Complete Ptosis Research Articles

Occipital lobe infarction: a rare presentation of bilateral giant cavernous carotid aneurysms: a case report

BackgroundCavernous carotid aneurysm (CCA) represents 2–9% of all intracranial aneurysms and 15% of internal carotid artery (ICA) aneurysms; additionally, giant aneurysms are those aneurysms that are > 25 mm in size. Bilateral CCAs account for 11–29% of patients and are commonly associated with structural weaknesses in the ICA wall, secondary to systemic hypertension. CCAs are considered benign lesions, given the low risk for developing major neurologic morbidities (i.e., subarachnoid hemorrhage, cerebral infarction, or carotid cavernous fistula). Moreover, concurrent presentation with posterior circulation cerebral infarction is even rarer, given different circulation territory from CCA. Here, we report on a patient with bilateral giant CCAs who presented with both typical and atypical symptoms.Case presentationAn 88-year-old hypertensive woman presented with acute vertical oblique binocular diplopia, followed by complete ptosis of the right eye. Ophthalmic examination showed dysfunction of the right third, fourth, and sixth cranial nerves. Further examination revealed hypesthesia of the areas supplied by the ophthalmic (V1) and maxillary (V2) branches of the right trigeminal nerve. Bilateral giant cavernous carotid aneurysms, with a concurrent subacute right occipital lobe infarction, were discovered on brain imaging and angiogram. Additionally, a prominent right posterior communicating artery (PCOM) was revealed. Seven months later, clinical improvement with stable radiographic findings was documented without any intervention.ConclusionsDysfunction of the third, fourth, and sixth cranial nerves, and the ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerves, should necessitate brain imaging, with special attention given to the cavernous sinus. Despite unilateral symptomatic presentation, bilateral lesions cannot be excluded solely on the basis of clinical findings. CCA should be included in the differential diagnosis of cavernous sinus lesions. Although rare, ipsilateral posterior circulation cerebral infarction (i.e., occipital lobe infarction) can occur in CCA patients, presumably as a result of distal embolization through an ipsilateral, prominent PCOM. Spontaneous clinical improvement with stable radiographic support may occur.

Perineural spread of basosquamous carcinoma to the orbit, cavernous sinus, and infratemporal fossa

ABSTRACTBasosquamous carcinoma is a rare, highly aggressive variant of basal cell carcinoma with elevated rates of recurrence, perineural invasion, and metastasis. We describe a patient who presented with unilateral complete ophthalmoplegia, ptosis, optic neuropathy, and trigeminal neuropathy due to perineural intracranial invasion of nasal basosquamous carcinoma via the sphenopalatine fossa to the cavernous sinus, orbit, and infratemporal fossa. To our knowledge, this is the first reported case of basosquamous carcinoma with perineural invasion involving the cavernous sinus in the English language ophthalmic literature. Physicians should be aware of the diagnostic features, clinical challenges and aggressive nature of basosquamous carcinoma, a rare diagnosis that can lead to significant morbidity/mortality when left unrecognized.

Marcus Gunn Syndrome and implications for Oral and Maxillofacial surgery (OMFS)

Introduction Marcus Gunn Syndrome, also known as Jaw Wink Syndrome or trigemino-oculomotor synkinesis, was first reported in 1883. It typically presents at birth with unilateral ptosis and eyelid elevation on jaw opening. Pathophysiology is explained by an oculofacial synkinesis. There is an aberrant connection of the oculomotor nerve and the mandibular branch of the trigeminal nerve resulting in eyelid elevation on mouth opening. The typically congenital syndrome is exceptionally rare. It is often diagnosed in infancy with complete ophthalmic examination and ptosis evaluation. This syndrome does not often require surgical intervention but it may still have an impact in clinical management. Case description A 32-year-old male presented in the OMFS outpatient clinic in Countess of Chester Hospital for extraction of his lower third molars. His past medical history included a known diagnosis of Marcus Gunn Syndrome but he was otherwise fit and well. He had resting ptosis of the left and elevation of the left eyelid on jaw protrusion. Results and conclusions Third molars were removed uneventfully under local anesthesia and no further treatment was required. Literature suggests that patients with Marcus Gunn Syndrome may have an atypical oculocardiac reflex during their surgical procedure and patients are at increased risk of malignant hypothermia. In this case, the procedure was performed under local anesthesia but this condition may impact on surgical planning if general anesthesia was to be considered.

