Oftalmoplejia dolorosa / Painful ophthalmoplegia

La oftalmoplejía dolorosa es una entidad poco frecuente que se caracteriza por dolor orbitario asociado a parálisis oculomotora ipsilateral, en algunos casos con afectación simpática ocular y alteraciones sensitivas a nivel de los territorios inervados por las ramas maxilar y oftálmica del trigémino. Puede ser causada por gran número de procesos, entre ellos, alteraciones vasculares, traumatismos, enfermedades tumorales o infecciones. Presentamos el caso de un varón de 83 años que acude por cuadro de cefalea en región frontal izquierda que englobaba la región orbitaria, asociada a sensación de hipoestesia y ptosis palpebral ipsilateral. Fue diagnosticado de síndrome de Tolosa-Hunt, una inflamación granulomatosa idiopática a nivel del seno cavernoso de causa desconocida. Se inició tratamiento empírico con corticoides presentando una rápida e importante recuperación

Painful ophthalmoplegia is a rare entity characterized by orbital pain associated with ipsilateral oculomotor paralysis, and sometimes with ocular sympathetic involvement and sensitive impairment in the areas supplied by the maxillary and ophthalmic branches of the trigeminal nerve. It can be caused by numerous conditions, among them, vascular alterations, traumas, tumor diseases, or infections. We present the case of an 83-year-old man with headache in the left frontal region including the orbital region, associated with hypoesthesia and ipsilateral ptosis. He was diagnosed with Tolosa-Hunt syndrome, an idiopathic granulomatous inflammation of the cavernous sinus of unknown cause. Empirical treatment with corticosteroids was initiated, resulting in a rapid and significant recovery

Damage to the inferior oblique muscle branch of the oculomotor nerve: a complication during orbital fat decompression.

PURPOSE: To present patients who suffered damage to the inferior oblique muscle branch of the oculomotor nerve during orbital fat decompression. METHODS: This study was a retrospective chart review of all patients who underwent orbital decompression surgery between April 2009 and June 2016 by the authors. RESULTS: Among 414 sides from 226 consecutive patients who underwent orbital decompression, the inferior oblique muscle branch was injured in two sides (0.5%) of two patients. Both patients showed hypotropia and incyclotropia immediately after surgery. Within 6 months of injury, ocular deviation on primary gaze had mostly resolved after conservative treatment. None of the patients underwent strabismus surgery. Postoperative computed tomographic images demonstrated that the affected branch was indistinct 3-4 mm posterior to the inferior oblique muscle. CONCLUSIONS: This report indicates that injury to the inferior oblique muscle nerve branch can occur at a point posterior to the inferior oblique muscle during orbital fat decompression; however, the resulting ocular deviation improves considerably within 6 months of injury.

Orbital apex syndrome after trauma in a 6-year-old - a rare occurrence.

Orbital apex syndrome is rare, but can occur as a consequence of trauma from fracture of the medial orbit. This case report highlights the fact that a high index of suspicion is needed when a patient presents with a facial injury, especially in children who cannot give an account of the actual events that transpired. Radiological investigation should be done early when an underlying injury is suspected in a trauma patient. A low threshold for computed tomography should be maintained when proptosis and vision loss are present.

Incarceration of the inferior oblique muscle branch of the oculomotor nerve in patients with orbital floor trapdoor fracture.

PURPOSE: To examine the clinical characteristics of patients with concomitant incarceration of the inferior oblique muscle branch of the oculomotor nerve who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. METHODS: Fifty-nine patients were retrospectively reviewed. Concomitant inferior oblique muscle branch incarceration was diagnosed by inferior oblique muscle underaction on the Hess chart and a missing inferior oblique muscle branch on computed tomographic images on baseline examination. RESULTS: Eleven patients (18.6%) were diagnosed with concomitant branch incarceration. The patients with branch incarceration were all under 19 years of age, and were younger than those without branch incarceration (P = 0.026). There were no significant differences between the groups in terms of cause of injury, presence of concomitant medial wall fracture, hypoesthesia of the cheek region, or ocular and periocular complications (P > 0.050). All patients with branch incarceration underwent surgical reduction, whereas 16 of 48 patients without branch incarceration were observed without surgery (P = 0.021). Although preoperative binocular single vision field was smaller in patients with branch incarceration (P = 0.026), it improved after surgery, comparable to that of patients without branch incarceration (P = 0.079). CONCLUSIONS: Concomitant incarceration of inferior oblique muscle branch of the oculomotor nerve occurred in 18.6% of patients who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. Patients with branch incarceration were all under 19 years of age. Branch incarceration resulted in a smaller binocular single vision field, which considerably improved after surgical reduction.

