Regeneración aberrante del III nervio craneal por aneurisma cerebral bilateral. Reporte de caso / Aberrant regeneration of the III cranial nerve due to bilateral cerebral aneurism

RESUMEN Los trastornos de la motilidad ocular constituyen motivo de consulta periódica en Oftalmología. La regeneración aberrante, trastorno muy poco reportado, es considerada la sincinesia oculomotora de mayor invalidez y complejidad. Diversas condiciones neuroftalmológicas están implicadas en la etiopatogenia de la enfermedad, la mayoría de las cuales puede ocasionar la muerte. El manejo de los síntomas y signos provocados por paradójicos movimientos oculares conjugados es difícil. Se reportó un caso con remisión tardía a neuroftalmología por diagnóstico inicial y evolución desfavorable. La historia psicofísica arrojó diagnóstico definitivo de regeneración aberrante del III nervio craneal secundario, a aneurisma cerebral de la carótida interna bilateral, agravado por reanastomosis quirúrgica. Una rigurosa, obligatoria e impostergable historia neuroftalmológica, se impone ante toda parálisis del III nervio craneal para brindar un diagnóstico etiológico preciso y de esta forma proteger la vida.

ABSTRACT The disturbances in ocular motility are the cause of periodical consultation in Ophthalmology. The aberrant regeneration, a scarcely reported disturbance, is considered the oculomotor synkinesis of highest disability and complexness. Several neuro-ophthalmologic conditions are implicated in the disease ethiopathogeny, and most of them could lead to death. The management of the symptoms and signs caused by paradoxical conjugated ocular movements is difficult. A case is reported of late remission to Neuro-ophthalmology due to unfavorable diagnosis and evolution. The psycho-physical history led to a definitive diagnosis of aberrant regeneration of the III secondary cranial nerve, to cerebral aneurism of the bilateral internal carotid, worsened by surgical re-anastomosis. In front of any paralysis of the III cranial nerve, it is necessary a rigorous, obligatory and immediate neuro-ophthalmological history to arrive to a precise etiological diagnosis, protecting life in that way.

Correção de estrabismo incomitante por cirurgia de recuo-ressecção combinadas do mesmo músculo reto / Incomitant strabismus correction through combined resection and recession of the same rectus muscle

Resumo O presente trabalho relata o caso de um paciente, masculino, 38 anos, com estrabismo incomitante e consequente diplopia, submetido à cirurgia debilitadora com recuo e fortalecimento com ressecção do músculo reto inferior direito. O objetivo desta técnica cirúrgica é a correção do desvio em sua posição de maior incomitância, sem prejudicar o alinhamento ocular na posição primária do olhar (PPO). O resultado satisfatório, em concordância com os dados da literatura atual, contribui para fazer desta técnica uma opção no tratamento de estrabismos incomitantes de difícil manejo.

Abstract The present study reports a case of a patient, 38-year-old man, with incomitant strabismus and consequent diplopia, submitted to debilitating surgery with recession and strengthening resection of the right inferior rectus muscle. This surgical technique aims to correct the deviation in its greater incomitence position, without impairing the ocular alignment in the primary position of the eye (PPO). The satisfactory result, in agreement with data of current literature, contributes to make this technique an option in the treatment of challenging incomitant strabismus.

Diplopia vertical persistente pós-facectomia e tireoidopatia associadas / Persistent vertical post-facectomy and associated thyroid disease

RESUMO Os autores relatam o caso de uma paciente feminina de 69 anos que desenvolveu diplopia vertical persistente após facectomia extracapsular sob anestesia peribulbar. Paciente apresentava história de tireoidopatia tratada o que tornou a condcução da diplopia mais complexa. Os autores enfatizam a necessidade de se realizar propedêutica orbitária detalhada para se descartar quadros restritivos da musculatura extraocular associados à diplopia pós-facectomia.

ABSTRACT The authors report a case of a 69 year-old woman who developed persistent vertical deviation and diplopia after extracapsular cataract surgery and had a positive past history of thyroid disease. The authors emphasize the need of for detailed orbit propedeutics in order to rule out restrictive strabismus associated with post-facectomy diplopia.

A Case of Ocular Myasthenia Gravis Presenting as Double Depressor Palsy

A 65-year-old man who had been experiencing diplopia in front and down gaze for 15 days visited our hospital. Hypertropia was noted in the patient's left eye, and limitation of depression was found in the adduction, primary gaze, and abduction. Brain magnetic resonance imaging showed no remarkable findings. Two weeks after the first visit, the patient complained of ptosis in the left eye. An ice test was performed and the ptosis was resolved after the test. Then, anti-acetylcholine receptor binding antibody levels were checked and found to be slightly elevated. We prescribed methylprednisolone per os 24 mg for 2 weeks, and his symptoms improved after the 2-week treatment. Five weeks after his first visit, the patient showed an ortho result in the alternate prism cover test and normal ocular movements. This may be the first case in which ocular myasthenia gravis presented as double depressor palsy, and in such cases, the possibility of ocular myasthenia gravis should be considered to rule out double depressor palsy.

