Sixth Nerve Palsy Research Articles

Abducens nerve palsy in a young girl with otorrhea: A case of Gradenigo's syndrome

Abducens nerve palsy in a young girl with otorrhea: A case of Gradenigo's syndrome

Lateral rectus palsy as the first presentation of Kikuchi Fujimoto’s disease

Kikuchi Fujimoto’s Disease (KFD) or histiocytic necrotising lymphadenitis is recognised as a disease with a benign and indolent course. The common clinical symptoms of KFD include fever, headache, arthralgia and cervical lymphadenopathy. The diagnosis is based on clinical grounds and histological findings of lymph node biopsy. Kikuchi disease presenting with neurological manifestations is seldom seen. Out of all reported neurological manifestations, aseptic meningitis, brainstem encephalitis and cerebellar ataxia are common. We report a case of a 16 year old girl presenting with right sided lateral rectus palsy as the first presentation of KFD.

Clinical Features of Surgery Candidates for Different Types of Extraocular Muscle Palsy

Introduction: Clinical manifestations of cranial nerve palsies are of great importance, and surgeons should consider them before planning surgical protocol. Materials and Methods: This retrospective study was conducted on preoperative hospital records of 598 Iranian patients with different types of extraocular muscle palsy, including third (90 patients), fourth (501 patients), and fifth (7 patients) nerve palsy at Farabi Hospital, Tehran Province, Iran. Results: In terms of fourth nerve palsy, the mean spherical equivalent (SE) in the right and left eye was 0.23±1.51 and 0.19±1.45 diopter, respectively. Also, the mean angle of vertical deviation was 15.54±8.85 Δ at near and 15.66±8.93 Δ at far. In patients with third nerve palsy, the mean SE in the right and left eye was -0.02±2.08 and 0.08±1.95 diopter, respectively. Also, the mean angle of vertical deviation was 17.8±17.4 Δ at near and 17.8±17.5 Δ at far. In terms of six nerve palsy, the mean SE in the right and left eye was -1.27±3.37 and -1.08±2.52 diopter, respectively. Also, the mean angle of esotropia was 32.4±7.7 Δ at near and 33±6.7 Δ at far. The frequency of amblyopia in patients with third, fourth, and sixth nerve palsies was 21 patients (23.3%), 70(14%), and 4(57.1%), respectively. Conclusion: The clinical characteristics of patients with different types of EOM palsy are remarkably different, which can be attributed to the different properties of these kinds of deviations.

A deep learning-based image analysis for assessing the extent of abduction in abducens nerve palsy patients before and after strabismus surgery

PurposeThis study aimed to propose a novel deep learning-based approach to assess the extent of abduction in patients with abducens nerve palsy before and after strabismus surgery. MethodsThis study included 13 patients who were diagnosed with abducens nerve palsy and underwent strabismus surgery in a tertiary hospital. Photographs of primary, dextroversion and levoversion position were collected before and after strabismus surgery. The eye location and eye segmentation network were trained via recurrent residual convolutional neural networks with attention gate connection based on U-Net (R2AU-Net). Facial images of abducens nerve palsy patients were used as the test set and parameters were measured automatically based on the masked images. Absolute abduction also was measured manually, and relative abduction was calculated. Agreements between manual and automatic measurements, as well as repeated automatic measurements were analyzed. Preoperative and postoperative results were compared. ResultsThe intraclass correlation coefficients (ICCs) between manual and automatic measurements of absolute abduction ranged from 0.985 to 0.992 (P＜0.001), and the bias ranged from −0.25 ​mm to −0.05 ​mm. The ICCs between two repeated automatic measurements ranged from 0.994 to 0.997 (P＜0.001), and the bias ranged from −0.11 ​mm to 0.05 ​mm. After strabismus surgery, absolute abduction of affected eye increased from 2.18 ​± ​1.40 ​mm to 3.36 ​± ​1.93 ​mm (P＜0.05). The relative abduction was improved in 76.9% patients (10/13) after surgery (P＜0.01). ConclusionsThis image analysis technique demonstrated excellent accuracy and repeatability for automatic measurements of ocular abduction, which has promising application prospects in objectively assessing surgical outcomes in patients with abducens nerve palsy.

