Sixth Nerve Palsy Research Articles

Isolated ocular motor nerve palsy associated with raised homocysteine

Ocular motor mono-neuropathies frequently occur from micro-vascular ischemia to the nerve in the presence of atherosclerotic risk factors such as old age, diabetes mellitus, hypertension, and dyslipidemia. Other possible causes include trauma, intra-cranial neoplasm, aneurysm, inflammation, infection, and brainstem infarction. Recently, hyper-homocysteinemia has emerged as an independent risk factor for systemic and ocular vaso-occlusive disorders. Ocular pathologies such as retinal vascular occlusion and non-arteritic anterior ischemic optic neuropathy have been found to be associated with mild hyper-homocysteinemia. This case series describes four patients with isolated third and sixth cranial nerve palsy where hyper-homosysteinemia was the only risk factor.

Fleeting diplopia and wobbly feet: Miller-Fisher syndrome-presenting as bilateral abducent nerve palsy

A case report of a healthy young male, presented with binocular diplopia of sudden onset with mild bilateral abduction limitation, progressed rapidly to near total ophthalmoplegia. Rest of the ophthalmic examination, blood pressure, and magnetic resonance imaging of brain were normal. Basic blood work-up was normal except mildly raised serum triglycerides. He gave a history of mild giddiness and ataxia. Neurological evaluation done showed absent deep tendon reflexes and serum anti-GQ1b antibody was raised. A diagnosis of Miller-Fisher syndrome was made and he was given intravenous immunoglobulin. Post-treatment his ocular motility recovered well, with minimal residual diplopia noted for distance. In individuals with abducent nerve palsy, normal imaging, and no systemic risk factors, a careful history asking for subtle neurological symptoms and a complete central nervous system examination is warranted to rule out conditions like Miller-Fisher syndrome which may not be a familiar entity to many ophthalmologists.

Using Principles of Neuroplasticity and Visual-Vestibular Function in the Treatment of 6th Cranial Nerve Palsy or Paresis

Sixth cranial nerve (abducens) palsy is a common manifestation of acquired brain injury. Abducens nerve damage results in esotropia and horizontal diplopia. The current standard of care appears to be no treatment initially other than monocular occlusion or limited use of Fresnel prism, followed by Botox or strabismus surgery at 6-12 months post injury.

Case Report of Combined Sixth and Twelfth Cranial Nerve Palsy: A Rare Case of Clival Syndrome Arising from Thymoma

Case Report of Combined Sixth and Twelfth Cranial Nerve Palsy: A Rare Case of Clival Syndrome Arising from Thymoma

Huge Arachnoid Cyst Presented with Bilateral Sixth Cranial Nerve Palsy

Huge Arachnoid Cyst Presented with Bilateral Sixth Cranial Nerve Palsy

Expressionless Physiognomy–A Case of Moebius Syndrome

Moebius syndrome (MBS) is a rare neurological disorder which characterized by bilateral or unilateral facial nerve weakness with bilateral abducens nerve palsy. It can affect multiple cranial nerves with an incidence of 2–20 cases per million births. We report a 6 years female child with MBS with morpho-functional deficits and developmental problems.

Metastatic Prostate Carcinoma Masquerading as Primary Sphenoid Sinus Tumour: A Case Report

Metastasis from prostate adenocarcinoma to Paranasal Sinuses (PNS) is extremely rare. Usually, they metastasise to the pelvic lymph nodes and bones of the axial skeleton. Authors hereby, present a case of a 71-year-old male patient with diplopia on left lateral gaze and frontal headache since two months. On examination, he had left lateral rectus palsy. Computed Tomography (CT) Brain was normal. CT PNS and Magnetic Resonance Imaging (MRI) brain revealed an ill-defined isodense lesion causing clival erosion and extending anteriorly to the sphenoid sinus. The patient underwent endoscopic endonasal trans-sphenoidal excision. The histopathological diagnosis was adenocarcinoma. Immunohistochemistry (IHC) was done for further evaluation which showed both CK7 and CK20 to be negative. Hence, sinonasal carcinoma was excluded and possibility of metastatic tumour was considered. Ultrasonography (USG) abdomen was normal and further IHC showed Prostate-Specific Antigen (PSA) positivity. Elevated serum PSA and Positron Emission Tomography (PET) scan confirmed primary carcinoma prostate with multiple skeletal metastases. The patient was treated with a Gonadotropin-Releasing Hormone (GnRH) antagonist and an antiandrogen which showed good response. So, the possibility of metastasis from an occult primary prostate carcinoma was considered as the differential diagnosis in an elderly patient presenting with sinonasal mass. Hence, proper screening and IHC studies are mandatory for accurate diagnosis and treatment.

