Long-term prognosis in patients with vasculopathic sixth nerve palsy

PURPOSE: To better define the long-term prognosis in patients with a vasculopathic sixth nerve palsy (6NP), specifically addressing the degree of recovery and incidence of recurrent similar episodes. DESIGN: Observational case series. METHODS: Retrospective chart review. SETTING: An outpatient neuroophthalmic practice. STUDY POPULATION: Patients with one or more vascular risk factors and an acute, isolated 6NP that spontaneously recovered. OBSERVATION PROCEDURE: Information regarding resolution of the 6NP, subsequent vascular events and recurrent ocular motor nerve palsy was obtained from chart review of follow-up clinic visits, mailed questionnaires and telephone interviews. The duration of follow-up ranged from 2 to 13 years. MAIN OUTCOME MEASURES: Resolution of 6NP (complete or incomplete) and incidence of recurrent ocular motor nerve palsy. RESULTS: Fifty-nine patients were identified with a mean age of 65.3 years +/- 11.6 (range 34-90 years). Fifty-one patients (86%) experienced complete resolution of their first episode of vasculopathic 6NP and eight patients (14%) had incomplete resolution. A subsequent episode of ocular motor mononeuropathy occurred in 18 of 59 (31%) patients. The number of recurrences ranged from one (in 14 patients) to four (in one patient). There was no association between any risk factor and recurrence of ocular motor nerve palsy. Similarly, incomplete resolution of the vasculopathic 6NP was not associated with any risk factor. CONCLUSIONS: Patients with a vasculopathic 6NP usually have complete resolution of their ophthalmoplegia, but nearly one third of patients in our study later experienced at least one episode of recurrent vasculopathic ocular motor nerve palsy.     

First a third, then a fourth nerve palsy in multiple intracranial aneurysms

Background Intracranial aneurysms may be a cause of ocular motor dysfunction, the third nerve being more often involved than the two other cranial ocular motor nerves. Methods We report the unusual occurrence of an isolated fourth nerve palsy related to a cavernous carotid aneurysm, angiographically confirmed. The patient already underwent clipping of a ruptured posterior communicating artery aneurysm 17 years earlier, revealed at that time by a third nerve palsy. Results Endovascular treatment of the cavernous carotid aneurysm was performed, resulting in complete recovery of the palsy. Conclusion Occurrence of an acquired fourth nerve palsy in a patient with a past history of aneurysm should prompt neurovascular imaging as multiple aneurysms may cause sequential ocular motor palsies.     

Central trochlear palsy

Historically, the trochlear (IV) nerve has been "neglected" by neurologists and ophthalmologists. However, the reported incidence of trochlear palsy in two large series has more than doubled in the past two decades, indicating increasing awareness of this nerve. Trauma is the most common cause of trochlear palsy, as the trochlear nerve is anatomically more vulnerable to trauma than the other ocular motor nerves. Trochlear palsy can also be caused by vascular and inflammatory diseases, congenital factors, toxic substances and tumors. Diplopia secondary to vertical and horizontal deviation is the most common presentation. The trochlear nerve has a relatively high recovery rate after the underlying cause of injury has been corrected. In this article, the anatomy and physiology of the trochlear nerve are described, and the various etiologies, methods of diagnosis and differential diagnosis of trochlear palsy are reviewed.     