Age-Related Risk of Stroke Following Ocular Motor Cranial Nerve Palsy.

This cohort study aims to examine the relationship between the occurrence of cranial nerve palsy (CNP) affecting the third, fourth, or sixth cranial nerve and the subsequent risk of stroke, with a particular focus on the modulating effect of age on this association. We established a cohort of individuals diagnosed with third, fourth, or sixth CNP who underwent national health screening within 2 years of diagnosis from 2010 to 2017. A control group was matched by sex and age at a ratio of 1:5. Participants were followed until December 31, 2019. We use multivariable Cox proportional hazards regression analyses to assess the association between ocular motor CNP and subsequent stroke stratified by age. Covariates including lifestyle, health behavior, underlying comorbidities, and Charlson comorbidity index score were also adjusted. Compared with the control group, the ocular motor CNP group had a higher risk of stroke after adjusting for potential confounders (hazard ratio [HR], 1.23 [95% CI,, 1.08-1.39]). The risk of stroke increased by 8.91 times in individuals with ocular motor CNP who were in their 30s (HR, 8.91 [95% CI, 1.63-48.66]). The risk increased by 2.49 times in those who were in their 40s, 1.78 times in those who were in their 50s, and 1.32 times in those who were in their 60s (HRs, 2.49, 1.78, and 1.32 [95% CI, 1.39-4.45, 1.31-2.42, and 1.08-1.62], respectively). However, for those who were in their 20s, 70s, or 80s, the incidence of stroke did not significantly increase. Our study establishes an association between ocular motor CNP and an increased risk of stroke, particularly in young adults.

Approaching Saber-Sheath Trachea in a Patient with Bilateral Vocal Cord Abductor Palsy and Post Tracheostomy Tracheal Stenosis.

Human trachea has variable shapes and the most common are circular and oval-shaped. Other shapes are rare to find and usually related to some diseases. Such as the Saber-sheath shaped trachea, which was commonly attributed to patients with chronic obstructive pulmonary disease (COPD). This case is about a patient who was detected to have dual pathology, bilateral vocal cord abductor palsy, and post-tracheostomy complicated with tracheal stenosis for 40 years. Symptoms worsened in the last three years until he was admitted to the ward. However, upon managing this case with multilevel airway obstruction, we have found out that this patient who did not have COPD, has a Saber-sheath trachea shape. This finding may indicate that the shape is not limited to a certain disease only.

Endoscopic transorbital approach to the petrous apex: is orbital rim removal worthwhile for the exposure? An anatomical study with illustrative case.

