Pupil-sparing oculomotor nerve palsy due to midbrain infarction.

Vasculopathic oculomotor nerve palsies with pupillary sparing are thought to be due to ischemic damage to the nerve in the subarachnoid space or the cavernous sinus. We present two cases of patients with isolated pupil-sparing oculomotor nerve palsies due to midbrain infarcts. Focal ischemic midbrain lesions should be considered in cases of pupil-sparing oculomotor nerve palsies.

Disk edema and peripheral neuropathy.

A 55-year-old woman presented with an eight-year history of progressive gait dysfunction and a 2-3 week history of horizontal diplopia. Examination of the patient revealed acute papilledema, intermittent esotropia, and upper and lower motor neuron findings in her lower extremities. CT scan of the head showed communicating hydrocephalus. A spinal cord tumor extending from T11 to L3 was visualized by MR imaging of the spine. All of her symptoms, except for a left foot drop, resolved with aggressive removal of the tumor, which was a myxopapillary ependymoma. Mechanisms of the neuro-ophthalmic picture and treatment of this syndrome are discussed.

Atherosclerotic carotid disease and the eye.

The evaluation and management of retinal ischemia from atherosclerotic carotid disease is in a state of flux reflected by the change from emphasizing surgical management in the '70s toward skepticism about the benefit of surgery in the '80s. In addition, reliable noninvasive diagnostic testing of the carotid artery has reduced the risk. The decision to consider surgical versus medical management must be made on an individual basis based on the patient's health, age, and the risk of angiography and surgery at each institution. In children and young adults, amaurosis fugax is a benign condition. In the older population amaurosis fugax is often the sentinel event of diffuse atherosclerotic disease and possible early death from myocardial infarction. A team including the neurologist, internist, ophthalmologist, and surgeon optimizes care of the whole disease and not just the symptom. It is hoped that information in the next decade will supply additional guidance in the care of this multifaceted malady.

Superior oblique myokymia. A misnomer.

Clinical examination of a 26-year-old, white man with episodic vertical diplopia and oscillopsia led to the diagnosis of "superior oblique myokymia." The dissimilarity between the observed superior oblique movements and myokymia as defined in other nervous system disorders is striking. Therefore, we suggest that superior oblique microtremor may be a better term to describe these superior oblique movements.

Beesting papillitis.

A 72-year-old, white male presented with sudden, painless loss of vision bilaterally associated with optic disc swelling. His visual loss occurred within 24 hours of receiving multiple beestings. Clinical examination revealed papillitis. Optic neuritis associated with beestings is a rare complication which is not understood fully.

Cryptococcal meningitis. An atypical presentation.

A previously healthy 23-year-old white female presented with a history of horizontal diplopia prior to any other symptoms. Physical examination revealed bilateral sixth cranial nerve palsies, papilledema, right Horner's syndrome, and right hemiparesis. Cryptococcus neoformans was isolated from the cerebrospinal fluid. This is the first documented case of Horner's syndrome associated with cryptococcal meningitis.

Paradoxical lid elevation with sustained upgaze: a sign of Lambert-Eaton syndrome.

Myasthenia gravis and Lambert-Eaton myasthenic syndrome are causes of acquired extraocular muscle weakness and ptosis. Exacerbation of ptosis after sustained upgaze is a clinically useful sign in the diagnosis of myasthenia gravis. A 54-year-old woman with established Lambert-Eaton myasthenic syndrome exhibited transient improvement of her ptosis after sustained upgaze. We suggest that paradoxical lid elevation after sustained upgaze may be a clinically useful sign in distinguishing Lambert-Eaton myasthenic syndrome from myasthenia gravis.

Rhabdomyosarcoma causing rapid bilateral visual loss in children.

Rhabdomyosarcoma commonly involves the orbit resulting in unilateral proptosis, swelling, and restricted ocular motility. We saw two unusual cases of children with nasopharyngeal rhabdomyosarcoma which caused rapid bilateral visual loss due to simultaneous spread of the tumor to the orbital apices. Initial CT scans revealed the tumor, but were misinterpreted as "normal," causing a significant delay in diagnosis. We recommend high resolution CT scans of the nasopharynx, orbits, and suprasellar region in any child with rapid bilateral visual loss to rule out this common childhood tumor.