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Concept: Oculomotor nerve palsy

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Aims : To derive a reliable estimate of the frequency of pupillary involvement and to study the patterns and course of anisocoria in conjunction with ophthalmoplegia in diabetes-associated oculomotor nerve palsy. Materials and Methods: In this prospective analytical study, standardized enrolment criteria were employed to identify 35 consecutive patients with diabetes-associated oculomotor nerve palsy who were subjected to a comprehensive ocular examination. Standardized methods were used to evaluate pupil size, shape, and reflexes. The degree of anisocoria, if present and the degree of ophthalmoplegia was recorded at each visit. Results: Pupillary involvement was found to be present in 25.7% of the total number of subjects with diabetic oculomotor nerve palsy. The measure of anisocoria was < 2 mm, and pupil was variably reactive at least to some extent in all cases with pupillary involvement. Majority of patients in both the pupil-involved and pupil-spared group showed a regressive pattern of ophthalmoplegia. Ophthalmoplegia reversed much earlier and more significantly when compared to anisocoria. Conclusions: Pupillary involvement in diabetes-associated oculomotor nerve palsy occurs in about 1/4 th of all cases. Certain characteristics of the pupil help us to differentiate an ischemic insult from an aneurysmal injury to the 3 rd nerve. Ophthalmoplegia resolves much earlier than anisocoria in diabetic oculomotor nerve palsies.

Concepts: Eye, Cranial nerves, Oculomotor nerve, Pupil, Oculomotor nerve palsy, Edinger-Westphal nucleus, Anisocoria, Mydriasis

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Aberrant regeneration of a third nerve palsy (oculomotor synkinesis) excludes an ischaemic cause and in the absence of relevant trauma strongly suggests a compressive aetiology. A scan is mandatory in such cases. We describe the case of a 52-year-old woman who presented with complete pupil-involving third nerve palsy from a posterior communicating artery aneurysm, who later developed widespread aberrant regeneration of pupil, eyelid and third nerve territory rectus muscles.

Concepts: Muscle, Posterior communicating artery, Cerebral aneurysm, Case, Oculomotor nerve, In the Absence of Truth, Oculomotor nerve palsy

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We report the case of a 32-year-old woman with bilateral blowout fractures. She presented with diplopia showing impaired abduction of the left eye soon after trauma. No other orbito-ocular signs, such as exophthalmos, ptosis, or chemosis, were found. Orbital reconstruction was performed, but no improvement in her ophthalmoplegia was observed after surgery. A carotid angiography showed that she was suffering from a posteriorly draining carotid-cavernous sinus fistula with isolated abducens nerve palsy. Coil embolization was conducted under the consultation of a neurosurgeon, after which her ophthalmoplegia resolved fully. This is a rare case of posteriorly draining carotid-cavernous sinus fistula without classic orbito-ocular signs, the absence of which may cause diagnostic confusion.

Concepts: Scientific method, Surgery, Cranial nerves, Hydrocephalus, Fistula, Oculomotor nerve palsy, Abducens nerve, Lateral rectus muscle

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To present the surgical outcomes of a muscle union procedure in patients with paralytic strabismus, this retrospective study included 27 patients with paralytic strabismus who underwent a muscle union procedure. In this procedure, the two vertical rectus muscles are united with the paralytic horizontal muscle without splitting the muscles. Postoperative ocular deviations, complications, surgical success rates, and reoperation rates were obtained by examining the medical records of the patients. Seventeen patients had a sixth cranial nerve palsy, seven patients had a third cranial nerve palsy, and three patients had a medial rectus muscle palsy after endoscopic sinus surgery. The mean preoperative angle of horizontal deviation in the primary position was 56 ± 21 prism diopters. The mean follow-up period was 12 ± 9 months. The mean final postoperative ocular deviation was 8 ± 13 prism diopters. The success rate was 74%, and the reoperation rate was 0%. No significant complications, including anterior ischemia, occurred in any of the patients. One patient exhibited an increase in intraocular pressure in the immediate postoperative period, but this resolved spontaneously within 1 week. Our muscle union procedure was effective in patients with paralytic strabismus, especially in patients with a large angle of deviation. This muscle union procedure is potentially a suitable option for muscle transposition in patients with paralytic strabismus who have large-angle deviation or a significant residual angle after conventional surgery.

Concepts: Muscle, Cranial nerves, Standard deviation, Nerve, Superior rectus muscle, Oculomotor nerve palsy, Cover test

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Hyaluronic acid (HA) is the most popular agent today for intradermal injections to improve wrinkles and other cosmetic defects. Ischemic necrosis due to injection of HA is one of the serious complications. Because there are many vascular branches around the nose, caution and care should be given during facial filler injection. Although the incidence is rare, blindness and permanent visual loss may occur. We describe a 29-year-old woman presented with painful erythematous swelling with violaceous patch on right periocular area and glabella after HA filler injection. After injecting the filler, she felt pain and dizziness, and her vision became blurred. She immediately received hyaluronidase around the HA filler inject area and during hospitalized for 10 days, she was successfully treated with systemic steroid, vasodilator, prophylactic antibiotics, and LLLT (low-level laser therapy) without any defects.

