Bilateral internuclear ophthalmoplegia in a patient with Wernicke's encephalopathy.

The most common cause of bilateral internuclear ophthalmoplegia is multiple sclerosis. Wernicke's encephalopathy has been reported as a cause of unilateral internuclear ophthalmoplegia but not of bilateral internuclear ophthalmoplegia. In this report, we present the case of a patient with a history of alcohol abuse and acute onset of bilateral internuclear ophthalmoplegia whose clinical course and diagnostic studies are most consistent with a diagnosis of Wernicke's encephalopathy.     

Transient unilateral ophthalmoplegia without papilledema in a child with intracranial hypertension

Intracranial hypertension is usually presented with papilledema and headache. Complete ophthalmoplegia without papilledema is a very rare finding of intracranial hypertension in children.A 5-year-old male patient with unilateral ophthalmoplegia due to increased intracranial pressure is presented. The fundoscopic examination and the magnetic resonance imaging of the brain were normal. He underwent lumboperitoneal shunt insertion for intracranial hypertension and the ophthalmoplegia was resolved one month later.Complete ophthalmoplegia without papilledema may occur following intracranial hypertension. Prompt and accurate diagnosis should be done and appropriate treatment to reduce the pressure should be performed to save the life of the children.     

A case of complete ophthalmoplegia in herpes zoster ophthalmicus

PURPOSE: To report a case with complete ophthalmoplegia after herpes zoster ophthalmicus. METHODS: A 70-year-old male patient visited a clinic because of vesicular eruptions over the left side of his face with severe pain. Drooping and severe swelling of the left eyelid were present, along with keratitis and uveitis. While the lid swelling and uveitis were improving, external ophthalmoplegia and exophthalmos were discovered. Intramuscular injections of dexamethasone 5 mg were given for 10 days, followed by oral administration of prednisolone at a dosage of 15 mg for two weeks and 10 mg for two weeks. RESULTS: The patient was fully recovered from the complete ophthalmoplegia and exophthalmos six months after the onset of the cutaneous lesion. CONCLUSIONS: Complete ophthalmoplegia is a rare ophthalmic complication of herpes zoster infection. Therefore, an evaluation of extraocular muscle and lid function should be performed during the examination of herpes zoster patients in order to screen for ophthalmoplegia.     

Atypical clinical presentation of oculomotor (III) nerve palsy

The atypical clinical presentations of three patients with an oculomotor (III) nerve palsy are outlined. The first patient is a 49-year-old with a painful, pupil-sparing ophthalmoplegia of sudden onset due to a pituitary adenoma which had eroded into the cavernous sinus. The second patient is a 7-year-old with a traumatic III nerve palsy who despite full recovery of her oculomotility, has been symptomatic due to a permanent internal ophthalmoplegia. The third patient is an 8-year-old who has undergone prolonged optometric therapy for an "atypical esotropia," but in fact has a congenital III nerve palsy with oculomotor synkinesis and deep amblyopia.     

Acquired pendular nystagmus

A case of acquired pendular nystagmus is reported in a patient with multiple sclerosis. The nystagmus is vertical and monocular. The nystagmus is binocular after eye closure and is present only in primary position. During exacerbation of multiple sclerosis the pendular nystagmus disappears while bilateral internuclear ophthalmoplegia and rebound nystagmus are observed. On disappearance of internuclear ophthalmoplegia and rebound nystagmus, the pendular nystagmus reappeared.     

Acute phthisis bulbi and external ophthalmoplegia in herpes zoster ophthalmicus

A patient developed acute phthisis bulbi and external ophthalmoplegia with herpes zoster ophthalmicus (HZO). The clinical course and ocular complications of HZO are described briefly and the cause of phthisis bulbi and external ophthalmoplegia in zoster ophthalmicus is discussed. It is suggested that the acute hypotonia in HZO is due to an ischemic necrosis of the ciliary body, resulting from an occlusive vasculitis which may also be responsible for the external ophthalmolplegia.     

T-cell lymphoma presenting as painful ophthalmoplegia

PURPOSE: To present a case of peripheral T-cell lymphoma presenting as painful ophthalmoplegia. METHODS: A 61-year-old woman presented with a 2-week history of headache and eyeball pain. Examination showed mild exophthalmos, complete ophthalmoplegia, and ptosis of the left eye. Under the impression of nonspecific orbital inflammation, she was treated with oral prednisone with initial response. Two months later, she revisited the clinic with exacerbated symptoms. Anterior orbitotomy and incisional biopsy was performed for the inferior rectus muscle lesion. RESULTS: Histopathologic examination revealed an infiltrate of atypical lymphoid cells between degenerative muscle bundles. It was consistent with peripheral T-cell lymphoma. A metastatic workup was performed without any evidence of extraorbital tumor. The patient was recommended to be treated with chemotherapy, however, refused to take the treatment. The patient died of progression of the disease in a month. CONCLUSIONS: T-cell lymphoma in the orbit can present as painful ophthalmoplegia and take a rapid clinical course. The disease should be regarded as one of the differential diagnosis for painful ophthalmoplegia refractory to corticosteroid therapy.     

