Ocular motility disorders following coronavirus disease-19 vaccination.

PURPOSE: To describe clinical manifestations and short-term prognosis of ocular motility disorders following coronavirus disease-2019 (COVID-19) vaccination. METHODS: Ocular motility disorders were diagnosed by clinical assessment, high-resolution magnetic resonance imaging, and laboratory testing. Clinical manifestations, short-term prognosis, and rate of complete recovery were analyzed. RESULTS: Sixty-three patients (37 males, 26 females) with a mean age of 61.6 ± 13.3 years (range, 22-81 years) were included in this study. Among 61 applicable patients with sufficient information regarding medical histories, 38 (62.3%) had one or more significant underlying past medical histories including vasculopathic risk factors. The interval between initial symptoms and vaccination was 8.6 ± 8.2 (range, 0-28) days. Forty-two (66.7%), 14 (22.2%), and 7 (11.1%) patients developed symptoms after the first, second, and third vaccinations, respectively. One case of internuclear ophthalmoplegia, 52 cases of cranial nerve palsy, two cases of myasthenia gravis, six cases of orbital diseases (such as myositis, thyroid eye disease, and IgG-related orbital myopathy), and two cases of comitant vertical strabismus with acute onset diplopia were found. Among 42 patients with follow-up data (duration: 62.1 ± 40.3 days), complete improvement, partial improvement, no improvement, and exacerbation were shown in 20, 15, 3, and 4 patients, respectively. CONCLUSION: This study provided various clinical features of ocular motility disorders following COVID-19 vaccination. The majority of cases had a mild clinical course while some cases showed a progressive nature. Close follow-up and further studies are needed to elucidate the underlying mechanisms and long-term prognosis.

Ocular Lateral Deviation as a Vestibular Sign to Improve Detection of Posterior Circulation Strokes: A Review of the Literature.

BACKGROUND: Posterior circulation stroke can present with dizziness/vertigo without other general neurological symptoms or signs, making it difficult to detect, and missed stroke can deteriorate. Therefore, a sign that can be easily identified during an examination would be helpful to improve the detection of this type of stroke. OBJECTIVE: The objective of this review is to highlight an ocular sign that is seen in posterior circulation strokes called ocular lateral deviation (OLD). OLD is mostly seen in dorsolateral medullary strokes, and it is also seen in pontine and cerebellar strokes. OLD is detected by asking a patient to look straight ahead and then briefly close their eyes. Upon re-opening their eyes, the examiner will see that the eyes have deviated to one side; the patient's eyes will then make corrective saccade(s) to return to looking straight ahead. Complete eye deviation is a central sign of posterior circulation stroke. DISCUSSION: OLD is an under-recognized vestibular ocular sign of central vestibulopathies including posterior circulation stroke. The most common location is in the dorsolateral medulla, where one-third of such strokes have complete OLD. Eye deviation can also be appreciated on computed tomography or magnetic resonance imaging. OLD can be detected up to 6 months after a posterior circulation stroke. CONCLUSIONS: Checking for the sign of complete eye deviation in patients with dizziness/vertigo could be a simple, quick method for detecting posterior circulation stroke, and a means to improving the patients' outcome.

Manual Therapy Approach to the Extraocular Muscles in Migraine Treatment: A Preliminary Study.

The oculomotor system plays an important role in the development of migraines. This is an observational study that aims to investigate the rehabilitative efficacy of muscle energy therapy (MET) in reducing migraine symptoms. MET was based on post-isometric relaxation and reciprocal inhibition, targeting the extraocular muscles. Patients diagnosed with chronic migraines and positive results in the Smooth Pursuit Eye Movement Test were enrolled in the study. The effects of treatment were assessed using the following questionnaires: Migraine Disability Assessment (MIDAS), Neck Disability Index (NDI), Pittsburg Sleep Quality Index (PSQI), Dizziness Handicap Inventory (DHI), and the neck range of motion (ROM). Additionally, rheological parameters of neck muscles were assessed. We reported beneficial effects of MET on the amelioration of the frequency of headaches, neck pain and dizziness-related disabilities and disordered sleep. However, benefits concerning the neck motion and rheological properties of oculomotor structures were unconvincing. In conclusion, the study showed advantageous effects of manual oculomotor therapy consisting of reductions in migraine-related painful symptomatology. The results diminish the role of ocular muscle mechanical properties in the genesis of migraine, shifting attention to the modulatory role of the neuromuscular ocular component, likely involving trigeminal innervation, which can be subject to migraine manual therapy.

