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Taiwan Journal of Ophthalmology 2023Duane syndrome is one of the most common restrictive congenital strabismus characterized by variable horizontal duction deficits with globe retraction and shoots on... (Review)
Review
Duane syndrome is one of the most common restrictive congenital strabismus characterized by variable horizontal duction deficits with globe retraction and shoots on attempted adduction and narrowing of the palpebral aperture. It is now listed as a congenital cranial dysinnervation disorder. The disease is usually unilateral with female preponderance. Basic etiopathogenesis involves dysinnervation of the lateral rectus (LR) due to aplastic/hypoplastic abducens nucleus with a secondary aberrant supply to the LR by the medial rectus (MR) subnucleus of the oculomotor nerve. Diagnosis of the disease is usually clinical. Due to the variable presentation of the disease, surgical management is a challenge and has to be individualized to achieve alignment in the primary gaze, reduction in globe retraction, upshoots and downshoots, and correction of any abnormal head posture. Differential recessions of the lateral and MR muscles are done to correct esotropia or exotropia in the primary gaze. For globe retraction and shoots, Y-split or periosteal fixation of the LR muscles is done depending on the severity.
PubMed: 38249504
DOI: 10.4103/tjo.TJO-D-23-00078 -
Journal of Surgical Case Reports Jan 2024We present the case of a 58-year-old male with a 3-day history of sudden onset headache, loss of consciousness, and uncontrolled vomiting. The patient had 3/5...
We present the case of a 58-year-old male with a 3-day history of sudden onset headache, loss of consciousness, and uncontrolled vomiting. The patient had 3/5 quadriparesis and a Glasgow coma scale (GCS) score of 8, which merited neurocritical intensive care. Brain imaging suggested the presence of two lesions: (i) a fusiform aneurysm of 12 × 7 mm in an accessory A2 artery of the anterior cerebral artery and (ii) an unruptured saccular aneurysm of 3.3 × 2.8 mm in the distal segment of the basilar artery. He was deemed a candidate for microsurgical management. Postoperatively, he had 4/5 quadriparesis, paresis of the right oculomotor nerve, and a GCS score of 13. A 3-month follow-up showed a significant improvement in neurological function with a score of 2 on the modified Rankin scale. The presented case illustrates the relevance of a nuanced acquaintance to operate in diseased anatomical variants and complex pathologies of narrow corridors.
PubMed: 38239374
DOI: 10.1093/jscr/rjad742 -
Cureus Dec 2023The use of systemic steroids in managing herpes zoster ophthalmicus-related ophthalmoplegia (HZORO) remains a topic of debate. Here, a case involving third nerve HZORO...
The use of systemic steroids in managing herpes zoster ophthalmicus-related ophthalmoplegia (HZORO) remains a topic of debate. Here, a case involving third nerve HZORO is highlighted, where a regimen of oral valacyclovir followed by a brief course of oral steroids resulted in significant improvement within days and complete resolution of the palsy within a month of initiating the treatment. This case underscores the need for randomized controlled studies to definitively determine the efficacy of systemic steroids in alleviating or shortening the course of HZORO.
PubMed: 38226106
DOI: 10.7759/cureus.50553 -
Cureus Dec 2023We report a case of a 72-year-old male who presented to the hospital with a chief complaint of diplopia in the setting of a recent onset of urinary incontinence and...
We report a case of a 72-year-old male who presented to the hospital with a chief complaint of diplopia in the setting of a recent onset of urinary incontinence and right-sided back pain. He was subsequently diagnosed with prostate cancer, notably metastasizing to the right sphenoid bone, causing impingement of the oculomotor nerve. Our case is unique in that the patient's initial presentation of prostate cancer was oculomotor nerve palsy with subsequent histologic analysis of the primary tumor showing both small cell neuroendocrine carcinoma along with adenocarcinoma. Also, the initial routine stroke protocol MRI and computed tomography angiography (CTA) missed the lesion, while gadolinium-enhanced targeted MRI revealed lesions in both the spine and the orbit. This case emphasizes the need for enhanced contrast as well as focused imaging in patients presenting with diplopia with a negative initial workup for stroke. Ptosis can be a sign of metastasis from other cancers and it is important to have a broad differential including metastatic disease in patients' presenting with similar symptoms and negative initial workup who may otherwise be at risk of cancer.
PubMed: 38222194
DOI: 10.7759/cureus.50566 -
Journal of Veterinary Internal Medicine 2024Pseudoabducens paralysis resulting in resting medial strabismus (esotropia) is a rare consequence of a contralateral paramedian thalamic ischemic infarction in people....
Pseudoabducens paralysis resulting in resting medial strabismus (esotropia) is a rare consequence of a contralateral paramedian thalamic ischemic infarction in people. To date, esotropia has been reported in dogs in association with ipsilateral abducens neuropathy or extraocular myopathy, but not secondary to thalamic lesions. A 7-year-old male neutered Border Collie and a 12-year-old female neutered cross-breed dog were presented with peracute nonprogressive vestibular ataxia. Neurological examination identified right esotropia, nonambulatory tetraparesis, right head tilt, vestibular ataxia and nystagmus. Lesions in both dogs were localized to the vestibular system with thalamic involvement. Magnetic resonance imaging of the brain identified a left paramedian thalamic lacunar ischemic infarct in both dogs. Interruption of descending inhibitory pathways that decussate in the subthalamic region and innervate the contralateral motor nucleus of the oculomotor nerve leads to hypertonicity of the medial rectus. These cases indicate that esotropia is a rare but highly localizing sign in dogs with contralateral thalamic infarcts.
