Neuro-ophthalmological manifestations of diabetes mellitus during COVID-19-related lockdown in India

Purpose: The coronavirus disease 19 (COVID?19) pandemic has resulted in a huge impact on the health care system. Diversion of health care workforce toward management of a high number of COVID?19 cases and lockdown restrictions have affected the follow?up of patients. The objective of this study was to analyze the impact of this situation on the control of diabetes, eventually resulting in related neuro?ophthalmological complications. Methods: This retrospective case series included diabetic patients visiting the neuro?ophthalmology clinic at a tertiary care eye center in India from 25 March 2020 to 25 September 2020 during the lockdown. The incidence of diabetes?related neuro?ophthalmological complications, including third, fourth, sixth nerve palsies and non?arteritic anterior ischemic optic neuropathy (NAION) was evaluated and compared with that of the same period during 2019. Results: Overall disease incidence rate was significantly higher in the year 2020 (60.2%) compared to the previous year of 2019 (29.8%). The proportion of third nerve palsy (4.8% vs 16.3%, P < 0.001) and NAION (0.3% vs 14.3%, P < 0.001) had increased. Even though the percentage of sixth nerve palsy was 25% in 2020, this was not significantly different from 2019. There was a reduction in the percentage of fourth nerve palsy cases from the year 2019 to 2020. Conclusion: There was a significant increase in diabetes?related neuro?ophthalmic complications during the COVID?19 lockdown. This can possibly be attributed to worsening of glycemic control in diabetic patients.

Paresia unilateral do terceiro nervo após uso de Metronidazol oral / Unilateral third nerve palsy after use of oral Metronidazole

Resumo Paciente do sexo feminino, 19 anos, com queixa de diplopia, náusea e vômito de início súbito. Ao exame físico, a paciente apresentava rotação da cabeça para a esquerda e limitação da adução do olho direito, sugerindo paresia do músculo reto medial. Ausência de ptose palpebral ou paresia de outra musculatura ocular extrínseca e sem outras alterações na avaliação oftalmológica. Foi relatado pelo paciente o uso de Metronidazol, duas doses de 500 mg, no mesmo dia em que os sintomas começaram. A ressonância magnética do crânio foi solicitada. O resultado mostrou um cisto da glândula pineal, estando os outros aspectos dentro da normalidade. A paresia do músculo reto medial e diplopia persistiram por 14 dias, mesmo após a suspensão do antibiótico, optando, assim, por iniciar a corticoterapia oral, evoluindo com boa resposta clínica, melhora dos sintomas e regressão da paresia muscular.

Abstract Female patient, 19 years old, with a complaint of diplopia, nausea and vomiting of sudden onset. Upon physical examination, the patient presented herself with the head position rotated to the left and limitation of adduction of the right eye, suggesting paresis of the medial rectus muscle. Absence of palpebral ptosis or paresis of other extrinsic musculature of the eye, and without other alterations in the ophthalmological evaluation. It was reported by the patient the use of Metronidazole, two doses of 500 mg, the same day the symptoms started. The magnetic resonance imaging of the skull was requested. The result showed a cyst of the pineal gland, the other aspects being within normality. The paresis of the medial rectus muscle and diplopia persisted for 14 days, even after the antibiotic was discontinued, thus opting to initiate oral corticosteroid therapy, evolving with good clinical response, improvement of symptoms and regression of muscular paresis.

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.

Congenital third nerve palsy with synergistic depression on attempted adduction and trigemino‑oculomotor synkinesis: Underpinnings of a spectral dysinnervation disorder.

The authors describe a case of congenital partial pupil‑sparing third cranial nerve palsy with absent adduction, synergistic depression of globe and widening of palpebral fissure on attempted adduction and synergistic elevation and adduction on mouth opening and sideways thrusting of jaw. The case illustrates trigemino‑oculomotor synkinesis associated with congenital third nerve palsy. The possible mechanism of miswiring involving the medial longitudinal fasciculus and trigeminal nuclei is discussed. At least some cases of congenital third cranial nerve palsy may fall in the realm of congenital cranial dysinnervation disorders (CCDDs) sharing a much wider spectrum of presentation.

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.

