Temporary Medial Upper Eyelid Lagophthalmos after External Dacryocystorhinostomy.

Background. Report of three cases of medial upper eyelid lagophthalmos as complication of external dacryocystorhinostomy. History and Signs. Shortly after dacryocystorhinostomy (skin incision on the side of the nose), three of ten consecutive patients (28 ± 4 years; mean ± standard deviation), presented with an ipsilateral lagophthalmos of 4 ± 1 mm in voluntary eyelid closure and 6 ± 1 mm in spontaneous blink. The lagophthalmos was due to a selective paresis of the medial part of the orbicularis oculi muscle of the upper eyelid. Patient 1 complained bitterly of dry eye symptoms and of her lagophthalmos. Patient 2 had mild symptoms but became very concerned after peers made her aware of her asymmetric blink. Patient 3 was asymptomatic and did not notice anything particular. Therapy and Outcome. Lagophthalmos resolved spontaneously within three months after surgery, first by improvement of voluntary eyelid closure and then of spontaneous blinking. Conclusions. Temporary lagophthalmos can occur as a complication of external dacryocystorhinostomy, most likely due to damage of the (only recently described) superficial buccal and/or zygomatic branches of the facial nerve that run upward to cross over the medial ligament and innervate the medial part of the orbicularis oculi muscle.

[Headache from overuse of medication]. / Kopfschmerzen durch Uberkonsum an Medikamenten.

Medication overuse headache (MOH) occurs in about 1% of the general population. A marked increase of its prevalence has to be expected in the future, since more and more adolescents are subject to medication overuse. The revised International Classification of Headache Disorders contains detailed diagnostic criteria for headache due to particular groups of substances. They help recognizing MOH due to ergots, triptans, analgesics and opioids, and to distinguish them from each other MOH almost exclusively occurs in patients with a long history of migraine or chronic tension type headache, which suggests some genetic disposition. The treatment of choice of MOH is withdrawal of the causing drug. Long-term treatment for headache is ineffective during medication overuse. Relapse rate is variable depending on the substance overused, and may be considerable. Therefore, prophylaxis in patients with migraine or chronic tension type headache who do not yet suffer from MOH, is essential.

[Preventive treatment of migraine and chronic tension headache with moclobemide]. / Prophylaktische Behandlung von Migräne und chronischen Spannungskopfschmerzen mit Moclobemid.

Tricyclic antidepressants have been used for a long time in migraine prophylaxis and in the treatment of chronic tension-type headache. Because of their relatively frequent and unpleasant side effects, however, their use cannot be recommended without reservation. The selective and reversible monoamine oxidase inhibitor type A (MAO-A inhibitor), moclobemide (Aurorix), is much better tolerated and safer to use. For this reason, we began to use this substance in the prophylactic treatment of migraine and chronic tension-type headache. The obviously good efficacy in many cases prompted us to conduct a retrospective analysis of 61 headache patients treated with moclobemide. The patients, classified according to the diagnostic criteria of the International Headache Society, were treated for about 8 months on average with moclobemide. While on this therapy, 35 of the 42 migraine patients and 16 of the 17 patients with tension-type headache experienced good or very good improvement in their symptoms. In the migraine patients, the average number of monthly headache days declined from 7.8 before treatment to 1.2 at the end of treatment. In tension-type headaches, the effect occurred at the earliest 3-6 weeks and in the case of migraines at the earliest 6-8 weeks after the start of treatment. The therapeutic result was independent of any concurrent depression. Nine patients ended their treatment prematurely, seven because of side effects and two because of compliance problems. Treatment compliance, essential for the success of any long term treatment of headache, is promoted by open and detailed explanation of the treatment concept, and by medical supervision with individual adjustment of treatment. The patient should be instructed regarding the time required until the onset of action, the intended length of treatment, treatment of further headache attacks, and an appropriate lifestyle. The highly promising results with moclobemide in the prophylactic treatment of migraines and chronic tension-type headaches should be verified in a controlled study.

Cold-induced acral vasospasm in migraine as assessed by nailfold video-microscopy: prevalence and response to migraine prophylaxis.