No-split, no-tenotomy transposition of only the superior rectus muscle combined with medial rectus recession in patients with complete abducens nerve palsy

To evaluate the outcomes of no-split, no-tenotomy transposition of only the superior rectus muscle combined with medial rectus recession in patients with complete abducens nerve palsy. In this procedure, the temporal margin of the superior rectus muscle, 10 mm posterior to the insertion, was secured with a nonabsorbable suture and sutured to the sclera at a distance of 12 mm from the limbus in the superotemporal quadrant, halfway between the superior rectus and lateral rectus. Success was defined as distance and near alignment of ≤8Δ and no diplopia in primary position 6 months after surgery. A total of 8 patients with abducens nerve palsy underwent the procedure. At the last follow-up, the mean postoperative change in primary position deviation was 42.6Δ ± 8.1Δ (range,34Δ-57Δ) for distance and 42.1Δ ± 7.5Δ (35Δ -57Δ) for near, a significant reduction (P = 0.012). Abduction deficit also improved significantly (P = 0.010). Postoperatively, no vertical deviation or torsional diplopia was induced. At the 6 months' follow-up, compared with the first postoperative visit, an esodrift at near developed in 1 patient. Of the 8 cases, 6fulfilled the criteria for success. In our small study cohort, no-split, no-tenotomy superior rectus transposition and medial rectus recession improved esotropia and abduction limitation without inducing significant vertical deviations or torsional diplopia.

Carotid-Cavernous Fistula: Hemodynamic Dysfunction after Shingles? A Case Report and Review Literature

The patient, a 67-year-old female, presented with esotropia, diplopia, and eye redness, as seen in Figure 1. The diplopia started two months prior to the initial visit while the eye started to crossed in. The patient also complained of severe daily headaches along with ringing in her ears. She believes the symptoms started while she was recovering from shingles on her right side of the forehead. Prior MRI imaging was reported to be unremarkable. The patient was referred to neuro-ophthalmology service with possible diagnosis of thyroid eye disease given the red eye and esotropia. Patient had no history of other medical conditions except shingles in trigeminal distribution that occurred about 4-6 weeks before the onset of her symptoms. Central VA was recorded to be unaffected at 20/20 in both eyes with correction. On sensorimotor exam, there was severe horizontal diplopia at the primary, increasing in left, and right gazes due to bilateral VI nerve palsy. Intraocular pressure testing 22mmHg right eye and 19mmHg left eye, indicating ocular hypertension in the right eye. She had corkscrew blood vessels in both eyes. Optical coherence tomography (OCT) revealed normal retinal nerve fiber layer (RNFL) thickness in both eyes.

COVID‐19 vaccination and vision loss in three older male individuals homoplasmic for m.14484 T > C mutation in the ND6 gene

AbstractPurpose: To report three older male individuals, all homoplasmic for m.14484 T > C mutation in the ND6 gene, presenting onset of vision loss weeks‐months after covid vaccination. None reported a history of covid‐19 infection.Methods: All clinical data was extracted and reported here as a Case Series.Results: A 68 years old man (A) had a 3rd dose of BioNTech/Pfizer COVID‐19 vaccination on 1st Nov 2021. 10 days later his vision was 6/6 OD and 6/60 OS. By Dec 2021 VA was 6/36 OD and 6/60 OS. His nephew lost vision age of 18 years with LHON. In March 2022, visual acuities were HM OD and HM OS. In May 2022 visual acuity was HM OD, PL OS. He started on idebenone 300 mg tds.A 55 years old man (B) had a 1st dose Astra Zeneca COVID‐19 vaccination in mid Feb 2021. 12 days later, March 2021 he developed a Bell's Palsy and sensory neuropathy at the top of his legs, feet and upper arms, with difficulty walking. MRI showed enhanced optic nerves and enhanced lesions at C2. In April 2021, he lost vision in his right eye, followed by left eye in June 2021. By September 2021 vision was CF BEs. He started on idebenone 300 mg po tds. In May 2022 he was LogMAR @ 2 m 1.34 OD and MH OS.A 72 years old man (C) had his 2nd dose of BioNTech/Pfizer COVID‐19 vaccination in April 2021. In Sept 2021 he reported loss of vision in both eyes but could not date onset. He was the maternal cousin of individual B. In May 2022 vision was 3/60 OD CF OS. He started on idebenone 300 mg po tds.Conclusions: Adverse ocular events related to COVID‐19 vaccines are remarkable rare. There are >20 published case reports (~89 patients) of adverse ocular events within 28 days of COVID‐19 vaccination, with all three vaccines (Pfizer, AstraZeneca and Moderna). Reports incl. conjunctivitis, facial and abducens nerve palsy, CSR, uveitis, MEWDS, VKH, Graves' Disease, endothelial graft rejection, AAION and AZOOR. The role of vaccination in subsequent vision loss in those with underlying mitochondrial mutation is not clear.