Acute complete bilateral ophthalmoplegia and ptosis without ataxia or areflexia associated with serum anti‐GQ1b antibody

AbstractWe report the case of a 65‐year‐old woman who presented with acute complete bilateral ophthalmoplegia and ptosis. Deep tendon reflexes were normal and there were no signs of ataxia. On laboratory examination, the patient had vitamin B1 deficiency; however, symptoms did not improve after fursultiamine administration. Thereafter, it was found that the patient was seropositive for anti‐ganglioside Q1b immunoglobulin G antibody, and she was diagnosed with acute ophthalmoplegia and ptosis associated with anti‐ganglioside Q1b immunoglobulin G antibody. The patient's symptoms improved gradually without further treatment over the next several months. Ataxia and areflexia were not observed during the clinical course.

Complete ophthalmoplegia, complete ptosis and dilated pupil due to internal carotid artery dissection: as the first manifestation of Takayasu arteritis

BackgroundTakayasu arteritis is a rare, chronic large vessel vasculitis involving the aorta and its primary branches. As the disease progresses, the active inflammation of large vessels leads to dilation, narrowing and occlusion of the arteries. Arterial dissection is due to separation of the layers of the arterial wall resulting in a false lumen, where blood seeps into the vessel wall. Neurological sequelae of intracranial arterial dissection results from cerebral ischemia due to thromboembolism and hypo perfusion. Internal carotid artery dissection in Takayasu arteritis is very rare and complete ophthalmoplegia due to internal carotid artery dissection is also rare. This is the first case report of Takayasu arteritis presenting as complete ophthalmoplegia due to internal carotid artery dissection.Case presentationA 38-year-old Sri Lankan female presented with sudden onset severe headache, fixed dilated pupil, complete ptosis and ophthalmoplegia on the right side. On imaging, dissection and dilatation was evident in the right internal carotid artery from the origin up to the cavernous segment. She also had stenosis and aneurysmal dilatation of right subclavian artery. Takayasu arteritis was diagnosed subsequently. She was started on aspirin and high dose steroids.ConclusionsInternal carotid artery dissection within the cavernous sinus can lead to third, fourth and sixth nerve palsy due to compression, stretching and ischemia from occlusion of the nutritional arteries. This case report illustrates that internal carotid artery dissection should be a differential diagnosis in palsies of the third, fourth, or sixth cranial nerves, especially when associated with headache. In cases of internal carotid artery dissection, vasculitis such as Takayasu arteritis should also be considered.

Frontalis sling surgery: A treatment modality for cyclic oculomotor nerve palsy

Cyclic oculomotor nerve paresis and spasm are a rare disorder characterized by alternating spastic and paretic phase of the muscles supplied by the oculomotor nerve. A 26-year-old male presented with abnormal right eyelid movements since early childhood. Examination findings were consistent with diagnosis of right eye cyclic oculomotor nerve palsy. A paretic phase with complete upper eyelid ptosis, exotropia, hypotropia and dilatation of the pupil was followed by a phase of orthotropia, the absence of ptosis and normal pupil size. The whole cycle was of about 100s duration with patient having no voluntary control over the eyelid movements and ocular alignment. Systemic evaluation and neuroimaging were normal. A tarsofrontal silicone sling surgery done for the ptosis correction decreased the eyelid movements during different phases of the cycle.

