Effect of local heat versus ice on blepharoptosis resulting from ocular myasthenia.

OBJECTIVE: To determine the effect of heat versus ice application to a ptotic eyelid in patients with ocular or systemic myasthenia. DESIGN: Observational case series. PARTICIPANTS: Three consecutive patients and one subsequent patient with ptosis and clinical or laboratory signs of myasthenia were initially evaluated. METHODS: In all four patients, the heat test and the ice test were performed. In three patients, the modified sleep test was also performed. In the heat or ice test, the patient was asked to hold a heat or ice pack, respectively, over the closed ptotic eye for 10 to 15 minutes. The modified sleep test was performed by having the patient close both eyes for a 10- to 15-minute period. Photographs were taken before and immediately after each test. MAIN OUTCOME MEASURE: The effect of heat or ice on ptosis. RESULTS: Transient complete improvement of ptosis in three patients and marked improvement in one patient was noted after each test. The results of the heat, ice, and modified sleep tests were identical. CONCLUSIONS: Marked improvement of myasthenic ptosis in all four patients occurred regardless of local warming or cooling. The common denominator of all these tests, rest, seems to be the relevant factor in the study as designed.

Horner syndrome with equal-sized pupils in a case with underlying physiologic anisocoria.

A case is presented in which Horner syndrome occurred on the side of the larger pupil in underlying physiologic anisocoria. The unusual coincidence resulted in ipsilateral ptosis, but with clinically equal-sized and normally reactive pupils.

Amaurosis fugax in the young.

A 36-year-old healthy woman developed amaurosis fugax of the right eye lasting 1 minute. Work-up revealed right carotid stenosis thought most compatible with an atherosclerotic plaque. A carotid endarterectomy was performed which corroborated the radiologic diagnosis. An embolic event from ipsilateral carotid artery disease should be considered as a cause of amaurosis fugax even in the young.

Acute unilateral visual loss in the elderly due to retrobulbar optic neuropathy.

A 61-year-old man developed fever and a urinary tract infection followed five days later by acute visual loss in the right eye. Funduscopic examination was normal. A retrobulbar optic neuropathy was diagnosed but careful consideration was given to choroidal ischemia as an etiology. A sphenoidal mucocele was found on emergent MRI scan and drained expeditiously, with marked improvement in visual function. The diagnosis of giant cell arteritis should always be entertained when dealing with visual loss in the elderly.

Abduction defect associated with aberrant regeneration of the oculomotor nerve after intracranial aneurysm.

PURPOSE: To determine the cause of delayed-onset ipsilateral abduction defect associated with aberrant regeneration of the oculomotor nerve. METHODS: Isolated oculomotor palsy was noted after successful basilar artery aneurysm surgery in a 35-year-old patient. Several months later, aberrant regeneration of the oculomotor nerve and an ipsilateral abduction defect were first detected. RESULTS: Ocular electromyography demonstrated failure of relaxation of the ipsilateral medial rectus muscle on attempted abduction, suggesting cocontraction of horizontal recti muscles as the origin of the abduction defect. CONCLUSION: A late-onset ipsilateral abduction defect caused by failure of relaxation of the medial rectus muscle may be associated with basilar aneurysm.

Visual loss caused by choroidal ischemia preceding anterior ischemic optic neuropathy in giant cell arteritis.

Three patients with visual loss and normal fundi were discovered to have choroidal ischemia on fluorescein angiography. Each patient had a markedly increased Westergren erythrocyte sedimentation rate, but only one described symptoms of polymyalgia rheumatica, neck pain, and jaw claudication. Biopsy of the temporal artery confirmed giant cell arteritis in the two patients without constitutional symptoms. In one patient, typical anterior ischemic optic neuropathy developed the following day, whereas in the other two, anterior ischemic optic neuropathy later occurred despite the prompt administration of intravenous high-dose corticosteroids. Choroidal ischemia may be the first sign of giant cell arteritis in elderly patients with visual loss. Early diagnosis and treatment are mandatory in an attempt to forestall the development of anterior or posterior ischemic optic neuropathy, or central retinal artery occlusion in the affected or fellow eye.

Chiasmal compression from fat packing after transsphenoidal resection of intrasellar tumor in two patients.

After transsphenoidal resection of a pituitary (or other) tumor, the remaining intrasellar cavity, and sphenoid sinus are usually packed with exogenous fat or muscle to prevent cerebrospinal leak and prolapse of the optic chiasm into an empty sella. We treated two patients in whom chiasmal compression occurred postoperatively because of packing of fat. In one patient, the expected visual improvement in the postoperative period was suboptimal. The subsequent removal of fat resulted in total visual recovery. In the other patient, chiasmal compression persisted from intrasellar fat and residual tumor. Iatrogenic compression of the optic nerves or chiasm should be considered in all patients in whom visual recovery is incomplete.

Sudden visual loss with slow recovery.

A 58-year-old healthy man presented with a history of monocular visual loss with incomplete recovery. The differential diagnosis, evaluation, and possible therapeutic interventions are discussed. The presenter controversially felt that although the source of embolic material was likely ipsilateral carotid artery and no evaluation was necessary.

Thyroid ophthalmopathy presenting as superior oblique paresis.

Six patients with thyroid ophthalmopathy presented with what appeared to be a unilateral superior oblique paresis by the three-step test, which was eventually followed by more typical findings of thyroid disease. This early motility defect in thyroid ophthalmopathy may be caused by a restrictive process due to involvement of the inferior rectus muscle. Clues to the proper diagnosis included an increase in vertical deviation in upgaze, elevation of intraocular tension in upgaze, and the lack of excyclodeviation. These features should be assessed in patients with isolated superior oblique paresis.

Ocular manifestations of Mycoplasma pneumoniae infection.

Ocular manifestations of Mycoplasma pneumoniae infection, other than conjunctivitis, are uncommon. Optic disk swelling, optic nerve atrophy, retinal exudates and hemorrhages, and cranial nerve palsies have been infrequently reported. We describe a 15-year-old patient who developed bilateral optic disk edema and iritis during an acute infection with M. pneumoniae and review the world literature on findings associated with ocular manifestations of infection with this pathogen. Although our patient experienced complete resolution of iritis and optic disk edema after 6 weeks, several patients described in the literature have experienced permanent sequelae as a result of optic neuropathy.

Head nodding associated with intermittent esotropia.

Head nodding (to-and-fro turning about the vertical cervical axis) associated with abnormal eye movements may be seen in spasmus nutans and congenital nystagmus. In the absence of abnormal eye movements, it may be indicative of neurological disease (eg, cerebellar disease, basal ganglia dysfunction). We report a neurologically normal infant without nystagmus but with intermittent head nodding and intermittent esotropia, whose head movements manifested only when his eyes were straight. The head movements ceased with the occlusion of either eye or spontaneous onset of esotropia. When his head was forcibly stabilized, he immediately developed esotropia. The head movement presumably facilitated fusion, although the mechanism of action is unknown.