A clinical study of ocular motor nerve functions after petroclival meningioma resection.

BACKGROUND: Ocular motor dysfunction is one of the most common postoperative complications of petroclival meningioma. However, its incidence, recovery rate, and independent risk factors remain poorly explored. METHODS: A prospective analysis of 31 petroclival meningiomas was performed. Operative approaches were selected by utilizing a new 6-region classification of petroclival meningiomas we proposed. Two scores were used to evaluate the functions of the oculomotor and abducens nerves. Pearson correlation analysis and binary logistic regression analysis were used to identify independent risk factors for intraoperative oculomotor and abducens nerve injury. RESULTS: Postoperative new-onset dysfunctions in the pupillary light reflex and eye/eyelid movements as well as abducens paralysis were detected in eight (25.8%), ten (32.3%) and twelve (38.7%) cases, respectively. Their corresponding recovery rates after 6 months of follow-up were 75% (6/8), 80% (8/10), and 83.3% (10/12), respectively, and their mean times to start recovery were 4.03, 2.43, and 2.5 months, respectively. Tumor invasion into the suprasellar region/sphenoid sinus was the only risk factor for dysfunctions in both the pupillary light reflex (p = 0.001) and eye/eyelid movements (p = 0.002). Intraoperative utilization of the infratrigeminal interspace was the only risk factor for dysfunction in eyeball abduction movement (p = 0.004). CONCLUSIONS: Dysfunctions of the oculomotor and abducens nerves recovered within 6 months postoperatively. Tumor extension into the suprasellar region/sphenoid sinus was the only risk factor for oculomotor nerve paralysis. Eye/eyelid movements were more sensitive than the pupillary light reflex in reflecting nerve dysfunctions. Intraoperative utilization of the infratrigeminal interspace was the only risk factor for abducens nerve paralysis.

Detachable balloon embolization as the preferred treatment option for traumatic carotid-cavernous sinus fistula?

OBJECTIVE: The purpose of the study was to investigate the treatments and outcomes of patients with traumatic carotid-cavernous sinus fistula (TCCF). METHODS: All patients diagnosed with TCCF at our institution from January 2013 to December 2018 and meeting the inclusion/exclusion criteria were included in the study. RESULTS: A total of 24 patients were included in this study. Of them, 21 (87.5%) were treated with detachable balloon embolization, 1 (4%) with coil embolization, 1 (4%) with balloon-assisted coil embolization, and 1 (4%) with balloon-assisted coil and glue embolization. Among the 21 patients treated with detachable balloon embolization, 10 underwent double-balloon technique embolization including double-detachable balloon embolization (n = 6) and balloon-assisted detachable balloon embolization (n = 4). The fistulas in 17 patients (17/21, 81%) were successfully occluded after the first attempt of detachable balloon embolization, while those in the remaining 4 patients were occluded after a second surgery due to TCCF recurrence or pseudoaneurysm development. Preservation of the internal carotid artery (ICA) was observed in 19 cases after the first treatment by detachable balloon embolization (19/21, 90.4%). ICA was occluded in the remaining two patients, as revealed by a complete angiographic evaluation of the circle of Willis. All patients achieved complete resolution of ocular and orbital manifestations as well as pulsatile bruit, except for three patients whose oculomotorius and/or abducens remained paralyzed during the follow-up period. CONCLUSION: Although several endovascular treatment options are available for TCCF, the detachable balloon embolization is still the preferred method of TCCF, as evidenced in our study. Furthermore, double balloon technique, an improvement upon the conventional detachable balloon embolization, is extremely safe and can effectively treat patients with refractory TCCF.

Tapia Plus: un nuevo síndrome o una variante / Tapia syndrome plus: A new entity or a variant of Tapia syndrome?