Miller fisher syndrome presenting with prodromal thunderclap headache

Objectives We report a case of Miller-Fisher syndrome presenting initially with thunderclap headache. Case A 77 year old male with a history of type 2 diabetes mellitus, hypertension, depression and previous right pontine stroke, presented to our hospital with thunderclap headache and syncope. He reported a brief, non-bloody, diarrhoeal illness five weeks prior but he had otherwise been well. There was recurrent thunderclap headache over the following 24 hours with subsequent vomiting and syncope. He was diagnosed with vagal-induced sinus pause causing syncope. Plain CT brain and CT angiogram were unremarkable. Over the following 48 hours, the patient developed ocular signs, which progressed to complete ophthalmoplegia and complete ptosis. CSF examination was unremarkable (protein 0.30 g/L, acellular). MRI brain, including post-gadolinium enhanced imaging of orbits and cavernous sinus, was unremarkable. Three days after presentation, his reflexes began to diminish in the lower limbs and he developed heel-shin ataxia. The presumptive diagnosis was Miller Fisher syndrome and he was commenced on intravenous immunoglobulin (2 g/kg over three days). Supportive tests returning after initiation of treatment were positive serum anti-GQ1B IgG antibodies and positive stool culture for Campylobacter jejuni . Despite this, the patient’s severe headaches persisted, non-responsive to opiod analgesia and non-steroidal anti-inflammatory agents. Repeat CSF examination was unremarkable, with an opening pressure of 13 cm H2O. Twelve days after initial onset of headache, the patient was trialled on oral nimodipine 60 TDS, with resolution of headache over the following 12 hours. Conclusions Although not radiographically confirmed, we postulate the headache may have been due to reversible cerebral vasoconstriction syndrome (RCVS), given the characteristics of the headache and dramatic response to nimodipine. Although headache is infrequently observed in Miller Fisher syndrome, the exact aetiology is unclear and there has been no previously reported association with RCVS.

Traitement de la rétraction palpébrale supérieure associée à l’ophtalmopathie dysthyroïdienne en phase active inflammatoire avec l’injection de toxine botulique A

To evaluate the efficacy of transconjunctival botulinum toxin type A (BTX-A) in the treatment of upper eyelid retraction in the active inflammatory phase of dysthyroid orbitopathy, establish the ideal dose, and evaluate side effects. This is a comparative, prospective study in patients with thyroid orbitopathy, conducted at the Conde Ophthalmology Institute in Valenciana, Mexico. The patients included had dysthyroid orbitopathy in the inflammatory phase, and they were treated with subconjunctival injection of botulinum toxin type A (BTX-A) in the upper eyelid. Five units (group 1) and ten units (group 2) of BTX-A, in a single subconjunctival dose were applied to the non-dominant eye. We evaluated visual acuity, margin-to-reflex distance (RPM1), crease height, ocular motility, diplopia and keratitis, before and after administration of the toxin. The patients were followed at one, 4 and 16 weeks, with the Student t-test as a statistical analysis. At week 4, 15 patients (100%) showed a reduced margin to reflex distance. The mean result for group 1 was -1.75mm (range -1 to -2.5mm) and group 2 was -2mm (range -1 to -4mm). Statistically significant differences were seen between pre-treatment and week 4 in both groups, but no differences between doses. Complete improvement of keratitis and lagophthalmos was observed in 5 and 2 patients, respectively. Visual acuity, ocular motility and crease height did not change in 93% of the patients. One patient (group 1) exhibited complete ptosis and vertical diplopia, which resolved spontaneously at week 6. Transconjunctival BTX-A application is safe and effective for the treatment of eyelid retraction in dysthyroid orbitopathy. No difference was found between doses. No severe side effects were reported.

Metastatic Prostate Cancer Manifesting as Cavernous Sinus Syndrome—Case Report and Review of the Literature

