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Cureus Jan 2024Weber's syndrome, named after Hermann Weber, is characterized by midbrain lesions often caused by strokes, resulting in ipsilateral third nerve palsy, including ptosis...
Weber's syndrome, named after Hermann Weber, is characterized by midbrain lesions often caused by strokes, resulting in ipsilateral third nerve palsy, including ptosis and pupillary abnormalities, and contralateral hemiplegia. We discuss a case of a 35-year-old lady with cognitive impairment, right hemiparesis, diplopia, left eye ptosis, and lateral eye deviation. MRI of the brain with contrast suggested an acute infarct in the left-sided paramedian region of the midbrain. The oculomotor nucleus and cerebral peduncle were both affected by an abrupt left-sided paramedian midbrain stroke. The participation of particular midbrain nuclei together with symptoms including drooping eyelids, diplopia, and limb paralysis suggested Weber's syndrome. An MRI study of the brain is the modality of choice in suspected stroke cases and is more sensitive when it comes to the brainstem lesions. A comprehensive neurological examination with a clinical diagnosis of Weber's syndrome before radiological investigations is of great help for localizing brain stem lesions and thus aids in early diagnosis and treatment.
PubMed: 38318538
DOI: 10.7759/cureus.51624 -
Journal of Neuro-ophthalmology : the... Mar 2024Teprotumumab, an insulin-like growth factor I receptor inhibitory antibody, improved proptosis, diplopia, inflammatory signs/symptoms, and quality of life in patients... (Review)
Review
BACKGROUND
Teprotumumab, an insulin-like growth factor I receptor inhibitory antibody, improved proptosis, diplopia, inflammatory signs/symptoms, and quality of life in patients with active thyroid eye disease (TED) in clinical trials. The trials excluded patients with dysthyroid optic neuropathy (DON). Recently, many case reports and case series have reported the successful use of teprotumumab to treat DON. Here, we review the data from published cases and our clinical experience in treating patients having DON with teprotumumab.
METHODS
A literature search was conducted of patients with DON treated with teprotumumab from January 2020 through September 2022. Data from DON patients from the authors' (M.A.T. and C.A.B.) clinical practice were included. Primary outcome measure was mean (SD) improvements for visual acuity, color vision, and visual fields. Improvements in proptosis and clinical activity score (CAS) and diplopia were compared before and after teprotumumab administration.
RESULTS
Ten observational studies/case reports were identified along with 2 patients in our practice. In all, there were 24 active TED patients with DON (37 eyes) who were treated with teprotumumab. Mean (SD) age was 66.5 (13.6) years and 13 (54%) were females, disease duration ranged from 2 months to >15 years. 22/24 patients had none, minimal improvement or progression of visual loss with intravenous/oral corticosteroids, orbital decompression (n = 9), and orbital radiation (n = 2). There were 2 patients who received teprotumumab as the only therapy. Overall, 88% (21/24) reported improvement in visual acuity after teprotumumab and in 75% (18/24), improvement in vision was observed after just 2 infusions of teprotumumab. Three eyes had decompression surgery in close proximity to teprotumumab infusions and were excluded from analyses. Mean (SD) improvement in visual acuity was 3.73 lines (SD 3.74), range 2-15 lines in 33 eyes. The mean (SD) improvement in the mean deviation on visual field testing in 15 eyes was 5.6 db (3.0 db). Mean (SD) improvement in proptosis was 4.37 mm (SD: 2.11) (20 patients, 32 eyes); and clinical activity score: mean reduction of 5.1 (1.3) for 18 patients. Teprotumumab was well tolerated in all but one patient. Adverse events reported included fatigue, dysgeusia, hearing loss, nausea, hyperglycemia, and muscle spasms.
CONCLUSIONS
Teprotumumab is an effective treatment for DON in our experience and in published cases in whom treatment with steroids, surgery, or orbital radiation was unsuccessful.
Topics: Female; Humans; Infant; Male; Diplopia; Quality of Life; Optic Nerve Diseases; Graves Ophthalmopathy; Exophthalmos; Antibodies, Monoclonal, Humanized
PubMed: 37751310
DOI: 10.1097/WNO.0000000000001994 -
Ophthalmology. Retina Jan 2024Scleral buckling has been a reliable treatment option in the repair of primary rhegmatogenous retinal detachments. Occasionally, patients require scleral buckles (SBs)... (Observational Study)
Observational Study
PURPOSE
Scleral buckling has been a reliable treatment option in the repair of primary rhegmatogenous retinal detachments. Occasionally, patients require scleral buckles (SBs) to be removed for various reasons. While outcomes of SB removal have been investigated in this subset of patients, there has not been any large patient series to reach any conclusions. Long-term sequelae of SB removal are debated in the literature, specifically around the risk of redetachment.