Pediatric ocular motor cranial nerve palsy: Demographics and etiological profile

Purpose:The aim of this study was to describe epidemiological and clinical characteristics of pediatric ocular motor cranial nerve palsy.Methods:This was a retrospective record-based study, carried out at a tertiary eye care hospital in India, between January 2011 and January 2015 and included patients up to 16 years of age at the time of presentation, diagnosed with third, fourth, sixth nerve palsy or a combination of these with other cranial nerve palsy. Data analyzed included demographic details, etiologies, presence or absence of amblyopia, relevant investigations, and management.Results:A total of 90 cases were included in the study. Eighty patients (88.88%) presented with isolated nerve palsy. Forty-three patients (47.77%) had congenital nerve palsy. The most common nerve involved was third (n = 35, 38.88%) followed by sixth (n = 23, 25.55%) and fourth nerve (n = 22, 24.44%). Most common cause of third and fourth cranial nerve palsy was congenital (n = 18, 51.42% and n = 17, 77.30%, respectively), while it was trauma for the sixth nerve (n = 7, 30.40%). Amblyopia was most frequently associated with third cranial nerve palsy (n = 27, 77.14%). The radio-imaging yield was maximum (n = 7, 70%) for combined cranial nerve palsy. Overall 44 (48.88%) patients were managed conservatively, while 46 (51.11%) patients needed squint with or without ptosis surgery.Conclusion:The most common ocular motor cranial nerve involved in the pediatric population was the third cranial nerve, and it was found to be the most amblyogenic in this age group. The neuroimaging yield was maximum for combined cranial nerve palsy. The most common conservatively managed nerve palsy in this study group was the fourth nerve palsy.     

Vertical ocular motility disturbance in pseudotumor cerebri

Three patients with pseudotumor cerebri developed transient vertical ocular motor abnormalities. All had associated sixth nerve palsies and two had significant abnormalities of visual acuity and fields. Effective treatment of elevated intracranial pressure (ICP) resulted in resolution of the motility disturbance in all cases. This unusual oculomotor feature of elevated ICP may be due to skew deviation or fourth nerve palsy, but in either instance it is not a localizing sign.     

Isolated abducens nerve palsy with hyperhomocysteinemia: Association and outcomes

Ischemic abducens nerve palsy usually presents as isolated cranial nerve palsy in the middle aged and elderly patients with known risk factors such as diabetes mellitus, hypertension, dyslipidemia, carotid artery disease, etc., In this report, we describe four patients with isolated abducens nerve palsy who presented with an acute onset diplopia whose detailed history and examination were suggestive of an ischemic etiology. Detailed systemic and laboratory evaluation revealed hyperhomocysteinemia as the only potential risk factor. To the best of our knowledge this is the first report of association of hyperhomocysteinemia and isolated abducens nerve palsy.     

Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy

PURPOSE: Clinical features of acquired third, fourth, and sixth cranial nerve palsy showed variation among previous studies. Evaluation of natural course with objective criteria will establish accurate recovery rates and important factors for recovery. METHODS: Retrospective chart review was performed on 206 patients who visited a neuro-ophthalmic department with acquired third, fourth, and sixth nerve palsy. Aetiology and results of ocular exam on each visit were reviewed, and multivariate logistic regression analysis was performed to identify independent factors affecting recovery. RESULTS: The sixth cranial nerve was affected most frequently (n=108, 52.4%) and vascular disease (n=64, 31.1%) was the most common aetiology. Recovery was evaluated with change of deviation angle for 108 patients, who were first examined within a month of onset and followed up for at least 6 months. Ninety-two (85.2%) patients showed overall (at least partial) recovery and 73 (67.6%) showed complete recovery. In univariate analysis, initial deviation angle was found to be only significant factor associated with complete recovery (P=0.007) and most patients who experienced successful management of treatable underlying disease showed recovery. CONCLUSIONS: With objective criteria based on deviation angle, overall recovery rate from the third, fourth, and sixth nerve palsy was 85.2%. Patients who had smaller initial eyeball deviation or successful management of treatable underlying disease had a high chance of recovery.     

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.     

A new interpretation and quantitative method for diplopia test: 304 cases of ocular motor nerve palsy for clinical test and verify

We introduce a new interpretation and quantitative method for computerized diplopia test. By comparing this new method to the Hess screen test, we validate its applicability among 304 patients with ocular motor nerve palsy. This new method shows great assistant value as the Hess screen test in making accurate diagnosis and quantitative evaluation the severity of diplopia. Furthermore, it is more convenient and suitable for daily clinical use.     

