Experience in Diagnosis and Treatment of Oculomotor Nerve Palsy based on Channel Pattern Differentiation / 中医杂志

It is believed that the basic pathogenesis of oculomotor nerve paralysis （ONP） is qi and blood depletion and channel obstruction. Taking channel pattern differentiation as the core， it is recommended to use acupuncture mainly based on location， syndrome and channel deficiency-excess differentiation. Location and channel tropism differentiation mainly follows the principle of “where the channels and collaterals pass， the main treatment can reach”， and commonly uses acupuncture points on Dumai （督脉）， the hand Shaoyang （少阳） Sanjiao （三焦） channel， the hand Taiyang （太阳） small intestine channel， three yang channels of the foot， the hand Shaoyin （少阴） heart channel， the foot Jueyin （厥阴） liver channel， and others， and combines scalp acupuncture with electro-acupuncture to enhance channel stimulation. Pattern and channel tropism differentiation is to differentiate the entered channel according to clinical symptoms and zang-fu patterns. The differentiation of deficiency-excess should be payed attention to， and the principle of “supplementing the deficiency， and draining the excess” should be followed. The supplementing and draining method should be used rationally by considering the differences in the supplementing and draining acupoints themselves， as well as the actual condition of the patients. Simultaneously， it is suggested to combine manipulation and stimulation amount and effect in clinical practice.

Clinical observation on post-stroke oculomotor nerve palsy treated with the interaction of twelve meridian muscle regions and contralateral needling therapy / 中国针灸

OBJECTIVE@#To observe the clinical effect on post-stroke oculomotor nerve palsy treated with the interaction of twelve meridian muscle regions and contralateral needling therapy.@*METHODS@#A total of 46 patients with post-stroke oculomotor nerve palsy were randomized into an observation group and a control group, 23 cases in each one. In the control group, the intramusclar injection of mecobalamine at the buttock region was given, 1 mL each time, once every two days, 3 times weekly. Besides, citicoline sodium capsules were prescribed for oral administration, 0.2 g each time, 3 times daily. In the observation group, on the base of the treatment as the control group, the interaction of twelve meridian muscle regions and contralateral needling therapy was supplemented. Acupoints on the health sides included Juliao (ST 3) and Hanyan (GB 4), acupoints on the affected side included Jingming (BL 1), Sibai (ST 2), Yangbai (GB 14), Cuanzhu (BL 2), Shangming (Extra), Sizhukong (TE 23), Tongziliao (GB 1) and bilateral Fengchi (GB 20), Quchi (LI 11), Pianli (LI 6), Waiguan (TE 5), Hegu (LI 4) were selected. The needles were retained for 30 min in each acupuncture treatment, once a day, 5 times weekly. The treatment for 4 weeks was required in the two groups. Before and after treatment, the score of cervical range of motion (CROM), pupil size, eye fissure width and eyeball mobility were observed in the patients of the two groups. The clinical effect was evaluated in the two groups.@*RESULTS@#After treatment, CROM scores and pupil size were reduced in the patients of the two groups (<0.05), and the values in the observation group were lower than the control group (<0.05). The eye fissure width and eyeball mobility were increased in the two groups (<0.05), the eye fissure width and the mobility of the muscles of rectus internus, inferior rectus and inferior oblique in the observation group were larger than the control group (<0.05). The effective rate was 82.6% (19/23) in the observation group, higher than 65.2% (15/23) in the control group (<0.05).@*CONCLUSION@#The interaction of twelve meridian muscle regions and contrallateral needling therapy effectively relieves diplopia, pupil dilation, narrow eye fissure and limited eyeball mobility in the patients with post-stroke oculomotor nerve palsy.