Cavernous sinus syndrome (CSS) is a rare clinical entity which results in compression of the neurovascular structures in the cavernous sinus, potentially leading to headache, ophthalmoplegia, and neuropathy. The most common causes are tumor, trauma, inflammation, aneurysm, and infection. We report the case of an 82-year-old male with osseous-predominant metastatic prostate cancer who was admitted for intractable right-sided periorbital pain and diplopia. He also developed a headache with associated mild ptosis and weak cranial nerve (CN) VI function. He later developed complete right eye ptosis, complete CN VI paralysis, and palsies of CNs III and IV. Magnetic resonance imaging (MRI) of the sella turcica confirmed a distinct enhancing lesion in the cavernous sinus and he was diagnosed with CSS as a result of bony metastasis from his prostate cancer. He was started on high-dose steroids, and underwent directed radiation therapy. Bone metastasis is common with prostate cancer with predilection for more proximal structures such as the iliac bones and lumbar spine. Cases of CSS stemming from metastatic prostate cancer are rare. Thus, the development of CN palsy and ophthalmoplegia along with orbital pain should trigger a thorough investigation of the etiology of CSS which should include primary malignancies and metastasis from more distant structures such as the prostate.

Orbital Apex Syndrome with Central Retinal Artery Occlusion Following Tooth Extraction

A 39- year-old male, known diabetic presented with drooping of upperlid and visual loss in the left eye (LE) along with pain in the eye and periorbital region. This was preceded by tooth extraction 2 days back. There was inaccurate projection of rays in the left eye along with complete ptosis, proptosis, relative afferent pupillary defect (RAPD) and limitations of ductions. Fundoscopy revealed features of papillitis with central retinal artery occlusion (CRAO). The examination of the right eye was within normal limits. Patient had high blood sugar levels. Contrast enhanced computed tomography (CECT) scan of brain and orbit was suggestive of left paranasal sinusitis. The clinical and the radiological findings were suggestive of orbital apex syndrome with central retinal artery occlusion of the left eye (LE). The case was managed conservatively with systemic antibiotics, non-steroidal anti-inflammatory drugs and injection human insulin. Pain, proptosis and conjunctival chemosis subsided within 2 days but other features remained static. Dentogenic cause of orbital apex syndrome is very rare. We intend to discuss clinical features and management of such case.

Granuloma after sling surgery: an attempt to answer the 'why' and 'what to do next'.

To review cases of granuloma formation after sling surgery with a view to find out possible aetiological factors and propose a further plan of management MATERIALS AND METHODS: A retrospective analysis of 120 eyes of 108 patients who underwent frontalis sling surgery with silicone rod from Jan 2008 to Dec 2015 was conducted. All patients with severe ptosis and poor levator function who underwent frontalis sling surgery with silicone rod were included in the study irrespective of the cause of ptosis and method of passing the sling. A complete ophthalmic and ptosis examination was done. In all the cases, the prolene suture was tied over the sleeve to tighten it and it was buried along with the silicone rod in forehead pocket. All the cases with granuloma formation were first subjected to a microbiological examination including culture and sensitivity to antibiotics. All the patients were given a trial of antibiotics. We encountered 10 cases of granuloma in 120 eyes of 108 patients operated during this period. The duration between time of surgery and presentation varied from 2weeks to 4months. The microbiological examination revealed positive culture in 5 cases. None of the cases responded to the course of antibiotics given for 10days. The histopathological examination done in 5 cases (2 of them culture positive and 3 of them culture negative) revealed granulomatous inflammation of non-specific type. The sling was explanted in all cases which resulted in prompt resolution of granuloma in 7-10days. The granuloma is primarily due to exposure of the sling itself or the sleeve enveloping the sling or the suture tied around the sleeve thereby. They do not respond to antibiotics but respond very well to explantation. These patients can be taken up for re-sling surgery after a waiting period of 3months.

Complete 3rd cranial nerve dysfunction postdeflation/ excision of an encasing pituitary macroadenoma intrasellular cyst: A Case Report