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Oftalmoplejia dolorosa / Painful ophthalmoplegia

La oftalmoplejía dolorosa es una entidad poco frecuente que se caracteriza por dolor orbitario asociado a parálisis oculomotora ipsilateral, en algunos casos con afectación simpática ocular y alteraciones sensitivas a nivel de los territorios inervados por las ramas maxilar y oftálmica del trigémino. Puede ser causada por gran número de procesos, entre ellos, alteraciones vasculares, traumatismos, enfermedades tumorales o infecciones. Presentamos el caso de un varón de 83 años que acude por cuadro de cefalea en región frontal izquierda que englobaba la región orbitaria, asociada a sensación de hipoestesia y ptosis palpebral ipsilateral. Fue diagnosticado de síndrome de Tolosa-Hunt, una inflamación granulomatosa idiopática a nivel del seno cavernoso de causa desconocida. Se inició tratamiento empírico con corticoides presentando una rápida e importante recuperación

Painful ophthalmoplegia is a rare entity characterized by orbital pain associated with ipsilateral oculomotor paralysis, and sometimes with ocular sympathetic involvement and sensitive impairment in the areas supplied by the maxillary and ophthalmic branches of the trigeminal nerve. It can be caused by numerous conditions, among them, vascular alterations, traumas, tumor diseases, or infections. We present the case of an 83-year-old man with headache in the left frontal region including the orbital region, associated with hypoesthesia and ipsilateral ptosis. He was diagnosed with Tolosa-Hunt syndrome, an idiopathic granulomatous inflammation of the cavernous sinus of unknown cause. Empirical treatment with corticosteroids was initiated, resulting in a rapid and significant recovery

Damage to the inferior oblique muscle branch of the oculomotor nerve: a complication during orbital fat decompression.

PURPOSE: To present patients who suffered damage to the inferior oblique muscle branch of the oculomotor nerve during orbital fat decompression. METHODS: This study was a retrospective chart review of all patients who underwent orbital decompression surgery between April 2009 and June 2016 by the authors. RESULTS: Among 414 sides from 226 consecutive patients who underwent orbital decompression, the inferior oblique muscle branch was injured in two sides (0.5%) of two patients. Both patients showed hypotropia and incyclotropia immediately after surgery. Within 6 months of injury, ocular deviation on primary gaze had mostly resolved after conservative treatment. None of the patients underwent strabismus surgery. Postoperative computed tomographic images demonstrated that the affected branch was indistinct 3-4 mm posterior to the inferior oblique muscle. CONCLUSIONS: This report indicates that injury to the inferior oblique muscle nerve branch can occur at a point posterior to the inferior oblique muscle during orbital fat decompression; however, the resulting ocular deviation improves considerably within 6 months of injury.

Physiotherapy in Postinfection Injury to Cranial Nerves III, IV, and VI: A Case Study.

The patient with bacterial infection sequelae in the form of damage to cranial nerves III, IV, and VI was followed up. He had exhibited clinical and radiographic signs of paranasal sinusitis. Before his physiotherapy, the patient received standard treatment with natural and synthetic antibiotics and steroids. After acute signs of infection resolved without any functional improvement, the patient was referred to a rehabilitation unit to undergo neuromuscular re-education of the paralyzed extraocular muscles. Periorbital hydrocortisone iontophoresis and visuomotor exercises with intense ideomotor stimulation led to complete and rapid resolution of extraocular muscle paralysis and diplopia. Physiotherapy can be an effective treatment of choice after failed pharmacological treatment in patients with damage to cranial nerves III and VI. It has many theoretical advantages, including noninvasiveness and avoidance of first-pass metabolism of drugs administered systemically.

Objective Pupillometry as an Adjunct to Prediction and Assessment for Oculomotor Nerve Injury and Recovery: Potential for Practical Applications.

BACKGROUND: Pupillary light reflex examinations are intrinsic to any good neurological examination. Consistent evidence has shown that automated pupillometry assessments provide superior accuracy and interrater correlation compared with bedside eye examinations. Pupillary indexes such as the neurological pupil index (NPI) can also provide several hours of warning before the advent of herniation syndromes or third nerve palsy. METHODS: We determined the unique temporal relationship between NPI changes and third nerve palsy occurrence and recovery in an initially neurologically intact hospitalized patient. A 53-year-old woman presented with aneurysmal subarachnoid hemorrhage and headaches. Her aneurysm was treated surgically without complications. After lumbar drainage for hydrocephalus, she developed isolated left third nerve palsy that slowly recovered over the following weeks. Pupilometer data were obtained throughout her hospital stay. RESULTS: A total of 121 pupillary measurement sets were obtained. The NPI had decreased to an abnormal level (<3) 12 hours before she became symptomatic. The NPI also started improving 24 hours before improvement in her clinical examination. The patient did not display signs of neurological dysfunction related to vasospasm during her stay. CONCLUSION: The NPI seems to reliably correlate with third nerve function and appears to possess predictive temporal properties that could allow practitioners to anticipate neurological injury and recovery. These findings could affect the fields of neurosciences, trauma, military medicine, critical care, and ophthalmology.

