OBJECTIVE

To describe the clinical presentation, management and outcome of a rare case of isolated oculomotor nerve palsy in an immunocompromised adult secondary to a central nervous system (CNS) tuberculoma.

This is a case report.

A Filipino male in his 30s developed severe throbbing headache followed by binocular diplopia and drooping of the right upper eyelid. Findings were compatible with a neurologically-isolated pupil-involving, complete oculomotor nerve palsy on the right. Brain magnetic resonance imaging demonstrated enlargement and contrast enhancement of the cisternal portion of the right oculomotor nerve. Serologic testing was positive for the human immunodeficiency virus (HIV) and syphilis. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis and elevated protein. CSF polymerase chain reaction was positive for Mycobacterium tuberculosis (TB). The patient was treated with penicillin, quadruple anti-Koch’s, and anti-retrovirals. Eyelid position and ocular motility improved after treatment. Aberrant regeneration of the right oculomotor nerve was observed with elevation of the right eyelid on downgaze (pseudo-Graefe sign).

CNS tuberculoma may present as a neurologically-isolated oculomotor nerve palsy, particularly in immunocompromised individuals. In TB-endemic countries, like the Philippines, it should be considered in the differential diagnosis. Early recognition and appropriate antimicrobial therapy can lead to neurologic improvement.

OBJECTIVE

This study described the ophthalmic symptoms and signs in patients with nasopharyngeal carcinoma (NPCA).

This was a retrospective, cross-sectional, descriptive study involving patients with histologically-confirmed NPCA seen in two subspecialty eye clinics in a single referral hospital from January 2014 to December 2018. Chart review obtained data on symptoms and ophthalmic findings of patients with NPCA on the first visit. Descriptive statistics was used to analyze the data.

There were 36 patients in the study. There were 27 males (75%) and mean age was 47 years (Range: 13 - 83). Delay to consult was marked, with 28 patients (78%) presenting later than three months; 19 (53%) had invasion to distant sites on presentation. Almost all of the patients (35/36 or 97%) had either diplopia or blurring of vision, with nasal symptoms as the most common extra-ophthalmic accompanying symptom. Multiple cranial nerve palsies, particularly optic nerve plus at least one ocular motor nerve, was a prominent feature. The combination of nasal symptoms with ophthalmoparesis was noted in 24 patients (67%) and was identified as a red flag for NPCA.

Blurred vision and diplopia were the most common ocular complaints of patients with NPCA who were evaluated at the ophthalmology department of a tertiary hospital. Blurred vision is frequently from optic nerve involvement while diplopia is due to ophthalmoparesis secondary to multiple ocular motor cranial nerves involvement. Male patients in their 40s who present with combination of optic neuropathy or ocular motor palsies should be probed for presence of otologic or nasal symptoms as well as neck masses as these are the common presentation of NPCA in the ophthalmology clinics.

A white-eyed blowout fracture is an orbital floor fracture associated with restriction of ocular motility (suggestive of orbital content entrapment) but with minimal or absence of signs of soft tissue trauma. It can lead to significant patient morbidity. This case involved an 8-year-old boy with a white-eyed blowout fracture following facial trauma. He presented with binocular diplopia and a history of recurrent episodes of vomiting after the trauma and was referred to our centre for a suspected head injury. Visual acuity in both eyes was 6/9. Examination showed minimal left periorbital haematoma with left eye motility restriction on superior and medial gaze associated with pain. CT scan of the orbit showed left orbital floor fracture with minimal soft tissue entrapment. He underwent urgent open exploration of the left orbit and release of orbital tissue entrapment. Post-operatively, the left eye motility restriction improved significantly with resolution of diplopia. In conclusion, a high index of suspicion is crucial in diagnosing paediatric white-eyed blowout fractures due to lack of external ocular signs.
Diplopia

