients may lead to chances of transmission of the virus inside healthcare facilities among other visiting patients and healthcare workers.     

Small fiber neuropathy in the cornea of Covid-19 patients associated with the generation of ocular surface disease

PurposeTo describe the association between Sars-CoV-2 infection and small fiber neuropathy in the cornea identified by in vivo corneal confocal microscopy.MethodsTwenty-three patients who had overcome COVID-19 were recruited to this observational retrospective study. Forty-six uninfected volunteers were also recruited and studied as a control group. All subjects were examined under in vivo confocal microscopy to obtain images of corneal subbasal nerve fibers in order to study the presence of neuroma-like structures, axonal beadings and dendritic cells. The Ocular Surface Disease Index (OSDI) questionnaire and Schirmer tear test were used as indicators of Dry Eye Disease (DED) and ocular surface pathology.ResultsTwenty-one patients (91.31%) presented alterations of the corneal subbasal plexus and corneal tissue consistent with small fiber neuropathy. Images from healthy subjects did not indicate significant nerve fiber or corneal tissue damage. Eight patients reported increased sensations of ocular dryness after COVID-19 infection and had positive DED indicators. Beaded axons were found in 82.60% of cases, mainly in patients reporting ocular irritation symptoms. Neuroma-like images were found in 65.22% patients, more frequently in those with OSDI scores >13. Dendritic cells were found in 69.56% of patients and were more frequent in younger asymptomatic patients. The presence of morphological alterations in patients up to 10 months after recovering from Sars-CoV-2 infection points to the chronic nature of the neuropathy.ConclusionsSars-CoV-2 infection may be inducing small fiber neuropathy in the ocular surface, sharing symptomatology and morphological landmarks with DED and diabetic neuropathy.     

A rare case of Moebius sequence

We report a case of an 18-year-old male who presented with watering and inability to close the left eye completely since 6 months and inability to move both eyes outward and to close the mouth since childhood. Ocular, facial, and systemic examination revealed that the patient had bilateral complete lateral rectus and bilateral incomplete medial rectus palsy, left-sided facial nerve paralysis, thickening of lower lip and inability to close the mouth, along with other common musculoskeletal abnormalities. This is a typical presentation of Moebius syndrome which is a very rare congenital neurological disorder characterized by bilateral facial and abducens nerve paralysis. This patient had bilateral incomplete medial rectus palsy which is suggestive of the presence of horizontal gaze palsy or occulomotor nerve involvement as a component of Moebius sequence.     

Adie-Holmes syndrome associated with COVID-19 ınfection: A case report

With increasing experience, it has been suggested that the SARS-CoV-2 virus has a neurotropic effect. Here, we present a case of a tonic pupil who developed after COVID-19 infection. A 36-year-old woman presented with progressive photophobia and blurred vision. On neurological examination, loss of deep tendon reflexes accompanying a tonic pupil was detected and brain MR imaging was normal. With this case, we aimed to describe a rare pattern of neurological involvement caused by the possible SARS-CoV-2 virus.     

COVID-19 provoked internuclear ophthalmoplegia in a child with arrested hydrocephalus

Internuclear ophthalmoplegia (INO) is a neuro-ophthalmic disorder caused by damage in the medial longitudinal fasciculus between the third and sixth cranial nerve nuclei. We present a 4-year-old female diagnosed with INO triggered by coronavirus disease 2019 (COVID-19) infection. The patient had history of neonatal meningitis with hydrocephalus without history of surgical intervention. To the best of our knowledge, this is the first case with combined COVID-19 and chronic hydrocephalus as an etiology for INO in a child. COVID-19 may trigger neurological manifestations as INO in susceptible cases.     

Bilateral Abducens Paralysis Secondary to Compression of Abducens Nerve Roots by Vertebrobasilar Dolichoectasia

Abstract

Vertebrobasilar dolichoectasia is characterized by dilatation, tortuosity, and marked elongation of the vertebral and basilar arteries. Dolichoectatic arteries usually have thin arterial walls secondary to degeneration of the internal elastic lamina, reticular fibre deficiency, and smooth muscle atrophy. This anomaly is relatively uncommon and generally asymptomatic. Clinical manifestations of dolichoectasia result from the compression and displacement of adjacent structures, causing cranial nerve palsy, obstructive hydrocephalus, or ischaemic stroke. The authors present a case in which vertebrobasilar dolichoectasia led to the development of bilateral abducens nerve paralysis in a 9-year-old girl.     

Abstracts of the 2010 Meeting of the International Neuro-Ophthalmology Society,Lyon, France

Abstract

Endovascular treatment, including transarterial embolisation and transvenous embolisation, is generally considered effective for treating carotid-cavernous fistula. Immediate cranial nerve palsy following the procedure is the most common complication, but it usually resolves spontaneously. The authors report two cases of late-onset abducens nerve palsy after successful obliteration of direct carotid-cavernous fistulas, both of which required strabismus surgery.     

Isolated abducens nerve palsy induced by vincristine therapy.