Home- and Office-Based Vergence and Accommodative Therapies for Treatment of Convergence Insufficiency in Children and Young Adults: A Report by the American Academy of Ophthalmology.

PURPOSE: To review home- and office-based vergence and accommodative therapies for treatment of convergence insufficiency (CI) in children and young adults up to 35 years of age. METHODS: Literature searches were conducted through October 2020 in the PubMed database for English-language studies. The combined searches yielded 359 abstracts, of which 37 were reviewed in full text. Twelve of these were considered appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. RESULTS: Of the 12 studies included in this assessment, 8 were graded as level I evidence, 2 were graded as level II evidence, and 2 were graded as level III evidence. Two of the level I studies included older teenagers and young adults; the remainder of the studies exclusively evaluated children. Two randomized controlled trials found that office-based vergence and accommodative therapies were effective in improving motor outcomes in children with symptomatic CI. However, the studies reported conflicting results on the efficacy of office-based therapy for treating symptoms of CI. Data were inconclusive regarding the effectiveness of home-based therapies (including pencil push-ups and home computer therapy) compared with home placebo. In young adults, office-based vergence and accommodative therapies were not superior to placebo in relieving symptoms of CI. CONCLUSIONS: Level I evidence suggests that office-based vergence and accommodative therapies improve motor outcomes in children with symptomatic CI, although data are inconsistent regarding symptomatic relief. Evidence is insufficient to determine whether home-based therapies are effective.

An Algorithm for the Diagnosis of Vestibular, Cerebellar, and Oculomotor Disorders Using a Systematized Clinical Bedside Examination.

The bedside examination associated with their clinical history remains the most critical means to accurately diagnose the cause for most of the signs and symptoms related to pathology of the cerebellum and vestibular system in patients presenting with dizziness and imbalance. This paper focuses on those critical bedside examinations, suggests when laboratory testing might be useful to confirm the clinical suspicion, and considers the shared neural circuitry within the visual and vestibular systems to offer an algorithmic approach in conducting the clinical bedside examination.

Paraneoplastic Ophthalmoplegia as the Presenting Sign of Paediatric Glioblastoma Multiforme: A Case Report.

Glioblastoma multiforme (GBM) is an aggressive glioma that is infrequently diagnosed in the paediatric population. GBM and other primary brain tumours have rarely been associated with paraneoplastic syndromes. We report an unusual case of an 8-year-old boy presenting with an inability to abduct his left eye and almost complete ophthalmoplegia of his right eye, prior to any radiological evidence of GBM. This is the first documented case of paediatric GBM presenting with bilateral asymmetric ophthalmoplegia.

Upward Gaze Palsy: a Valuable Sign to Distinguish Spinocerebellar Ataxias.

Spinocerebellar ataxias (SCAs) represent a large group of heredodegenerative diseases, with great phenotypic and genotypic heterogeneity. However, in the clinical neurological practice, some symptoms and signs might help differentiate the SCAs. This study's aims were to evaluate the frequency of upward gaze palsy (UGP) and investigate its role in assisting in the clinical differentiation of SCAs. We included 419 patients with SCAs (248 with SCA3, 95 with SCA10, 38 with SCA2, 22 with SCA1, 12 with SCA7, and 4 with SCA6). This study compared UGP with other known markers of disease severity-age of onset, disease duration, SARA score, and size of CAG expansion, and also other semiologic features, as bulging eyes. This sign was significantly more prevalent in SCA3 (64.11%), compared with SCA10 (3.16%; p < 0.001) and other SCAs (SCA1, SCA2, SCA7-11.84%; p < 0.001). UGP showed very high sensibility ins SCA3 (92.9), although lacking of specificity (64.1%). The odds ratio (OR) of UGP were also very high, 23.52 (95% CI 12.38-44.69), and was significantly correlated with larger CAG expansions, age, and disease duration in SCA3 patients, but not with age of onset or severity of the ataxic syndrome. This study showed that UGP is highly suggestive of SCA3 and has high sensitivity for the differential diagnosis among SCAs, and it could be of great value for bedside semiologic tool.

Consecutive strabismus after infantile nystagmus syndrome surgery and potential risk factors.

