Ptosis after motorcycle accident.

A motorcycle accident precipitated by a health emergency led to loss of eye function. Advanced imaging revealed the diagnosis.

Isolated Third Cranial Nerve Palsy in Pituitary Apoplexy: Case Report and Systematic Review.

OBJECTIVES: To report a case of isolated third nerve palsy from pituitary apoplexy and perform a systematic literature review. MATERIALS AND METHODS: MEDLINE/EMBASE databases were searched up to September 2020. INCLUSION CRITERIA: Age≥18, isolated third nerve palsy from pituitary apoplexy. EXCLUSION CRITERIA: Age<18, presence of other neurological findings, no hemorrhage or infarction of pituitary. RESULTS: Case report: A 76-year-old woman presented with headache and right-sided ptosis. Right-eye exam revealed complete ptosis, absent pupillary constriction and accommodation, depressed and abducted eye on primary gaze, and -1 impaired depression, adduction, elevation, without other neurological findings. Brain MRI was suggestive of pituitary apoplexy. Pathology after transsphenoidal resection revealed an infarcted pituitary adenoma. Third nerve palsy resolved completely in 21 days. Systematic review: Twenty-three studies reporting 35 patients were selected from 182 abstracts. Twenty-nine (83%) had complete isolated third nerve palsy. Headache was reported in 31 (97%). Thirty-one had hemorrhage and 1 had infarction of pituitary. Cavernous sinus invasion occurred in 14 (50%). Twenty-eight were managed surgically (80%) and 7 medically (20%). Nerve palsy resolved completely in 27 (82%) and partially in 4 (11%). CONCLUSIONS: Pituitary apoplexy is an important differential diagnosis in patients with isolated third nerve palsy. Isolated third nerve palsy in apoplexy appears to have favorable prognosis.

Transient oculomotor paralysis after cerebral angiography: A case report.

RATIONALE: A special case of transient oculomotor nerve palsy after cerebral angiography. PATIENT CONCERNS: A 55-year-old man developed oculomotor nerve dysfunction after right radial artery puncture angiography. DIAGNOSES: Cerebral angiography-induced oculomotor nerve palsy. INTERVENTIONS: According to the patient's disease state, intravenous drip of dexamethasone 10 mg/d. OUTCOMES: Magnetic resonance imaging (MRI) showed no abnormalities, and the patient recovered completely after 48 hours of hormone therapy. LESSONS: Transient eye palsy caused by contrast agent encephalopathy is a clinically rare neurological dysfunction caused by adverse effects of contrast agents. Early prevention and correct treatment are critical.

Neurological Manifestations in COVID-19 Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Growing evidence showed that coronavirus disease 2019 (COVID-19) infection may present with neurological manifestations. This review aimed to determine the neurological manifestations and complications in COVID-19. METHODS: We conducted a systematic review and meta-analysis that included cohort and case series/reports involving a population of patients confirmed with COVID-19 infection and their neurologic manifestations. We searched the following electronic databases until April 18, 2020: PubMed, Embase, Scopus, and World Health Organization database (PROSPERO registration number: CRD42020180658). RESULTS: From 403 articles identified, 49 studies involving a total of 6,335 confirmed COVID-19 cases were included. The random-effects modeling analysis for each neurological symptom showed the following proportional point estimates with 95% confidence intervals: "headache" (0.12; 0.10-0.14; I2 = 77%), "dizziness" (0.08; 0.05-0.12; I2 = 82%), "headache and dizziness" (0.09; 0.06-0.13; I2 = 0%), "nausea" (0.07; 0.04-0.11; I2 = 79%), "vomiting" (0.05; 0.03-0.08; I2 = 74%), "nausea and vomiting" (0.06; 0.03-0.11; I2 = 83%), "confusion" (0.05; 0.02-0.14; I2 = 86%), and "myalgia" (0.21; 0.18-0.25; I2 = 85%). The most common neurological complication associated with COVID-19 infection was vascular disorders (n = 23); other associated conditions were encephalopathy (n = 3), encephalitis (n = 1), oculomotor nerve palsy (n = 1), isolated sudden-onset anosmia (n = 1), Guillain-Barré syndrome (n = 1), and Miller-Fisher syndrome (n = 2). Most patients with neurological complications survived (n = 14); a considerable number of patients died (n = 7); and the rest had unclear outcomes (n = 12). CONCLUSION: This review revealed that neurologic involvement may manifest in COVID-19 infection. What has initially been thought of as a primarily respiratory illness has evolved into a wide-ranging multi-organ disease.

Oculomotor Nerve Palsy Due to Unusual Causes.