We report a 28-year-old man with non-Hodgkin's lymphoma who presented with acute onset of diplopia 3 weeks after the completion of combination chemotherapy with vincristine. He had a left esotropia with marked decrease in abduction. Magnetic resonance imaging scan of the brain showed thickening and enhancement of the left abducens nerve. Lymphomatous and other intracranial pathologies were excluded, and vincristine neurotoxicity was considered as the possible etiology of the abducens nerve palsy. His diplopia improved gradually, then completely resolved 4 weeks after the cessation of vincristine therapy. We concluded that isolated ocular muscle paresis can be the presenting sing of a toxic neuropathy associated with vincristine use.     

Retinal and peripapillary vessel density increase in recovered COVID-19 children by optical coherence tomography angiography

PurposeTo evaluate retinal vascular changes in children who have recovered from coronavirus disease (COVID-19) using optical coherence tomography angiography (OCTA) and to compare the results with age-matched healthy children.MethodsIn this cross-sectional case–control study, children 6-18 years of age with laboratory-confirmed SARS-CoV-2 infection were compared with historic healthy controls. All participants underwent ophthalmological examination, including fundus photography and OCTA of the macular region and optic disk. COVID-19 children were examined 4-8 weeks after COVID-19 diagnoses. Demographic data, medical history, and COVID-19 symptoms were noted. OCTA parameters in the superficial capillary plexus (SCP) were analyzed according to ETDRS sectors and peripapillary quadrants.ResultsA total of 72 patients were included: 27 recovered COVID-19 children and 45 controls. Mean age for cases was 11.96 ± 3.8 years (18 females [66%]); for controls, 11.02 ± 2.0 years (29 females [64%]). Macular OCTA of the SCP showed a significant increase in retinal vessel density (VD) in recovered COVID-19 children compared with healthy controls in the inner ring (P = 0.001). Macular perfusion density (mPD) was also increased in the inner ring (P = 0.001). Peripapillary OCTA evidenced a significant higher flux index (FI) in all four quadrants (P < 0.001).ConclusionsRecovered COVID-19 children present increased retinal VD, mPD, and peripapillary FI shortly after recovery. Since the retinal vasculature is considered a unique window to assess microvascular changes, these findings may represent a potential in vivo biomarker of vascular abnormalities in COVID-19 children in other organs.

     

Retinal manifestations in patients following COVID-19 infection: A consecutive case series

Purpose:To describe retinal manifestations seen in patients associated with COVID-19 infection at a multi-specialty tertiary care hospital in Southern India.Methods:In this retrospective chart review, all consecutive cases presenting to the Retina-Uveitis service from May 2020 to January 2021 with retinal manifestations associated with COVID-19 infection or its sequelae or as a result of treatment given for COVID-19 were included.Results:Of the 7 patients, 3 were female, and 4 were male. Four patients had onset of symptoms during the active phase of COVID-19 infection. Four had bilateral and three had unilateral involvement. The manifestations ranged from mild to vision threatening. Vision threatening manifestations included infections: endogenous endophthalmitis, candida retinitis and tubercular choroidal abscess and bilateral pre-foveal hemorrhages. Milder manifestations included paracentral acute middle maculopathy, central serous chorio-retinopathy and voriconazole induced visual symptoms. Final visual acuity was 6/36 or better in the four severe cases and 6/9 or better in the mild cases.Conclusion:This study highlights the retinal manifestations associated with COVID-19 infection and its sequelae. As these patients presented with an association with COVID-19 (either during or after recovery), ophthalmologists should be vigilant and screen for such entities in case of complaints of visual symptoms or in the presence of systemic sepsis. The outcomes can be good with prompt and aggressive management.     

Isolated Pupil-Involving Third Nerve Palsy as the First Presentation of Sarcoidosis

Abstract

Neurosarcoidosis is seen in 5–15% of patients with systemic sarcoidosis. The most common cranial nerve presentations are optic neuropathy and facial nerve palsy. The authors present a case of sarcoidosis presenting with a pupil-involving third nerve palsy. The patient responded to corticosteroid therapy with resolution of investigations her cranial nerve palsy but progressed to develop cerebellar signs. This is the first documented case of a pupil-involving third nerve palsy occurring as the first presentation of neurosarcoidosis. Although typically a pupil-involving third nerve palsy necessitates urgent neuroimaging to rule out a posterior communicating artery aneurysm, it is important to recognise inflammatory causes in the differential diagnosis.     

Retinal vein occlusion in COVID-19: A novel entity

Coronavirus disease 2019 (COVID-19) is a form of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has been declared a pandemic by the World Health Organization (WHO). Ocular manifestations related to COVID-19 are uncommon with conjunctivitis being reported in a few cases. We report a unique case of vasculitic retinal vein occlusion (RVO) secondary to COVID-19 in a 52-year-old patient who presented with the diminution of vision in the left eye 10 days after he tested positive for SARS-CoV-2. All investigations for vasculitis were negative. This case supports the mechanism of thrombo-inflammatory state secondary to the “cytokine-storm” as the pathogenesis for systemic manifestations of COVID-19.