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Cureus May 2024Myasthenia gravis (MG) is a rare disorder that most commonly presents with ocular symptoms. Despite the highly sensitive blood work that can be used to diagnose the...
Myasthenia gravis (MG) is a rare disorder that most commonly presents with ocular symptoms. Despite the highly sensitive blood work that can be used to diagnose the disease, it is frequently misdiagnosed until the disease becomes systemic. Literature, however, shows that those who begin treatment with acetylcholinesterase inhibitors before systemic presentation have a better prognosis. We discuss the case of a patient who presented to the clinic with a chief complaint of diplopia that was subsequently referred to ophthalmology. It was not until lab work was done by a subspecialist that the diagnosis of MG was made. The patient quickly responded to an acetylcholinesterase inhibitor and has since had a great prognosis. Here, we are advocating for the inclusion of routine lab work in the evaluation of patients who present to the primary care setting with diplopia in the absence of red flag symptoms. This approach aids in deciphering the potential involvement of MG in diplopia or ptosis. While such symptoms justify referral to ophthalmology, logistical challenges often hinder a prompt evaluation. Early diagnosis with the incorporation of routine lab work offers the potential to expedite the diagnosis of a rare disease. In doing so, providers can improve prognosis and potentially mitigate additive medical consultations.
PubMed: 38882969
DOI: 10.7759/cureus.60521 -
Journal of the American Heart... Jun 2024This cohort study aims to examine the relationship between the occurrence of cranial nerve palsy (CNP) affecting the third, fourth, or sixth cranial nerve and the...
BACKGROUND
This cohort study aims to examine the relationship between the occurrence of cranial nerve palsy (CNP) affecting the third, fourth, or sixth cranial nerve and the subsequent risk of stroke, with a particular focus on the modulating effect of age on this association.
METHODS AND RESULTS
We established a cohort of individuals diagnosed with third, fourth, or sixth CNP who underwent national health screening within 2 years of diagnosis from 2010 to 2017. A control group was matched by sex and age at a ratio of 1:5. Participants were followed until December 31, 2019. We use multivariable Cox proportional hazards regression analyses to assess the association between ocular motor CNP and subsequent stroke stratified by age. Covariates including lifestyle, health behavior, underlying comorbidities, and Charlson comorbidity index score were also adjusted. Compared with the control group, the ocular motor CNP group had a higher risk of stroke after adjusting for potential confounders (hazard ratio [HR], 1.23 [95% CI,, 1.08-1.39]). The risk of stroke increased by 8.91 times in individuals with ocular motor CNP who were in their 30s (HR, 8.91 [95% CI, 1.63-48.66]). The risk increased by 2.49 times in those who were in their 40s, 1.78 times in those who were in their 50s, and 1.32 times in those who were in their 60s (HRs, 2.49, 1.78, and 1.32 [95% CI, 1.39-4.45, 1.31-2.42, and 1.08-1.62], respectively). However, for those who were in their 20s, 70s, or 80s, the incidence of stroke did not significantly increase.
CONCLUSIONS
Our study establishes an association between ocular motor CNP and an increased risk of stroke, particularly in young adults.
Topics: Humans; Male; Female; Middle Aged; Stroke; Adult; Risk Factors; Aged; Age Factors; Incidence; Oculomotor Nerve Diseases; Risk Assessment; Republic of Korea; Young Adult
PubMed: 38879451
DOI: 10.1161/JAHA.123.033437 -
Journal of Cranio-maxillo-facial... Jun 2024The orbital cavity is a subject of interest for various specialists, and achieving optimal outcomes requires comprehensive, multidisciplinary management. This study aims...
