Oculomotor palsy in diabetics.

INTRODUCTION: Oculomotor palsy is one of the most frequent neuro-ophthalmologic complications of diabetic patients. It generates less interest in the literature than the other ocular manifestations. Our goal was to study the clinical, epidemiological, therapeutic and prognostic characteristics of oculomotor palsy in the diabetic. METHODS: This is a retrospective study of 24 diabetic patients with oculomotor palsy. The ophthalmological examination emphasized ocular motility. We performed an orthoptic assessment and a Hess-Lancaster test. Neuro-imaging was ordered in case of IIIrd and IVth nerve involvement, bilateral involvement, multiple ocular cranial nerve palsy or associated optic neuropathy. Treatment consisted of glucose management and alternating monocular occlusion or prisms for the diplopia. Data were entered and analyzed on SPSS 11.5 software. RESULTS: The mean age of the patients was 58.5±11.9 years. Binocular diplopia was the main symptom. The oculomotor palsy involved the VIth nerve in 50% of cases and was bilateral in two cases. Three patients also had an optic neuropathy. The mean duration of diabetes was 11.7±11 years; poorly controlled diabetes was found in 75% of cases and an association with diabetic retinopathy was noted in 56% of cases. CONCLUSIONS: Long-standing uncontrolled type 2 diabetes, hypertension, coronary artery disease, left ventricular hypertrophy, and elevated hematocrit are the most common risk factors. The VIth nerve is commonly involved. Certain characteristics of the pupillary light reflex can help to differentiate an ischemic insult from an aneurysmal injury to the IIIrd nerve.

Literature review regarding the methodology of assessing third nerve paresis associated with non-ruptured posterior communicating artery aneurysms.

The association of third cranial nerve palsy subsequent to an enlarging posterior communicating artery (P-Com A) aneurysm has been well described. In our current communication, we review the relevant literature and propose a classification system for the severity of the third cranial nerve palsy, correlating it to the postoperative recovery. Our four grade scale (I-IV) included the degree of the levator palpebrae muscle paresis, the presence of pupillary reaction and the impairment of the third nerve mediated extraocular muscle movement. We evaluated five patients with third nerve palsy secondary to non-ruptured, P-Com A aneurysm. Patients were re-evaluated at 2, 4, 8, 24 weeks postoperatively. Four of the five patients had complete recovery within 4-8 weeks after surgery. One patient had grade II third nerve paresis and complete resolution of the third nerve symptoms within 4 weeks, whereas three patients with grade III and IV had complete resolution 4-8 weeks after surgery. The fifth patient, with grade IV paresis, had minimal (grade III) improvement 6 weeks after surgery, and incomplete recovery (grade I) 6 months postoperatively. Our simple grading system of third nerve palsy associated with P-Com A aneurysms, can be a helpful tool for the initial evaluation and for the monitoring of recovery in these patients.

[Diagnostic approach for acquired and isolated third cranial nerve palsy: 18 case reports]. / Conduite à tenir devant une paralysie du III acquise et isolée.

PURPOSE: The aim of this work was to establish a clinical diagnostic flow chart for third nerve palsy. MATERIAL AND METHODS: [corrected] We report a series of 18 patients with third nerve palsy seen at the department of ophthalmology in the Marseille North Hospital between 1997 and 1999. All patients had a complete clinical examination and were classified into four clinic types. An etiological diagnosis was given in all cases after a systematic approach, including first intention MRI. RESULT: Three patients presented abnormal pupil reflex secondary to an aneurysm diagnosed by carotid angiography; the MRI was pathological in two cases. The 15 other patients had pupil sparing. Among them, eight patients had a total external involvement secondary to diabetes mellitus; the MRI suggested an ischelic origin in four cases (50%) showing nuclear infarctus. In seven cases the external involvement was incomplete secondary to multiple etiologies: demyelinating illness, traumatic lesions, orbital tumor, metastasis or myasthenia gravis. The MRI contributed to diagnosing four cases. CONCLUSION: The MRI must be systematically used in all the patients with isolated third nerve palsy, except for patients with pupil sparing associated with total external involvement. Ischemic etiology was the rule: simple clinical surveillance is proposed, total spontaneous regression being the norm.

An imaging guide to the evaluation of third cranial nerve palsies.

PURPOSE: To devise a cost-effective imaging guide for the evaluation of third nerve palsies (TNP), based on an extensive review of the literature. METHODS: A review of the pertinent English language literature was performed to devise a guideline for the evaluation and neuroimaging of TNP. The authors also report a retrospective review of the cost of imaging studies performed on 91 patients with TNP. RESULTS: On the basis of the available literature, an imaging guide was developed and applied to a retrospective chart review of 91 patients from a single tertiary care center (Baylor College of Medicine). The cost effectiveness as well as the efficacy of the imaging guide was analyzed. CONCLUSIONS: The evaluation of TNP can be difficult; however, using such guides may allow for more appropriate and cost-effective evaluation of these patients.

A new classification of superior oblique palsy based on congenital variations in the tendon.

BACKGROUND: Superior oblique palsy is the most frequent isolated cranial nerve palsy seen in strabismus practice. It is traditionally diagnosed according to etiology as acquired, congenital, or idiopathic, but surgical treatment is based on deviation not etiology. Observations at surgery led to speculation that the superior oblique tendon is different in congenital compared with acquired superior oblique palsy and that this difference should be considered in surgical treatment. METHODS: The authors reviewed the charts of 82 patients (89 eyes) undergoing surgery on the superior oblique tendon for superior oblique palsy. In each case, the palsy had been diagnosed preoperatively as acquired, congenital, or idiopathic, and, at surgery, characteristics of the tendon anatomy were described. RESULTS: Thirty-eight superior oblique tendons (36 patients), diagnosed as congenital superior oblique palsy, included 33 abnormal tendons and 5 normal tendons. Twenty-four tendons (21 patients), diagnosed as traumatic superior oblique palsy, included 22 normal and 2 abnormal tendons. Twenty-seven tendons (25 patients), diagnosed as idiopathic, included 19 normal and 8 abnormal tendons. Abnormal tendons were divided into 4 categories: (1) redundant, (2) misdirected, (3) inserted in posterior Tenon's capsule, and (4) absent. CONCLUSIONS: The authors conclude that congenital superior oblique palsy is usually associated with a structural abnormality of the superior oblique tendon (87%). Whereas acquired superior oblique palsy usually has a normal tendon (92%). Superior oblique underaction in acquired superior oblique palsy results from a neural deficit. Potential variance in anatomy of the superior oblique tendon should be considered when undertaking surgery for superior oblique palsy.

Superior oblique palsy: diagnosis and treatment.

To pinpoint the diagnostic dilemmas and to look for differentiating preoperative features in cases of masked bilateral superior oblique palsy, the authors reviewed the charts of 50 patients (26 males and 24 females with an average age at presentation of 25.6 years) with an established diagnosis of superior oblique palsy seen between 1980 and 1987. Most patients had a history of symptoms from childhood or following trauma. Typically, patients complained of torticollis and diplopia and manifested inferior oblique overaction and superior oblique underaction of the paretic eye. Twenty-two of the patients underwent a total of 28 operations; surgery resulted in elimination of symptoms and neutralization of the hyperdeviation in 77%. On the basis of this experience the authors discuss the presenting features and the differential diagnosis of superior oblique palsy and present a rational approach to surgical intervention.