PURPOSE: The aim of this study is to evaluate the incidence of consecutive strabismus after infantile nystagmus surgery and its potential risk factors. METHODS: A retrospective study including 89 patients was conducted. Patients presented infantile nystagmus (idiopathic or ocular disease-associated nystagmus) without previous or coincidental strabismus. Sex, age at surgery, amblyopia, botulinum toxin (BT) injection before surgery, spherical equivalent, anisometropia, surgery procedure (Anderson's or retroequatorial recessions of four horizontal recti), and follow-up were analyzed. Kaplan-Meier and univariate Cox regression were performed. RESULTS: The median age at surgery was 5 years. The median follow-up was 36 months. The incidence of consecutive strabismus was 11.2%. There were eight patients with exotropia and two patients with esotropia. Consecutive strabismus was associated with severe bilateral amblyopia (p = 0.036), previous treatment with BT injection (p = 0.025), and large recessions of the four horizontal muscles (p = 0.001). The hazard ratio for patients with severe bilateral amblyopia was 5.4 (95% CI 1.1-25.8), and for patients previously treated with BT was 6.1 (1.3-29.3). The survival rate was 95.4% at 6 months and 88.5% at 3 years. CONCLUSION: Severe bilateral amblyopia, previous BT treatment, and type of surgery seem to be associated with consecutive strabismus after infantile nystagmus surgery. Most cases appear within the first months after surgery.

Wernekink Commissure Syndrome: A Rare Cause of Bilateral Cerebellar Syndrome.

PURPOSE: Focal signs are a big deal in neurology and are among the most important clues leading to diagnosis and localization. Wernekink commissure syndrome is due to lesions in the caudal paramedian midbrain involving the entire decussation of the superior cerebellar peduncles, resulting in the clinical hallmark of a bilateral cerebellar syndrome. CASE REPORT: A 79-year-old man presented with sudden, severe unsteadiness associated with slurring of speech, binocular double vision, and bilateral hand tremor. Examination showed right INO, moderately severe dysarthria, bilateral dysmetria and dysdiadochokinesia, with severe truncal ataxia and bilateral upper and lower limb ataxia. Also, bilateral coarse tremor was noted in both hands which was present at rest, action and on reaching for objects. Brain MRI revealed an acute infarction involving the Wernekinck decussation in the right caudal midbrain and mesencephalo-pontine junction. CONCLUSION: The differential of Wernekink Commissure Syndrome is complex, and localization and lateralization are extremely difficult owing to prominent bilateral cerebellar symptoms. The finding of an associated unilateral INO in some cases makes it possible to confidently narrow the list of differentials and localize the lesion to the paramedian tegmentum ipsilateral to the non-adducting eye.

[Disorders of oblique muscles in horizontal strabismus].

Horizontal strabismus, the most common type of strabismus, can be complicated by the disorder of inferior oblique muscle or superior oblique muscle. It may cause problems such as compensatory head posture, vertical diplopia, torsional diplopia, and abnormal binocular fusion. In horizontal strabismus cases, the disorder of oblique muscles should be recognized, and appropriate surgical methods should be chosen, so that the best postoperative ortho and binocular vision could be obtained. (Chin J Ophthalmol, 2020, 56: 171-175).

[Progress of ocular motor and structures in multiple sclerosis patients].

Multiple sclerosis (MS) is a demyelinating disease of central nervous system, which often affects ocular region and causes structural and functional changes of eyes. Therefore, there have been plenty of researches on the alteration of motor and structures of eyes by MS. This paper reviews and summarizes the progress of MS-related changes of ocular motor, cornea, structure and blood flow of retina, and optic nerve, and may provide a new insight for related clinical researches. (Chin J Ophthalmol, 2020, 56: 711-715).

Development of a core outcome set for amblyopia, strabismus and ocular motility disorders: a review to identify outcome measures.

BACKGROUND: Core Outcome Sets (COS) are defined as the minimum sets of outcomes that should be measured and reported in all randomised controlled trials to facilitate combination and comparability of research. The aim of this review is to produce an item bank of previously reported outcome measures from published studies in amblyopia, strabismus and ocular motility disorders to initiate the development of COS. METHODS: A review was conducted to identify articles reporting outcome measures for amblyopia, strabismus and ocular motility disorders. Using systematic methods according to the COMET handbook we searched key electronic bibliographic databases from 1st January 2011 to 27th September 2016 using MESH terms and alternatives indicating the different subtypes of amblyopia, strabismus and ocular motility disorders in relation to treatment outcomes and all synonyms. We included Cochrane reviews, other systematic reviews, controlled trials, non-systematic reviews and retrospective studies. Data was extracted to tabulate demographics of included studies, primary and secondary outcomes, methods of measurement and their time points. RESULTS: A total of 142 studies were included; 42 in amblyopia, 33 in strabismus, and 68 in ocular motility disorders (one study overlap between amblyopia and strabismus). We identified ten main outcome measure domains for amblyopia, 14 for strabismus, and ten common "visual or motility" outcome measure domains for ocular motility disorders. Within the domains, we found variable nomenclature being used and diversity in methods and timings of measurements. CONCLUSION: This review highlights discrepancies in outcome measure reporting within published literature for amblyopia, strabismus and ocular motility and it generated an item bank of the most commonly used and reported outcome measures for each of the three conditions from recent literature to start the process of COS development. Consensus among all stakeholders including patients and professionals is recommended to establish a useful COS.