Topics: Humans; Male; Female; Dogs; Animals; Esotropia; Strabismus; Brain; Infarction; Ataxia; Dog Diseases
PubMed: 38205674
DOI: 10.1111/jvim.16986 -
Frontiers in Molecular Neuroscience 2023Oculomotor nerve palsy (ONP) arises from primary abnormalities in the central neural pathways that control the extraocular muscles (EOMs). Long non-coding RNAs (lncRNAs)...
INTRODUCTION
Oculomotor nerve palsy (ONP) arises from primary abnormalities in the central neural pathways that control the extraocular muscles (EOMs). Long non-coding RNAs (lncRNAs) have been found to be involved in the pathogenesis of various neuroparalytic diseases. However, little is known about the role of lncRNAs in ONP.
METHODS
We collected medial rectus muscle tissue from ONP and constant exotropia (CXT) patients during strabismus surgeries for RNA sequencing analysis. Differentially expressed mRNAs and lncRNAs were revealed and included in the functional enrichment analysis. Co-expression analysis was conducted between these differentially expressed mRNAs and lncRNAs, followed by target gene prediction of differentially expressed lncRNAs. In addition, lncRNA-microRNA and lncRNA-transcription factor-mRNA interaction networks were constructed to further elaborate the pathological changes in medial rectus muscle of ONP. Furthermore, RT-qPCR was applied to further validate the expression levels of important lncRNAs and mRNAs, whose clinical significance was examined by receiver operating characteristic (ROC) curve analysis.
RESULTS
A total of 618 differentially expressed lncRNAs and 322 differentially expressed mRNAs were identified. The up-regulated mRNAs were significantly related to cholinergic synaptic transmission (such as and ) and the components and metabolism of extracellular matrix (such as and ), while the down-regulated mRNAs were significantly correlated with the composition (such as and ) and contraction force (such as and ) of muscle fibers. Co-expression analysis and target gene prediction revealed the strong correlation between and as well as and . Moreover, the differential expressions of lncRNAs (, and ) and mRNAs (, , , , , , and ) were validated by RT-qPCR. ROC curve analysis showed that lncRNAs (, , and ) and mRNAs (, , , , , and ) might be promising biomarkers of ONP.
CONCLUSIONS
These results may shed light on the molecular biology of EOMs of ONP, as well as the possible correlation of lncRNAs and mRNAs with clinical practice.
PubMed: 38173464
DOI: 10.3389/fnmol.2023.1293344 -
Graefe's Archive For Clinical and... May 2024To investigate the distinction between sagging eye syndrome (SES group) and acquired unilateral trochlear nerve palsy (Trochlear group) in the Bielschowsky head tilt...
PURPOSE
To investigate the distinction between sagging eye syndrome (SES group) and acquired unilateral trochlear nerve palsy (Trochlear group) in the Bielschowsky head tilt test (BHTT).
METHODS
Fifteen patients in the SES group (mean age 74.6 ± 5.2 years) and 14 patients in the Trochlear group (55.2 ± 15.9 years) visited the Department of Ophthalmology, Hyogo Medical University Hospital between November 2016 and October 2022 for treatment of their diplopia. Eye position was measured with the alternate prism cover test, and values for fixation of the dominant eye, or unaffected eye, were used. Cyclodeviation was measured with the synoptophore and the Glaucoma Module Premium Edition of the SPECTRALIS optical coherence tomography. In the BHTT, eye position was measured in three head postures: primary position (PP), head tilt to the side with hypertropia (Hyper), and head tilt to the side with hypotropia (Hypo). The differences in vertical deviation between PP and Hyper (Hyper - PP), PP and Hypo (PP - Hypo) and Hyper - Hypo were measured and compared.
RESULTS
Vertical deviation in primary position was 7.3 ± 4.5 PD in the SES group and significantly larger (17.1 ± 8.4 PD) in the Trochlear group (p = 0.002). The vertical deviation in Hyper was significantly larger in the Trochlear group with 7.7 ± 4.7 PD and 22.1 ± 9.4 PD, respectively (p < 0.001), whereas the that in Hypo was not significantly different between the two groups with 6.5 ± 3.4 PD and 8.4 ± 6.6 PD, respectively (p = 0.725). The SES group showed no significant difference according to the 3 head postures (p = 0.311), while the Trochlear group showed a significantly different with smaller mean values in vertical deviation in Hypo (p < 0.001). The difference in the vertical deviation for the 3 head postures was the largest in Hyper - Hypo (1.7 ± 2.1 PD and 13.6 ± 7.1 PD, respectively), and the accuracy of SES was at the cutoff value of 6 PD, and it was considered not to be SES if the value was 6PD or higher. The accuracy of SES determination was 100% sensitivity and 100% specificity, and the area under the curve was 1.0.