An unusual presentation of lacrimal gland pleomorphic adenoma / Apresentação não usual de um caso de adenoma pleomórfico de glândula lacrimal

Tumors of the lacrimal gland are rare in clinical practice. Among all of them, the most common epithelial tumor is the lacrimal gland pleomorphic adenoma, which is a benign indolent tumor that usually affects adults in the third and fourth decades of life. We present an unusual case of lacrimal gland pleomorphic adenoma. Its management, radiological findings and outcomes are also described, along with a brief review of the literature.

Os tumores da glândula lacrimal são raros na prática clínica. Dentre eles, o tumor epitelial mais comum é o adenoma pleomórfico da glândula lacrimal, que consiste em um tumor benigno, indolente, que geralmente acomete adultos na terceira e quarta décadas de vida. Apresentaremos um caso raro de adenoma pleomórfico de glândula lacrimal, bem como a condução do caso, achados radiológicos e o seu desfecho, além de um breve resumo da literatura.

Traumatic avulsion of extraocular muscles: case reports / Avulsão traumática de músculos extraoculares: relatos de casos

We described the clinical, surgical details and results (motor and sensory) of the retrieving procedure of traumatically avulsed muscles in three patients with no previous history of strabismus or diplopia seen in the Department of Ophthalmology, State University of Campinas, Brazil. The slipped muscle portion was reinserted at the original insertion and under the remaining stump, which was sutured over the reinserted muscle. For all three cases there was recovery of single binocular vision and stereopsis.

Foram descritos os quadros clínicos, detalhes cirúrgicos e resultados (motores e sensoriais) da reinserção de músculos traumaticamente avulsionados, em três pacientes sem estória prévia de estrabismo ou diplopia, atendidos no Departamento de Oftalmologia da Universidade Estadual de Campinas. A porção muscular deslizada foi reinserida na linha da inserção original e sob o coto remanescente, o qual foi acomodado e suturado sobre o músculo reinserido. Para os três casos houve recuperação da visão binocular única e da estereopsia.

Síndrome de Charles Bonnet en cuatro casos con atrofia óptica / Charles Bonnet syndrome in four cases with optical atrophy

El síndrome de Charles Bonnet constituye un trastorno muy poco reportado. En Cuba, que se conozca, no hay referencia de casos publicados hasta este momento. Se caracteriza por la presencia de alucinaciones visuales complejas en individuos con pérdida visual, mentalmente sanos y con conciencia crítica de la naturaleza irreal de sus alucinaciones. Se presentan cuatro casos con este síndrome relacionados con déficit visual secundario a atrofia óptica...

Charles Bonnet syndrome is an underreported disorder. As far as we know, there are no publicized references in Cuba up to the present time. This syndrome involves complex visual hallucinations in visually impaired individuals, who are mentally healthy and have intact cognition of the unreal nature of their hallucinations...

Diplopia após injeção de toxina botulínica tipo A para rejuvenescimento facial / Diplopia after injection of botulinic toxin type A for facial rejuvenation

Relato de 4 casos de pacientes encaminhadas ao serviço de Ortóptica deste Hospital, que apresentaram diplopia após a injeção de toxina botulínica tipo A para rejuvenescimento facial. Nas medidas de ângulo do estrabismo em posições diagnósticas todas apresentaram microestrabismo paralítico, sendo duas por déficit da função do músculo oblíquo inferior e duas por déficit de função de músculo reto lateral. Baseados nos casos descritos, aconselha-se aos profissionais que fazem uso desta toxina para fins de rejuvenescimento facial que estejam atentos para a diplopia como efeito colateral.

Report of 4 patients referred to the Orthoptics Service of this Hospital, who presented diplopia after the injection of botulinic toxin type A for facial rejuvenation.When measuring the angle of the strabismus in the diagnostic positions, all of the patients presented paralitical micro strabismus, two of them due to inferior oblique paresisand the other two due to lateral rectus paresis. Based on the cases described, we advise the professionals that make use of BTA for facial rejuvenation to be aware of diplopia as a complication.