Etiology, localization of the lesion, and prognosis for patients firstly diagnosed in ophthalmology department with oculomotor nerve palsy / 中南大学学报(医学版)

OBJECTIVES@#Oculomotor nerve palsy is a kind of disease with many causes, showing eye movement disorders, abnormal eyelid position, and/or damage of the pupil. The etiology of oculomotor nerve palsy in different departments is different. The study discussed the etiology, localization of the lesion, and prognosis for oculomotor nerve palsy firstly diagnosed in department of ophthalmology.@*METHODS@#Clinical data of 137 hospitalized patients with oculomotor nerve palsy at the Department of Ophthalmology, the First Medical Center of PLA General Hospital from 2009 to 2018 were retrospectively collected. The etiology and its distribution characteristics in different age groups, the location of the lesion, and the prognosis of patients were analyzed.@*RESULTS@#In 137 patients, the top 3 causes for oculomotor nerve palsy were head trauma (38.69%), cavernous sinus lesions (12.40%), and orbital inflammation (9.49%). Other causes included intracranial aneurysm, the intracranial space-occupying lesion, cerebral vessel diseases, infection, orbital tumors, diabetes, the operation of nasal cavity. Traumatic oculomotor nerve palsy was more common in young adults aged 20-49 years and in the patients with cerebral vascular disease in elderly people aged 60-69 years, while diabetic oculomotor nerve palsy is common in middle-aged and elderly people aged 50-69 years. The age distribution of other etiological types was relatively balanced. Seventy-five cases of orbital apex lesions were due to trauma, inflammation, infection, and tumor; 40 cases of cavernous sinus lesions were due to inflammation, tumor, and thrombosis; 6 cases of subarachnoid lesions were due to aneurysms, tumors, and trauma; 5 cases were oculomotor nucleus lesions were due to infarction; 11 cases could not be allocated because of unknown etiology. After treatment, the corrected visual acuity of oculomotor nerve palsy side was not significantly improved. The patients with oculomotor nerve palsy caused by intracranial aneurysm, cerebrovascular disease, and diabetes mellitus had the highest proportion of partial or complete recovery from ptosis and ocular dyskinesia.@*CONCLUSIONS@#Oculomotor nerve palsy is a common cause of ophthalmoplegia and diplopia. Head trauma, cavernous sinus lesions, and orbital inflammation are the most common causes for oculomotor nerve palsy first diagnosed in ophthalmology department. Traumatic oculomotor nerve palsy is common in adolescents. Oculomotor nerve palsy caused by diabetes and cerebrovascular disease are common in the middle-aged and elderly people. Most of the lesions locate in the orbital apex and cavernous sinus. The prognosis of corrected visual acuity is poor. The prognosis of ptosis and ocular dyskinesia caused by intracranial aneurysm, cerebrovascular disease, and diabetes is good. Figuring out the cause timely and accurately is the basis and key to treat oculomotor nerve palsy.

Pituitary Apoplexy Presenting as Isolated Bilateral Oculomotor Nerve Palsy

PURPOSE: To report a case of pituitary apoplexy presenting as isolated bilateral oculomotor nerve palsy. CASE SUMMARY: A 46-year-old male presented with bilateral ptosis and acute severe headaches for 6 days. He underwent head surgery and bilateral vitrectomy 12 years prior to his visit because of ocular and head trauma. He mentioned that previous visual acuities in both eyes were not good. The initial corrected visual acuity was finger counting in the right eye and 20/500 in the left eye. Ocular motility testing revealed the limitation of adduction, supraduction, and infraduction with complete bilateral ptosis in both eyes, and his left pupil was dilated. He was diagnosed with an isolated bilateral oculomotor nerve palsy. Magnetic resonance imaging indicated pituitary gland hemorrhage with a tumor, which was suspicious of pituitary apoplexy. The patient was treated intravenous with 1.0 g methylprednisolone to prevent the corticotropic deficiency. In addition, he underwent surgical decompression using a navigation-guided transsphenoidal approach and aspiration biopsy. He was confirmed with pituitary adenoma using a pathological examination. The patient's ocular movements began to dramatically improve by the third day postoperatively. At 4 months postoperative follow-up, his ocular movement and double vision were completely recovered. CONCLUSIONS: This was a rare case of pituitary apoplexy with bilateral isolated oculomotor nerve palsy, which was the first report in the Republic of Korea. A full recovery was achieved after early surgical treatment.

Recurrent isolated oculomotor nerve palsy caused by schwannoma in a pediatric patient

Isolated schwannomas of motor nerves to extraocular muscles are uncommon. In addition, most previous studies on oculomotor nerve schwannoma discuss adult patients, and pediatric cases are rare. We report a 10-year-old girl who developed recurrent oculomotor nerve palsy caused by schwannoma without any vascular malformation. Although the incidence is rare in pediatric patient, the recurrent isolated oculomotor nerve palsy due to schwannoma can develop, and it should be considered in the differential diagnosis of ocular motility disorders in pediatric patients. Careful imaging evaluation is needed to identify schwannoma due to its small size, deep location in the brain, and rarity.