CONCLUSION
The difference in Hyper - Hypo in the BHTT may be the most useful index in differentiating SES from acquired unilateral trochlear nerve palsy; if the difference was more than 6 PD, the probability of SES was very low.
Topics: Humans; Aged; Oculomotor Muscles; Trochlear Nerve Diseases; Strabismus; Ophthalmology; Glaucoma
PubMed: 38141057
DOI: 10.1007/s00417-023-06347-z -
Journal of Neurological Surgery Reports Oct 2023Clival tumors are rare and heterogeneous. Although some benign prototypical sellar lesions may present as clival tumors, the likelihood of malignant disease is...
Clival tumors are rare and heterogeneous. Although some benign prototypical sellar lesions may present as clival tumors, the likelihood of malignant disease is higher. Here we define a novel algorithm for the workup and management of clival masses through an illustrative case of colorectal adenocarcinoma metastasis to the clivus. In this case report, the best practice guidelines for managing clival masses are described through a literature review and refined by senior author consensus. We conducted a focused systematic review to characterize the present case in the context of clival metastasis from gastrointestinal malignancy. An 83-year-old woman presented with 4 weeks of headaches and blurry vision. Examination revealed partial right abducens and left oculomotor palsies. Magnetic resonance imaging (MRI) identified a large, weakly enhancing sellar and clival mass with sphenoid sinus extension. An aggressive subtotal endoscopic endonasal resection was performed with removal of all sphenoid, clival, and sellar disease without cavernous sinus wall resection. Pathology confirmed colorectal adenocarcinoma; computed tomography (CT) imaging identified an ascending colon mass with metastases to the liver and mesenteric nodes. Palliative oncologic therapies were recommended, but she elected hospice, and died 3 months after initial presentation. Gastrointestinal clival metastases are exceedingly rare among sellar and clival pathologies, with eight prior cases reported, most of which presented with diplopia from abducens nerve involvement. Clival masses are uncommon skull base lesions that are associated with more aggressive diseases. We present a consolidated framework for decision-making in these challenging patients, alongside an unusual case example that illustrates the importance of increased suspicion for malignant clinical entities in this setting.
PubMed: 38124781
DOI: 10.1055/a-2215-0974 -
Frontiers in Immunology 2023To explore the clinical manifestations of glutamic acid decarboxylase 65 (GAD65) antibody-positive patients with extraocular symptoms and the possible mechanism.
OBJECTIVE
To explore the clinical manifestations of glutamic acid decarboxylase 65 (GAD65) antibody-positive patients with extraocular symptoms and the possible mechanism.
METHOD
Assays for the presence of GAD65 antibodies were performed on patients' serum and cerebral spinal fluid (CSF). The brain and ocular structures involved in eye movement were assessed via magnetic resonance imaging (MRI). Tests such as electromyography (EMG), particularly repetitive nerve stimulation (RNS), and neostigmine tests were utilized for differential diagnosis. Additionally, the interaction of GAD65 antibodies with muscle tissue was confirmed using immunofluorescence techniques.
RESULT
Each patient exhibited symptoms akin to extraocular myasthenia gravis (MG), with two individuals reporting diplopia and two experiencing ptosis. GAD65 antibodies were detected in either the serum or CSF, which were shown to bind with monkey cerebellum slides and mouse muscle slides. Neuroimaging of the brain and extraocular muscles via MRI showed no abnormalities, and all patients tested negative for the neostigmine test, RNS EMG, and the presence of MG antibodies. However, thyroid-related antibodies were found to be abnormal in four of the patients.
CONCLUSION
Our results showed that GAD65 antibodies are not only associated with encephalitis, cerebellum ataxia or stiff-person syndrome caused by the decrease of GABAergic transmission but also diplopia and ptosis. Therefore, we should pay more attention to extraocular muscle paralysis patients without pathogenic antibodies directed against the components of neuromuscular junctions.
Topics: Animals; Mice; Humans; Oculomotor Muscles; Diplopia; Neostigmine; Antibodies; Myasthenia Gravis; Paralysis
PubMed: 38106406
DOI: 10.3389/fimmu.2023.1256089 -
Plastic and Reconstructive Surgery.... Dec 2023Complications in aesthetic medicine can be considered a consequence of the inexperience of the performing physician, but in some cases, they can unveil far more serious...
Complications in aesthetic medicine can be considered a consequence of the inexperience of the performing physician, but in some cases, they can unveil far more serious conditions, hitherto silent. We present a case of a 48-year-old patient who, following botulinum toxin type A (Botox) injection for treatment of forehead wrinkles, returned to our attention 12 days later for a discrete, newly onset right eyelid ptosis. This ptosis was a telltale sign of the presence of an intracranial aneurysm closely related with the oculomotor nerve. The lack of compensatory action by the frontalis muscle in maintaining the eyelid in position allowed us to highlight the extrinsic compression deficit of the oculomotor nerve. Subsequently, the patient underwent endovascular treatment of the aneurysm, leading to complete resolution of the case.
PubMed: 38093722
DOI: 10.1097/GOX.0000000000005452