The endoscopic transorbital approach (ETOA) has been demonstrated to be a feasible ventral route to the petrous apex. Yet, it has been pointed to as a deep and narrow corridor for anterior petrosectomy; particularly, medialization of the instruments can become an issue when targeting the petroclival area. To overcome this limitation, an ETOA with orbital rim removal (ETOA-OR) has been suggested, but not de facto compared, with a transorbital approach without removal of the rim. This addition could augment the surgical exposure and freedom of movement when accessing the petrous apex area. Five human cadaveric heads (10 sides) were dissected. First, anterior petrosectomy was performed via a conventional ETOA (without orbital rim removal). Second, en bloc removal of the orbital rim was performed, with enlargement of the orbital craniectomy and, subsequently, further drilling of the medial petrous apex. Qualitative and quantitative comparisons are provided. An illustrative surgical case is also shown. The transorbital route allowed the authors to perform an anterior petrosectomy in all specimens. The landmarks of bone removal are superposed onto those in the transcranial route. The ETOA-OR increased the volume of craniectomy (from 4.0 mL to 5.5 mL), the lateromedial angulation, and superoinferior angulation of the instruments within the petrous area. Thus, this approach improved the exposure of the medial petroclival area, allowing for an augmented petrosectomy (from 1.4 mL to 2.0 mL, 39.5% increase) and for increased maneuverability, both in the petrous area (from 44.1 cm2 to 76.5 cm2, 73.3% increase) and in the posterior fossa (from 20.2 cm2 to 52.0 cm2, 158% increase). The ETOA-OR was also pragmatically applied to treat a recurrent petroclival meningioma. Complete removal was achieved, the abducens nerve palsy improved, and the trigeminal neuralgia decreased in severity, yet still required medication. The authors provide the first formal anatomical comparison between the transorbital approach with preservation of the orbital rim and a transorbital approach with removal of the rim to access the petrous apex. In addition, an illustrative case is used as a proof of concept and feasibility. According to the authors' data, the ETOA-OR significantly improves surgical exposure and the surgeon's comfort in this deep region. The bony defect can be reconstructed to avoid cosmetic deformities, maintaining the minimally disruptive concept of transorbital surgery.

Uncommon presentation of orbital myositis following herpes zoster ophthalmicus

Herpes zoster ophthalmicus (HZO) is a manifestation of the reactivation of the varicella zoster virus, characterised by vesicular rash along the ophthalmic division of the trigeminal nerve. A rare but significant complication of HZO is orbital myositis, marked by painful swelling of extraocular muscles and periorbital tissues. We present the case of a 72-year-old woman initially presenting with ophthalmological symptoms, notably conjunctival congestion and superficial punctate keratitis, preceding the typical vesicular rash of herpes zoster. The subsequent development of diplopia led to the detection of lateral rectus palsy. Neuroimaging revealed orbital myositis, with the patient showing marked improvement following treatment with oral steroids. This case emphasize the importance of recognizing orbital myositis as a complication of HZO.

Synchronous Ewing sarcoma of the fibula with involvement of the orbit and abducens nerve palsy

Simultaneous or synchronous Ewing sarcoma (ES) is the occurrence of multifocal lesions without pulmonary involvement. This is a very rare condition. We present a case of multifocal synchronous ES of the fibula with orbital involvement and adducens nerve palsy. A 17-year-old boy presented with pain and swelling in both legs for 6 weeks. He was unable to walk due to pain. He was pale and cachexic. There was proptosis and ptosis in the right eye. His investigations were consistent with a multifocal malignant tumor. There were lesions in the left fibula, tibia, right tibia, and right orbit. The histopathological diagnosis was Ewing sarcoma (ES). This is the first report of synchronous ES involving the orbit and abducens nerve.

Listeria Rhombencephalitis: A Case of an Immunocompetent Adult

Listeriosis is one of the most important foodborne diseases, caused by a Gram-positive facultative anaerobic intracellular bacterium found in food and the environment, Listeria monocytogenes. It causes one of the most life-threatening bacterial infections of the central nervous system (CNS). Meningoencephalitis and rhomboencephalitis are the most common forms and immunosuppression represents the main risk factor. In this article, we report a case of severe, invasive Listeria monocytogenes rhombencephalitis in a healthy middle-aged man, admitted to our hospital with meningeal syndrome associated with left VI nerve palsy. No apparent abnormality was found in a head CT and brain magnetic resonance imaging. Following the preliminary LP results, a diagnosis of bacterial meningitis was suspected and empirical antibiotic and antiviral therapy was initiated. Because of the lack of any significant improvement in his clinical status, on day 2 of his admission, a genetic identification of CSF pathogens by high-throughput genome sequencing was performed and identified L. monocytogenes. The Clinical status improved with complete recovery after appropriate antibiotic treatment with sulfamethoxazole-trimethoprim. In conclusion, in an infectious context, pontine involvement should systematically evoke the diagnosis of listeriosis.