Microsurgical treatment of large parasellar meningiomas by pterional craniotomy: A clinical experience with 34 cases / 第二军医大学学报

Objective To introduce the microsurgery treatment method for large parasellar meningiomas by pterional craniotomy and its curative effect. Methods The clinical data of 34 patients with large parasellar meningiomas, who underwent microsurgery via pterional or extensive pterional craniotomy in Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine Jul. 2006 to Aug. 2016, were retrospectively analyzed. The patients included 13 men and 21 women with ages ranging from 21 to 72 (average, 49±13) years old. The course of disease ranged from 1 to 55 (average, 13±10) months. Maximum diameter of tumors ranged from 3.3 to 5.2 (average, [4.3±0.6]) cm. Results No surgical death occurred in this study. Postoperatively, the cranial imaging examination showed that 24 of 34 cases were totally removed, 5 cases were subtotally removed, and 5 cases were partially removed. The postoperative follow-up time was 24-48 (average, 36±13) months. Twenty-eight cases had good prognoses with Karnofsky score being 80 to 100, and six cases had fair prognoses with Karnofsky score being 60 to 79. Five cases had postoperative oculomotor paralysis, which was improved with nutritional nerve treatment. Conclusion The microsurgical treatment via pterional or extensive pterional craniotomy can improve the total resection rate of the large parasellar meningiomas. Palliative operations combined with postoperative radiotherapy may be employed for the tumors that can only be subtotally and partially removed.

Professor 's experience in the treatment of oculomotor nerve palsy with acupuncture based on the interactions of twelve muscle regions and opposing needling theory / 中国针灸

It was to introduce professor 's experience in the treatment of oculomotor nerve palsy with acupuncture based on the interactions of twelve muscle regions and opposing needling theory. In the treatment, the TCM syndrome differentiation is taken as the general principle, the theory of the interactions of twelve muscle regions and opposing needling as the specific feature. The contrary needling is used at Hanyan (GB 4) and Juliao (ST 3) on the healthy side. The meridian-collateral and the exterior-interior differentiations are adopted to identify the syndromes. At the early stage of the disease, the treating principle focuses on expelling wind, eliminating cold and promoting the circulations of meridians and collaterals. The shallow needling, less acupoints and gentle stimulation are required. At the middle and late stage, the treating principle concentrates on strengthening the antipathogenic and harmonizing and blood. The deep needling, the multiple acupoints and the strong stimulation are applied. Additionally, the four-needling technique at Fengchi (GB 20), the multiple shallow needling at the eyelid margin, the opposing needling and the quantity of needling sensation are used in combination, which were developed by professor . With those comprehensivemethods, the symptoms of oculomotor nerve palsy are relieved and the significant clinical therapeutic effects achieved.

A Case of Partial Oculomotor Nerve Palsy Caused by Vascular Compression in Idiopathic Intracranial Hypertension / 대한평형의학회지

Pupil-involving oculomotor nerve palsy (ONP) is frequently associated with compressive lesion such as intracranial aneurysm originating from the posterior communicating arteries. Vascular variant of posterior intracranial circulation is regarded as an uncommon cause and association between these vascular variants and intracranial hypertension has not been reported. We present an 18-year-old girl with pupil-involving ONP combined with idiopathic intracranial hypertension who revealed compression of oculomotor nerve by a vascular variant of superior cerebellar artery (SCA). This is a rare case of an ONP attributed to compressive effect from an aberrant SCA affected by intracranial hypertension.