Abstract Central nervous system injury in particular cranial nerve palsy has been reported to be as high as 2%. Such prevalence of palsy generally attributed to surgical manipulation at the cavernous sinus, especially incurring the abducens nerve. We report the first case of acute oculomotor nerve sequel to the release of cystic fluid wrapping the nerve following a transsphenoidal excision of pituitary macroadenoma in a 57-year-old woman. She attended with the presentation of acute excruciating headache associated with partial drooping of right eye. The computed tomography and magnetic resonance imaging (MRI) were consistent with pituitary apoplexy of an underlying pituitary macroadenoma. Urgent transsphenoidal hypophysectomy was done. Intra-operatively, cystic fluid was aspirated during pituitary tumour dissection. At the same time, curettage was employed to removal residual tumour after the tumour biopsy. Immediate post-operative assessment noted complete right eye ptosis, with clinical evidence of complete right third and fourth nerve palsies. MRI was repeated a week later in view of such palsy non-resolution. However, no local compression or edema noted. Observation and monitoring were opted versus surgical revision. Propitiously the aforementioned cranial nerve palsies persist for a month and subsequently subsided. In this case, we highlight the potential deleterious impact of aspirating cystic component and curettaging during pituitary surgery. Likely postulated accounts for such occurrence include sudden release of fluid pressure with resultant cystic traction on its enfolding cranial nerves and subsequent neuropraxia. We aim to invite comments that could enlighten us on this gray area.

A Case Report on Severe Hypothyroidism Associated with Complete Bilateral Ptosis: A Rare Presentation

Thyroid hormones exert a major control over many vital functions of the human body and thus have an important role in maintaining homeostasis. Therefore, the hypothyroid state is associated with a wide spectrum of symptoms affecting almost all bodily functions. Among the major organs affected, nervous system and body metabolism are severely affected. Facial appearance, including ocular changes, is a characteristic of the hypothyroid state. The most prominent ocular features of hypothyroidism include loss of eyelashes and eyebrows, especially on the temporal side, puffiness of the eyelids, ocular irritation and ocular protrusion. Mild drooping of the eyelids is also seen in some patients due to loss of sympathetic tone; however the occurrence of complete bilateral ptosis is rare in the setting of hypothyroidism. Our patient, who presented with sudden onset bilateral ptosis, had no manifestations of diseases involving the ocular structure, cranial nerves or central nervous system primarily; the cause may be attributed to severe hypothyroidism considering the dramatic response to thyroxine replacement therapy.

Successful Conservative Management of a Case of Traumatic Superior Orbital Fissure Syndrome

We report the case of a 22-year-old man who presented with complete ptosis, anisocoria, and total limitation of ocular motility of the right eye following blunt trauma. He was diagnosed to have traumatic superior orbital fissure syndrome based on clinical and radiologic evaluation. The patient achieved complete recovery of cranial nerve function. This unusual complication is reported in less than 1% of cases of craniomaxillofacial trauma. The clinical presentation with external and internal ophthalmoplegia but sparing of vision occurs as a result of the functional compromise of the neurovascular structures traversing the superior orbital fissure while sparing the optic nerve within the optic canal. Management may include observation, repair of associated fractures, megadose steroid therapy, and surgical decompression of the superior orbital fissure. A review of literature reveals that this condition with a unique ocular presentation is underreported in ophthalmic literature, perhaps as initial diagnosis may be obscured by coexisting craniofacial trauma.

Traumatic oculomotor nerve palsy.

Traumatic oculomotor nerve palsy.

Clinical analysis of transcranial orbitotomy approach on cranio-orbital tumors.

The aims of this study were to investigate 21 cases of transcranial orbitotomy for cranio-orbital tumors and evaluate the clinical value of the surgical approach. A retrospective study was done on 21 patients with cranio-orbital tumors. According to the tumors' location, shape, boundary, and invasion on the images, coronal scalp flap approach, subfrontal approach, or pterion approach for transcranial orbitotomy was performed. The surgical route was coronal scalp flap approach in 7 cases (including 3 cases combined with lateral orbitotomy), subfrontal approach in 6 cases, or pterion approach in 8 cases (including 1 case combined with evisceration of orbit). Tumors were en bloc resection in 4 cases, block resection or curettage in 13 cases, and incomplete resection in 4 cases. Postoperatively, the mean reduction in exophthalmos was 4 mm; maximum reduction was 11 mm. Ocular movement restriction was made better in 10 of 14 patients, whereas there was no change in 4 of 14 patients. Ophthalmoplegia occurred in 2 cases, complete ptosis occurred in 3 cases, and mydriasis occurred in 3 cases. No vision loss or cerebrospinal fluid leak was observed. Fourteen patients were followed up, including 2 patients with metastatic carcinoma who died dead because of systemic metastasis; 2 patients had a recurrence (schwannoglioma and meningioma). No recurrence was found in the other 10 patients. Cranio-orbital tumors can be removed effectively through transcranial orbitotomy, whereas operative approach is convenient to the surgical procedure and can offer better exposure. Being familiar with the tumors' location, adhesion, and invasion, coupled with the skilled surgical techniques, would improve the results and reduce serious complications.

