Orbital tuberculosis is a rare form of extrapulmonary tuberculosis, even in endemic areas. It may involve the soft tissue, lacrimal gland, periosteum, or bones of the orbital wall. We present a case of orbital tuberculosis on the lower eyelid. An 18-year-old woman with no underlying disease visited our clinic for evaluation of an oval nodule (1.5× 1.2 cm) on the right lower eyelid. Incision and drainage without biopsy was performed 2 months ago in ophthalmology department, but the periorbital mass had deteriorated, as the patient had erythematous swelling, tenderness, and cervical lymphadenopathy. Visual acuity was normal; there were no signs of proptosis, diplopia, or ophthalmoplegia. Computed tomography revealed a small abscess cavity without bony involvement. We performed an excision and biopsy through a percutaneous incision under local anesthesia. Histological examination revealed a granuloma and was diagnosed as orbital tuberculosis. The patient was additionally treated with anti-tuberculosis therapy for 6 months and recovered without complication or recurrence by 7 months. Orbital tuberculosis occurs in patients with or without associated pulmonary tuberculosis, and should be considered as a differential diagnosis in patients with inflammatory orbital disease and an orbital mass. If recurrence occurs despite adequate initial treatment, we recommend an additional examination and excisional biopsy.
Abscess ; Adolescent ; Anesthesia, Local ; Biopsy ; Diagnosis, Differential ; Diplopia ; Drainage ; Exophthalmos ; Eyelids ; Female ; Granuloma ; Humans ; Lacrimal Apparatus ; Lymphatic Diseases ; Ophthalmology ; Ophthalmoplegia ; Orbit ; Orbital Diseases ; Periosteum ; Recurrence ; Tuberculosis ; Tuberculosis, Pulmonary ; Visual Acuity

PURPOSE: To evaluate the classification, diagnosis, and natural course of ophthalmoplegia associated with mitochondrial disease. MATERIALS AND METHODS: Among 372 patients with mitochondrial disease who visited our hospital between January 2006 and January 2016, 21 patients with ophthalmoplegia were retrospectively identified. Inclusion criteria included onset before 20 years of age, pigmentary retinopathy, and cardiac involvement. The 16 patients who were finally included in the study were divided into three groups according to disease type: Kearns-Sayre syndrome (KSS), KSS-like, and chronic progressive external ophthalmoplegia (CPEO). RESULTS: The prevalences of clinical findings were as follows: ptosis and retinopathy, both over 80%; myopathy, including extraocular muscles, 75%; lactic acidosis, 71%; and elevated levels of serum creatine kinase, 47%. Half of the patients had normal magnetic resonance imaging findings. A biochemical enzyme assay revealed mitochondrial respiratory chain complex I defect as the most common (50%). The prevalence of abnormal muscle findings in light or electron microscopic examinations was 50% each, while that of large-scale mitochondrial DNA (mtDNA) deletions in a gene study was 25%. We compared the KSS and KSS-like groups with the CPEO patient group, which showed pigmentary retinopathy (p < 0.001), cardiac conduction disease (p=0.013), and large-scale mtDNA deletions (p=0.038). KSS and KSS-like groups also had gastrointestinal tract disorders such as abnormal gastrointestinal motility (p=0.013) unlike the CPEO group. CONCLUSION: Patients with KSS had gastrointestinal symptoms, which may indicate another aspect of systemic involvement. The presence of large-scale mtDNA deletions was an objective diagnostic factor for KSS and a gene study may be helpful for evaluating patients with KSS.
Acidosis, Lactic ; Classification ; Creatine Kinase ; Diagnosis ; DNA, Mitochondrial ; Electron Transport ; Enzyme Assays ; Gastrointestinal Motility ; Gastrointestinal Tract ; Genes, vif ; Humans ; Kearns-Sayre Syndrome ; Magnetic Resonance Imaging ; Mitochondrial Diseases* ; Muscles ; Muscular Diseases ; Ophthalmoplegia* ; Ophthalmoplegia, Chronic Progressive External ; Prevalence ; Retinitis Pigmentosa ; Retrospective Studies