DESIGN
We performed a retrospective, observational study to evaluate the clinical indications for, and outcomes of, SB removal.
PARTICIPANTS
No control patients in this retrospective, observational study.
METHODS
Eighty-six individuals with a history of SB removal from June 1, 2000, to January 1, 2021, were followed from a large academic center and a private, retina-only practice in Chicago. Exclusion criteria were age of < 18 years and unplanned or self-explanted SB removal.
MAIN OUTCOME MEASURES
Data extracted included patient symptoms before SB removal, indications for removal, resolution of symptoms following removal, rate of redetachment, and rate of additional ocular surgery. Secondary outcomes included identifying factors associated with poorer outcomes.
RESULTS
Eighty-six eyes with history of SB removal were included with an average follow-up of 4 years. Approximately 60% were males and the mean age at the time of SB removal was 59 years. Leading indications for removal were exposure (61.63%), infection (20.93%), and diplopia/strabismus (19.77%). The average time from SB placement to removal was 12.28 ± 11.16 years. Most patients requiring SB removal presented with symptoms, specifically of pain and discomfort (65.12%), diplopia (22.09%), and drainage/discharge (18.60%). Of these patients, 86.59% experienced symptom resolution following SB removal. Notably, 6.56% (4 eyes) of all eyes with at least 1 year of follow-up experienced a redetachment requiring surgery. Within this subset, the average time from SB placement to removal was 2.05 ± 2.01 years and time to redetachment following removal was 15.95 ± 25.71 months. Nine percent of all eyes required additional strabismus or oculoplastic surgery.
CONCLUSIONS
Scleral buckle removal provides a high rate of symptomatic relief and low risk of subsequent detachment. Nevertheless, close monitoring is warranted to monitor for recurrent retinal detachments.
FINANCIAL DISCLOSURE(S)
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Topics: Male; Humans; Middle Aged; Adolescent; Female; Scleral Buckling; Retinal Detachment; Diplopia; Retrospective Studies; Treatment Outcome; Visual Acuity; Strabismus
PubMed: 37531997
DOI: 10.1016/j.oret.2023.07.029 -
Cureus Sep 2023Infection with the varicella-zoster virus (VZV) is very common worldwide and is one of the main causes of infectious encephalitis. Immunosuppressed patients are at...
Infection with the varicella-zoster virus (VZV) is very common worldwide and is one of the main causes of infectious encephalitis. Immunosuppressed patients are at increased risk of severe disease and central nervous system (CNS) involvement. We report the case of a 43-year-old man with HIV infection and poor adherence to antiretroviral therapy who presented to the emergency department (ER) with complaints of diplopia and a frontal headache, referring to having a child with chickenpox. Brain magnetic resonance imaging revealed three hyperintense T2-weighted lesions surrounded by edema in the right sublenticular, left occipital and left parietal regions, and VZV DNA was detected in the cerebrospinal fluid (CSF). After admitting the diagnosis of VZV encephalitis, the patient was treated with intravenous acyclovir, with clinical improvement and a favorable outcome.
PubMed: 37849585
DOI: 10.7759/cureus.45378 -
Plastic and Reconstructive Surgery Oct 2023Postoperative diplopia is reported in up to 52% of orbital bone fracture (OBF) repair. Evidence on these risk factors is based on low-quality data, single-institution...
PURPOSE
Postoperative diplopia is reported in up to 52% of orbital bone fracture (OBF) repair. Evidence on these risk factors is based on low-quality data, single-institution studies, and small sample sizes. Our study is the largest and first multi-center study to determine the predictors of postoperative diplopia following OBF repair.
METHODS
We conducted a retrospective review of patients who underwent OBF repair at two centers from 2015 to 2019. Our primary outcome was the incidence or persistence of postoperative diplopia at least 2 weeks following OBF repair. Descriptive statistics were calculated. Multivariable logistic regression was performed to determine significant predictors of postoperative diplopia.
RESULTS
Of 254 patients, the median (interquartile range [IQR]) age was 36.1 (27.8-50.7) years, and the median (IQR) follow-up was 79.5 (40.3-157.3) days. The most common postoperative ocular symptom was diplopia [n=51/254 (20.1%)]. Patients who had preoperative limited ocular motility or enophthalmos had adjusted odds ratio [aOR] (95% confidence interval [CI]) 2.33 (1.03-5.24) and 2.35 (1.06-5.24) the odds of developing postoperative diplopia, compared to patients who did not have these preoperative symptoms, respectively. Patients who had combined orbital floor and medial wall and moderate OBF (>2 cm2 defect or >3 mm displacement) on preoperative CT scan had aOR (95% CI) 2.16 (1.04-4.46) and 3.77 (1.44-9.83) the odds of developing postoperative diplopia, compared to patients without these preoperative CT findings, respectively.