Causes and clinical characteristics of oculomotor nerve palsy / 第二军医大学学报

Oculomotor nerve plays an important role in regulating the function of eyeball by controlling levator palpebrae superioris muscle, superior rectus muscle, inferior rectus muscle, medial rectus muscle, inferior oblique muscle, sphincter pupillae muscle and ciliary muscle. Oculomotor nerve palsy is a common clinical symptom characterized by diplopia, ptosis, ophthalmoplegia or pupillary dysfunction. The etiologies of oculomotor nerve palsy are complicated, including intracranial aneurysm, cerebral infarction and hemorrhage, diabetes, intracranial inflammation, craniocerebral trauma, congenital disease and so on. Palsy caused by different etiologies has corresponding clinical features. In this review, we summarized the common causes of oculomotor nerve palsy-and their corresponding pathogenesis, clinical manifestations, signs, treatments and prognosis, hoping to provide help for rapid identification of etiology and effective treatment of the oculomotor nerve palsy.

Imaging of Cranial Nerves III, IV, VI in Congenital Cranial Dysinnervation Disorders

Congenital cranial dysinnervation disorders are a group of diseases caused by abnormal development of cranial nerve nuclei or their axonal connections, resulting in aberrant innervation of the ocular and facial musculature. Its diagnosis could be facilitated by the development of high resolution thin-section magnetic resonance imaging. The purpose of this review is to describe the method to visualize cranial nerves III, IV, and VI and to present the imaging findings of congenital cranial dysinnervation disorders including congenital oculomotor nerve palsy, congenital trochlear nerve palsy, Duane retraction syndrome, Möbius syndrome, congenital fibrosis of the extraocular muscles, synergistic divergence, and synergistic convergence.

A Prospective Study on Effect of Stress on Sleep Quality in Young Medical Students in a Tertiary Hospital

Objective: The objectives of this study was to evaluate the sleep disruption risk enhancement among the young Medical students due to increasing the demand of clinical and academic duties and Studying the relation between sleep quality and psychological stress  which can be useful in implementing an organized mental health program in medical colleges. The main aim is to study the prevalence and the effect of stress on sleep quality in young medical students. Methods: This Prospective cross sectional study was conducted on Medical students of Teerthanker Mahaveer Medical College & Research Centre to recognize the effect of stress on sleep quality among 75 medical students. The instruments used for data collection were a self-report Pittsburg Sleep Quality Index (PSQI) and the General Health Questionnaire (GHQ). Results: Results of present study showed that 59% of subjects were poor sleepers. Furthermore, there was a significant correlation between general health status and sleep quality of students (r = 0.5118, p = 0.0001). Conclusions: A considerable proportion of medical students are affected by poor sleep quality. Sleep disruption acts as a barrier for students’ performance in examinations. So, it is important to implement health promotion and educational programs for them.

Bifrontal Extradural Hematoma (EDH) Causing Isolated Right 3rd Nerve Palsy with Spontaneous Partial Recovery

All neurosurgeons are aware of traumatic intracranial hematomas presenting with oculomotor nerve palsy which requires immediate surgical intervention. Isolated third nerve palsy with no other neurological signs due to head injury is a rare occurrence. We report a case of head injury with bifrontal extradural hematoma presenting as  isolated right sided  third nerve palsy which partially improved with nonsurgical management. We also discuss the possible causes of such involvement.

Cases of Oculomotor Nerve Palsy in Herpes Zoster Ophthalmicus

PURPOSE: To report two case of oculomotor palsy accompanied by herpes zoster ophthalmicus (HZO). CASE SUMMARY: Two patients with HZO who were suffering from skin lesions, facial pain, and medicated with an antiviral agent from the dermatologic department, were diagnosed with oculomotor palsy. They presented with ptosis, dilated pupils, and ophthalmoplegia after 10 days, and 4 days after began developing skin lesions. They were diagnosed with HZO-induced oculomotor palsy and the ophthalmoplegia improved in all cases. CONCLUSIONS: Oculomotor nerve palsy rarely occurrs in HZO patients and is usually followed by skin lesions. We recommend examinations for functions of extraocular motility, ptosis, and pupil to diagnose and treat the HZO-induced oculomotor nerve palsy even if consulted with the dermatologic department or only showing mild conjunctivitis, episcleritis, or keratitis.

Bilateral thalamic infarcts presenting oculomotor nerve palsy: case report.

Bilateral thalamic infarctions are rare; oculomotor nerve palsy can be the result of direct or indirect damage to the oculomotor nerve. We report a case of oculomotor nerve palsy associated with changes in visual pattern and speech disturbances. There is no loss of consciousness. A computed tomography scan of brain showed acute bilateral thalamic infarct. Oculomotor nerve palsies with pupillary involvement warrant thorough investigation and there is no treatment to re-establish function of the weak nerve other than the body’s own healing process.