The orbital cavity is a subject of interest for various specialists, and achieving optimal outcomes requires comprehensive, multidisciplinary management. This study aims to report 10 years of experience in the preoperative, surgical, and postoperative care of patients with orbital lesions, examining their clinical, radiological, and anatomopathological features and outcomes. A retrospective review of 125 patients who underwent surgical treatment for intraorbital masses between January 2012 and December 2021 was performed. Outcome measures included postoperative diplopia, exophthalmos, decimal visual acuity, eyeball position, ocular motility, operative time, complications, and aesthetic results. A total of 107 patients were included. All cases were discussed with a neuroradiologist to determine the best therapeutic approach based on preoperative imaging. Preoperative diplopia was linked to extraconal (p = 0.03) and anterior (p = 0.001) lesions, and exophthalmos and visual acuity deterioration were associated with intraconal (p = 0.02; p = 0.03) and retrobulbar (p = 0.001; p = 0.02) lesions. Complications (11.2%) included diplopia, worsened visual acuity, postoperative blepharoptosis, and postoperative ectropion. Of the patients, 80.4% reported an "excellent" aesthetic outcome. This study underscores the importance of a multidisciplinary approach based on a thorough analysis of preoperative imaging. Periorbital approaches tailored to the lesion's three-dimensional location enables safe access to most intraorbital lesions, resulting in minimal complications and good aesthetic results.
PubMed: 38876957
DOI: 10.1016/j.jcms.2024.06.019 -
Medicine Jun 2024Oculomotor nerve palsy (ONP) is often discovered in the ophthalmology department, manifested as ptosis with the same side, eyeball in the fixed external booth, or...
INTRODUCTION
Oculomotor nerve palsy (ONP) is often discovered in the ophthalmology department, manifested as ptosis with the same side, eyeball in the fixed external booth, or accompanied by limited inward, upward, and downward movements. The present case report described the effect of electroacupuncture (EA) on a breast cancer patient with ONP after chemotherapy.
PATIENT CONCERNS
A 56-year-old breast cancer patient presented with severe ptosis and fixed right eye exotropia. Besides, it is challenging to perform the movement inward, upward, and downward, and with obvious diplopia.
DIAGNOSES
The breast cancer patient was diagnosed with ONP, chemotherapy history.
INTERVENTIONS
The patient was introduced to acupuncture department to receiving EA treatment.
OUTCOMES
After 12 times of EA treatments, the symptom of ptosis was significantly improved, and the right upper eyelid can lift autonomously as same as the left eye. Besides, the patient's right lateral eye could move freely, and the symptoms of double vision disappeared.
CONCLUSION
The case suggests that EA may be an effective alternative treatment for ONP.
Topics: Humans; Female; Middle Aged; Electroacupuncture; Oculomotor Nerve Diseases; Breast Neoplasms; Blepharoptosis; Antineoplastic Agents
PubMed: 38875429
DOI: 10.1097/MD.0000000000038547 -
Frontiers in Neurology 2024The pattern of extraocular muscle involvement in ocular myasthenia gravis varies across different reports, diverging from our own observations. Thus, we employed two...
Investigation of the differential susceptibility of extraocular muscles in patients diagnosed with ocular myasthenia gravis based on the computerized diplopia test and the Ocular Motor Nerve Palsy Scale.
INTRODUCTION
The pattern of extraocular muscle involvement in ocular myasthenia gravis varies across different reports, diverging from our own observations. Thus, we employed two novel tools to discern this pattern.
METHODS
A retrospective analysis was conducted to collect and organize clinical data from 43 patients diagnosed with ocular myasthenia gravis. Each patient underwent both the computerized diplopia test and the Ocular Motor Nerve Palsy Scale assessment to evaluate the involvement of extraocular muscles.
RESULTS
Among the patients, there were 30 male and 13 female individuals, with a total of 113 affected extraocular muscles identified. Among all the affected extraocular muscles, the involvement of the levator palpebrae superioris muscle accounted for 35.40%, medial rectus muscle 7.7%, lateral rectus muscle 16.81%, superior rectus muscle 13.27%, inferior rectus muscle 12.39%, superior oblique muscle 1.77%, and inferior oblique muscle 2.65% of the total affected extraocular muscles. The positivity rates of the Neostigmine test were 89.19%, AChR antibody detection was 59.38%, and repetitive nerve stimulation was 34.38%. The AChR antibody positive rate among patients with only diplopia was 100%; among those with only ptosis, it was 80%; and among those with both diplopia and ptosis, it was 86.67%.