Evolving global risk assessment of ocular hypertension to glaucoma

PURPOSE OF REVIEW: To discuss current knowledge of global risk assessment in ocular hypertension. RECENT FINDINGS: The ophthalmologist treating patients with ocular hypertension is frequently faced with the clinical dilemma of which patients to treat and how vigorous treatment should be. The goal of risk assessment for glaucoma is to identify patients at greatest risk for symptomatic vision loss. Risk factors can be identified by history such as age, race, and family history or can be clinically observed by examination such as elevated intraocular pressure, optic nerve head appearance, central corneal thickness, and visual field abnormalities. Risk assessment is a well accepted tool in other fields of medicine. Parallels can be drawn between the evolution of risk assessment for coronary artery disease and glaucoma. Validated risk calculators for ocular hypertension are currently available mostly derived from the Ocular Hypertension Treatment Study. SUMMARY: The aim of assessing global risk for conversion from ocular hypertension to glaucoma is to identify patients who are most likely to benefit from early treatment. Calculation of risk should be accompanied by thorough analysis of risks, benefits, and alternatives for the individual patient.     

The impact of diabetes on corneal nerve morphology and ocular surface integrity

Diabetes mellitus is a chronic disease that results from inadequate insulin production or ineffective insulin utilization. It is one of the most common systemic diseases worldwide with increasing prevalence. Diabetes mellitus is associated with premature mortality, macrovascular complications such as cardiovascular disease, and microvascular complications, including nephropathy leading to kidney failure, potentially blinding diabetic retinopathy, and diabetic neuropathy. While the retinal complications of diabetes are well recognized by eye care professionals, the effects on the ocular surface are poorly understood. Recent studies have reported on the association between peripheral neuropathy and corneal neuropathy, showing the latter to be of predictive value for the systemic disease. Corneal neuropathy can lead to loss of corneal sensation and can ultimately result in neurotrophic ulcers and significant visual morbidity. The epithelial fragility and poor wound healing that result from reduced epithelial adhesion to the underlying basement membrane in diabetes, together with corneal neuropathy, are thought to increase the susceptibility to persistent corneal erosions and infection, as well as to increase the risk of post-surgical complications. The aim of this article is to review the impact of diabetes on corneal nerve morphology and ocular surface integrity. Changes in the tear film and ocular surface microbiome are highlighted in discussion of the mechanisms that underpin ocular surface changes that increase the susceptibility to corneal erosion and infection.     

Congenital vertical ocular motor apraxia

The case of a 4 1/2-year-old boy with congenital vertical ocular motor apraxia who was otherwise developmentally and neurologically normal is reported. The presence of perinatal hypoxia in this patient may have been etiologic. While the presence of a supranuclear vertical ocular motor abnormality usually suggests a serious, acquired neurologic or systemic disease it may rarely occur as an isolated congenital finding, as demonstrated in this case.     

Ocular motor nerve palsy: a clinical and etiological study

PURPOSE: To clinically describe cases of ocular motor nerve palsy and to determine the possible causes. MATERIALS AND METHODS: Thirty-one consecutive patients with ocular motor nerve palsies were investigated. All underwent complete ophthalmological, as well as neurological, otorhinolaryngological and general examination. Computerised tomography (CT)-scan of the brain and complementary laboratory tests were obtained from each participant. RESULTS: Paralysis of the sixth (38.4%) and the third (35.3%) cranial nerve were the most common. The Lees screen test was found to be very sensitive, confirming the diagnosis of ocular motor nerve palsy, even in cases with minimal manifestations. Complete ptosis and full mydriasis were mostly seen in isolated cases of the third cranial nerve palsy. The majority of eyes (63.2%) with third cranial nerve palsy had pupil sparing. Overall, an etiological diagnosis was made in 93.5% of cases. The common causes were vascular conditions (25.8%), otorhinolaryngologic diseases (19.7%) and trauma (12.9%). CT scan failed to reveal any abnormality in 54.8% of cases. CONCLUSION: Patients with ocular motor nerve palsy should be carefully examined in close collaboration with other specialists, especially where sophisticated, complementary investigations are impossible.     

