ABSTRACT
Multiple sclerosis (MS) is the most common demyelinating disease affecting the central nervous system. It has a wide range of manifestations and commonly affects the visual system. Many patients with MS report decreased vision, diplopia, nystagmus, and abnormal ocular motility. Nevertheless, bilateral horizontal gaze palsies are exceptionally rarely seen. We present the case of a 24-year-old female who came to our pediatric ophthalmology clinic complaining of bilateral horizontal gaze palsy, photophobia, and eye pain for 2 days. Although the patient had a family history of MS, there was no similar or previous complaint, with an unremarkable past medical and surgical history. During the examination, she was found to have a complete bilateral absence of horizontal saccade and pursuit, with slight limitations in vertical ones. There was no nystagmus or skew deviation, and the rest of the cranial nerves (CNs) were intact. Her ocular vital signs were normal, and her corrected visual acuity was 20/20 with full-color vision. The rest of the physical and neurological examinations were unremarkable. After referral to neurology, the magnetic resonance imaging showed multiple hyperintense lesions in deep white matter, pons, and midbrain. The correlation of imaging findings with clinical presentation confirmed the diagnosis of a clinically isolated syndrome. Extra-ocular motility (EOM) significantly improved after pulse steroid therapy and five sessions of plasma exchange, but the patient developed 35 prism diopter of acquired concomitant esotropia. She underwent a right medial rectus botulinum toxin injection which dramatically improved her condition, and became orthotropic during the last 2 months of follow-up after the injection.
ABSTRACT
INTRODUCTION: Myasthenia gravis (MG) is an autoimmune disease characterized by excessive and intense weakness of both respiratory and skeletal muscles. Management of MG involves both medical and surgical treatment. The surgical management includes resection of the thymus gland by many approaches, either bilateral thoracoscopic maximal thymectomy (BTT) or trans-sternal maximal thymectomy (TS). We hypothesized that bilateral thoracoscopic maximal thymectomy is as effective as trans-sternal maximal thymectomy to treat and control the disease. OBJECTIVE: This study aimed to compare the two approaches (BTT and TS) and determine which is better in terms of outcomes. METHODOLOGY: A retrospective cohort study was conducted among 50 myasthenia gravies patients; 30 patients underwent bilateral thoracoscopic maximal thymectomy (BTT) and 20 were operated by trans-sternal maximal thymectomy (TS). The study was conducted at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia, between 2007 and 2017. RESULT: The mean age of the MG patients was 32.6 years, ranging from 14 to 75. Thirty-four (68%) patients were females, and 16 (32%) were males. The BTT showed less operation time (P<0.0001) and less intubation time (anesthesia time), which was statistically significant (P<0.0001). Hospital stay and ICU stay were both reported to be less in BTT (4.03 and 0.37, respectively) with p-values of 0.006 and 0.0001, respectively. There was no significant association between all categorical study variables and the MG patients' outcome (BTT/TS) in terms of mortality, morbidity, complete stable remission, pharmacological remission, and complications. CONCLUSION: Bilateral thoracoscopic maximal thymectomy is as effective as trans-sternal maximal thymectomy to control and treat the disease.
