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

A cholesterol granuloma is the most common primary lesion of the petrous apex, and accounts for 40% of the pathologies that arise in this region. The primary treatment for symptomatic lesions is by surgery to decompress and drain or to completely remove the lesion. Here we describe the use of infralabyrinthine approach to access a lesion through the temporal bone and completely remove it with the assistance of a 0-degree endoscope. A 43-year-old man visited our clinic for diplopia. Magnetic resonance imaging revealed a 2.3-cm cholesterol granuloma located in the left petrous apex that caused deviation of the left abducens nerve. The tumor was completely removed using the endoscopic-assisted infralabyrinthine approach; the patient is currently being followed up, and there is no evidence of disease recurrence. This case report describes the successful completion of a petrous apex cholesterol granuloma that preserved the cochlear and vestibular systems.
Abducens Nerve ; Adult ; Cholesterol* ; Diplopia ; Endoscopes ; Granuloma* ; Humans ; Magnetic Resonance Imaging ; Pathology ; Recurrence ; Temporal Bone

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

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

We encountered a very rare case of spontaneous spinal cerebrospinal fluid (CSF) leakage and a spinal intradural arachnoid cyst (AC) that were diagnosed at different sites in the same patient. These two lesions were thought to have interfered with the disease onset and deterioration. A 30-year-old man presented with sudden neck pain and orthostatic headache. Diplopia, ophthalmic pain, and headache deteriorated. CSF leakage was confirmed in C2 by radioisotope cisternography, and an epidural blood patch was performed. While his symptoms improved gradually, paraparesis suddenly progressed. Thoracolumbar magnetic resonance imaging (MRI) revealed an upper thoracic spinal intradural AC, which was compressing the spinal cord. We removed the outer membrane of the AC and performed fenestration of the inner membrane after T3-4 laminectomy. Postoperative MRI showed complete removal of the AC and normalized lumbar subarachnoid space. All neurological deficits including motor weakness, sensory impairment, and voiding function improved to normal. We present a case of spontaneous spinal CSF leakage and consecutive intracranial hypotension in a patient with a spinal AC. Our report suggests that if spinal CSF leakage and a spinal AC are diagnosed in one patient, even if they are located at different sites, they may affect disease progression and aggravation.
Adult ; Arachnoid ; Blood Patch, Epidural ; Cerebrospinal Fluid Leak ; Cerebrospinal Fluid ; Diplopia ; Disease Progression ; Headache ; Humans ; Intracranial Hypotension ; Laminectomy ; Magnetic Resonance Imaging ; Membranes ; Neck Pain ; Paraparesis ; Spinal Cord ; Subarachnoid Space

Vertebral artery injuries associated with C1 lateral mass screw insertion rarely occur during C1-2 fusion. The posterior inferior cerebellar artery (PICA) is uncommonly located at the C1 lateral mass insertion position. A 71-year-old woman with atlanto-axial subluxation and cord compression underwent C1-2 fusion. Sixth nerve palsy and diplopia were detected postoperatively, and decreased consciousness occurred on postoperative day 4. Brain magnetic resonance image (MRI) and computed tomography (CT) revealed PICA infarction. In the preoperative CT angiography, the PICA originated between the C1 and C2 level. In the postoperative CT scan, the PICA was not visible. The patient was treated conservatively for two weeks and recovered. PICA originating between the C1 and C2 level comprises 1.1–1.3% of cases. Therefore, vertebral artery anomalies should be evaluated prior to C1-2 fusion to prevent vessel injuries.
Abducens Nerve Diseases ; Aged ; Angiography ; Arteries ; Brain ; Brain Infarction ; Consciousness ; Diplopia ; Female ; Humans ; Infarction ; Pica ; Tomography, X-Ray Computed ; Vertebral Artery