PURPOSE: To present a case of orbital inflammation and optic perineuritis preceding vesicular eruption in herpes zoster ophthalmicus(HZO). CASE SUMMARY: An 84-year-old woman with a history of gall bladder cancer and hypertension complained of left periorbital erythematous edema and discomfort. On examination, visual acuity was 20/25 bilaterally; no tenderness, proptosis or ophthalmoplegia was observed. Pupils were equal, round, and reactive to light without relative afferent pupillary defects. Slit-lamp examination revealed severe conjunctival injection and chemosis without keratitis or uveitis. The remainder of the ocular examination was unremarkable. Magnetic resonance imaging confirmed left-sided preseptal swelling with an enlarged left lacrimal gland, high signal intensity of the retrobulbar fat and optic nerve sheath. Systemic antibiotic therapy with steroids was started under a presumed diagnosis of idiopathic orbital inflammatory disease, but the clinical presentation was unresolved. After 2 days, vesicular lesions confined to the first division of the trigeminal nerve and pseudodendritic keratitis developed on the left side leading to a diagnosis of HZO. Treatment with acyclovir immediately resolved anterior segment inflammation and periorbital edema. While on therapy, visual acuity deteriorated to 20/125 and the pupil became dilated and unresponsive to light over a few days. All signs and symptoms of acute orbitopathy and postherpetic neuralgia had resolved 3 months later with the exception of pupil abnormality and visual acuity. CONCLUSIONS: HZO may present with symptoms and signs of orbital inflammation and optic perineuritis even in the absence of a vesicular rash. Thus, HZO should be considered in the differential diagnosis of unexplained acute orbital syndromes.
Acyclovir ; Aged, 80 and over ; Dacryocystitis ; Diagnosis ; Diagnosis, Differential ; Edema ; Exanthema ; Exophthalmos ; Female ; Gallbladder Neoplasms ; Herpes Zoster Ophthalmicus* ; Herpes Zoster* ; Humans ; Hypertension ; Inflammation* ; Keratitis ; Lacrimal Apparatus ; Magnetic Resonance Imaging ; Neuralgia, Postherpetic ; Ophthalmoplegia ; Optic Nerve ; Orbit* ; Pupil ; Pupil Disorders ; Steroids ; Trigeminal Nerve ; Uveitis ; Visual Acuity

PURPOSE: To investigate the neuro-ophthalmic diagnosis and clinical manifestations of intracranial aneurysm. METHODS: A retrospective survey of 33 patients who were diagnosed with intracranial aneurysm and underwent neuro-ophthalmic examination from April 2008 to December 2016. Frequency of the first diagnosis of intracranial aneurysm in ophthalmology, neuro-ophthalmic diagnosis, location of intracranial aneurysm, examination of intracranial aneurysm rupture, and neurologic prognosis of Terson's syndrome patients were analyzed by image examination, neurosurgery, and ophthalmology chart review. RESULTS: Of the 33 patients, most patients (n = 31, 94%) were diagnosed with intracranial aneurysm at the neurosurgical department and only 2 patients were diagnosed initially at the ophthalmology department. Causes and association were: Terson's syndrome (n = 10, 30%), third cranial nerve palsy (n = 10, 30%), internclear ophthalmoplegia (n = 4, 12%), visual field defect (n = 3, 9%), optic atrophy (n = 3, 9%), sixth cranial nerve palsy (n = 2, 6%), and nystagmus (n = 1, 3%). The location of intracranial aneurysms were: anterior communicating artery (n = 13, 39%), medial communicating artery (n = 12, 36%), and posterior communicating artery (n = 5, 15%). Ten of 33 patients had Terson's syndrome, and 6 patients (60%) with Terson's syndrome had apermanent neurological disorder such as agnosia, gait disorder and conduct disorder. CONCLUSIONS: Third cranial nerve palsy was the most common neuro-ophthalmic disease in patients presenting with intracranial aneurysm. The neuro-ophthalmic prognoses for those diseases were relatively good, but, if Terson's syndrome was present, neurological disorders (agnosia, gait disorder, conduct disorder) were more likely to remain after treatment.
Abducens Nerve Diseases ; Agnosia ; Arteries ; Conduct Disorder ; Diagnosis ; Gait ; Humans ; Intracranial Aneurysm* ; Nervous System Diseases ; Neurosurgery ; Oculomotor Nerve ; Ophthalmology ; Ophthalmoplegia ; Optic Atrophy ; Paralysis ; Prognosis ; Retrospective Studies ; Rupture ; Visual Fields