In order to learn the prevalence of cold-induced vasospasm in migraine patients, blood cell velocity measurements of finger nailfold capillaries were performed in 58 consecutive patients suffering from migraine with and without aura. In 5 (8.6%) patients capillaroscopy could not be performed because of reduced nailfold transparency; 21 of the remaining 53 patients (39.6%) showed blood flow stop due to vasospasm under cold provocation. There was no significant difference (P = 0.69) in the occurrence of vasospastic reaction between migraine with (12 of 32 patients = 37.5%) and without (9 of 21 patients = 42.9%) aura. The clinical and capillaroscopic course under migraine prophylaxis was observed in 18 vasospastic patients. After sixteen weeks 14 patients showed good clinical improvement of their migraine. The vasospastic reaction persisted in only 1 patient. This patient and 3 others with abolished vasospasm were still suffering from migraine. These findings suggest that observing blood cell velocity noninvasively in nailfold capillaries under cold provocation could be useful for objectively monitoring the response to prophylactic treatment in migraine patients or for testing new potentially antimigraine drugs.

[Vertigo and migraine]. / Drehschwindel und Migräne.

Vertigo consists of a variety of syndromes and can be due to many etiologies. One of these causes is migraine, which in our experience is often overlooked, although migrainous vertigo is well known in the literature. Vertigo in migraine can occur as aura or during the headache phase, or independent of the attacks as aura without headache. The aim of this retrospective study was to analyze cases with vertigo and migraine: 23 (8%) of 298 patients with migraine examined in a neurological outpatient department also had rotational vertigo. 48% of these patients had vertigo independent from typical migraine headache. Two types of vertigo were found: permanent vertigo, and vertigo with the characteristics of paroxysmal positional vertigo. 57% of the vertiginous attacks lasted hours, 26% even days, and 17% minutes. Most of the patients had several attacks of vertigo, some involving up to 30 episodes. To recognize migraine as a cause of vertigo has therapeutic implications. Most of our patients with vertigo and migraine showed a good response to antimigraine therapy.

Nuclear and infranuclear disorders.

Lesions of the brain stem can either affect the nuclei or the fascicles of the third, fourth or sixth cranial nerves and thus produce ocular motor disorders. Lesions of the oculomotor nuclear complex differ from lesions of the third nerve, since the motoneurones in the nucleus are specifically grouped. Similarly, a lesion of the sixth nerve nucleus results in a conjugate gaze palsy and not in an abducens palsy, because of 'interneurones' being intermingled with the abducens motoneurons. Isolated lesions of a nerve fascicle, which is the part of the cranial nerve running through the brain stem, usually cannot be distinguished clinically from lesions of the nerve outside the brain stem unless other brain stem signs are present. In the case of an isolated ocular motor nerve palsy, modern imaging techniques, particularly magnetic resonance imaging, may help to localize the lesion to the brain stem. Most often, however, brain stem lesions also involve structures surrounding the ocular motor nuclei or fascicles, sometimes leading to characteristic eponymic syndromes. In congenital eye movement disorders the pathoanatomical situation is more complex. Since the lesion takes place during intrauterine or early postnatal development, corrective misdirection of neurones occurs in addition to aplasia or hypoplasia of parts of the cranial nerves. Correspondingly, abnormal movements accompanying an attempted eye movement can be observed in some characteristic syndromes.

[Octopus perimetry in neuro-ophthalmologic diseases. A contribution to the problem of optimal program choice based on 427 cases]. / Octopusperimetrie bei neuroophthalmologischen Erkrankungen. Ein Beitrag zum Problem der optimalen Programmwahl anhand von 427 Fällen.

From the patient population of the University Eye Clinic Basel 427 cases, who had been tested with the Octopus perimeter 201 because of neuro-ophthalmologic problems, were retrospectively examined. Above all it was interesting to find out, which program to use in order to get a maximum degree of information with a minimum of examinations. The quantitative programs 31 to 34 gave most often the clinically relevant information concerning the opticus- and chiasma affections. The only exception was the anterior ischemic opticoneuropathy where the semiquantitative program 07 delivered the better information. With supragenicular affections program 07 delivered by far, and most often, the clinically relevant information. Because of our results we can make the following recommendations: if a pregenicular lesion is suspected, it is sensible to use quantitative programs with a homogenous test point distribution within 30 degrees testing area. If a supragenicular lesion is suspected, the registration of the total extension of the defect is of greater practical value than a quantitative threshold determination. In this case, the survey program 07 is suitable. If visual disturbance is present, without a hint of its location, it is recommended to start with the survey program 07 and thereafter, according to test results, specifically continue with a quantitative program.