Orbital Apex Syndrome in a Patient with Sphenoethmoidal Fungal Rhinosinusitis

A 65 years old lady with uncontrolled diabetes mellitus came with Right Eye (RE) vision loss after 7 day history of drooping of RE upper lid. RE showed painful ophthalmoplegia and complete ptosis. Otorhinolaryngologica l (E.N.T.) examination detected edematous mucosa and mucopurulent discharge from sphenoethmoidal recess. Computed Tomography (C.T.) scan showed bilateral sphenoid and right ethmoidsinusitis with no intracranial spread. Most of the lesions were located at orbital apex with no bony erosion, as confirmed with Magnetic Resonance Imaging (MRI). Clinically, it was Orbital Apex Syndrome (OAS) due to noninvasive fungal rhinosinusitis. Treatment with antibiotics and antifungals was initiated. Functional Endoscopic Sinus Surgery (FESS) was electively done on 7th hospital day. Fungal masses were removed from sphenoid sinus and sent for histopathological study. Microbiological study showed Conidiobolus coronatus as causative agent. Conidiobolus rhinosinusitis leading to orbital apex syndrome is very rare. Probably the first reported case in India.

Sea Snake Bites Resulted in a Mimic of Brain Death

A 69 year old man with deep coma presented after an alleged history of sea snake bite. Patient presented with irresponsiveness to painful stimuli, complete ptosis, internal and external ophthalmoplegia. He was given continuous ventilator support despite signs of brain stem dysfunction. On admission day 20, the patient was weaned off ventilator and discharged from the hospital. Whenever treating patients who were suspected with a history of snake bite, an emergency physician should always consider severe envenomation in the differential diagnosis of acute neuroparalytic syndrome, which may avert the unfortunate misdiagnoses of brain death.

Isolated third cranial nerve palsy from non-aneurysmal internal carotid artery compression

An 86 year-old-female, presented with a 6-day history of sudden onset of left-sided retro-orbital pain, ptosis and diplopia. On examination, her blood pressure was 190/90 and had a normal heart rate and temperature. Neurological examination revealed only complete left side oculomotor nerve—CN3 palsy with complete ptosis, mydriasis and with the eye looking down and out and unable to adduct the orbit. The pupillary reaction was sluggish. Her medical history included hypertension and chronic kidney failure but was not on …

Role of Magnetic Resonance Imaging in Herpes Zoster Ophthalmicus Ophthalmoplegia

Aims: To hypothesize the mechanisms of herpes zoster ophthalmicus (HZO) related ophthalmoplegia by magnetic resonance imaging (MRI). Case Presentation: A 61-year-old Chinese man diagnosed with right sided HZO and a positive Hutchinson’s sign, subsequently developed right eye complete ptosis, mydriasis and limitation of elevation 1 month after the onset of HZO. MRI showed thickening and enhancement of right oculomotor nerve and enhancement of right extraocular muscles. CSF revealed leukocytosis and positive varicella zoster virus (VZV) DNA without any clinical signs of meningitis. The diagnosis HZO-related ophthalmoplegia and asymptomatic VZV meningitis was made based on the clinical and laboratory findings. The external ocular muscle palsies of this patient were due to both oculomotor nerve palsy and orbital myositis demonstrated by MRI. Conclusion: The pathogenesis of HZO associated ophthalmoplegia is attributed to multiple factors such as neuritis of the cranial nerve and orbital myositis which can be diagnosed with MRI.