[Advances in research of synergistic divergence].

Synergistic divergence is a rare condition characterized by complete absence of adduction that is associated with simultaneous abduction of the affected eye on attempted adduction. This causes the affected eye to move further into abduction on gaze to the normal side and results in extreme divergence of both eyes. It is sometimes referred to as exotropic Duane syndrome with synergistic divergence (type 4 Duane syndrome) or congenital fibrosis syndrome with synergistic divergence. Diseases combined with synergistic divergence fall within the category of congenital cranial dysinnervation disorders (CCDDs). The ocular associations reported with synergistic divergence are uncommon and include Horner syndrome, ocular albinism, foveal hypoplasia, Goldenhar syndrome and pupillary abnormalities. MRI and electro-oculographic study suggested that this is the result of CCDDs. Various surgical techniques have been tried in individual cases including large recession of the lateral rectus muscle, lateral rectus muscle extirpation, large resection of the medial rectus (MR) muscle, weakening procedures of the oblique muscles, combination of lateral rectus orbital wall fixation with MR resection, but further investigations with large-scale samples are needed. Recent research advances in the definition, etiology, and treatment of synergistic divergence are reviewed in this article. (Chin J Ophthalmol, 2019, 55:63-67).

DO ORTHOPTIC EXERCISES HAVE ANY INFLUENCE ON CHILDREN AND ADOLESCENTS DIAGNOSED WITH CONVERGENCE INSUFFICIENCY AND ATTENTION DEFICIT/HYPERACTIVITY DISORDER?

The aim was to determine whether improvement of near point of convergence (NPC) and binocular vision after orthoptic exercises had any impact on children and adolescents diagnosed with attention deficit/hyperactivity disorder (ADHD) and convergence insufficiency (CI). In this clinical trial, 50 children and adolescents aged 6 to 18 years diagnosed with ADHD and CI received orthoptic therapy that included home-based exercises (pencil push-ups and stereograms) and office-based therapy on synoptophore. Binocular vision and NPC were measured before, during and after therapy. Study subjects showed significant improvement (p<0.05) in NPC and binocular vision after orthoptic exercises. We found statistically significant correlation between stereovision improvement (Lang I) and near point of convergence, suggesting that improvement of binocular function is possible in children with ADHD and CI. Our results showed that NPC enhancement improved stereovision in patients with ADHD. Since progress of binocular function has positive effect on near work and diminishes visual symptoms in children and adolescents with ADHD and CI, it might be reasonable to suppose that orthoptic therapy helps these children improve concentration as well. Further studies are needed to determine whether it might have positive impact on attention.

Clinical Differences between Radiographic and Physical Horizontal Gaze Deviation: Utility of Using the Two in Patients with Ischemic Stroke.

Background and Purpose: Radiographic horizontal gaze deviation (RHGD) has been identified as a useful finding on computed tomography (CT) that indicates the affected side in supratentorial ischemic stroke; however, it remains unclear whether RHGD is essentially the same phenomenon as physical horizontal gaze deviation (PHGD). To resolve the issue, this study was conducted. Methods: Retrospective analyses were performed for 671 patients with ischemic stroke and 142 controls who were hospitalized and underwent head CT. First, clinical findings were examined to find differences between RHGD-positive and RHGD-negative patients. Second, patients were classified by their stroke mechanisms and/or affected vascular territories. For each subgroup, RHGD was compared with PHGD in frequency. Third, the proportions for patients divided by positivity for PHGD and RHGD were calculated in the subgroups. Results: Patients with RHGD had PHGD more often than those without. In all stroke subgroups, RHGD was more frequent than PHGD. The frequency difference was prominent in small-artery occlusion (SAO) and posterior inferior cerebellar artery (PICA) stroke. In SAO of the basilar artery pontine perforator, RHGD was positive in 25% and largely contralesionally-directed. In PICA stroke, lesions in the vestibulocerebellum were associated with contralesional RHGD. Moreover, lesions in the lateral medulla also caused RHGD, which was mainly directed to the ipsilesional side. PHGD-positive stroke without RHGD was infrequent, whereas RHGD-positive stroke without PHGD was commonly observed (PICA stroke, 45.9%; other subgroups, 21.1%-27.5%). Conclusions: RHGD had different characteristics from PHGD; therefore, assessments of both PHGD and RHGD may lead to more accurate diagnoses.