Conjunctival tumour as an acute myeloblastic lymphoma presentation in a paediatric patient

AbstractPurpose: The most frequent ocular tumours are those that affect the conjunctiva which have a wide spectrum of presentation and can arise from any cell lineage that forms the conjunctiva, being the most representatives those that origins from epithelial and melanocytic cells. A case of a 10‐month‐old female patient who was diagnosed with acute myeloblastic leukaemia after studying a conjunctival tumour is presented.Methods: The case of a 10‐month‐old female with a conjunctival lesion located in the right eye who was also being studied for two masses, one on the right preauricular zone and the other on the left zygomatic area is described. About her medical history, she had an aplastic crisis due to parvovirus infection when she was 8 months old. No ophthalmological background was reported. On the clinical exam of the right eye, a pink conjunctival lesion located in the outer corner of the superior conjunctival fornix was found. The ocular motility was normal and the eyeball position was normal.Results: A biopsy of the conjunctival mass was performed immediately. The histopathology report showed infiltration with leukaemic cells. After this finding, a bone marrow biopsy, lumbar puncture, full‐body CT scan and an orbit MRI were performed, concluding the patient was suffering from an acute myeloblastic leukaemia with extramedullary involvement (face, orbit, ovaries) and central nervous system affection. After two cycles of chemotherapy, complete remission is achieved, including the conjunctival and orbital lesions.Conclusions: Haematology‐Oncology systemic diseases can imply the eye and the orbit. The manifestations most commonly found in children with leukaemia are proptosis, retinal and choroidal affection, optic nerve damage, and sixth nerve palsy. In the conjunctiva, it usually manifests as a subconjunctival salmon‐pink flesh coloured mass. Excision‐biopsy study is essential in the differential diagnosis of conjunctival neoplasms.

Complication of acute Otitis media in pediatrics: a case report

The acute otitis media (AOM) is a frequent bacterial infection in Pediatrics. Despite the advance of antibiotic therapy in the treatment of this infection, there is the possibility of a rare complication, Gradenigo Syndrome (GS). This is a serious complication that should be suspected in a patient with abducens nerve paralysis, pain in the trigeminal innervation area and AOM. The objective of this work was to describe a case report in pediatric regarding to Gradenigo’s Syndrome and reinforce the importance of early diagnosis in the treatment. In addition, a literature review of articles in journals indexed in the following databases was carried out: Pubmed, Lilacs and Scielo. The case report presented is a 7-year-old girl, presenting a typical clinical of GS that evolved satisfactorily with the management based on broad-spectrum antibiotic therapy, without the need for a subsequent surgical approach. Thus, it is clear that the identification of the classic triad of GS, in addition to performing imaging tests, allows for an early diagnosis of the disease, favoring a conservative approach with antibiotic therapy.

Development and 5-year Evaluation of Diagnosis-Specific Protocols for Visual Neuro-Rehabilitation in a Multicenter Inpatient Rehabilitation Network