PURPOSE: To report the clinical manifestations and computed tomography (CT) findings of patients with a trapdoor type medial orbital wall blowout fracture.METHODS: From March 2009 to October 2016, the clinical records and computed tomography findings of patients who underwent surgical treatment for a trapdoor type medial orbital wall blowout fracture were retrospectively analyzed.RESULTS: A total of eight patients (six males and two females) were enrolled with a combined mean age of 14.4 years. Clinical manifestations were eyeball movement limitation (abduction and adduction) and ocular motility pain (eight patients, 100%), diplopia (seven patients, 87.5%), and nausea and vomiting (four patients, 50%). On CT, the distance from the orbital apex to the fracture site was an average of 22.0 mm and occurred in the middle position of the entire wall. Two patients had missed rectus completely dislocated into the ethmoid sinus through the fracture gap and six patients had definite involvement in the fracture gap and edema of the medial rectus muscle. The medial rectus muscle cross-sectional area was 47.7 mm² which was edematous compared to the contralateral eye (40.1 mm²). Orbital wall reconstruction was performed an average of 4.1 days after the injury. In all patients with oculocardiac reflex-like nausea and vomiting immediately improved after surgery. Six out of eight patients who had eyeball movement limitations (abduction and adduction) preoperatively showed adduction limitation after surgery. The eyeball movement limitation and diplopia disappeared 11.7 days and 46.7 days after surgery, respectively.CONCLUSIONS: Patients with trapdoor type medial wall blowout fracture showed characteristic computed tomographic findings and clinical manifestations such as eyeball movement limitation, ocular motility pain, diplopia, and oculocardiac reflex. An understanding of clinical findings and quick surgical treatment are therefore required. The type of eyeball movement limitation was abduction and adduction limitation preoperatively and adduction limitation postoperatively.
Diplopia ; Edema ; Ethmoid Sinus ; Humans ; Male ; Nausea ; Orbit ; Reflex, Oculocardiac ; Retrospective Studies ; Vomiting

The aim of the study is to evaluate the hemodynamic changes and the parenchymal perfusion associated with carotid cavernous fistulas before and after embolization using two-dimensional (2D) parenchymal blood flow analysis. A 15-year-old boy presented with 2-month history of progressive right eye proptosis, chemosis, and diplopia after a motor vehicle accident. Intracranial liquid embolization using Onyx-18 through the inferior petrosal approach was done with balloon protection at the opening of the fistula in the internal carotid artery, resulting in complete occlusion of the fistula. Parenchymal blood flow analysis was done before and immediately after embolization. 2D parametric parenchymal blood flow analysis is newly introduced software that can provide data cannot be conveyed by conventional digital subtraction angiography alone. The software allows for objective assessment of the arterial steal and the parenchymal perfusion both pre, and post-embolization. Pre-embolization assessment may influence the therapeutic decision, while post-embolization assessment can evaluate the treatment efficacy.
Adolescent ; Angiography, Digital Subtraction ; Carotid Artery, Internal ; Diplopia ; Embolization, Therapeutic ; Exophthalmos ; Fistula ; Hemodynamics ; Humans ; Male ; Motor Vehicles ; Perfusion ; Treatment Outcome

diplopia and enophthalmos, proper diagnosis and timing of repair are crucial. However, clinical decision-making in the management of patients with orbital blowout fractures is challenging, and various aspects of orbital fracture management are uncertain. Numerous approaches have been used for reduction of blowout fracture. Controversies exist regarding indications for surgery, timing of surgery, and optimal reconstruction material. Recently, with expanding use of and indications for endoscopy in orbital blowout fracture surgery, otolaryngologists participate more often in facial trauma surgery, including blowout fracture. In this review, several controversial issues of surgical indication, surgical timing, method of approach, and choice of reconstruction material are discussed from the perspective of otolaryngology surgeons.]]>
Clinical Decision-Making ; Diagnosis ; Diplopia ; Endoscopy ; Enophthalmos ; Humans ; Incidence ; Methods ; Orbit ; Orbital Fractures ; Otolaryngology ; Paranasal Sinuses ; Prolapse ; Surgeons

The most cases with orbital metastases have been reported in patients with a prior established diagnosis of cancer and widespread systemic involvement. However, ocular symptoms can be developed as an initial presentation of cancer in patients without cancer history. We report a case of rapid progression from trochlear nerve palsy to orbital apex syndrome as an initial presentation of advanced gastric cancer.
Diagnosis ; Diplopia ; Humans ; Neoplasm Metastasis ; Optic Nerve Diseases ; Orbit ; Stomach Neoplasms ; Trochlear Nerve Diseases ; Trochlear Nerve