Orbital metastases are rare and predominantly unilateral occurrences. Bilateral metastases affecting the extraocular muscles are extremely rare. A few case reports of bilateral metastases to extraocular muscles described binocular diplopia with conspicuous bilateral external ophthalmoplegia as an initial symptom. We report a case in which unilateral ptosis was an initial symptom and bilateral incomplete ophthalmoplegia was found on initial neurologic examination in invasive ductal carcinoma of the breast. The patient had hormone receptor-positive breast cancer, and so was treated by hormonal therapies and closely monitored. The presence of a secondary orbital lesion presents many difficulties of differential diagnosis and treatment. A thorough neurologic examination to detect ocular manifestations is most important for localization and broad differential diagnosis including mechanical orbital metastatic lesion.
Breast ; Breast Neoplasms ; Carcinoma, Ductal ; Carcinoma, Ductal, Breast ; Diagnosis, Differential ; Diplopia ; Humans ; Muscles ; Neoplasm Metastasis ; Neurologic Examination ; Ophthalmoplegia* ; Orbit ; Orbital Neoplasms ; Telescopes

PURPOSE: In the present study, the clinical characteristics and prognosis of patients clinically diagnosed with classic Miller Fisher syndrome were evaluated. METHODS: We retrospectively investigated the clinical and laboratory findings as well as treatment outcomes using the medical records of patients diagnosed with Miller Fisher syndrome. Symptom triad including acute ophthalmoplegia, ataxia, and areflexia were evaluated. RESULTS: This study included 10 patients. Nine patients had antecedent infectious illness which took an average of 11 ± 9.7 days for onset of diplopia from antecedent infectious systemic illness. Seven patients showed bilateral paralytic strabismus. Specifically, 5 patients showed the involvement of vertical and horizontal extraocular muscles. Pupil impairment and blepharoptosis were observed in 4 patients, limb weakness in 3 patients, dysarthria in 3 patients and facial palsy in 1 patient. Two patients showed contrast enhancement of the abducens nerve on brain magnetic resonance imaging (MRI) and 2 patients showed albumin-cell dissociation on cerebrospinal fluid (CSF) analysis. Eight patients had anti-GQ1b antibodies in their blood serum analysis. Six patients were treated with intravenous immunoglobulins and the other patients were observed with regular follow-ups. The duration of diplopia was 2.9 ± 1.2 months in the treatment group and 3.1 ± 1.7 months in the control group (p > 0.05). The duration of ataxia was 1 ± 0.4 months in the treatment group and 1 ± 0.9 months in the control group (p > 0.05). CONCLUSIONS: Miller Fisher syndrome should be considered in patients with antecedent infection; acute ophthalmoplegia, ataxia and areflexia as well as anti-GQ1b antibody can be helpful for diagnosis. Final outcomes in the treated group were not significantly different from the control group and all patients showed good final outcomes.
Abducens Nerve ; Antibodies ; Ataxia ; Blepharoptosis ; Brain ; Cerebrospinal Fluid ; Diagnosis ; Diplopia ; Dysarthria ; Extremities ; Facial Paralysis ; Follow-Up Studies ; Humans ; Immunoglobulins, Intravenous ; Magnetic Resonance Imaging ; Medical Records ; Miller Fisher Syndrome* ; Muscles ; Ophthalmoplegia ; Prognosis* ; Pupil ; Retrospective Studies ; Serum ; Strabismus