BACKGROUND: An isolated oculomotor nerve (CN III) palsy is a diagnostic concern because of the potential for serious morbidity or life-threatening causes. We present 5 unusual causes of oculomotor nerve palsy that escaped initial diagnosis in order to raise awareness of their associated features that will facilitate correct diagnosis. METHODS: This study consisted of a retrospective analysis of clinical features and imaging of 5 patients who were referred for neuro-ophthalmologic evaluation with presumed diagnosis of oculomotor nerve palsy of unknown reasons. RESULTS: A complete CN III palsy and an inferior division CN III palsy were diagnosed with a schwannoma in the cavernous sinus and orbital apex portion, respectively; a middle-aged woman with aberrant regeneration was found to have a small meningioma; an adult man with ptosis was diagnosed with cyclic oculomotor paresis with spasms; and a patient after radiation was diagnosed with neuromyotonia. CONCLUSIONS: Localizing the lesion of oculomotor nerve palsy and careful examination of the imaging is crucial. Aberrant regeneration, cyclic pupil changes, and past medical history of amblyopia, strabismus, or radiation are also very helpful for diagnosis.

Cranial Nerve Disorders Associated With Immune Checkpoint Inhibitors.

OBJECTIVE: To describe the spectrum, treatment, and outcome of cranial nerve disorders associated with immune checkpoint inhibitor (Cn-ICI). METHODS: This nationwide retrospective cohort study on Cn-ICI (2015-2019) was conducted using the database of the French Refence Center. In addition, a systematic review of the literature (MEDLINE, Scopus, and Web of Science) for records published between 2010 and 2019 was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the search terms cranial nerve or neuropathy or palsy and immune checkpoint inhibitors. RESULTS: Among 67 cases with ICI-related neurologic toxicities diagnosed in our reference center, 9 patients with Cn-ICI were identified (7 men, 78%, median age 62 years [range 26-82 years]). Patients were receiving a combination of anti-cytotoxic T-lymphocyte antigen 4 and anti-programmed cell death 1 (PD-1)/PD-1 ligand (n = 5, 56%) or anti-PD-1 antibodies alone (n = 4, 44%). Cn-ICI involved optic (n = 3), vestibulocochlear (n = 3), abducens (n = 2), facial (n = 2), and oculomotor (n = 1) nerves. Two patients had involvement of 2 different cranial nerves. Treatment comprised corticosteroids (n = 8, 89%), ICI permanent discontinuation (n = 7, 78%), plasma exchange (n = 2, 22%), and IV immunoglobulin (n = 1, 11%). Median follow-up was 11 months (range 1-41 months). In 3 cases (33%), neurologic deficit persisted/worsened despite treatment: 2 optic and 1 vestibulocochlear. Among cases from the literature and the present series combined (n = 39), the most commonly affected cranial nerves were facial (n = 13, 33%), vestibulocochlear (n = 8, 21%), optic (n = 7, 18%), and abducens (n = 4, 10%). Trigeminal, oculomotor, and glossopharyngeal nerves were less frequently affected (total n = 7). CONCLUSION: Cranial nerve disorders can complicate treatment with ICIs. Approximately one-third of the patients had persisting deficits, most frequently involving hearing and vision loss.

Contralateral Surgery for the Treatment of Third Nerve Palsy with Aberrant Regeneration.

PURPOSE: To report the results of contralateral recession-resection of the horizontal muscles in oculomotor nerve palsy with aberrant regeneration to correct both the strabismus and the ptosis in one procedure. DESIGN: Retrospective case series. METHODS: This is an institutional study on patients with oculomotor nerve palsy with aberrant innervation who had contralateral eye muscle surgery in 2 different centers. Patients were included if they have both exotropia and aberrant regeneration with a ptosis that improved on adduction. All patients had contralateral lateral rectus recession and medial rectus resection. Ductions, versions, angle of misalignment, and degree of ptosis were evaluated before surgery and at last follow-up. RESULTS: Eleven patients were identified. The mean age at surgery was 15.0 ± 9.2 years. Five patients were male (45%). Trauma was the cause in 8 (72%) cases. The mean angle of exotropia was 42 ± 14 prism diopters. The mean degree of ptosis was 3.9 ± 1.6 mm. The mean lateral rectus recession was 8.2 ± 1.1 mm, and the mean medial rectus muscle resection was 6.7 ± 0.9 mm. The mean follow-up was 6.4 ± 2.5 months. After surgery, none of the patients had residual exotropia >10 prism diopters. The mean degree of ptosis after surgery was 0.9 ± 0.8 mm. None of the patients required further surgery for ptosis or strabismus. CONCLUSION: Contralateral eye muscle in third nerve palsy with aberrant innervation offers the advantage of simultaneous correction of both strabismus and ptosis through a single procedure.

Brainstem tuberculoma: A delayed IRIS.

We describe a twenty six years old lady with tuberculous meningitis who developed new onset left ptosis and binocular diplopia with features of left fascicular 3rd nerve palsy after 9 months of anti tubercular therapy (ATT) and imaging revealed new onset tuberculoma in the mid-brain. Tuberculoma responded to steroids while continuing ATT. Formation of new tuberculoma as a part of immune reconstitution inflammatory syndrome (IRIS) is possible even after prolonged therapy of 9 months, which responded well to only steroids without altering ATT.

Management of Visual Dysfunction in Patients with Parkinson's Disease.