Peoría paradójica en fístulas carótido-cavernosas durales: cuando el cuerpo se enferma más para curarse / Paradoxical worsening in carotid-cavemous ductal fistulas: when the body get more sick in order to cure

Las fístulas carótido-cavernosas son comunicaciones arteriovenosas patológicas entre la arteria carótida interna intravenosa y el seno venoso-cavernoso que la rodea. Un sistema de flujo y presión elevados irrumpe sobre otro de bajo flujo y velocidad. Ello origina los síntomas y signos. La gran mayoría, son resultantes de traumatismos craneales siendo de alto flujo y alta velocidad-fístulas traumáticas o directas; menos comunes son las llamadas fístulas espontáneas o durales localizadas en la duramadre y alimentadas por ramas menígeas provenientes de las arterías carótidas externa, interna o ambas y de las arterias vertebrales. Estas últimas raras veces tienen implicaciones graves para la vida, pero la pérdida visual constituye el mayor riesgo; no obstante, con elevada frecuencia, ocurre la oclusión espontánea, por lo que se impone la observación hasta que la sintomatología justifique el tratamiento. En el curso evolutivo puede ocurrir la trombosis aguda de la fístula y más propiamente de la totalidad de la vena oftálmica superior la que produce un distintivo cuadro de notable agravamiento de los síntomas que en forma contradictoria ocurre antes de la mejoría y reversión de los síntomas, el síndrome de empeoramiento o peoría paradójica. Para ilustrar el síndrome se presentan los casos clínicos de los pacientes

Caroid-cavernous fistulas are pathological arteriovenous communications between the intracavernous internal carotid artery and the cavernous sinus. A system of high flow and pressure bursts over another system of low flow and slow velocity. This causes the symptoms and signs. The vast majority are related with head trauma being high flow and high speed fistulas: traumatic or direct. Less common are the so-called spontaneous or dural fistulas located in the duramater and fed by meningeal branches from the external, internal, or both carotic arteries and the vertebral arteries. These latest rarely have serious implications for life, but visual loss is the greatest risk; however, with high frequency spontaneously occlusion occurs, and then observation imposes until symptoms justified the treatment. During its evolution acute thrombosis of the fistula itself can occur along the entire length of the ophthalmic vein which produces a distinctive and paradoxical worserning and reversal of symptoms, which is called the syndrome of paradoxical worserning. Clinical cases of two patients are presented to illustrate the syndrome

Diplopia em adultos / Diplopia in adults

No presente trabalho os autores fazem uma revisão bibliográfica sobre diplopia abordando, entre outros aspectos, sua investigação diagnóstica e seu tratamento.

Isolated pathetick nerve paresis by compression from a dolichoectatic basilar artery: case report

The article describes a woman with 53 year-old that has presented diplopia when looking down and adopted a tilted head position in order to read for the last six months. The neuro-ophthalmic examination shows isolated right superior oblique muscle paresis. The magnetic resonance and the angioresonance show the dolicoectatic basilar artery compressing the right ventral lateral brainstem.

O artigo descreve uma mulher de 53 anos que há seis meses apresenta diplopia ao olhar para baixo, além de adotar postura inclinada da cabeça para ler. O exame neuro-oftalmológico revelou paresia isolada do músculo oblíquo superior direito. Os exames de ressonância magnética e angioressonância evidenciaram dolicoectasia da artéria basilar, que comprimia a face ventral lateral direita do tronco cerebral.

Esotropia do adulto durante o período gestacional: relato de caso / Adult esotropia during pregnancy: case report

Os autores relatam o caso de uma paciente que apresentou quadro reincidente de esotropia aguda e diplopia durante o período gestacional. Não havia história de trauma ou qualquer alteração sistêmica, excetuando-se a gravidez. Tratamento oclusivo alternado foi instituído, e após o parto houve remissão espontânea dos sinais e sintomas.

The authors report a case of a female patient who presented, for the second time, diplopia and acute esotropia during pregnancy. There was no trauma involved neither was systemic disease. The patient was treated with conventional occlusion, and, soon after delivery, the squint was resolved.

Pineal Cavernous Malformations: Report of Two Cases

Pineal hemorrhage only occurs in rare cases, and this known to have several different causes such as germ cell tumors, pineal cysts and vascular malformations, including the cavernous malformations. Pineal cavernous malformations are extremely rare: to date only fifteen cases have been reported worldwide. Although the diagnosis of pineal cavernous malformation is not easy because of the extreme rareness of this condition, the presence of this lesion can be suspected based on its typical radiological findings. Case 1. A 42-year- old man presented with a limitation in his upward gazing. Radiologic examinations showed acute hemorrhage in the pineal region. He underwent ventriculo-peritoneal (VP) shunting but the patient's condition deteriorated after the shunting surgery. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. Case 2. A 37-year-old man presented with diplopia. Radiologic examinations showed acute hemorrhage in the third ventricle. He underwent VP shunting, and after this procedure the diplopia was aggravated. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. If there is no doubt about the pineal cavernous malformation on MR imaging, we strongly recommend early surgical intervention without performing a risky biopsy. In this study, we describe our experiences for the diagnosis of cavernous malformations in the pineal region with special emphasis on the radiological aspects and the clinical course of this disease.