Parálisis unilateral aislada del nervio oculomotor común posterior a trauma craneoencefálico leve / Isolate unilateral oculomotor palsy after mild traumatic brain injury

La parálisis aislada del nervio oculomotor común (NOC) es una presentación clínica infrecuente del traumatismo craneoencefálico (TCE) leve. Escasas son las descripciones de casos en los que se ha podido demostrar el daño aislado del NOC por avulsión de las raíces con lesión axonal traumática y microhemorragia intraneural. Presentamos el caso de una paciente de 23 años que posterior a TCE leve inició con ptosis palpebral derecha, diplopía binocular y fotofobia. Al examen clínico se apreció una oftalmoparesia completa del III par craneal derecho, sin otras alteraciones. Los exámenes de neuroimagen no demostraron daño estructural compresivo sobre el NOC afectado. Se realizó resonancia magnética (RM) con ECO de gradiente y T1 contrastado. Demostrándose signos de hemorragia intraneural del NOC derecho, además de lesión axonal traumática desde su origen en el pedúnculo cerebral derecho hasta alcanzar la fisura orbitaria. Protocolos específicos de RM contribuyen a evidenciar lesiones aisladas del NOC

Isolated traumatic oculomotor nerve (ON) palsy is an uncommon clinical presentation of mild traumatic brain injury (TBI). There are very few cases in which it has been possible to demonstrate the isolated damage of the ON by avulsion of the roots, accompanied with traumatic axonal injury and intraneural microhemorrhage. We present a 23-year-old female who, after mild TBI, began to experience right ptosis, binocular diplopia, and photophobia. Clinical examination showed a complete ophthalmoparesis of the right ON, without other neurological deficits. Neuroimaging studies demonstrated no structural compressive damage of the right ON. Magnetic resonance imaging (MRI) with Gradient-echo and T1 weighted post-gadolinium was made, demonstrating signs of intraneural hemorrhage of the right ON, in addition to traumatic axonal injury extending from the right cerebral peduncle to the orbital fissure. Specific MRI protocols contribute as evidence of an isolated lesion to the ON

Assessment of neuro-optometric rehabilitation using the Developmental Eye Movement (DEM) test in adults with acquired brain injury / Valoración de la rehabilitación neuro-optométrica mediante la prueba DEM (Developmental Eye Movement) en adultos con daño cerebral adquirido

Purpose: This pilot study sought to determine the efficacy of using the Developmental Eye Movement (DEM) test in the adult, acquired brain injury (ABI) population to quantify clinically the effects of controlled, laboratory-performed, oculomotor-based vision therapy/vision rehabilitation. Methods: Nine adult subjects with mild traumatic brain injury (mTBI) and five with stroke were assessed before and after an eight-week, computer-based, versional oculomotor (fixation, saccades, pursuit, and simulated reading) training program (9.6 h total). The protocol incorporated a cross-over, interventional design with and without the addition of auditory feedback regarding two-dimensional eye position. The clinical outcome measure was the Developmental Eye Movement (DEM) test score (ratio, errors) taken before, midway, and immediately following training. Results: For the DEM ratio parameter, improvements were found in 80-89% of the subjects. For the DEM error parameter, improvements were found in 100% of the subjects. Incorporation of the auditory feedback component revealed a trend toward enhanced performance. The findings were similar for both DEM parameters, as well as for incorporation of the auditory feedback, in both diagnostic groups. Discussion: The results of the present study demonstrated considerable improvements in the DEM test scores following the oculomotor-based training, thus reflecting more time-optimal and accurate saccadic tracking after the training. The DEM test should be considered as another clinical test of global saccadic tracking performance in the ABI population