An unusual case of early onset opsoclonus-myoclonus syndrome: Case report and literature review.

Opsoclonus-myoclonus syndrome is a rare neurological condition characterized by opsoclonus, myoclonus, ataxia, irritability, and sleep disturbances. In pediatric patients, symptoms usually start between 16 and 18 months of age; opsoclonus-myoclonus syndrome presentation in children under 6 months is rare. Approximately 50% of cases are associated with neuroblastoma. We report an early onset presentation of opsoclonus-myoclonus syndrome in a previously healthy, 3-month-old female infant. The diagnostic workup revealed no abnormalities. The patient underwent monthly cycles of dexamethasone pulses and intravenous immunoglobulin with a favorable response. After a few months, the patient presented intermittent opsoclonus before the next scheduled pulse so from the 9th cycle onwards, the intravenous immunoglobulin dose was increased to 2 g/kg. After 9 months of treatment, she was diagnosed with a latent Mycobacterium tuberculosis infection. Due to this infection, dexamethasone pulses were discontinued, and intravenous immunoglobulin treatment was maintained with clinical improvement The patient received 18 intravenous immunoglobulin cycles, leaving her with a score of one on the Mitchell-Pike scale. Developmental milestones have been attained according to age. Despite the range of therapeutic options for managing opsoclonus-myoclonus syndrome described in the literature, the efficacy of these available therapies needs to be better established. A modified upfront approach with dexamethasone and intravenous immunoglobulin could be an option in settings where rituximab is unavailable.

Orbital floor fracture (blow out) and its repercussions on eye movement: a systematic review.

The aim of this systematic review was to investigate the relationship between fractures of the floor of the orbit (blow outs) and their repercussions on eye movement, based on the available scientific literature. In order to obtain more reliable results, we opted for a methodology that could answer the guiding question of this research. To this end, a systematic review of the literature was carried out, using a rigorous methodological approach. The risk of bias was assessed using version 2 of the Cochrane tool for the risk of bias in randomized trials (RoB 2). This systematic review was carried out according to a systematic review protocol previously registered on the PROSPERO platform. The searches were carried out in the PubMed (National Library of Medicine), Scopus, ScienceDirect, SciELO, Web of Science, Cochrane Library and Embase databases, initially resulting in 553 studies. After removing duplicates, 515 articles remained, 7 were considered eligible, of which 3 were selected for detailed analysis. However, the results of the included studies did not provide conclusive evidence of a direct relationship between orbital floor fractures and eye movement.

Classification of short and long term mild traumatic brain injury using computerized eye tracking.

Accurate, and objective diagnosis of brain injury remains challenging. This study evaluated useability and reliability of computerized eye-tracker assessments (CEAs) designed to assess oculomotor function, visual attention/processing, and selective attention in recent mild traumatic brain injury (mTBI), persistent post-concussion syndrome (PPCS), and controls. Tests included egocentric localisation, fixation-stability, smooth-pursuit, saccades, Stroop, and the vestibulo-ocular reflex (VOR). Thirty-five healthy adults performed the CEA battery twice to assess useability and test-retest reliability. In separate experiments, CEA data from 55 healthy, 20 mTBI, and 40 PPCS adults were used to train a machine learning model to categorize participants into control, mTBI, or PPCS classes. Intraclass correlation coefficients demonstrated moderate (ICC > .50) to excellent (ICC > .98) reliability (p < .05) and satisfactory CEA compliance. Machine learning modelling categorizing participants into groups of control, mTBI, and PPCS performed reasonably (balanced accuracy control: 0.83, mTBI: 0.66, and PPCS: 0.76, AUC-ROC: 0.82). Key outcomes were the VOR (gaze stability), fixation (vertical error), and pursuit (total error, vertical gain, and number of saccades). The CEA battery was reliable and able to differentiate healthy, mTBI, and PPCS patients reasonably well. While promising, the diagnostic model accuracy should be improved with a larger training dataset before use in clinical environments.