CONCLUSION
During primary assessment of the patient with OBF, preoperative ocular signs and symptoms, fracture severity, and location of OBF are key predictors of postoperative diplopia.
PubMed: 37815322
DOI: 10.1097/PRS.0000000000011136 -
The British Journal of Ophthalmology Nov 2023Orbital decompression is commonly performed to correct proptosis in patients with Graves' orbitopathy (GO). In literature, the incidence of new-onset constant diplopia...
BACKGROUND
Orbital decompression is commonly performed to correct proptosis in patients with Graves' orbitopathy (GO). In literature, the incidence of new-onset constant diplopia after orbital decompression varies. Few studies have evaluated changes in duction and cyclodeviation after orbital decompression. We evaluated the changes in duction, cyclodeviation, eye position and degree of diplopia after orbital decompression.
METHODS
We retrospectively analysed data from patients who underwent orbital decompression at our hospital between January 2016 and July 2020. Data regarding the type of decompression, eye position, duction, cyclodeviation and level of diplopia according to the Gorman score were recorded.
RESULTS
Data from 281 eyes/orbits of 156 patients were analysed. Proptosis decreased from 23.8±2.5 to 20.9±2.5 mm. Horizontal and vertical duction range decreased (horizontal d=0.40 and vertical 0.30; p=0.000) after surgery; however, the change was not clinically significant (≤5°). Horizontal deviation changed towards esodeviation (d=-0.45; p=0.000), whereas vertical deviation remained stable (d=0.15; p=0.161). Preoperative cyclotorsion in the primary and downgaze positions changed towards incyclodeviation (primary: d=0.30, p=0.021; downgaze d=0.30, p=0.039). Diplopia improved in 22% (18 patients), whereas new-onset constant diplopia developed in 11% (12 patients). Elevation has an excellent predictive value of causing new-onset constant diplopia when measured preoperatively as <19°, sensitivity 88.0%, specificity 41.7% (area under the curve 0.812 (95% CI 0.660 to 0.963); p=0.000).
CONCLUSION
After orbital decompression, incidence of new-onset constant diplopia was 11% and 22% of the patients had partial or complete improvement of their diplopia. The changes in duction, cyclodeviation and horizontal deviation showed a statistical but not clinical difference. Patients with GO and a preoperatively restricted elevation of <19° are at risk of developing new-onset constant diplopia. In addition, preoperative incyclodeviation may worsen after decompression surgery.
PubMed: 38041682
DOI: 10.1136/bjo-2023-323480 -
Survey of Ophthalmology 2024A 63-year-old man with diabetes presented with unilateral ptosis and an exotropia. A diagnosis of isolated diabetic III nerve palsy was made. Subsequent...
A 63-year-old man with diabetes presented with unilateral ptosis and an exotropia. A diagnosis of isolated diabetic III nerve palsy was made. Subsequent neuro-ophthalmologic evaluation showed multiple cranial nerves involvement consistent with a diagnosis of orbital apex syndrome. Review of past medical history was significant for a previous nasopharyngeal carcinoma, and biopsy of the involved site was consistent with tumor recurrence. This case highlights the importance of correct medical history taking and anatomo-clinical correlation in neuro-ophthalmology.
Topics: Humans; Male; Middle Aged; Blepharoptosis; Exotropia; Nasopharyngeal Neoplasms; Oculomotor Nerve Diseases; Magnetic Resonance Imaging; Tomography, X-Ray Computed; Carcinoma; Nasopharyngeal Carcinoma
PubMed: 38007200
DOI: 10.1016/j.survophthal.2023.11.007 -
Journal of Neuro-ophthalmology : the... Mar 2024Thyroid eye disease (TED) is a condition caused by inflammatory damage to the periocular tissue that often leads to double vision. Teprotumumab is an insulin-like growth...
BACKGROUND
Thyroid eye disease (TED) is a condition caused by inflammatory damage to the periocular tissue that often leads to double vision. Teprotumumab is an insulin-like growth factor 1 receptor antibody that was FDA approved for the management of TED in 2020, although much is yet to be elucidated regarding its effects on diplopia outcomes among patients with TED. Diplopia is a significant and life-altering effect of TED. Previous studies have reported the effect of teprotumumab on double vision subjectively using the Gorman diplopia score. However, there is a gap in the literature addressing the effect of teprotumumab treatment on objective ocular alignment measures. The purpose of our study was to address this gap.