A child with unilateral abducens nerve palsy and neurovascular compression in Chiari malformation type 1 resolved with posterior fossa decompression: illustrative case.

Unilateral cranial nerve (CN) VI, or abducens nerve, palsy is rare in children and has not been reported in association with Chiari malformation type 1 (CM1) in the absence of other classic CM1 symptoms. A 3-year-old male presented with acute incomitant esotropia consistent with a unilateral, left CN VI palsy and no additional neurological symptoms. Imaging demonstrated CM1 without hydrocephalus or papilledema, as well as an anterior inferior cerebellar artery (AICA) vessel loop in the immediate vicinity of the left abducens nerve. Given the high risk of a skull base approach for direct microvascular decompression of the abducens nerve and the absence of other classic Chiari symptoms, the patient was initially observed. However, as his palsy progressed, he underwent posterior fossa decompression with duraplasty (PFDD), with the aim of restoring global cerebrospinal fluid dynamics and decreasing possible AICA compression of the left abducens nerve. Postoperatively, his symptoms completely resolved. In this first reported case of CM1 presenting as a unilateral abducens palsy in a young child, possibly caused by neurovascular compression, the patient's symptoms resolved after indirect surgical decompression via PFDD.

MANAGEMENT OF ISOLATED SIXTH CRANIAL NERVE PALSY WITH VIDDHAKARMA AS AN ADJUVANT THERAPY: A CASE SERIES

Background: In Patients with Abducens nerve palsy, diplopia is the most common presenting symptom. Patient will have horizontal uncrossed diplopia which is greater at distance, which worsens in the direction of the palsied muscle and gets better in the contralateral gaze. Vasculopathic risk factors such as diabetes mellitus and hypertension are more common in elderly people due to microvascular ischemia. Treatment options with sixth cranial nerve palsy include alternate patching, prism therapy, strabismus surgery and botulism injections. Here, we present case series of two patients of Isolated Abducens nerve palsy, secondary to Diabetes Mellitus and Hypertension, who underwent Viddhakarma along with other Ayurvedic management. Data were collected prospectively with a follow-up of three months. Case Report: Two cases presented to the Out-patient department with pre-diagnosis of Sixth Cranial Nerve Palsy with signs and symptoms of binocular horizontal diplopia, inability to abduct left eye and mild esotropia secondary to hypertension and diabetes mellitus. In Ayurveda, symptom of Dwitiya Patalgat Doshdushti (Timira) by Acharya Vagbhata and Trutiya Patalgat Doshdushti (Timira) by Acharya Sushruta can be correlated with the diplopia. Snayugata vitiation of Vata Dosha leads to Ekangavata which causes constriction of Sira and Snayu. Thus, sixth cranial nerve palsy can be correlated with Ekangavata and Timira. Viddhakarma as an adjuvant therapy to the Ayurvedic treatment regimen, patients started showing improvement in the symptoms within one to one and a half months and symptoms resolved completely, thereby enhancing the quality of life of the patient. Conclusion: Neuro-ophthalmological cases related to cranial nerve palsies can be treated successfully with Ayurvedic management and Viddhakarma as an adjuvant therapy.