ObjectiveTo provide a retrospective evaluation of a new eye and vision rehabilitation care pathway in a U.S. multi-site inpatient rehabilitation network involving the occupational therapy (OT) staff and a consulting doctor of optometry (OD) specializing in vision rehabilitation. DesignRetrospective study. SettingTwo Inpatient Rehabilitation Facilities (IRFs) and 1 Long Term Acute Care Hospital (LTACH). ParticipantsThere were 2083 records reviewed (44% women, avg. age 59 years). The most common diagnoses were hemispatial neglect (19.2%), homonymous field defects (18.5%), and oculomotor cranial nerve palsies (16.7%) (N=2083). InterventionsClinical care was reviewed where diagnosis-specific protocols were developed and training was provided to OTs in order to reinforce OD-prescribed interventions during daily treatment sessions, including (1) third, fourth, and sixth ocular cranial nerve palsies (OCNPs) with prisms fitted for full time, postural adaptation training, and oculomotor re-education using pursuits, saccades, head-rotations, and binocular vision exercises including alternate cover and vergence; (2) homonymous hemianopia with training awareness of field loss, eccentric viewing, and fitting of Peli lens for optical field expansion; and (3) prism adaptation therapy (PAT) for left hemispatial neglect. Main Outcome MeasuresFrequency of diagnoses. HypothesisDiagnoses with developed protocols were most common. Secondarily, feasibility and efficacy by anonymous OT survey. Results2083 vision consults were performed over 5 years. The most common diagnoses were hemispatial neglect (n=399, 19.2%), homonymous field defects (n=386, 18.5%), and OCNPs (n=347, 16.7%). None of the OTs reported the protocols were infeasible and 63% (IQR 38%-69%) reported their patients benefited from the interventions. The survey suggested prism for OCNPs helped in 42%, and Peli lens and PAT both helped in 38%. ConclusionsData support the feasibility of this inpatient eye and vision rehabilitation care pathway which may be used as a foundation for creating or refining similar programs elsewhere. Uniform administration of IRF-based visual neuro-rehabilitation care could provide a substrate for future clinical trials to evaluate efficacy.

Otitic Hydrocephalus or Obstructive Hydrocephalus?


 
 
 
 Dear Editor:
 
 
 
 
 I came across the article entitled “Fatal Otitic Hydrocephalus Due to Sinus Thrombosis : A Case Report”, and I would like to thank the authors for sharing their experience with this case.
 In their discussion, the authors state that otitic hydrocephalus “is characterized by increased intracranial pressure with clear CSF, transient sixth nerve palsy, headache, vomiting, papilledema with no other detectable CNS signs and no actual dilation of ventricles.” They go on to state that “otitic hydrocephalus is a misnomer according to some because it may occur in the absence of otitis and because patients do not show the ventricular dilatation seen in true hydrocephalus.” Lastly, they state that “the diagnosis of OH is made by exclusion and a brain abscess should be ruled out by CT scan.”
 However, in the description of their case, the authors state the following:1)“Lumbar tap showed elevated cerebrospinal fluid (CSF) opening pressure of 270 mm H2O, decreased glucose and increased protein content”
 2) “Repeat CT scan on the second post-op day showed marked dilatation of the third and lateral ventricles due to compression of
 the fourth ventricle...”3) “He underwent ventriculostomy and evacuation of abscess on the fourth post-operative day.”
 These statements contradict the main diagnostic features of otitic hydrocephalus, and thus call into question the diagnosis of otitic hydrocephalus in this particular case. In fact, the clinical data points to the presence of an obstructive hydrocephalus. There is no doubt that the patient has evidence of lateral sinus thrombophlebitis. However, not all cases of lateral sinus thrombophlebitis are associated with otitic hydrocephalus.
 
 
 

NCOG-30. MULTISESSION RADIOSURGERY FOR UNFAVORABLE NONFUNCTIONING PITUITARY MACROADENOMA: 5-YEAR OUTCOMES FROM A SINGLE INSTITUTION PROTOCOL

Abstract Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established for single-session radiosurgery, but mature outcomes are lacking for multisession radiosurgery. We report our institution’s 5-year efficacy and safety results for unfavorable nonfunctioning pituitary macroadenoma patients treated with 5-fraction robotic radiosurgery. Between 2010-2020, patients who completed 5-fraction radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem or pituitary gland). Local control was calculated using the Kaplan-Meier Method. RESULTS Twenty predominately female patients (60%), age from 21-77 (median: 53 years) were included in this study. All underwent primary resection. Indications for radiosurgery included unresectable recurrence (85%) and residual disease progression (70%). Median tumor volume was 3.4 cm3 (range: 0.3-20.8 cm3) and 40% of the tumors were suprasellar. A mean dose of 30 Gy (range: 25Gy-30Gy), was delivered to a median isodose line of 80% (range: 75%-89%). Toxicity was minimal with 12 patients (40%) developing acute short-lived headaches and 1 patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no radiation induced optic or pituitary dysfunction identified in this cohort. At a median follow up of 5 years local control at 5 years was 95%. There was 1 in-field failure pathologically confirmed following surgery for pituitary tumor hemorrhage and 2 radiographically confirmed out-of-field failures in patients with large tumors (> 20 cc) treated with lower doses (25 Gy). CONCLUSIONS The treatment of unfavorable nonfunctioning pituitary macroadenoma with 5-fraction robotic radiosurgery provides excellent local control to date, with minimal toxicity. Continued follow-up for the long term optic and pituitary function preservation and tumor control is needed.