Prevalence of ocular motor cranial nerve palsy and associations following stroke

Aim

Occurrence of ocular motor cranial nerve palsies (OMCNP), following stroke, has not been reported in relation to the type of OMCNP seen and in relation to brain area affected by stroke. The aim of this study was to identify all patients referred with suspected visual impairment to establish the presence and type of OMCNP.

Methods

Prospective, observation study with standardised referral and assessment forms across 20 sites. Visual assessment included visual acuity measurement, visual field assessment, ocular alignment, and movement and visual inattention assessment. Multicentre ethics approval and informed patient consent was obtained.

Results

In total, 915 patients were recruited with mean age of 69.18 years (SD 14.19). Altogether, 498 patients (54%) were diagnosed with ocular motility abnormalities. Of these, 89 patients (18%) had OMCNP. Unilateral third nerve palsy was present in 23 patients (26%), fourth nerve palsy in 14 patients (16%), and sixth nerve palsy in 52 patients (58%). Out of these, 44 patients had isolated OMCNP and 45 had OMCNP combined with other ocular motility abnormalities. Location of stroke was reported mainly in cerebellum, brain stem, thalamus, and internal and external capsules. Treatment was provided for each case including prisms, occlusion, typoscope, scanning exercises, and refraction.

Conclusions

OMCNP account for 18% of eye movement abnormalities in this stroke sub-population. Sixth CNP was most common, followed by third and fourth CNP. Half were isolated and half combined with other eye movement abnormality. Most were treated with prisms or occlusion. The reported brain area affected by stroke was typically the cerebellum, brain stem, and diencephalic structures.     

Predictors of nonrecovery in acute traumatic sixth nerve palsy and paresis

PURPOSE: To evaluate whether nonrecovery from acute traumatic sixth nerve palsy could be predicted from demographic factors or palsy characteristics. DESIGN: Prospective, observational case series SETTING: Multicenter (academic and private practices). OUTCOME MEASURE: Nonrecovery, defined as the presence of diplopia in primary position or more than 10 prism diopters of distance esotropia in primary position at 6 months after onset. METHODS: Using data from a previously described cohort of 84 eligible patients with acute traumatic sixth nerve palsy, we performed multivariate analyses of demographic factors and palsy characteristics. RESULTS: Nonrecovery at 6 months after onset was associated with a complete palsy (adjusted risk ratio, 9.11; 95% confidence interval [CI], 2.77-14.84) and with a bilateral palsy or paresis (adjusted risk ratio, 2.53; 95% CI, 0.98-4.29). The choice of conservative management (observation, prism, or patch) versus acute injection of Botulinum toxin (within 3 months of injury) did not influence final recovery. CONCLUSIONS: In acute traumatic sixth nerve palsy or paresis, failure to recover by 6 months after onset was associated independently with inability to abduct past midline at presentation and bilaterality. Although the overall recovery rate is high in acute traumatic sixth nerve palsy or paresis, a complete or bilateral case has a poor prognosis and is more likely to need strabismus surgery.     

Isolated Fourth Nerve Palsy in Tuberculous Meningitis

Tuberculous meningitis is a type of subacute meningitis and like other intracranial processes can compromise ocular motor nerves, causing palsies. Trochlear nerve is an unusual isolated manifestation in this type of pathology. The authors report a 5-year-old boy presented in their clinic with a trochlear nerve palsy as unique neurological manifestation of tuberculous meningitis. Treatment with complete anti-tuberculous therapy and botulinum A toxin was needed to get the complete resolution of the nerve palsy. In tuberculous meningitis, the presence of high protein levels and higher number of cells in cerebrospinal fluid is associated with cranial nerve involvement. Usually cranial nerve palsies occur in combination. VI cranial nerve alone or a combined disorder of VI and III cranial nerves are the palsies most frequently presented. Much less common is an isolated disorder of IV cranial nerve in the course of meningitis. The length of full treatment with anti-tuberculous therapy in this case was of 1 year. The persistence of palsy 1 month after the beginning of the symptoms indicated the possibility of a botulinum toxin injection with complete resolution of the process without disability, ocular motility has remained normal on follow-up.     