Finger microcirculation in classical migraine. A video-microscopic study of nailfold capillaries.

We assessed microcirculation in nailfold capillaries of 22 patients with classical migraine and 22 normal subjects matched for age and sex using video-microscopy. Blood flow measurements were performed under standardized room temperature, after a 3-min warm water bath and after local cooling. Under standardized conditions, skin temperature at the fingertip was significantly lower in patients with migraine. Morphological differences, however, could not be found between patients and controls. After cooling of the nailfold area, blood flow stop due to vasospasm occurred in 18 of the 22 migraine patients in contrast to 1 of the 22 control subjects only. Capillary blood cell velocity was significantly decreased in the migraine group under all test conditions. Drug treatment did not account for the different prevalences of vasospasm in migraine patients and normal controls. Our findings demonstrate that patients with migraine often have subclinical microcirculatory disorders of the upper limbs.

Transcranial stimulation of the human frontal eye field by magnetic pulses.

Single transcranial magnetic pulsed stimuli were applied over the cortical area of the putative right frontal eye field (FEF) in 11 healthy subjects. An especially designed figure of eight shaped twin coil was used, to focus the stimulus, the strength of which was adjusted to the individual motor threshold of the left hand muscles. Eye positions and movements were recorded by an infrared reflection technique. Three different experiments were performed: 1. Stimulation during different primary gaze position did not evoke any discernible eye movement. 2. Stimulation just prior to visually elicited horizontal saccades did not cause a significant alteration of the latency, velocity, or amplitude of the saccades. 3. Only stimulation during an antisaccade task induced a significant latency prolongation, when the stimulus was applied between 50 to 90 ms after the target flashed up. This latency prolongation was found in all subjects for the antisaccades to the right, with a statistically significant average latency difference of +66 +/- 55.5 ms. In contrast, the antisaccades to the left were prolonged in the female subjects only by an average of +98 +/- 41.8 ms (p = 0.0064), whereas in the male subjects they did not alter with stimulation (average difference: -3 +/- 41.9 ms, p = 0.753). Significant latency prolongations were only obtained when the magnetic FEF stimuli were applied within a vulnerable period, which varied from subject to subject.

[The eye as a reference organ for diseases of the nervous system. Simple examination methods for office practice and at the bedside]. / Das Auge als Hinweisorgan auf Erkrankungen des Nervensystems. Einfache Untersuchungsmethoden für die Praxis und am Krankenbett.

The eye is not only for vision. In diseases of the nervous system it can fulfill the task of a diagnostic tool. As a highly developed sensory organ, the eye is affected by disorders of the visual pathways, the pupillo-motor structures or the ocular motor system. Several simple clinical tests are presented which can be performed in practice or at the bedside without any technical equipment.

[Isolated trochlear nerve paralysis following head trauma]. / Isolierte Trochlearisparesen nach Schädeltrauma.

39 cases with isolated trochlear nerve palsies of traumatic origin have been analyzed retrospectively. 18 patients (46%) had had cerebral contusion, 15 (39%) cerebral concussion, and 6 patients (15%) a minor head trauma. 33 patients had unilateral trochlear nerve palsies and 6 (all of them with cerebral contusion) bilateral. The degree of the palsies did not correlate with the severity of the head trauma. Essential pathogenetic mechanisms were frontal or occipital blows. We emphasize a fact hitherto underestimated in the literature, that even a relatively mild head trauma (cerebral concussion or minor head trauma) can cause isolated trochlear nerve palsies. This was the case in 21 of our 39 patients (54%). Simple clinical examination techniques are described (Bielschowsky phenomenon, pencil test), which allow detection of trochlear nerve palsies in most cases.

Quantitative analysis of slow eye movements with an IBM/AT compatible personal computer in the diagnosis of multiple sclerosis.

A self-developed software program is presented, by means of which it is possible to make routine recordings and automated analysis of slow eye movements in patients with suspected multiple sclerosis. The menu-guided program runs on an IBM/AT compatible personal computer and allows on-line survey of slow eye movements. Furthermore, interactive evaluation of the data is possible. Hard copies can be made from interesting slow eye movements and their calculated parameters. Finally, tables containing various parameters such as gain, pursuit amplitude, phase difference and number of corrective saccades as well as some simple statistical calculations can be printed out.