Unrevealing abducens palsy vs. divergence insufficiency: A comprehensive review

Background: The article "Unraveling Abducens Palsy vs. Divergence Insufficiency" provides a comprehensive review of two common ophthalmological conditions, namely Abducens Palsy and Divergence Insufficiency. Aim: In this review article, we aim to unravel the key differences between these conditions, providing healthcare professionals with valuable insights for accurate diagnosis. It provides a comprehensive analysis of the clinical features, diagnostic criteria, etiology, and management strategies for each condition. Methods: A systematic literature search was conducted in electronic databases, including PubMed, MEDLINE, and Google Scholar. Case reports, clinical trials, observational studies, and review articles were considered. The extracted data included information on the clinical presentation, diagnostic tests, etiology, and treatment options for these conditions. Results: The authors emphasize the importance of a thorough ophthalmological examination, including the Hirschberg test and forced duction test, in diagnosing Abducens Palsy accurately. The article also explores the potential causes of Divergence Insufficiency, such as age-related changes and neurologic disorders. The management strategies for both conditions are thoroughly discussed, encompassing both conservative and surgical approaches. Conclusion: The authors present a comprehensive analysis of the clinical features, diagnostic criteria, and management strategies for these two conditions.It serves as a valuable resource for healthcare professionals, providing them with the necessary knowledge to accurately diagnose and manage Abducens Palsy and Divergence Insufficiency. Further research in this field is warranted to enhance our understanding of the underlying mechanisms and optimize treatment outcomes.

Direct V3 Vertebral Artery Access for Embolization of Partially Thrombosed Fusiform Basilar Trunk Aneurysm: Technical Case Instruction.

Fusiform vertebrobasilar aneurysms carry significant morbidity. Endovascular strategies are preferred; however, unsafe or unfeasible access can call for innovative strategies. An octogenarian patient with an enlarging fusiform proximal basilar artery aneurysm causing a sixth nerve palsy was found to have multiple anatomic features that precluded a transradial or transfemoral endovascular approach. She was thus treated with direct microsurgical access of the V3 segment of the vertebral artery for subsequent coil embolization and flow diversion. This case introduces a novel combined microsurgical and endovascular strategy for treating a complex partially thrombosed fusiform basilar artery aneurysm. This approach should be reserved only for patients where conventional endovascular access is dangerous or unfeasible.

Single-Stage Endoscopic Repair of Pediatric Basal Encephalocele: A Comprehensive Multimedia Case Report.

Basal encephaloceles are the result of a concomitant cranial and dural defect that allows for inferior displacement of cerebral tissue, meninges, and cerebrospinal fluid into the paranasal sinuses and outside the cranial vault. This work illustrates a step-by-step surgical approach of a successful single-stage, endoscopic repair of a congenital basal encephalocele in a 10-year-old child, using a free mucosal middle turbinate graft that provided effective results without utilization of traditional open reconstructive techniques or vascularized flaps. A previously healthy 10-year-old male with a history of unilateral clear rhinorrhea was admitted as an inpatient because of an acute episode of nausea, vomiting, and confusion, accompanied by fever, diplopia, and bilateral abducens nerve palsies. Preoperative imaging revealed a 2-cm right-sided intranasal mass accompanied by a subcentimeter skull base defect spanning the lateral lamella. After completing a course of intravenous antibiotic therapy for 1 week after a negative lumbar puncture to ensure clearance of intracranial infection, the decision was made to proceed with definitive endoscopic skull base repair to obviate recurrent bacterial meningitis episodes and potential neurological complications. This study demonstrates technical feasibility of a single-stage endoscopic endonasal approach for pediatric basal encephalocele resection and repair which minimizes craniofacial morbidity associated with traditional open approaches and sinonasal morbidity associated with local pedicle-based flaps for small cranial base defects in this unique patient population.

Clinico demographic profile and short-term outcome of Pediatric Idiopathic Intracranial Hypertension in a tertiary care hospital of Bangladesh