CONCLUSION
The involvement of the extraocular muscles is not uniform. The levator palpebrae superioris exhibits the highest incidence rate, followed by the four rectus muscles and two oblique muscles. The inferior oblique involvement typically occurs when four or more EOMs are affected. Moreover, the levator palpebrae superioris and medial rectus show a higher tendency for bilateral involvement compared with other extraocular muscles.
PubMed: 38872815
DOI: 10.3389/fneur.2024.1353248 -
Cureus May 2024Scleral buckle (SB) removal is done for a variety of reasons following treatment of rhegmatogenous retinal detachments (RRD), such as buckle exposure, migration, and...
Scleral buckle (SB) removal is done for a variety of reasons following treatment of rhegmatogenous retinal detachments (RRD), such as buckle exposure, migration, and infection. The most worrying complication of SB removal is retinal redetachment. We report a unique case of a patient developing strabismus about one month after scleral buckle removal for anterior migration and exposure of the scleral buckle. We also share a successful strabismus surgery which had a main aim of relieving diplopia in the patient's primary gaze.
PubMed: 38872683
DOI: 10.7759/cureus.60227 -
Clinical Practice and Cases in... May 2024A 52-year-old female presented to the emergency department with four days of right periorbital pain, ipsilateral temporal headache, diplopia, and photophobia. Physical...
CASE PRESENTATION
A 52-year-old female presented to the emergency department with four days of right periorbital pain, ipsilateral temporal headache, diplopia, and photophobia. Physical examination of the right eye revealed painful ophthalmoplegia, cranial nerves III and VI paresis, increased intraocular pressure, and mild proptosis. Magnetic resonance venogram and magnetic resonance imaging orbits with contrast demonstrated an abnormal signal surrounding the right cavernous sinus/petrous apex. Tolosa-Hunt syndrome (THS) was diagnosed. Per neurology recommendations, the patient was placed on a steroid regimen over the course of three weeks. She was discharged on hospital day nine following resolution of symptoms. She had no recurrence of symptoms or residual deficits noted at her two-week follow-up appointment.
DISCUSSION
With an estimated annual incidence of one case per million, THS is a sinister etiology of unilateral headache, painful ophthalmoplegia, and oculomotor palsy. Tolosa-Hunt syndrome is caused by granulomatous inflammation in the cavernous sinus and is highly responsive to corticosteroids. Magnetic resonance imaging studies of the cavernous sinus and orbital apex are highly sensitive for THS and characteristically show enlargement and focal-enhancing masses within the affected cavernous sinus.
PubMed: 38869347
DOI: 10.5811/cpcem.2582 -
Heliyon Jun 2024The efficacy of rituximab (RTX) in treating steroid-resistant Graves' orbitopathy (GO) has been limitedly studied in Asians. Moreover, RTX has been considered even less...
BACKGROUND AND OBJECTIVES
The efficacy of rituximab (RTX) in treating steroid-resistant Graves' orbitopathy (GO) has been limitedly studied in Asians. Moreover, RTX has been considered even less for patients with steroid-resistant dysthyroid optic neuropathy (DON) who failed to undergo orbital decompression surgery for physical or financial reasons, or who responded poorly to the procedure. This study aimed to investigate the efficacy of RTX in treating steroid-resistant active moderate-to-severe and sight-threatening GO in a Chinese population.
METHODS
Data from 28 patients with steroid-resistant GO prescribed a single dose of 500 mg RTX were retrospectively retrieved. Treatment responses and contributing factors were analyzed.