Quantification and analysis of saccadic and smooth pursuit eye movements and fixations to detect oculomotor deficits.

Assessment of deficits in oculomotor function may be useful to detect visuomotor impairments due to a closed head injury. Systematic analysis schemes are needed to reliably quantify oculomotor deficits associated with oculomotor impairment via brain trauma. We propose a systematic, automated analysis scheme using various eye-tracking tasks to assess oculomotor function in a cohort of adolescents with acute concussion symptoms and aged-matched healthy controls. From these data we have evidence that these methods reliably detect oculomotor deficits in the concussed group, including reduced spatial accuracy and diminished tracking performance during visually guided prosaccade and self-paced saccade tasks. The accuracy and tracking deficits are consistent with prior studies on oculomotor function, while introducing novel discriminatory measures relative to fixation assessments - methodologically, a less complicated measure of performance - and thus represent a reliable and simple scheme of detection and analysis of oculomotor deficits associated with brain injury.

Traumatic avulsion of the oculomotor nerve documented by high-resolution magnetic resonance imaging.

Autopsy studies have described definitive traumatic avulsion of the oculomotor nerve from the brainstem; however, detailed characterization of mechanisms and localization of traumatic nerve injury has yet to be definitively described in vivo. We report the case of a 13-year-old girl in whom high-resolution magnetic resonance imaging confirmed irreversible injury to the left oculomotor nerve after trauma.

Imaging of Ocular Motor Pathway.

Eye movement is controlled by ocular motor pathways that encompass supranuclear, nuclear, and infranuclear levels. Lesions affecting certain locations may produce localizing signs that help radiologists focus on specific anatomic regions. Some pathologic conditions, such as aneurysms and meningiomas, have unique imaging characteristics that may preclude unnecessary tissue biopsies. Some conditions are life threatening and require urgent or emergent imaging. MR imaging is the imaging of choice in evaluation of ocular motor palsy, with magnetic resonance angiography or computed tomography angiography indicated in cases of suspected aneurysms or neurovascular conflicts.

Ptosis fluctuante como presentación del síndrome de hipotensión licuoral espontánea / Fluctuating ptosis as the presenting symptom of spontaneous liquoral hypotension syndrome

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[Dural-cavernous fistulas revealed by bilateral alternating third and sixth nerve palsies]. / Fistule durale carotido-caverneuse révélée par une paralysie bilatérale à bascule des troisièmes et sixièmes nerfs crâniens.

A 74-year-old male was referred for disequilibrium, associated with right third and sixth nerve palsies observed 2weeks after head trauma with no loss of consciousness. On clinical examination, 4months after the injury, contralateral (left) third and sixth nerve palsies were observed, while ocular motility was now normal on the right side. The remainder of the ophthalmological examination was normal. Upon further history, tinnitus was found to have been present since the trauma, and auscultation of the preauricular area demonstrated a systolic bruit. Cerebral angiogram confirmed the presence of bilateral dural-cavernous fistulas. Clinical features of indirect or dural-cavernous fistulas and therapeutic options proposed in the literature are reviewed.

Isolated third nerve palsy from mild closed head trauma.

Head injury is a common occurrence in motor vehicle accidents. There are numerous causes for cranial nerve injury that include head trauma or other lesions. Few studies regarding cranial nerve injury following mild head trauma (GCS: 14 - 15) exist in the literature. The oculomotor nerve is a somatic and visceral motor nerve. When it is completely injured the result is ptosis, pupils that are non-reactive to light and a lack of eye movement. We report the case of a completely isolated oculomotor nerve palsy associated with minor head injury.

Intraoperative oculomotor nerve monitoring predicts outcome following clipping of posterior communicating artery aneurysms.

Valid parameters do not exist to predict oculomotor nerve palsy (ONP, ptosis and/or diplopia) intraoperatively. In 49 operations involving 46 patients with posterior communicating artery aneurysms, the oculomotor nerves were stimulated after the aneurysms were clipped. A quantitative analysis of evoked compound muscle action potential (CMAP) parameters (stimulus threshold, amplitude and latency) from the levator palpebrae superioris (LPS) muscle was performed. Absolute values of CMAP amplitude statistically correlated with initial and long-term oculomotor nerve function (ONF) after surgery (p<0.05). In addition, subarachnoid hemorrhage (SAH) significantly influenced the CMAP threshold (p<0.05). Monitoring of LPS muscle activity is valuable in the assessment of ONF, and the CMAP amplitude of LPS may be a reliable predictor of ONF. Moreover, SAH has an impact on the parameters of the LPS CMAP.