Background: Diagnosis of IIH (idiopathic intracranial hypertension) in children is challenging. The pathogenesis of IIH is still largely unknown. The aim of this study to evaluate the clinico-demographic profile and short-term outcome of IIH among Bangladeshi children. Methodology: This observational cohort study was done in pediatric Neurology Department, National Institute of Neurosciences and Hospital Bangladesh from January 2018 to July 2019. Total 19 cases were enrolled who were clinically suspected and/or had normal CSF with opening pressure (OP) above 250 mmH2O. They were further categorized as “definite IIH”, definite IIH without papilledema, and “probable IIH”. Clinical, radiological profile and short-term outcome were analyzed by SPSS version 22. Result: Among them most were probable IIH (74%). Episodic (57.9%), moderate, diffuse headache was the predominant symptom along with vomiting, double vision, unilateral VI nerve palsy and papilledema. Obesity was found in 21% cases. Mean CSF pressure was 21.84+7.62cm H2O and found high in definite IIH. All the cases were treated with acetazolamide and serial LP was done in 4(15.8%) cases. Definite IIH requires longer hospital stay (6.42 ± 2.87days). Recurrence was observed in 10.5% cases and visual impairment was found in 15.8% cases. Conclusion: This study found wide range of diversity between clinical feature and CSF opening pressure in Pediatric IIH and diagnostic confirmation was challenging. Initial treatment response was satisfactory with a low recurrence rate. J Bangladesh Coll Phys Surg 2024; 42: 161-168

Vocal Fold Motion Impairment in Neurodegenerative Diseases.

Vocal fold motion impairment (VFMI) is the inappropriate movement of the vocal folds during respiration, leading to vocal fold adduction and/or abduction problems and causing respiratory and vocal impairments. Neurodegenerative diseases (NDDs) are a wide range of disorders characterized by progressive loss of neurons and deposition of altered proteins in the brain and peripheral organs. VFMI may be unrecognized in patients with NDDs. VFMI in NDDs is caused by the following: laryngeal muscle weakness due to muscular atrophy, caused by brainstem and motor neuron degeneration in amyotrophic lateral sclerosis; hyperactivity of laryngeal adductors in Parkinson's disease; and varying degrees of laryngeal adductor hypertonia and abductor paralysis in multiple system atrophy. Management of VFMI depends on whether there is a presence of glottic insufficiency or insufficient glottic opening with/without severe dysphagia. VFMI treatment options for glottic insufficiency range from surgical interventions, including injection laryngoplasty and medialization thyroplasty, to behavioral therapies; for insufficient glottic opening, various options are available based on the severity and underlying cause of the condition, including continuous positive airway pressure therapy, botulinum toxin injection, tracheostomy, vocal fold surgery, or a combination of interventions. In this review, we outline the mechanisms, clinical features, and management of VFMI in NDDs and provide a guide for physicians who may encounter these clinical features in their patients. NDDs are always progressive; hence, timely evaluation, proper diagnosis, and appropriate management of the patient will greatly affect their vocal, respiratory, and swallowing functions as well as their quality of life.

P026 Neurofascin antibodies complicating a case of severe systemic lupus erythematosus