Abducens nerve ocular neuromyotonia following non-sellar or parasellar tumors

Ocular neuromyotonia is an uncommon disorder resulting from episodic involuntary discharge of ocular motor nerves producing sustained contraction of their respective ocular muscles. Ocular neuromyotonia manifests in brief spells of diplopia occurring spontaneously or after eccentric gaze holding. In most cases, ocular neuromyotonia follows months or years after radiotherapy to the sellar and parasellar region and involves the oculomotor nerve. We report two unusual cases of abducens nerve ocular neuromyotonia that followed radiation therapy of tumors in areas other than the sellar or parasellar region.     

Adult-onset acquired oculomotor nerve paresis with cyclic spasms: relationship to ocular neuromyotonia

PURPOSE: To describe the characteristics and significance of acquired oculomotor nerve paresis with cyclic spasm. METHOD: Retrospective case series of two patients with a history of previous skull base irradiation for intracranial tumor who developed double vision and were found to have oculomotor nerve paresis with cyclic spasm. Both patients underwent a complete neuroophthalmologic assessment, including testing of eyelid position, pupillary size and reactivity, and ocular motility and alignment during both the paretic and spastic phases of the condition. RESULTS: Both patients developed unilateral lid retraction and ipsilateral esotropia with limitation of abduction during the spastic phase of the cycle, with ipsilateral ptosis, exotropia, and variable limitation of adduction during the paretic phase. The cycles were continuous and were not induced or altered by eccentric gaze. CONCLUSIONS: Cyclic oculomotor nerve paresis with spasms may occur years after irradiation of the skull base. This condition is different from the more common ocular motor disturbance that occurs in this setting-ocular neuromyotonia. However, in view of the similarity between these two disorders, it seems likely that they are caused by a similar peripheral mechanism.     

德黑兰15例HIV患者眼部病变的临床特点

目的:探讨德黑兰HIV患者眼部病变的发生频率及其特点。方法:采用横向研究,选取7个月间收录的141例(282眼,其中男性125例,女性16例)不同程度的HIV患者,每位患者拥有全部的个人资料,包括人口统计信息、HIV传播途径、最近CD4淋巴细胞计数、普通性/血源性病毒和弓形虫病的血清学研究、抗逆转录病毒治疗史以及相关的全身性疾病。结果:患者141例中,HIV涉及眼部病的为15例(10.6%),包括3例结核性脉络膜炎,2例巨细胞病毒性视网膜炎,2例单纯疱疹病毒相关病变,1例HIV相关的视网膜病变,1例眼带状疱疹,1例待定为玻璃体炎以及3例涉及颅神经损伤包括2例凝视麻痹和1例视乳头炎。CD4淋巴细胞计数在涉及眼部病变的患者中比没有涉及眼部病变的患者低(204.7±123.8vs403.7±339.7,P=0.029),但两组间其他相关因素没有差异。结论:在德黑兰,结核性脉络膜炎和神经性眼科疾病损伤是HIV患者最常见的眼部损伤,这与最近发表在发达国家的不一致。     

糖尿病性眼肌麻痹临床分析

目的 探讨糖尿病性眼肌麻痹的临床特点.方法 对25例(25只眼)经常规眼科检查,眼肌检查及实验室生化检查后,确诊为糖尿病性眼肌麻痹进行分析.结果 25只眼均单眼发病,受累神经以动眼神经麻痹多见,为15例,其次外展神经麻痹6例,滑车神经麻痹3例,复合神经(Ⅲ+Ⅳ)麻痹1例.结论 中老年糖尿病患者易并发眼肌麻痹,糖尿病性微循环病变是导致神经缺血缺氧以致变性的病理基础.