RESULTS
The median follow-up time was 22 (8-34) weeks. 23 (82.1 %) patients had a positive objective outcome recommended by the European Group on Graves' Orbitopathy (EUGOGO), while 25 (92.6 %) had a decrease in 7-item clinical activity score (CAS) by at least 2. Diplopia, visual dysfunction, and MRI-detected T2 relaxation time of the involved extraocular muscles improved significantly at the last follow-up compared to baseline (81.0 % vs. 47.6 %, 38.9 % vs. 16.7 %, and 87.8 (8.64) vs. 75.8 (10.9) ms, respectively; all values < 0.05). No significant improvement was seen in terms of proptosis and eye muscle duction. Notably, a higher baseline IgG4 to IgG ratio was a predictor for RTX-induced positive EUGOGO outcomes. After RTX treatment, all 8 patients with DON demonstrated inactivation, and 4 improved in visual acuity by ≥ 1 line. No patient with DON experienced obvious deterioration.
CONCLUSION
A single dose of 500 mg RTX seemed to be an effective and tolerable treatment for steroid-resistant GO. However, larger-scale studies with a control group are required for a more solid conclusion. The role of RTX in steroid-resistant DON management where surgery is unavailable or ineffective should be further explored.
PubMed: 38867959
DOI: 10.1016/j.heliyon.2024.e31932 -
Cureus May 2024Sarcoidosis is a multisystem granulomatous disorder with an unknown etiology that typically involves the lungs, skin, and lymph nodes, with neurological involvement...
Sarcoidosis is a multisystem granulomatous disorder with an unknown etiology that typically involves the lungs, skin, and lymph nodes, with neurological involvement being relatively rare. We discuss a case of neurosarcoidosis in a 64-year-old man who initially presented with unexplained cognitive impairment, insomnia, hyponatremia, paresthesias, and weight loss and later developed uveitis, diplopia, and dysphagia. Ultimately, findings of hilar and mediastinal lymphadenopathy on chest computed tomography (CT) resulted in bronchoscopy, which led to the diagnosis. This case highlights a rare presentation of sarcoidosis with an unusual constellation of symptoms. We discuss the difficulty involved in diagnosing this disorder as well as its highly variable course.
PubMed: 38864033
DOI: 10.7759/cureus.60146 -
The American Journal of Case Reports Jun 2024BACKGROUND Craniopharyngioma is a rare, partly cystic embryonic malformation of the sellar and parasellar region and is usually benign. This report is of a 55-year-old...
BACKGROUND Craniopharyngioma is a rare, partly cystic embryonic malformation of the sellar and parasellar region and is usually benign. This report is of a 55-year-old woman presenting with a second diagnosis of craniopharyngioma following diagnosis and successful treatment of craniopharyngioma as a 5-year-old child. CASE REPORT Our patient was diagnosed with craniopharyngioma at age 5 when she presented with headaches accompanied by nausea and vomiting, decreased visual acuity, polyurea, and polydipsia for 6 months. She was found to have diplopia and grade II papilledema. A skull X-ray showed separation of the sutures and a calcified mass in the suprasellar region. A pneumoencephalogram showed extension of the tumor into the third ventricle. Surgery was performed via transcallosal approach followed by radiotherapy at 5000 rays. She was followed up clinically and radiologically and had been disease-free until age 55, when she presented with headache and facial numbness. On examination, she had right-eye Horner syndrome, decreased sensation in the right side of the face, diplopia, and grade 2 facial palsy. An MRI revealed interval significant recurrence of the craniopharyngioma at the sellar/suprasellar mass with extension to the right Meckel's cave and the right posterior fossa. On April 6, 2023, she underwent surgical resection through a right-sided craniotomy and Kawase approach. This was followed by CyberKnife radiation therapy. CONCLUSIONS This report has presented a rare recurrence of craniopharyngioma with a 50-year interval and has highlighted the challenges in the diagnosis and the multidisciplinary approach to patient diagnosis and management.
Topics: Humans; Female; Craniopharyngioma; Pituitary Neoplasms; Middle Aged; Child, Preschool; Neoplasm Recurrence, Local; Magnetic Resonance Imaging
PubMed: 38857198
DOI: 10.12659/AJCR.943300