Recurrent isolated sixth nerve palsy in children.

Six children had recurrent sixth nerve palsy the average duration of which was six weeks. One youngster, after several episodes of sixth nerve palsy, had residual esotropia and underwent strabismus surgery. The average interval between recurrences was 1.3 years. Ipsilateral recurrences were a prominent feature. Thus far the recurrences of palsy in this group of patients has not been associated with any identifiable intracranial process. Multiple recurrences in the absence of any recognizable febrile illness clearly suggests that not all "benign" sixth nerve palsies in children are due to postinfectious processes. The etiology of isolated benign sixth nerve palsy remains uncertain. Benign sixth nerve palsy with recurrence may account for a larger percentage of truly "isolated" palsies in otherwise healthy youngsters than has been generally appreciated since several widely quoted papers on this subject have included individuals with multiple neurologic deficits at the time of initial presentation. This report of recurrent palsies for which etiologies were not established should not diminish the concern that there might be an identifiable, serious, cause for sudden onset of sixth nerve palsy in a youngster. The diagnosis of "benign" sixth nerve palsy is one of exclusion that is made retrospectively and only after an adequate period of close observation.

Eleven cases of sarcoidosis of the optic nerve.

Of 11 patients (eight women and three men, ranging in age from 16 to 48 years) who had sarcoidosis of the optic nerve that caused decreased visual acuity and visual field abnormalities, only two were known to have sarcoidosis at the time the visual impairment developed. Four patients had granulomas involving the optic nerve head, four had granulomatous inflammation of the orbital or intracranial optic nerve or chiasm, and three had retrobulbar neuritis. All 11 patients had histologically confirmed idiopathic noncaseating granulomatous inflammation and eight of the 11 had abnormalities compatible with sarcoidosis in chest roentgenograms. In the three patients in whom the serum level of angiotensin-converting enzyme was determined, it was increased in one and normal in the other two. Computed tomography of the anterior visual pathways was the single most useful neurodiagnostic study. Treatment with corticosteroids was beneficial in six of the 11 cases. These cases demonstrated that sarcoidosis should be included in the differential diagnosis of any inflammatory or compressive lesion involving the anterior visual pathways.

Traumatic superior oblique palsies.

The differences in the clinical and diagnostic characteristics of 33 consecutive traumatic unilateral (21 patients, 62%) and bilateral (12 patients, 38%) superior oblique palsies were studied. The unilateral palsies had a large hypertropia in primary position, more vertical than torsional diplopia, a compensatory head tilt to obtain fusion, and a positive Bielschowsky head tilt test. In contrast, the bilateral palsies had small hypertropias in primary gaze that alternated on right and left gaze, a large V-pattern esotropia with excyclotorsion that was frequently bilateral, and a compensatory head position with fusion in upgaze. The results of the study indicate that a V-pattern in excess of 25 prism diopters, an excyclotorsion of greater than 10 degrees, or head trauma severe enough to cause loss of consciousness should also signal bilateral involvement. Torsional diplopia was present in only 20% of unilateral palsies vs 75% of bilateral palsies. The Bielschowsky head tilt test was diagnostic in 100% of the patients with unilateral palsy and 83% of the patients with bilateral palsy. It was undiagnostic in the supine position in all patients. Spontaneous resolution occurred in 65% of the unilateral palsies but in only 25% of the bilateral palsies. Surgical correction was successful in relieving persistent symptoms.

Sarcoidosis and its ophthalmic manifestations.

Of 532 cases of sarcoidosis in the southeastern United States, ocular manifestations were a prominent feature of the disease in 202 (38%) of the patients. Approximately one fifth of them sought medical attention because of ocular complaints. This was the second most frequent clinical manifestation, exceeded only by pulmonary symptoms. When ocular segment structures were affected, the anterior segment was involved in 171 (84.7%) of cases. Chronic granulomatous uveitis was the most common abnormality in 106 cases (52.5%). Posterior segment disease occurred in 51 (25.3%) of cases, usually in the form of chorioretinitis or preiphlebitis; it was sometimes the sole manifestation of ocular sarcoidosis, but usually accompanied abnormalities in the anterior part of the eye. The incidence of central nervous system sarcoidosis was increased when posterior segment involvement was observed. Orbital and adnexal structures, primarily lacrimal gland, were affected in 53 (27.7%) of cases.

Retinal vascular changes in retrograde optic atrophy.

Five patients with unilateral optic atrophy of extraocular origin had a normal retinal vasculature. Clinical examination of the patients included color fundus photographs and fluorescein angiography. After comparing the blood vessels in the blind eye with those in the normal fellow eye, we concluded that vascular attenuation is neither invariably associated with optic atrophy, nor solely caused by decreased local oxygen demand in the retina.

The significance of intraocular hemorrhages due to subarachnoid hemorrhage.

A retrospective study of 320 patients with spontaneous subarachnoid hemorrhage revealed a 20.8% incidence of intraocular hemorrhages. While diagnostically helpful, intraocular hemorrhages also were prognostically significant. The overall patient mortality was 31.6%. In those with intraocular hemorrhages the mortality was 53.6% compared to 19.7% in those without intraocular hemorrhages. Fifty-eight percent with bilateral intraocular hemorrhages died versus 48% with unilateral hemorrhages. Vitreous hemorrhage, though infrequent, may be a major complication in survivors of subarachnoid hemorrhage.