METHODS
We performed a retrospective review of patients who were diagnosed with TED, presented with diplopia, and treated with teprotumumab in a single-center academic ophthalmology practice. The primary outcome was change in ocular alignment in primary gaze position at 6 months (completion of teprotumumab treatment). Secondary outcomes included change in ocular alignment in other gaze positions, proptosis, eyelid position, and clinical activity score (CAS) at 6 months compared with baseline. To determine what factors may predict ocular alignment response to teprotumumab, we analyzed baseline characteristics among 3 groups, divided based on whether ocular alignment was worsened, stable, or improved at 6 months.
RESULTS
Seventeen patients met inclusion criteria, 3 (18%) worsened, 10 (59%) were stable, and 4 (24%) improved. CAS ( P = 0.02) was significantly different among the groups and was higher in those who worsened and those who improved compared with those who remained stable. Right gaze horizontal prism deviation ( P = 0.01) and left gaze horizontal prism deviation ( P = 0.03) were significantly different among the groups, with a greater degree of left gaze horizontal prism deviation in the worse group than the stable group ( P = 0.04).
CONCLUSIONS
Our study demonstrated that most patients remained stable after teprotumumab treatment regarding ocular alignment in primary gaze and the number of patients who improved was slightly higher than the number of patients who worsened after teprotumumab treatment. There are some baseline measures, such as CAS and right and left gaze horizontal prism deviation that can help better predict how a patient will respond to teprotumumab treatment. Our results can better inform physicians of how to counsel patients with TED when considering teprotumumab therapy.
Topics: Humans; Graves Ophthalmopathy; Diplopia; Antibodies, Monoclonal, Humanized; Exophthalmos
PubMed: 38294416
DOI: 10.1097/WNO.0000000000002001 -
Ceska a Slovenska Oftalmologie :... 2023Intraocular pressure (IOP) measurement in patients with thyroid-associated orbitopathy (TAO) can be difficult and misleading, particularly in patients with diplopia and...
INTRODUCTION
Intraocular pressure (IOP) measurement in patients with thyroid-associated orbitopathy (TAO) can be difficult and misleading, particularly in patients with diplopia and eye deviation (esotropia or hypotropia). However, when measuring IOP, it is also necessary to pay sufficient attention to TAO patients without diplopia in primary gaze direction and without motility disorder that might not be readily apparent.
PURPOSE
The aim of this study was to evaluate the accuracy of measurement of intraocular pressure (IOP) using three different types of tonometers: the rebound tonometer (iCARE), the Goldmann applanation tonometer (GAT) and the non-contact airpuff tonometer (NCT) in patients with inactive TAO. Materials and Methods: A total of 98 eyes of 49 adult patients with TAO were examined. The study group included 36 females and 13 males, with an age range of 19-70 years and a median age of 55.0. All the patients had evidence of thyroid disease, a history of mild to moderate TAO, no clinical signs or symptoms of active disease, and no diplopia in direct gaze direction. In addition to a comprehensive eye examination, all the patients underwent measurement of intraocular pressure with three tonometers: NCT, iCARE, and GAT. The measurements with these three devices were compared.
RESULTS
The mean IOP was 18.1 ± 2.4 mmHg (range 13-25 mmHg) with GAT, 22.3 ±5.0 mmHg (range 13-35 mmHg) with NCT, and 18.0 ±2.4 mmHg (range 13.3-26 mmHg) with iCARE. The mean difference between the GAT and iCARE measurements (using the Bland-Altman analysis) was -0.1 ±1.16 mmHg (limits of agreement -2.4 to 2.1). The mean difference between the GAT and NCT measurements was 4.2 ±3.6 mmHg (limits of agreement -2.8 to 11.2). The mean difference between the iCARE and NCT measurements was -4.3 ±3.7 mmHg (limits of agreement -11.6 to 2.9). No significant difference was found between GAT and iCARE (p = 1.000). However, there was a significant difference between GAT and NCT (p < 0.0001), as well as between iCARE and NCT (p < 0.0001). Conclusions: In patients with TAO, NCT significantly overestimates IOP values compared to the GAT and ICare. By contrast, the iCARE rebound tonometer provides IOP measurements comparable to the gold standard GAT in these patients.
Topics: Adult; Male; Female; Humans; Young Adult; Middle Aged; Aged; Graves Ophthalmopathy; Diplopia; Reproducibility of Results; Tonometry, Ocular; Intraocular Pressure; Strabismus
PubMed: 38086704
DOI: 10.31348/2023/38