Manejo de las alteraciones oculomotoras en la orbitopatía distiroidea / Oculomotor alterations handling in the thyroid orbithopaty

Objetivo: El objetivo es definir un protocolo operatorio reproductible frente a la diplopia en pacientes portadores de orbitopatía distiroidea (ODT). Material y Método: Estudio retrospectivo descriptivo que analiza una serie de 37 pacientes operados entre septiembre de 1998 y abril 2003 de cirugía de retroceso muscular, bajo anestesia general o anestesia tópica potencializada, frente una diplopia invalidante en posición primaria y en posición de lectura. La determinación de la cuantía de retroceso dependió de la evaluación perioperatoria dada por el test de ducción forzada (TDF) y el test de elongación muscular (TEM). Se definió como buen resultado post operatorio la desaparición de la diplopia en posición primaria y de lectura con un seguimiento mínimo de 3 meses. Resultados: 26 mujeres y 11 hombres, edad promedio 51 años y seguimiento de 9,4 meses. Se practicaron 27 cirugías sobre diplopias verticales y 14 sobre diplopias horizontales. En las diplopias verticales se siguió el protocolo de TEM (+), es decir, 1 mm retroceso por 1 mm hipoextensibilidad, con buen resultado en 25 pacientes. En las diplopias horizontales, 2 cirugías con suturas ajustables, con buen resultado y en el resto se practicaron 1 mm retroceso por 3 DP de desviación, ya que el TEM era levemente positivo o normal y el resultado fue bueno en 8 casos. Conclusiones: Pensamos que el hecho de realizar un retroceso muscular en relación a la cuantía de la fibrosis constituye un gesto fisiológico. Así 26/27 cirugías practicadas según protocolo de TEM tuvieron buen resultado. La cirugía ajustable nos parece una buena alternativa en el caso de diplopias horizontales con una fibrosis moderadas de rectos internos.

Lid swelling and diplopia as presenting features of orbital sarcoid.

Sarcoid is an idiopathic multisystem non-caseating granulomatous disease with protean clinical manifestations. In the eye, the common sites of involvement are the skin of eyelid, conjunctiva, uveal tract, retina, optic nerve and lacrimal gland.

rare cause of diplopia: the dural fistula of the cavernous sinus, about a case

Dural fistulas of the cavernous sinus represent a relatively unknown etiology for diplopia. The authors report on a case where combination of MR and transcranial Doppler [especially transocular] helped in diagnostic and therapeutic approach. They propose a new algorithm for the management of diplopia

Dermolipoma ocular: relato de caso / Ocular dermolipoma: a case report

Dermolipoma e um tumor conjuntival benigno, congenito, usualmente bilateral, lentamente progressivo, que pode determinar prejuizos funcionais a motilidade ocular, com diplopia e desconforto. Entretnto, alteracoes cosmeticas sao geralmente os principais motivos de procura do oftalmologista. O tratamento e microcirurgico, devendo-se evitar lesoes nos musculos extra-oculares, ductos e glandula lacrimal, mesmo as custas de uma remocao apenas paarcial do dermolipoma. Quando pequenos e assintomaticos a conduta e essencialmente conservadora e expectante, para evitar riscos de lesoes operatorias. Dermolipomas oculares, embora raros, sao ocasionalmente relatados na literatura medica; este caso foi o unico encontrado em cerca de 7000 pacientes atendidos pela autora nos ultimos anos

Causes of diplopia.

A prospective study of 96 diplopia patients was analyzed concerning the common types and causes in order to develop early and proper management. Two-thirds (62) of the patients were male (64.6%). The average age was 34.5 +/- 15.7 years (+/- SD). The result revealed that the common types of diplopia were horizontal, vertical and torsional diplopia, respectively. The common causes of diplopia were head trauma (38.5%), systemic diseases from diabetes mellitus, hypertension (20.8%), undetermined group (15.6%), eye diseases (9.4%), and etc. Sixth cranial nerve paralysis was frequently found among the third, fourth and sixth cranial nerves. There were 13 cases of spontaneous fusion in the primary position. Only 7 of 12 surgical cases eventually achieved satisfactory alignment and fusion.