NCMP-10. NEURO-OPHTHALMOLOGICAL FINDINGS IN CHILDREN AND ADOLESCENTS WITH MEDULLOBLASTOMA - A RETROSPECTIVE ANALYSIS

Abstract BACKGROUND Medulloblastoma represents the most common malignant pediatric brain tumor. Ophthalmic complications are possible sequelae. METHODS Pediatric medulloblastoma (MB) patients treated at the Medical University of Vienna from January 2012 to August 2021 were analyzed and their last ophthalmic assessment was reviewed. RESULTS Fifty-six MB patients could be included (71.4% non-WNT/non-SHH, 16.1% SHH-activated, 8.9% WNT-activated, 3.6% non-specified). Mean age at diagnosis was 7.2 years (range 0-19). Median follow-up to last ophthalmological assessment was 19.7 months (range 0.1-93.2). Thirty-four children underwent tumor resection at our hospital, their tumor localizations were: vermis (55.9%), floor of the 4th ventricle (26.5%), cerebellar hemispheres (11.8%), lateral recess (5.9%). Symptoms at presentation were evaluable for 51 children: 92.2% had symptoms of elevated intracranial pressure, 76.5% ataxia and 21.6% visual disturbances. Postoperative posterior fossa syndrome was observed in 11.1% of 54 children. 98.2% had chemotherapy as part of their initial treatment and all children older than four years (85.7%) received postoperative irradiation of the posterior fossa. In 13 (23.2%) intraventricular chemotherapy was applied. At the last follow-up 21 patients experienced relapse after primary treatment. At the final assessment, frequent neuro-ophthalmological abnormalities included: oculomotor disturbance (75%), esotropia (35.7%) including abducens palsy (12.5%), other cranial nerve palsies (21.4%), horizontal gaze-evoked nystagmus (51.8%), spontaneous nystagmus (16.1%), ocular tilt reaction (21.4%), and optic disc abnormalities (14.3%). Good visual acuity (≥20/25) was maintained in 62.5% patients. Visual field and optical coherence tomography was successfully performed in 75% and 66.1% of patients, respectively. Optic pathway lesions were detected in 4 patients (7.1%), including two cases with occipital metastases, one with optic nerve metastasis and one with leptomeningeal carcinomatosis. Orthoptic treatment with prisms and strabismus surgery was required in 14.3% and 7.7% of children, respectively. CONCLUSION Children with MB frequently suffer from neuro-ophthalmological late-effects. Regular monitoring is warranted to initiate appropriate management.

Sarcoidosis in Close Family Members and Susceptibility to High Grade B-Cell Lymphoma: A Case Report Study

The presented case is an 81- year-old woman who had experienced episodes of facial twitching without loss of consciousness and flu like symptoms for a few weeks prior to her admission. examinations were unremarkable except for left 3rd nerve and right 6th nerve palsy, right peripheral facial palsy and right -side hemiparesis. FH was positive for sarcoidosis. neuroimaging were in favor of PCNSL.
 Sarcoidosis and malignancy maybe etiologically related in at least 25% of cases. Coexis- tence of sarcoidosis and lymphoma have been reported previously. Our patient had two daughters with sarcoidosis and her chest CT scan showed multiple lymph nodes inmedias- tinum. Unfortunately, due to the location and the technical restriction, biopsy of mediasti- nal lymph nodes was not performedfor our patient and we could not differentiate whether it was reactive, paraneoplastic or granulomatous. We present this case as concurrence of lymphoma and sarcoidosis in a family, which could guide a new concern for the patient with granulomatous infiltrative disease for early diagnosis and familial screening.