OBJECTIVE: Several studies have reported that periprocedural dual antiplatelet therapy lowers the incidence of thromboembolic complications (TEC) associated with coiling of unruptured aneurysms. We hypothesized that preprocedural administration of dual antiplatelet agents (aspirin and cilostazol) for 7days may reduce the risk of complications associated with diagnostic cerebral digital subtraction angiography (DSA).METHODS: We retrospectively reviewed the records of patients who underwent diagnostic cerebral DSA between September 2015 and April 2018. Of the 419 patients included (149 men, 270 women, mean age 58.5 years), 221 (72 men, 149 women, mean age 57.8 years) who underwent cerebral DSA between September 2015 and June 2016 were not premedicated with antiplatelet therapy. The remaining 198 (77 men, 121 women, mean age 59.4 years) who underwent cerebral DSA between July 2016 and April 2018 were premedicated with dual antiplatelet therapy (aspirin and cilostazol). We defined ischemic stroke as a cerebral DSA-induced complication identified on magnetic resonance imaging (MRI) among patients with neurological symptoms.RESULTS: Of the 221 patients who did not receive antiplatelet therapy, 210 (95.0%) showed no neurological symptoms; however, 11 (5.0%) developed neurological symptoms with MRI-proven ischemic stroke, which represents a TEC. Of the 198 patients who received dual antiplatelet therapy, 196 patients (99.0%) showed no evidence of TEC. The remaining 2 (1.0%) developed diplopia and motor weakness each, and MRI confirmed acute ischemic stroke (p=0.019).CONCLUSIONS: The use of dual antiplatelet agents (aspirin and cilostazol) for 7 days before DSA may reduce the risk of cerebral DSA-induced TEC.
Aneurysm ; Angiography, Digital Subtraction ; Diplopia ; Female ; Humans ; Incidence ; Magnetic Resonance Imaging ; Male ; Platelet Aggregation Inhibitors ; Premedication ; Retrospective Studies ; Stroke ; Thromboembolism

Oculomotor nerve palsy limits the specific direction eyeball movement, and represents diplopia, mydriasis, and ptosis. The vascular-associated etiologies of oculomotor nerve palsy are the microvascular ischemia due to hypertension or diabetes, or compression of the nerve by the aneurysm. For the aneurysm, if not treated properly, it may result in mortality or severe neurological impairment. Thorough history taking, physical examinations, and proper imaging modality are needed to make an accurate diagnosis. A 76-year-old female with decreased mentality and anisocoria presented at our emergency department. An 83-year-old female presented with right ptosis and lateral-side deviated of the right eyeball. No definite lesion was noted on the initial non-contrast brain computed tomography (CT) and magnetic resonance imaging diffusion. An aneurysm was detected on CT angiography taken several hours later in the former patient. For the latter patient, a giant aneurysm was detected on magnetic resonance angiography that had been performed at another hospital 4 days earlier. These two patients underwent transfemoral cerebral angiography with coiling. They were discharged with no neurological sequelae.
Aged ; Aged, 80 and over ; Aneurysm ; Angiography ; Anisocoria ; Brain ; Carotid Artery, Internal ; Cerebral Angiography ; Diagnosis ; Diffusion ; Diplopia ; Emergency Service, Hospital ; Female ; Humans ; Hypertension ; Ischemia ; Magnetic Resonance Angiography ; Magnetic Resonance Imaging ; Mortality ; Mydriasis ; Oculomotor Nerve Diseases ; Oculomotor Nerve ; Physical Examination

Atorvastatin is one of the most widely prescribed medications for dyslipidemia treatment. In Korea, post combined therapy with ezetimibe, a 73-year-old woman was reported by a community pharmacy to have experienced visual field defect, which recovered after drug discontinuation. She had never experienced this symptom before, and several studies have reported an association between use of statins and visual disorders such as blurred vision, diplopia, and cataract. Blockage of cholesterol accumulation, oxidative stress, or myopathy is expected to be a cause of this symptom. Naranjo scale, Korean causality assessment algorithm (Ver.2), and World Health Organization-Uppsala Monitoring Center (WHO-UMC) criteria were the three tools used to determine causality between the visual disorder and atorvastatin. The results represent ‘probable’, ‘certain’, and ‘probable/likely’ causality, respectively. Our results, in combination with a review of literature, indicate that ocular adverse effects are highly likely related to atorvastatin.
Aged ; Atorvastatin Calcium ; Cataract ; Cholesterol ; Diplopia ; Drug-Related Side Effects and Adverse Reactions ; Dyslipidemias ; Ezetimibe ; Female ; Global Health ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Korea ; Muscular Diseases ; Oxidative Stress ; Pharmacies ; Vision Disorders ; Visual Fields