Objetivo: Este estudio piloto trató de determinar la eficacia del uso de la prueba DEM (Developmental Eye Movement) en la población adulta con daño cerebral adquirido (DCA) para cuantificar clínicamente los efectos de la rehabilitación/terapia visual controlada, realizada en laboratorio, y de carácter oculomotor. Métodos: Se valoraron nueve sujetos adultos con daño cerebral traumático leve (mTBI) y cinco con ictus, con anterioridad y posterioridad a un programa de entrenamiento de ocho semanas, informático oculomotor y versional (movimientos de fijación, sacádicos, de persecución y lectura simulada, de 9,6 horas en total). El protocolo incorporó un diseño cruzado e intervencional, con y sin adición de retroalimentación auditiva en relación a la posición bi-dimensional de los ojos. La medida del resultado clínico se llevó a cabo mediante la puntuación de la prueba DEM (Developmental Eye Movement) (ratio, errores) realizada con anterioridad, en el punto medio, e inmediatamente tras el entrenamiento. Resultados: Para el parámetro de ratio DEM, se encontraron mejoras en el 80-89% de los sujetos. Para el parámetro de error DEM, se encontraron mejoras en el 100% de los sujetos. La incorporación del componente de retroalimentación auditiva reveló una tendencia hacia la mejora del rendimiento. Los hallazgos fueron similares para ambos parámetros DEM, así como para la incorporación de la retroalimentación auditiva, en ambos grupos diagnósticos. Discusión: Los resultados del presente estudio demostraron mejoras considerables de las puntuaciones de la prueba DEM tras la terapia oculomotora, lo que refleja una mayor optimización y precisión del seguimiento sacádico en el tiempo tras la terapia. Deberá considerarse la prueba DEM como una prueba clínica para valorar el rendimiento del seguimiento sacádico global en la población de DCA

Parálisis nuclear del III par craneal en el contexto de un traumatismo craneoencefálico / Nuclear paralysis of the oculomotor nerve within the context of traumatic brain injury

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Premanifest Huntington's disease: Examination of oculomotor abnormalities in clinical practice.

INTRODUCTION: Different oculomotor abnormalities have been reported to occur in premanifest Huntington's disease. The aim of this study is to investigate which oculomotor items of the Unified Huntington's Disease Rating Scale (UHDRS) are affected in premanifest individuals compared to healthy controls, and if CAG repeat length and age are correlated with oculomotor abnormalities in premanifest Huntington's disease gene carriers. METHODS: We compared baseline data of 70 premanifest individuals and 27 controls who participated in the Enroll-HD study at the Leiden University Medical Center, the Netherlands. Premanifest gene carriers were divided in individuals near to disease onset and individuals far from disease onset. RESULTS: Using a logistic regression model, only horizontal ocular pursuit of the six oculomotor items of the UHDRS was significantly more frequently affected in premanifest individuals close to disease onset compared to controls (p = 0.044, OR 13.100). Age was significantly higher in premanifest individuals with affected horizontal ocular pursuit (p = 0.016, OR 1.115) and with affected vertical ocular pursuit (p = 0.030, OR 1.065) compared to premanifest individuals without ocular pursuit deficits. CONCLUSIONS: Our results suggest that horizontal ocular pursuit is the only affected oculomotor item of the UHDRS in premanifest individuals and could be used to assess early clinical signs of Huntington's disease. Saccade initiation and saccade velocity do not seem useful for detecting differences between premanifest individuals and controls.

Orbital fat volume in the inferolateral quadrant in Japanese: a guide for orbital fat decompression without injury to the oculomotor nerve.