A Case of the Third Nerve Palsy in a Patient with Orbital Aspergillosis

PURPOSE: To report a case of orbital aspergillosis with third nerve palsy. CASE SUMMARY: A 75-year-old male presented with abrupt onset of visual impairment, extraocular movement limitation, and ptosis. The patient previously experienced rhinolalia and headache and was diagnosed with sinusitis 2 months prior, and was treated with oral antibiotics for 1 week. Orbital magnetic resonance imaging revealed a mass with bone erosion including the nasal cavity, ethmoid bone, and left orbit suggestive of fugal sinusitis. Aspergillus was detected histopathologically in the mass which was removed by endoscopic surgery. Amphotericin B was administered intravenously for 7 days along with voriconazole. There was no recurrence during the follow-up period. Extraocular movement limitations and ptosis were recovered postoperatively. CONCLUSIONS: The present study results indicate that visual impairment and third nerve palsy can develop in a patient with orbital aspergillosis.

Parálisis Parcial del Nervio Oculomotor Secundaria a Zoster Sine Herpete: Reporte de Un Caso / Partial Palsy of the Oculomotor Nerve Due to Zoster Sine Herpete: A Case Report

Introducción: Herpes Zoster es la reactivación del Virus Varicela Zóster en los ganglios sensoriales y/o autonómicos, típicamente caracterizado por dolor profundo de distribución dermatómica y erupciones vesiculares en piel. De manera infrecuente, puede presentarse el Zoster Sine Herpete, condición en la cual se presenta la distribución dermatómica del dolor en ausencia de lesiones dérmicas, convirtiendo el diagnóstico en un reto clínico. Caso clínico: Hombre de 69 años con dolor periorbitario, epifora, ptosis y pérdida de la aducción del ojo derecho. Los estudios imagenológicos y de laboratorio fueron normales, descartando así las principales causas de parálisis del nervio oculomotor. Se hizo diagnóstico presuntivo de Zoster Sine Herpete y se inició prueba terapéutica con valaciclovir, observándose resolución total de la sintomatología seis semanas después. Discusión: Este caso puede ser el primero en describir una parálisis parcial dolorosa del nervio oculomotor como única manifestación clínica de la reactivación del Virus Varicela Zóster y busca alertar al personal médico sobre una enfermedad latente que hace de sus reapariciones una gama de presentaciones no siempre fáciles de identificar.

Introduction: Herpes zoster is the reactivation of the varicella zoster virus in the sensorial and/ or autonomic ganglia, typically characterized by cutaneous vesicular eruptions and deep pain with dermatomal distribution. Infrequently can occur the Zoster Sine Herpete; condition in which there is dermatomal distribution of the pain in absence of dermic injuries, making the diagnosis a challenge for the clinician. Case report: 69 years old man with periorbital pain, epiphora, ptosis and loss of adduction of the right eye. The imaging and laboratory studies were normal, excluding with this the main causes of oculomotor nerve palsy. A presumptive diagnosis of Zoster Sine Herpete was done and a therapeutic test with valacyclovir was initiated, showing complete resolution 6 weeks later without sequelaes. Discussion: This case may be the first in describing partial painful oculomotor nerve palsy as the only manifestation of the varicella zoster virus reactivation and seeks to aware the medical staff about a latent disease that makes from his reappearances a wide range of presentations not always easily to identify.

Ophthalmoplegia in Herpes Zoster Ophthalmicus / 대한피부과학회지

No abstract available.

Isolated Sphenoid Sinus Mucocele Presenting as Third Nerve Palsy

A sphenoid mucocele often presents late due to its deep seated anatomical site. And it has varied presentation due to its loose relationship to the cavernous sinus and the base of the skull. We describe a case of large sphenoid sinus mucocele. A middle aged old man suddenly developed third cranial nerve palsy. Brain imaging study revealed an isolated sphenoid sinus mucocele, compressing right cavernous sinus. Endoscopic marsupialization of the mucocele via transnasal approach led to complete resolution of the third cranial nerve palsy. Involvement of the third cranial nerve in isolated mucocele is rare but important neurosurgical implications which must be excluded. In addition, proper and timely treatment must be performed to avoid permanent neurologic deficit.