Two Cases with Positive Ice Tests Mimicking Ocular Myasthenia Gravis

PURPOSE: To report two patients with positive ice tests who had diplopia and blepharoptosis caused by something other than ocular myasthenia gravis. CASE SUMMARY: A 35-year-old female presented with a one-week history of inability to adduct the left eye and left blepharoptosis. Although the ice test was positive, serum anti-acetylcholine receptor binding antibody and the repetitive nerve stimulation test were negative. Brain angiography showed an aneurysm of the left posterior communicating artery, leading to the diagnosis of left pupil-sparing oculomotor nerve palsy. A 25-year-old female presented with an 8-month history of intermittent horizontal diplopia and blepharoptosis in the right eye. The ice test was positive, however serum anti-acetylcholine receptor binding antibody and the repetitive nerve stimulation test were negative. Anti-nuclear antibody was positive (titer 1:160). CONCLUSIONS: The ice test is a useful screening test for myasthenia gravis. However, a series of differential diagnoses including blepharoptosis and ocular motility disorder should be considered because these conditions also show a positive result in the ice test.

A Case of Isolated Third Nerve Palsy with Preeclampsia

PURPOSE: Isolated oculomotor nerve palsy in preeclampsia patients have not been reported in Korea. Herein, we report 1 case of a patient in her 32nd week of gestation diagnosed with preeclampsia experiencing oculomotor nerve palsy in the left eye which improved after delivery. CASE SUMMARY: 28-year-old pregnant woman in her 32nd week of gestation with no underlying diseases visited our clinic with the chief complaint of diplopia and left eye ptosis. The patient suffered headache symptoms 1 week prior and did not undergo any exams. The visual acuity, anterior segment, and, fundus showed no abnormal signs and the pupil light reflex was normal, but the patient showed left eye ptosis with +2 mm/-2 mm on the marginal reflex distance (MRD) exam, 25 prism exotropia and 6 prism hypotropia, supraduction and adduction limitation -2 and, infraduction limitation -1. To exclude other systemic disorders and brain lesions, laboratory tests and brain magnetic resonance imaging (MRI) was performed, and preeclampsia was diagnosed based on high blood pressure (150/110 mm Hg) and mild proteinuria. Imaging and labatory tests showed other disorders thus the patient was treated conservatively. Two weeks after the ocular symptoms appeared, the left ptosis and ocular movement restriction worsened, but systemic signs and tests shown no aggravation, thus we maintained conservative therapy and after delivery at 37-weeks, the symptoms slowly improved and recovered completely after 2 months. CONCLUSIONS: Full systemic examination including MRI and laboratory tests must be performed in pregnant women who suddenly experience ocular symptoms and are diagnosed as oculomotor motor nerve palsy. If diagnosis and treatment are appropriate, good prognosis can be expected in this disease.

Clinical characteristics of posterior communicating artery aneurysm-induced oculomotor nerve paresis before and after endovascular coiling / 中华神经医学杂志

Objective To investigate the clinical characteristics of posterior communicating artery (PcomA) aneurysm-induced oculomotor nerve paresis (ONP) before and after endovascular coiling,and provide a reference for diagnosis,treatment and prognosis of PcomA aneurysm-induced ONP.Methods A total of 55 patients with ONP attributable to PcomA,admitted to our hospital from July 2007 to January 2013,were chosen in our study;their clinical data and postoperative recovery were retrospectively analyzed to investigate clinical characteristics of ONP attributable to PcomA.Results The average preoperative paralysis time was 12.24±5.33 days in patients with complete preoperative paralysis and 8.90±3.51 days in patients with incomplete preoperative paralysis with significant difference (P=0.014).Of the 55 patients,31 (56.36％) had complete recovery ofoculomotor nerve function,19 incomplete recovery (34.55％),and 5 (9.09％) remained unchanged after endovascular treatment.Most patients (41/50) began to improve in 3 months after endovascular treatment.The complete recovery ratio between patients encountered improvement of ONP within 30 days and over 30 days had statistical differences (P=0.032).Of 31 patients received complete resolution of ONP at the end of the follow-up,25 (80.65％) fully recovered 6 months after endovascular treatment.Thirty patients (96.77％) fully recovered within one year of endovascular treatment.One (3.23％) received complete resolution of ONP over one year of operation.Within 31 patients encountered complete resolution of ONP,there were 24 patients (77.42％) whose duration of recovery was less than 3 months and 7 patients (22.58％) more than 3 months.Functional recovery was noted firstly in the levator palpebrae muscle,followed by the medial rectus muscle,superior rectus muscle,constrictor muscles of the iris,and ciliary muscle.Patients with incomplete recovery often had residual diplopia in upward gaze and pupillary dysfunction.Conclusions The degrees of oculomotor nerve palsy before endovascular coiling are significantly associated with the paralysis time.Endovascular treatment can promote the recovery of PcomA-induced ONP.The earlier the ONP starting improvement,the better the ONP recoverary after endovascular treatment.The muscles which functional damage occurs early will encounter improvement lately.