Abstract 13090: Not Your Simple Swimmer’s Ear: Ramsay Hunt Syndrome Complicated by Gradenigo Syndrome, Varicella Zoster Meningoencephalitis, and Superimposed Bacterial Necrotizing Otitis Externa in a Heart Transplant Patient on Chronic Immunosuppression

Introduction: Orthotopic heart transplantation (OHT) increases the risks of varicella-zoster reactivation, and severe complications may arise due to infection in the setting of active immunosuppression. Complications include meningitis, facial nerve palsy (known as Ramsay Hunt Syndrome), and bacterial superinfection. When severe bacterial ear infections spread to the petrous apex, facial pain accompanied by otitis media and abducens nerve palsy may also occur, classically known as Gradenigo Syndrome. Case Report: We present a case of a patient 15 months post OHT who came in with left-sided facial droop and pain, abducens palsy, crusting facial rash, and ear swelling. Imaging revealed necrotizing otitis externa, with associated otitis media, petrous apicitis, and signs suggestive of encephalitis. A viral panel resulted positive for zoster infection, with superimposed methicillin-resistant staphylococcus aureus infection. Despite treatment with antibiotics and antivirals, the patient's mentation declined, with subsequent lumbar puncture revealing zoster meningoencephalitis. The patient’s mycophenolate mofetil (MMF) immunosuppression was suspended, and he was continued solely on therapeutic tacrolimus. His antiviral was switched to intravenous acyclovir and he was continued on six weeks of antibiotic therapy. The patient demonstrated resolution of his acute infection, however he continues to have residual facial and abducens nerve palsies. On discharge, the patient was resumed on MMF without any cardiac complications. Conclusions: This is the first documented case of Ramsay Hunt Syndrome, complicated by Gradenigo Syndrome and varicella-zoster virus meningoencephalitis in an OHT recipient. Our patient's immunosuppression level was the most important factor leading to the concurrence of these novel complications. Physicians should consider and assess for symptoms of these potential sequelae in all transplant patients, and carefully manage immunosuppressive agents to allow for resolution of the infection, while avoiding rejection. While residual neurologic deficits may be challenging to manage, this case demonstrated successful treatment of these complications while avoiding significant cardiac sequelae.

Right Sided Sphenoid Fungal Sinusitis Presenting with Contralateral Abducens Paralysis: A Rare Case Report

Abstract Isolated sphenoid sinus disease can be difficult to diagnose and treat due to the non-specificity of their symptoms and to the likelihood that these pathologies can present late with complications. For these reasons, significant delays in the diagnosis and treatment of the patient may happen. In addition, due to the proximity of the sphenoid sinus to vital structures such as the optic nerve, internal carotid artery, cavernous sinus and cranial nerves, any delay in treatment has the potential to lead to catastrophic outcomes, which is why swift diagnosis and early treatment are of the essence. In the differential diagnosis of isolated sixth cranial nerve palsy, sphenoid sinus pathologies must be kept in mind and the patients worked up with CT and/or MRI. Swift diagnosis and treatment before intracranial progression occurs could prevent severe complications. In our case report, we present a patient with isolated right sphenoid sinus aspergilloma (fungus ball) presenting with hemicranial headache and contralateral 6th cranial nerve involvement. In the literature, ipsilateral 6th cranial nerve involvement secondary to sphenoid sinusitis has been commonly reported, however so far only two cases of contralateral cranial nerve involvement have been reported, therefore our case represents a very rare presentation of a rare pathology. The patient has been operated with an endoscopic transnasal approach and in her postoperative follow up, lateral gaze function of the left eye has been observed to be significantly improved. Our case underlines the importance of considering sphenoid sinus aspergillomas in the differential diagnosis of patients presenting with unexplained cranial nerve pathologies, especially in the presence of headache, and the importance of early radiological studies and early operative treatment in these patients.

Evaluation of diplopia as a vital and remarkable ocular finding among cancer patients.

Diplopia is an important and debilitating symptom of malignancies due to different pathogenetic mechanisms. Data is lacking in the literature because of the rarity of the diplopia in patients with cancer. We aimed to evaluate the etiological and clinical factors of diplopia in patients with different types of cancer. We retrospectively investigated 22 cancer patients with diplopia who were admitted between 2018 and 2021. The diagnosis of primary cancer, the underlying factors causing diplopia, and the life expectancy after diplopia were evaluated. Among available data of 620 cancer patients applied to our ophthalmology department, 22 (3.55%) had diplopia. Paralytic strabismus was found in 19 patients and restrictive strabismus was found in 3 patients. Among the paralytic cases, 6th nerve palsy was found to be the most common with a rate of 68%. In 18 of 22 (82%) patients, the cause of diplopia was due to orbital or brain metastasis or local invasion. Two patients had diplopia secondary to radiotherapy and 2 had diplopia due to chemotherapy. Metastasis is the most common cause of diplopia in patients with cancer and screening for metastasis is crucial as soon as diplopia begins for a better life expectancy.