PURPOSE: The inferior oblique muscle branch of the oculomotor nerve is susceptible to injury during orbital fat removal from the inferolateral quadrant of the orbit. Understanding the amount of removable orbital fat volume in this quadrant may be helpful in achieving maximum fat decompression without causing nerve injury. The aim of this study was to calculate the orbital fat volume in the inferolateral quadrant using computed tomographic (CT) images. METHODS: In this retrospective, observational study, contiguous 1-mm coronal CT images were obtained from 53 sides (30 patients). The cross-sectional areas of the orbital fat in the inferolateral quadrant were measured from the level just behind the inferior oblique muscle to the orbital apex. The cross-sectional areas reached the inferior oblique muscle branch medially, the lateral orbital wall laterally, the inferior edge of the lateral rectus muscle superiorly, and the orbital floor inferiorly. An integrated value between the cross-sectional areas and the CT slice thickness was calculated. RESULTS: The mean orbital fat volume in the inferolateral quadrant was 3.9 ± 1.4 mL (range: 1.3-7.0 mL). Multiple regression analysis demonstrated a significant relationship between orbital fat volume and Hertel exophthalmometry measurement (adjusted r 2 = 0.101; P = 0.012), although the thickness of the lateral and inferior recti muscles was deleted from the regression equation by stepwise process. CONCLUSIONS: The orbital fat volume in the inferolateral quadrant can serve as a guide for orbital fat removal without causing injury to the inferior oblique muscle nerve branch.

Oculomotor Cognitive Control Abnormalities in Australian Rules Football Players with a History of Concussion.

This study used oculomotor, cognitive, and multi-modal magnetic resonance imaging (MRI) measures to assess for neurological abnormalities in current asymptomatic amateur Australian rules footballers (i.e., Australia's most participated collision sport) with a history of sports-related concussion (SRC). Participants were 15 male amateur Australian rules football players with a history of SRC greater than 6 months previously, and 15 sex-, age-, and education-matched athlete control subjects that had no history of neurotrauma or participation in collision sports. Participants completed a clinical interview, neuropsychological measures, and oculomotor measures of cognitive control. MRI investigation involved structural imaging, as well as diffusion tensor imaging and resting-state functional MRI sequences. Despite no group differences on conventional neuropsychological tests and multi-modal MRI measures, Australian rules football players with a history of SRC performed significantly worse on an oculomotor switch task: a measure of cognitive control that interleaves the response of looking towards a target (i.e., a prosaccade) with the response of looking away from a target (i.e., an antisaccade). Specifically, Australian footballers performed significantly shorter latency prosaccades and found changing from an antisaccade trial to a prosaccade trial (switch cost) significantly more difficult than control subjects. Poorer switch cost was related to poorer performance on a number of neuropsychological measures of inhibitory control. Further, when comparing performance on the cognitively more demanding switch task with performance on simpler, antisaccade/prosaccades tasks which require a single response, Australian footballers demonstrated a susceptibility to increased cognitive load, compared to the control group who were unaffected. These initial results suggest that current asymptomatic amateur Australian rules football players with a history of SRC may have persisting, subtle, cognitive changes, which are demonstrable on oculomotor cognitive measures. Future studies are required in order to further elucidate the full nature and clinical relevance of these findings.

Trauma ocular

Objetivo: Generar recomendaciones basadas en la mejor evidencia disponible acerca del manejo de personas con trauma ocular

Orbital apex syndrome after trauma in a 6-year-old - a rare occurrence.

Orbital apex syndrome is rare, but can occur as a consequence of trauma from fracture of the medial orbit. This case report highlights the fact that a high index of suspicion is needed when a patient presents with a facial injury, especially in children who cannot give an account of the actual events that transpired. Radiological investigation should be done early when an underlying injury is suspected in a trauma patient. A low threshold for computed tomography should be maintained when proptosis and vision loss are present.

Incarceration of the inferior oblique muscle branch of the oculomotor nerve in patients with orbital floor trapdoor fracture.

PURPOSE: To examine the clinical characteristics of patients with concomitant incarceration of the inferior oblique muscle branch of the oculomotor nerve who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. METHODS: Fifty-nine patients were retrospectively reviewed. Concomitant inferior oblique muscle branch incarceration was diagnosed by inferior oblique muscle underaction on the Hess chart and a missing inferior oblique muscle branch on computed tomographic images on baseline examination. RESULTS: Eleven patients (18.6%) were diagnosed with concomitant branch incarceration. The patients with branch incarceration were all under 19 years of age, and were younger than those without branch incarceration (P = 0.026). There were no significant differences between the groups in terms of cause of injury, presence of concomitant medial wall fracture, hypoesthesia of the cheek region, or ocular and periocular complications (P > 0.050). All patients with branch incarceration underwent surgical reduction, whereas 16 of 48 patients without branch incarceration were observed without surgery (P = 0.021). Although preoperative binocular single vision field was smaller in patients with branch incarceration (P = 0.026), it improved after surgery, comparable to that of patients without branch incarceration (P = 0.079). CONCLUSIONS: Concomitant incarceration of inferior oblique muscle branch of the oculomotor nerve occurred in 18.6% of patients who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. Patients with branch incarceration were all under 19 years of age. Branch incarceration resulted in a smaller binocular single vision field, which considerably improved after surgical reduction.