Parkinson's disease (PD) is a movement disorder with many symptoms responsive to treatment with dopamine agonists, anti-cholinergics and the dopamine precursor, levodopa. The cardinal features of PD include tremor, rigidity, bradykinesia, and postural instability. There also are non-motor features that include sleep disorders, cognitive and affective dysfunction, hyposmia, pain and dysautonomia (constipation, bloating, orthostasis, urinary symptoms, sexual dysfunction, dysphagia). Among these non-motor features are signs and symptoms of visual system impairment that range from subtle examination findings to those causing severe disability. In this review we describe common PD-related abnormalities in the visual system, how they present, and potential treatments.

Plus-minus lid syndrome with ataxia and severe apathy-A rare manifestation of midbrain infarct.

Plus-minus lid syndrome is a rare manifestation of midbrain infarct, characterized by ptosis of one eye and lid retraction in the other eye. It has also been described in ocular myasthenia gravis, orbital myositis, or after lesions of the oculomotor nerve. Our patient was a 55-year-old man with hypertension and atrial fibrillation, who presented to us with acute onset left-sided ptosis and right-sided eyelid retraction. He was apathic and had right-sided ataxia. His MRI of the brain showed acute infarct involving the paramedian midbrain. To our knowledge, severe apathy and resultant executive function disorder have not been described previously in a patient having plus-minus lid syndrome with ataxia.

Pupil-Involving Oculomotor Nerve Palsy Following Tonsillectomy and Adenoidectomy.

Ocular complications of adenotonsillectomy are rare. The authors describe a 6-year-old boy who developed mydrasis and limitations of supraduction and infraduction after adenotonsillectomy. This was attributed to the hemorrhagic compression of the nerve in the cavernous sinus. This is the first report of pupil-involving oculomotor nerve palsy following adenotonsillectomy. [J Pediatr Ophthalmol Strabismus. 2019;56:e76-e78.].

Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.

Acute isolated medial rectus palsy due to infarction as a result of hypercoagulable state: A case report and literature review.

Isolated medial rectus palsy in an otherwise healthy individual is a very rare entity. However, this may point towards underlying systemic pathology. This is a case report of an otherwise healthy young adult male who presented with sudden onset non-progressive blurring of vision in right eye. A series of investigations were performed and the patient was diagnosed to have a rheumatological disorder. Isolated muscle palsies in young patient may be masking a systemic disorder and needs to be evaluated thoroughly.

Clinical characteristics of tuberculous meningitis combined with cranial nerve palsy.

OBJECTIVE: To retrospectively analyze the data of 72 patients with tuberculous meningitis (TBM) combined with cranial nerve palsy, to explore the incidence, clinical features, CSF assay changes and outcome in patients with TBM. PATIENTS AND METHODS: A total of 72 patients were diagnosed as TBM with cranial nerve palsy. The gender, age, clinical manifestations, CSF examinations, cerebral magnetic resonance imaging (MRI) enhancement scan were collected. All these patients had completed at least 2 months of follow up after anti-tuberculous treatment. RESULTS: This study retrospectively evaluated 486 patients; include 254 (52.3%) men and 232 (47.7%) women. The mean age was 35.2 ±â€¯17.0 years. 72 patients (14.8%) were diagnosed as TBM with cranial nerve palsy. Among them, 38 cases (52.8%) had optic nerve palsy (the 2nd nerve), 41 cases (56.9%) had oculomotor nerve palsy (the 3rd nerve), 3 cases (4.2%) had abducens nerve palsy (the 6th nerve), and 10 cases (13.9%) had auditory nerve palsy (the 8th nerve). 16 patients (22.2%) had two groups of cranial nerve involvement (oculomotor nerve and optic nerve in 10 cases, optic nerve and auditory nerve in 5 cases, and optic nerve and abducens nerve in 1 case). Two patients (2.8%) had three groups of cranial nerve involvement (oculomotor nerve, optic nerve and abducens nerve). CSF MTB was detected by acid fast bacilli (no patient was positive), MTB DNA detection by multiplex polymerase chain reaction (PCR) (3 patients were positive) and MTB cultures (2 patients were positive). There was no significant difference of CSF cells and biochemistry investigations between the patients with or without cranial nerve palsy. Magnetic resonance imaging (MRI) enhancement scan were done in 66 (91.7%) patients after admission. It was abnormal in 57 (86.3%) patients. 15 cases (26.3%) had meningeral enhancement, 25 cases (43.9%) had tuberculoma, 11 cases (19.3%) had hydrocephalus and 6 cases (10.5%) with infarct. All patients were followed up after 2 months of anti-tuberculous treatment. 70 patients (97.2%, 70/72) with the cranial nerve palsy were fully recovered without obvious sequel. CONCLUSION: The complications of cranial nerve palsy in TBM patients are not uncommon, and the rate of misdiagnosis is high, which makes them vulnerable to emergencies such as disturbance of consciousness. Effective anti-tuberculous treatment can restore most cranial nerve palsy.