Complete Oculomotor Nerve Palsy Complicated by Inflammation of the Cavernous Sinus in Herpes Zoster Ophthalmicus

PURPOSE: To report a case of complete oculomotor nerve palsy with pupil involvement complicated by inflammation of the cavernous sinus. Complete resolution was obtained after 12 days of antiviral and steroid treatments. CASE SUMMARY: A 60-year-old male presented with edema and vesicles of the right upper eyelid. The patient had myalgia, cough, fever and headache 1 week earlier and was treated with conservative therapy. The patient received an antiviral agent (famciclovir 250 mg) twice a day and steroid agent (methylprednisolon 4 mg) once a day at the dermatology department for 1 week. The eyelid edema and vesicles improved. However, ptosis, ocular movement limitation, mydriasis of the right eye and diplopia occurred. Brain magnetic resonance imaging revealed hyperintensity in the right cavernous sinus with enhancement, implicating inflammation. The patient was diagnosed with right complete oculomotor nerve palsy with pupil involvement. An antiviral agent (famciclovir 250 mg) three times a day and a steroid agent (prednisolone 40 mg) once a day were prescribed. From the next day, ptosis and ocular movement limitation improved and 12 days later, completely resolved. CONCLUSIONS: Ocular movement limitation and mydriasis can be accompanied by herpes zoster ophthalmicus without uveitis and cerebral aneurysm. Administering active antiviral and steroid treatment to obtain rapid resolution is important.

Study of Routine Biochemistry Analytes in Leptospirosis for Evaluating Organ and System Specific Involvement.

During 1988-1997 there were 527 cases of Leptospirosis out of which 104 were fatal in south Gujarat, mainly due to liver and renal failure. Pulmonary involvement, though uncommon, led to high mortality. 90% present of patients of leptospirosis have anicteric leptospirosis while only 10% patients of leptospirosis have icteric leptospirosis, a more severe type. Methods and Results: Laboratory reports of samples of patients of Leptospirosis from July 2010 to August 2011 at Biochemistry laboratory of New Civil Hospital were collected from the Laboratory Database. Result: Out of 1293 number of samples of Leptospirosis patients, received at Biochemistry laboratory of New Civil Hospital, Surat. ALT in 71.4 %, Total Bilirubin in 71.8 %,Direct Bilirubin in 89.7 %, Creatinine in 64.3 % and Amylase in 72 % were found elevated. This study shows that 63% of patients have abnormal Liver function and 78% of patients with pancreatic involvement in agreement with a study by Atanasova M G which shows that increased amylase levels are seen in 41.67% of mild cases, in 25% of moderate cases and in 88.24% of severe cases. Conclusion: This study shows that majority of cases of leptospirosis at New Civil Hospital Surat (a tertiary care centre) are icteric leptospirosis and a large majority of them have pancreatic involvement.

Cherubism – A case report.

Cherubism is an autosomal dominant fibro-osseous lesion of jaws involving more than one quadrant that stabilizes after growth period, usually leaving some facial deformity and malocclusion.Here we present a case of 7 years old male patient who came with complaint of bilateral enlargement of lower face since 4 years. A thorough physical and radiographic examination was done and a diagnosis of cherubism was made.