Posttraumatic Uncal Herniation in a Conscious Patient.

The incidence of primary traumatic oculomotor nerve palsies in craniocerebral trauma is approximately 1.2% and is usually persistent and associated with loss of consciousness, other neurologic deficits, and skull base or orbital fractures. This case is a rare demonstration of complete left third nerve palsy from uncal herniation after trauma without any loss of consciousness.

Diffusion Tensor Imaging Tractography Detecting Isolated Oculomotor Nerve Damage After Traumatic Brain Injury.

A 24-year-old woman was hit by a bus and suffered an isolated complete oculomotor nerve palsy. Computed tomography scan did not show a skull base fracture. T2*-weighted magnetic resonance imaging revealed petechial cerebral hemorrhages sparing the brainstem. T2 constructive interference in steady state suggested a partial sectioning of the left oculomotor nerve just before entering the superior orbital fissure. Diffusion tensor imaging fiber tractography confirmed a sharp arrest of the left oculomotor nerve. This recent imaging technique could be of interest to assess white fiber damage and help make a diagnosis or prognosis.

Quantification and analysis of saccadic and smooth pursuit eye movements and fixations to detect oculomotor deficits.

Assessment of deficits in oculomotor function may be useful to detect visuomotor impairments due to a closed head injury. Systematic analysis schemes are needed to reliably quantify oculomotor deficits associated with oculomotor impairment via brain trauma. We propose a systematic, automated analysis scheme using various eye-tracking tasks to assess oculomotor function in a cohort of adolescents with acute concussion symptoms and aged-matched healthy controls. From these data we have evidence that these methods reliably detect oculomotor deficits in the concussed group, including reduced spatial accuracy and diminished tracking performance during visually guided prosaccade and self-paced saccade tasks. The accuracy and tracking deficits are consistent with prior studies on oculomotor function, while introducing novel discriminatory measures relative to fixation assessments - methodologically, a less complicated measure of performance - and thus represent a reliable and simple scheme of detection and analysis of oculomotor deficits associated with brain injury.

Parálisis de la mirada horizontal y escoliosis progresiva en un paciente con endotropia congénita y limitación de abducción. A propósito de un caso / Horizontal gaze palsy and progressive scoliosis in a patient with congenital esotropia and inability to abduct. A case report

CASO CLÍNICO: Presentamos el caso de un paciente varón de 4 años de edad, remitido por endotropia congénita con limitación de abducción, tortícolis horizontal con fijación cruzada y escoliosis toraco-lumbar. El análisis genético del gen ROBO3 confirmó el diagnóstico de parálisis de la mirada horizontal y escoliosis progresiva (HGPPS). DISCUSIÓN. La HGPPS es una alteración infrecuente de la motilidad ocular, caracterizada por ausencia de movimientos conjugados horizontales y escoliosis progresiva de inicio precoz. Esta entidad debe ser considerada como parte del diagnóstico diferencial de la endotropia congénita con fijación cruzada e incapacidad de abducción

CASE REPORT: The case is presented on a 4-year-old child with congenital esotropia, limitation of abduction, cross-fixation, and thoracolumbar scoliosis. Genetic testing of ROBO3 gene confirmed the diagnosis of horizontal gaze palsy and scoliosis (HGPSS). DISCUSSION: HGPPS is a rare congenital disorder characterised by absence of conjugate horizontal eye movements and progressive scoliosis developed in childhood and adolescence. We highlight this motility disorder as a part of the differential diagnosis of early childhood esotropia with cross- fixation and limitation of abduction