Cystoid Macular Edema in a Patient with Chronic Progressive External Ophthalmoplegia with Mitochondrial Myopathy

Purpose: To report the findings of cystoid macular edema in a patient with chronic progressive external ophthalmoplegia and other systemic features of mitochondrial myopathy. Design: Observational case report. Methods: Retrospective review of the ophthalmic examination and genetic studies of a patient with chronic progressive ophthalmoplegia. Results: Fundus photos, retinal optical coherence tomography, and fluorescein angiography were significant for findings consistent with bilateral cystoid macular edema, which were found to have resolved after 18 months without treatment. The medical examination supported the diagnosis of chronic progressive external ophthalmoplegia. Fundus photos, retinal optical coherence tomography, and fluorescein angiography were significant for findings consistent with cystoid macular edema. Conclusions: This case demonstrates the occurrence CME in a patient with CPEO and additional systemic features.     

Inadvertent retrobulbar administration of hypertonic saline prior to cataract extraction.

A 36-year-old woman with retinitis pigmentosa was scheduled for removal of posterior subcapsular cataracts and experienced inadvertent retrobulbar administration of hypertonic saline. The patient developed retrobulbar pain and ophthalmoplegia that slowly improved over time. Hypertonic saline may cause ophthalmoplegia and pain if inadvertently given as a retrobulbar injection.     

Reversible bilateral internuclear ophthalmoplegia following head injury

PURPOSE: Internuclear ophthalmoplegia is a syndrome produced by a lesion in the medial longitudinal fasciculus. Head trauma is a rare cause. We describe an unusual case of bilateral internuclear ophthalmoplegia as an isolated sequela following a minor head injury that resolved completely 3 months later. METHODS: Case report. Magnetic resonance images. RESULTS: A 34-year-old male developed typical bilateral internuclear ophthalmoplegia after closed head injury. Attempted convergence was normal. Magnetic resonance imaging clearly delineated the focal hemorrhage in the medial longitudinal fasciculus region by showing a small bright lesion in the pontomesencephalic junction in the midline on both T2-weighted and T1-weighted images. The diplopia resolved 4 weeks later. Three months after the accident, his versions were completely normal. CONCLUSION: Isolated internuclear ophthalmoplegia should be considered in the differential diagnosis when one encounters an adduction deficit in a recently traumatized patient. Magnetic resonance images enhance the ability to correlate the clinical findings with the anatomic lesion.     

Acute bilateral ophthalmoplegia in a young woman

A 34-year-old woman presented with bilateral ophthalmoplegia, ptosis, and mild gait ataxia. Tensilon test, magnetic resonance imaging, and cerebrospinal fluid analysis were normal. She initially denied any alcohol intake but later admitted to significant alcohol and multisubstance abuse. The patient improved dramatically after treatment with thiamine. Wernicke's encephalopathy is discussed, highlighting that it may be present with normal mentation. It should be considered in the differential diagnosis of bilateral ophthalmoplegia even in the absence of altered mental status.     

Pituitary apoplexy associated with cardiac surgery

Two cases of pituitary apoplexy were detected in the immediate postoperative period after cardiac surgery with extracorporeal bypass. Both patients had pituitary adenomas that were asymptomatic and previously undiagnosed. One patient, a 57-year-old man, had unilateral total ophthalmoplegia and blepharoptosis with sparing of the visual system. The second patient, a 55-year-old man, had headache, marked bilateral visual loss, and ophthalmoplegia with subsequent development of a hemiparesis. Pituitary apoplexy was confirmed pathologically in both cases. Hemodynamic instability during and immediately after surgery and anticoagulation are probable precipitating factors.     

Ocular manifestations after primary varicella infection

PURPOSE: To report a case of ocular manifestations after a primary varicella infection. METHODS: Review of the literature and a case report of a 10-year-old male patient with history of blurry vision and an enlarged pupil 2 months after a varicella infection. Examination revealed uveitis, interstitial keratitis, and internal ophthalmoplegia. RESULTS: The uveitis resolved with topical steroids; the interstitial keratitis resolved with a faint scar, and the internal ophthalmoplegia persisted. CONCLUSION: This case report describes a patient with uncommon ocular manifestations after primary varicella.     