[Eye movement patterns in homonymous hemianopsia and visual hemineglect. Criteria of oculographic delineation based on 19 cases and their diagnostic significance]. / Augenbewegungs-Muster bei homonymer Hemianopsie und visuellem Hemineglekt. Okulographische Abgrenzungs-Kriterien anhand von 19 Fällen und diagnostische Bedeutung.

Patients with homonymous hemianopia are quite differently handicapped in daily life. While residual visual functions in the blind hemifield can be responsible for such differences in visual orientation, compensatory oculomotor mechanisms or the presence of additional visual hemineglect may also play a role. In order to find objects in their blind hemifield such patients essentially employ three oculomotor searching strategies: A "staircase" strategy, an "overshoot" strategy, and a "predictive" strategy. Patients with additional visual hemineglect, however, are neither able to use the predictive strategy, nor can they develop an overshoot strategy with time. Oculographic criteria compiled previously by the present authors were employed in 19 cases with homonymous hemianopia and/or visual hemineglect to demonstrate the possibility of an objective and quantitative delimitation of these two disorders. The practical importance of such a delimitation is that patients with hemineglect are much more handicapped, but ignore or underestimate their handicap.

[Infrared reflection method for recording horizontal eye movements. An improved version for routine diagnostic studies]. / Die Infrarot-Reflexionsmethode zur Registrierung horizontaler Augenbewegungen. Eine verbesserte, für diagnostische Routineuntersuchungen geeignete Version.

Basically, the infrared reflection method for recording of horizontal eye movements has been conceived in the fifties already. The method has proved to be a valuable tool for recording of eye movements, particularly saccades. More recently there is increasing interest in recording of horizontal saccades for diagnostic purposes. Previous versions of this method, however, were not suitable for routine recordings. After several technical improvements the method now is ready for routine recordings of horizontal eye movements in the diagnosis of neurological and opthalmological disorders. In order to accentuate the strengths and weaknesses of the infrared reflection method, it is compared with DC-Electrooculography.

[Clinically detectable oculomotor disorders in multiple sclerosis. Results of studies on 100 patients]. / Klinisch erfassbare Augenbewegungsstörungen bei multipler Sklerose.

The eye movements of 100 patients with a definite diagnosis of multiple sclerosis were systematically examined using simple clinical tests, whose reliability had been first verified on 40 healthy controls. In 76 of the patients one or more eye movement disorders were observed. The most frequent finding was dissociation of the horizontal saccades due to mainly abortive forms of Internuclear Ophthalmoplegia (INO). In about half of these cases other signs of INO were present. The majority of the remaining pathological findings could be attributed to cerebellar disorders which mainly consisted of saccadic hypermetria, disordered VOR-suppression or rebound nystagmus.

Eye-movement disorders in brain-stem and cerebellar stroke.

Vertebrobasilar strokes can yield varied disturbances of eye movements, by affecting specific centers and pathways contained in the brain stem and cerebellum. Unique disorders combining supranuclear, nuclear, and infranuclear syndromes may occur. Some eye-movement abnormalities are useful localizing signs (eg, gaze palsies, rotatory nystagmus, and ipsilateral saccadic bias), but many others are not. The use of techniques such as magnetic resonance imaging may provide new insights in clinicotopographic correlations in patients with good recovery, in the absence of pathologic verification.

[Effect of contact lenses and visual acuity on the registration of saccadic eye movements using an infrared reflection method]. / Der Einfluss von Kontaktlinsen und Sehschärfe auf die Registrierung sakkadischer Augenbewegungen mit der Infrarot-Reflexionsmethode.

In order to examine the influence of contact lenses and visual acuity on recordings of saccadic eye movements with the infrared reflection method, horizontal 20 and 30 degrees saccades were recorded with and without contact lenses in 16 subjects (32 eyes) usually wearing contact lenses. As far as the main parameters of the saccades (accuracy, peak velocity and duration) were concerned, the reliability of the measurements (recognizable through the mean values) was not essentially influenced by the contact lenses. The precision of the measurements (recognizable through the standard deviation) was with the contact lenses significantly but, for clinical use, not essentially worse. The velocity waveforms of the saccades, however, were considerably changed by contact lenses in some cases. This is why examinations, in which saccadic velocity waveforms are used for diagnosis, should be performed without contact lenses. Visual acuity had no measurable influence on the main parameters of the saccades. However, considerably more corrective saccades were observed with contact lenses than without. There were reasons to believe that not the contact lenses themselves, but better visual acuity was responsible for the larger number of corrective saccades.