Abstract Background/Aims Juvenile-onset systemic lupus erythematosus (jSLE) is an autoimmune disease that results in increased disease activity and damage compared to adult-onset SLE. There is increased medication burden, severe organ manifestations and higher incidence of renal, cardiovascular and neuropsychiatric (NP) involvement. Anti-nervous system (NS) antibodies are seen across immune mediated diseases including SLE. Myelin oligodendrocyte glycoprotein (MOG) and neurofascin (NF) 186 antibodies are particularly associated with higher frequencies of NP-SLE. These patients can present with the distinct clinical phenotype associated with that antibody (i.e., demyelination with MOG, neuropathy with NF186). Methods We present an SLE patient with progressive neurological features and anti-NF antibodies who responds well to ocrelizumab after modest response to initial immunotherapy. Results An 18 year old female has active jSLE including malar rash, alopecia, arthralgia, aphthous ulcers, headaches. She presents with lower limb and ascending abdominal paraesthesia and left 6th cranial nerve palsy alongside a recent respiratory tract infection. ANA 1:5120 homogenous pattern, high dsDNA, low C3 and C4, thrombocytopenia and antibodies to Sm, Ro, RNP, anti-Rib-P and strongly positive lupus anticoagulant antibodies and low titre anti-cardiolipin (aCL) IgG and IgM. Lumbar puncture is unremarkable. Nerve conduction studies (NCS) demonstrate progressive predominant motor inflammatory neuropathy without demyelination. CT, MRI brain and MRI spine are normal. She is treated as atypical Guillain-Barre Syndrome (GBS)/ Miller-Fischer with 5 days IV immunoglobulin 2g/kg and also for active SLE with 3 days 500mg IV methylprednisolone. She is intubated following worsening dysphagia, dysarthria, muscle weakness and reduced consciousness. Plasma exchange and pulsed cyclophosphamide are subsequently given. Eye and facial movements worsen with NCS showing worsening patchy axonal sensorimotor polyneuropathy. Serial MRI brain is suggestive of posterior reversible encephalopathy syndrome (PRES). Autonomic instability is seen with labile blood pressure and tachycardia. Given the unusual presentation, anti-NF antibodies are tested and identified at 1:3200 positive, NF155 and 186, both IgG1 and IgG2. Given previous adverse reaction to rituximab, she received ocrelizumab which lead to a marked improvement in her sensorimotor symptoms and functionality. C3 and C4 levels show considerable improvement which is sustained and dsDNA levels normalise. B cell depletion therapy was chosen following a small case series of patients with neurofascin antibodies who developed severe autoimmune neuropathies. Half of these patients responded well to rituximab. One proposed mechanism being the targeting of immature CD20+ B cells inhibits plasmablast generation, which may be responsible for neurofascin antibody production early on in the disease. Conclusion Anti-NS antibodies are seen in SLE patients and their presence can suggest increased frequency of NP-SLE suggesting a potential future role as a biomarker. One should consider anti-NF antibody testing in patients with a GBS-like illness with progressive neuropathy, respiratory involvement and autonomic dysfunction despite standard immunotherapy. Disclosure P. Yee: None. M. Mouyis: None.

Lyme Disease with Isolated Sixth Cranial Nerve Palsy (P8-10.004)

Lyme Disease with Isolated Sixth Cranial Nerve Palsy (P8-10.004)

Neuroophthalmic Manifestations and Management of Cryptococcal Meningitis in HIV-negative Pregnant Woman : A Rare Case

Abstract
 Introduction : Cryptococcal meningitis (CM) is Cryptococcus infection affecting mostly immunocompromise patients. However, immunocompetent and pregnant woman can also be affected. This condition can cause neuroophthalmic manifestations which may result in permanent vision loss or even death if not managed properly. However, literatures on neuroophthalmic manifestations and management of HIV-negative pregnant woman with CM are very scarce.
 Case Illustration : We present a rare case of 25 y.o. HIV-negative pregnant woman with neuroophthalmic manifestations associated with CM. The patient was consulted from neurology department with complaints of painless vision loss accompanied by diplopia, severe headache, nausea, and frequent vomitus. Ophthalmological examination showed best corrected visual acuity 20/40 in both eyes, ophthalmoplegia, and grade 4 papilledema. Lumbal puncture result was 89 cmH20. Cerebrospinal fluid (CSF) analysis showed mononuclear cells domination, increased protein, and decreased glucose. Indian ink stain showed Cryptococcus organism. Patient was given intravenous fluconazole, topical nonsteroid anti-inflammatory drug, and therapeutic lumbal punctures which result in clinical improvement.
 Discussion : CM can cause neuroophthalmic manifestations resulting from increase intracranial pressure (ICP) due to fungal load in arachnoid granulation which obstruct CSF outflow. The manifestations found in this patient were papilledema, ophthalmoplegia, and diplopia due to 6th nerve palsy. The management was multidisciplinary with obstetrics-gynecology and neurology department, focused in pathogen eradication and ICP management to prevent neuroophthalmic sequelae, with considerationof maternal-fetal life saving dilemma.
 Conclusion : Various neuroophthalmic manifestations can be involved in CM. Prompt and appropriate therapy in a rare case of HIV-negative pregnant woman with CM can decrease both maternal and fetal morbidity and mortality risk.