Cavernous sinus syndrome (CSS) is defined as the involvement of two or more of the third, fourth, fifth (V1, V2) or sixth cranial nerves or involvement of only one of them in combination with a neuroimaging-confirmed lesion in the cavernous sinus. Some cases of CSS are attributed to Tolosa-Hunt syndrome (THS), an idiopathic inflammatory disease of the cavernous sinus. THS is characterized by painful ophthalmoplegia due to granulomatous inflammation in the cavernous sinus. THS is a diagnosis of exclusion that requires a vigorous series of differential diagnoses, and corticosteroid therapy is known to dramatically resolve clinical findings of THS. We report a case of a patient with painful ophthalmoplegia associated with vision loss, which was suspected to be THS. This patient followed a relatively typical clinical course of THS on steroid pulse therapy. We emphasize the differential diagnosis of THS, its presentation, and treatment.
Abducens Nerve ; Cavernous Sinus ; Diagnosis ; Diagnosis, Differential ; Headache* ; Humans ; Inflammation ; Ophthalmoplegia ; Tolosa-Hunt Syndrome*

Alternating recurrent painful ophthalmoplegia is caused by various neurological conditions including Tolosa-Hunt syndrome, sellar mass, and parasagittal meningioma. We experienced a rare case of recurrent painful ophthalmoplegia occurring on the contralateral side as a manifestation of idiopathic hypertrophic tentorial pachymeningitis. We propose that idiopathic hypertrophic pachymeningitis should be considered in the differential diagnosis of alternating recurrent painful ophthalmoplegia.
Diagnosis, Differential ; Meningioma ; Meningitis* ; Ophthalmoplegia* ; Tolosa-Hunt Syndrome

No abstract available.
Adult ; Autoantibodies/*blood ; Gangliosides/blood/*immunology ; Humans ; Male ; Ophthalmoplegia/blood/*diagnosis/immunology ; Recurrence ; Syndrome

PURPOSE: Ocular manifestations in snake-bite injuries are quite rare. However, the unusual presentations, diagnosis and their management can pose challenges when they present to the ophthalmologist. Early detection of these treatable conditions can prevent visual loss in these patients who are systemically unstable and are unaware of their ocular condition. To address this, a study was conducted with the aim of identifying the various ocular manifestations of snake bite in a tertiary care center. METHODS: This is a one-year institute-based prospective study report of 12 snake bite victims admitted to a tertiary hospital with ocular manifestations between June 2013 to June 2014, which provides data about the demographic characteristics, clinical profiles, ocular manifestations, and their outcomes. RESULTS: Twelve cases of snake bite with ocular manifestations were included of which six were viper bites, three were cobra bites and three were unknown bites. Six patients presented with bilateral acute angle closure glaucoma (50%), two patients had anterior uveitis (16.6%) of which one patient had concomitant optic neuritis. One patient had exudative retinal detachment (8.3%), one patient had thrombocytopenia with subconjunctival hemorrhage (8.3%) and two patients had external ophthalmoplegia (16.6%). CONCLUSIONS: Bilateral angle closure glaucoma was the most common ocular manifestation followed by anterior uveitis and external ophthalmoplegia. Snake bite can result in significant ocular morbidity in a majority of patients but spontaneous recovery with anti-snake venom, steroids and conservative management results in good visual prognosis.
Acute Disease ; Adolescent ; Adult ; Animals ; Antivenins/therapeutic use ; *Elapidae ; Female ; Follow-Up Studies ; Glaucoma, Angle-Closure/diagnosis/*etiology/therapy ; Humans ; Male ; Middle Aged ; Ophthalmoplegia/diagnosis/*etiology/therapy ; Prospective Studies ; Snake Bites/*complications/diagnosis/therapy ; Snake Venoms/*poisoning ; Tertiary Healthcare ; Time Factors ; Uveitis, Anterior/diagnosis/*etiology/therapy ; *Viperidae ; Young Adult