Periosteal Fixation in Bilateral Total Third Nerve Palsy

PURPOSE: We present a new technique of anchoring the eyeball to the nasal periosteum with supramaximal recession of the lateral rectus muscle in one eye for exotropia management in bilateral total third nerve palsy combined with trochlear nerve palsy. CASE SUMMARY: A 38-year-old man presented with drooping of both upper lids and exodeviation of the left eye with a history of intraventricular hemorrhage 9 months previously. We noted bilateral ptosis, dilated pupils, right fixing eye, left face turn, and left exotropia over 100 prism diopters (PD) in the primary position with an inability to move both eyes together except abduction. He was diagnosed with bilateral total third nerve palsy and trochlear nerve palsy. We fixated the left globe (sclera anterior to the insertion of the medial rectus muscle) to the nasal periosteum including the medial palpebral ligament using a nonabsorbable suture. A large recession of the left lateral rectus muscle (14 mm) was also performed. Ocular alignment in the primary position was exotropia of 25PD and cosmetically satisfactory after 6 months of follow-up. CONCLUSION: Supramaximal recession of the lateral rectus muscle and periosteal fixation using nonabsorbable suture is an effective technique for the management of exotropia secondary to total third nerve palsy.

Third Nerve Palsy in Idiopathic Hypereosinophilic Syndrome: Report of Two Cases

The idiopathic hypereosinophilic syndrome (IHES) is a heterogenous spectrum of disorders, characterized by a long lasting hypereosinophilia without identifiable underlying cause and by the presence of various end-organ dysfunction. The neurologic manifestations of IHES can be encephalopathy, organic psycho syndrome and polyneuropathy and in rare cases polymyositis. Central nervous system involvement is the second mostclinically important complication of the hypereosinophilic syndrome as it is associated with chronic disability and a poor prognosis. In this report, we describe two patients of IHES who presented anisolated third nerve palsy with pupillary involvement and were improved by corticosteroid therapy. They satisfied the criteria of IHES and the third cranial nerve was the only site of neurologic involvement. Early recognition of neurologic involvement in IHES and prompt treatment could lead to good outcome

Two Cases of Rhino-Orbitocerebral Mucormycosises that Manifested as Noninflammatory Oculomotor Nerve Palsy

PURPOSE: Rhino-orbitocerebral mucormycosis is the disease that cause orbital cellulitis, orbital apex syndrome, and orbital necrosis. We report two cases of mucormycosis that began with only noninflammatory oculomotor nerve palsy. METHODS: 74-year-old man and 53-year-old woman with DM visited our hospital for sudden ptosis, mydriasis, and paralytic strabismus. MRI scan and other neurological examinations were negative except mild sinusitis. Patients were diagnosed as complete third nerve palsy. RESULTS: A few days later, they developed orbital apex syndrome with exophthalmos and abrupt reduction of visual acuity. Emergency biopsy of sinusitis was done, and revealed mucormycosis. CONCLUSIONS: Sudden oculomotor nerve palsy in chronic debilitating patients with DM and sinusitis should be suspected as prodrome of rhino-orbito-cerebral mucormycosis.

Surgical Correction of Exotropia due to Oculomotor Nerve Palsy

In third nerve palsy, the functions in the four of the six extraocular muscles are compromised and its treatment is the most difficult problem in the paralytic strabismus. In surgical method, large recession and resection of horizontal rectus muscles, lateral rectus muscle transposition to medial rectus muscle and superior oblique muscle transposition are used for strabismus surgery on oculomotor nerve palsied eye. We compared the results of two methods of surgical correction. In three eyes, lateral muscle transpositions to medial rectus muscle were performed. On the last follow up examination (men; 6.7 months), two eyes resulted in severe hypertropia and unacceptable ocular alignment and no improvement of limited adduction. In six eyes of whom superior oblique muscle transpositions were performed, all resulted in acceptable ocular alignment, no hypertropia, and the limitations of adduction were improved markedly. Therefore, in the treatment of third nerve palsy, sperior oblique muscle transposition is more effective than lareral rectus muscle transposition to medial rectus muscle.

Strabismus Surgery on Congenital Oculomotor Nerve Palsied Eye

In congenital third nerve palsy, the function in four of the six extraocular muscles is compromised, and its treatment is the most difficult problem in paralytic strabismus. In general, either large recession and resection on horizontal rectus muscles or superior oblique muscle transposition is used for treatment. We compared the results of the two methods of surgical therapy. A Total of nine eyes in nine cases underwent surgical correction for ocular alignment in the primary position, In four eyes of four cases horizontal rectus muscle surgery was performed. In five eyes of five cases superior oblique muscle transposition was performed. Postoperatively, one of four cases who underwent horizontal rectus muscle surgery and four of five cases who underwent superior obique muscle transposition resulted in acceptable ocular alignment, in which the angle of deviation at the primary position was within 2 delta. Therefore, in the treatment of congenital third nerve palsy, superior oblique muscle transposition is more effective than horizontal rectus muscle surgery for the correction of ocular alignment.