Concepts: Inflammation, Therapy, Cranial nerves, Ischemia, Low level laser therapy, Oculomotor nerve, Laser medicine, Oculomotor nerve palsy

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OBJECTIVE Pituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach. In this paper the authors present a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space. METHODS Six injected specimens were used to demonstrate in detail the surgical anatomy related to the approach. Four cases in which the proposed approach was used were retrospectively reviewed. RESULTS From a technical perspective, the first step involves accessing the superior compartment of the cavernous sinus. The interclinoid ligament should be identified and the dura forming the oculomotor triangle exposed. The oculomotor dural opening may be then extended posteriorly toward the posterior petroclinoidal ligament and inferolaterally toward the anterior petroclinoidal ligament. The oculomotor nerve should then be identified; in this series it was displaced superomedially in all 4 cases. The posterior communicating artery should also be identified to avoid its injury. In all 4 cases, the tumor invading the parapeduncular space was completely removed. There were no vascular injuries and only 1 patient had a partial oculomotor nerve palsy that completely resolved in 2 weeks. CONCLUSIONS The endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure. The surgical corridor is increased by opening the dura of the oculomotor triangle and by working below and lateral to the cisternal segment of the oculomotor nerve.

Concepts: Pituitary adenoma, Internal carotid artery, Cranial nerves, Injury, Cavernous sinus, Oculomotor nerve, Trochlear nerve, Oculomotor nerve palsy

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To describe lower cranial nerve palsy (LCNP) following vertical over-distraction when performing occipitocervical fusion (OCF) to treat vertical atlantoaxial dislocation (AAD) and basilar invagination (BI) and to investigate its possible causes.

Concepts: Cranial nerves, Oculomotor nerve palsy

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Ocular neuromyotonia is a rare, albeit treatable, ocular motor disorder, characterised by recurrent brief episodes of diplopia due to tonic extraocular muscle contraction. Ephaptic transmission in a chronically damaged ocular motor nerve is the possible underlying mechanism. It usually improves with carbamazepine. A 53-year-old woman presented with a 4-month history of recurrent episodes of binocular vertical diplopia (up to 40/day), either spontaneously or after sustained downward gaze. Between episodes she had a mild left fourth nerve palsy. Sustained downward gaze consistently triggered downward left eye tonic deviation, lasting around 1 min. MR scan of the brain was normal. She improved on starting carbamazepine but developed a rash that necessitated stopping the drug. Switching to lacosamide controlled her symptoms.

Concepts: Brain, Muscle, Symptoms, Eye, Muscular system, Diplopia, Binocular vision, Oculomotor nerve palsy

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PurposeThe purpose of this study is to evaluate the efficacy and safety of botulinum toxin injection as a primary treatment for strabismus in a cohort of patients with nasopharyngeal carcinoma (NPC)-related chronic sixth nerve palsy.Patients and methodsWe retrospectively reviewed all cases of NPC-related sixth nerve palsy receiving botulinum toxin injection in the Hong Kong Eye Hospital between January 2009 and January 2016. Only cases with diplopia for at least 6 months; and failed a trial of Fresnel prism therapy were recruited. We excluded cases with prior strabismus surgery and multiple cranial nerve palsies. Patients were offered botulinum toxin injection as primary treatment for their strabismus and were given further injections or offered surgery if diplopia persisted. Success with botulinum toxin was defined as a final distant orthophoria of <15 PD in primary gaze, no diplopia in primary position, and no head turn, as measured 6 months after the last injection, without requiring a second treatment.ResultsA total of 25 patients were included in the study. All patients received concurrent chemo-radiotherapy for NPC. There was a statistically significant reduction in the mean deviation at distant after the last injection compared to that at presentation (P<0.001, Wilcoxin signed rank test). Overall, 7 patients (28%) achieved clinical success and 15 patients (64%) remained diplopia-free by repeated botulinum toxin injections alone. Nine patients went on to receive definitive surgery and all achieved good ocular alignment after surgery. Transient ptosis or vertical deviation was seen in 7 patients, which resolved within 3 months and no serious complications arose from the treatment in our series.ConclusionsBotulinum toxin injection is a relatively less-invasive alternative to surgery that can be done under a topical anesthesia setting, which improves patient's quality of life via reduction in diplopia. It is a recommendable initial option in patients with chronic nerve palsies who may have higher risks associated with strabismus surgery.Eye advance online publication, 26 January 2018; doi:10.1038/eye.2017.276.

Concepts: Statistics, Statistical significance, Anesthesia, Cranial nerves, Strabismus, Nasopharyngeal carcinoma, Botulinum toxin, Oculomotor nerve palsy