Anti-GQ1b-Negative Miller Fisher Syndrome with Acute Areflexic Mydriasis and Cholinergic Supersensitivity

Miller Fisher syndrome is a rare variant of Guillain-Barré syndrome and it is characterised by ophthalmoplegia, ataxia, and areflexia. Pupillomotor involvement occurs in approximately half of the patients with the disorder. The authors report a patient with acute areflexic mydriasis, external ophthalmoplegia, areflexia, and ataxia. Although the pupils were unreactive to light and near stimuli, administration of 0.1% pilocarpine resulted in marked miosis, suggesting cholinergic supersensitivity. Antibodies against GM1, GD1b, and GQ1b were negative. This is the first report of acute areflexic mydriasis with cholinergic supersensitivity in anti-GQ1b-negative Miller Fisher syndrome.     

The Role of Botulinum Toxin in the Management of Ophthalmoplegia Secondary to Miller Fisher Syndrome

Miller Fisher syndrome is an acute demyelinating polyneuropathy classically presenting with ataxia, areflexia, and ophthalmoplegia. The authors report the case of a 27-year-old female, who presented with limb weakness and double vision following a prodromal pharyngitis. Ophthalmic examination revealed fluctuant ophthalmoplegia eventually consistent with bilateral sixth cranial nerve palsies, prompting investigation for anti-ganglioside antibodies, which returned positive. Due to disabling diplopia, the patient was treated with botulinum toxin, with a resulting favourable reduction in the size of strabismus. Four months following her presentation, the patient was orthophoric and resumed normal activities.     

Saccadic velocity measurements in internuclear ophthalmoplegia.

Five patients with internuclear ophthalmoplegia had horizontal saccades measured by electro-oculography. In all patients, abduction saccadic velocities were normal while adduction saccades were slowed either binocularly or monocularly. In one patient, adduction saccades were reduced in velocity, even though full adduction was present. Saccadic velocity measurements may be helpful in diagnosing internuclear ophthalmoplegia, especially in the early or subclinical case. As bilateral internuclear ophthalmoplegia frequently suggests multiple sclerosis, prolonged examination with more sophisticated and difficult diagnostic tests is avoided.     

Bilateral Internuclear Ophthalmoplegia as a Presenting Manifestation of Primary Sjögren’s Syndrome

Bilateral internuclear ophthalmoplegia has been linked with various pathological conditions of the central nervous system (CNS), such as multiple sclerosis, stroke, tumours, and brainstem inflammatory processes. Herein the authors report a case of a 45-year-old female patient who presented with diplopia due to bilateral internuclear ophthalmoplegia, with no evidence of brainstem lesion in brain magnetic resonance imaging (MRI) and was diagnosed with primary Sjögren’s syndrome.     

Bilateral optic neuritis related to chronic inflammatory demyelinating polyneuropathy

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a condition that mainly affects the peripheral nervous system; however, the central nervous system has also been involved in rare cases. Herein, we describe the case of a 33-year-old man with CIDP who presented with progressively blurred vision and pain with eye movement in both eyes for 1 month. Ocular examination revealed reduced visual acuities of 0.15 (oculus unitas or OU) and unremarkable fundi (OU). Furthermore, bitemporal visual field defects and prolonged visually evoked potentials were evident. Brain magnetic resonance imaging revealed nothing remarkable along the optic nerve and chiasm. These findings were compatible with the diagnosis of bilateral optic neuritis. The patient''s symptoms and visual acuity improved after 5 days of intravenous (IV) corticosteroid pulse therapy, which was subsequently replaced by oral prednisolone therapy with a tapering schedule. The patient''s visual acuity returned to 1.0 (OU) 6 months after treatment. However, bilateral optic neuritis recurred in 7 months while the patient was on oral prednisolone and azathioprine. IV corticosteroid pulse therapy was subsequently reinitiated and the patient''s visual acuity returned gradually to 1.0 (OU). Bilateral optic neuritis is a rare manifestation of CIDP. It responded well to IV corticosteroid therapy in our case.     

Internuclear ophthalmoplegia in acquired immunodeficiency syndrome

We describe the case of a patient with acquired immunodeficiency syndrome (AIDS) who had internuclear ophthalmoplegia (INO) and subsequent rapid neurologic deterioration. To our knowledge, this is the first report of a patient with AIDS and INO.     

Eyelid leishmaniasis in a patient with neurogenic ptosis.

A patient with chronic progressive external ophthalmoplegia contracted cutaneous leishmaniasis of the upper eyelid. Infection of this site is rare because eyelid movements usually prevent the sandfly vector from biting the skin there. It is postulated that the relative immobility of the upper eyelid in this patient was a major predisposing factor for the infection.