Extraocular Movements Research Articles

Vision loss, third and fourth nerve palsy and non‐responsive midriasis after contralateral retrobulbar anaesthesia

AbstractPurpose: The purpose of this communication is to report a case of vision loss, third, and fourth nerve palsy and midriasis after contralateral retrobulbar anaesthesia. Although contralateral vision loss has been reported after locoregional block, very little evidence has been found about contralateral extraocular movement palsy and midriasis. Mechanism is not well known, though it is believed to be a consequence of the accidental subdural/subarachnoid anaesthetic injection.Methods: A case which took place at our hospital was selected. A retrobulbar block was performed by the service of anesthesiology in an 80‐year‐old patient prior to cataract surgery on the right eye. The block consisted of a 5 ml injection of 0.5% levobupicain and 2% lidocain (1:1) in his right eye under monitorization and sterile conditions. 10 min after the injection the patient presented bradycardia, hypotension and decreased consciousness. He was administered 0.6 mg atropine, 3 ephedrine bolus and 8 migr noradrenaline and his constants came back to normality. He was kept in observation in the recovery room. After consciousness recovery he claimed vision loss in the fellow eye.Results: At the exploration we found complete vision loss with no light perception, ptosis, third and fourth nerve palsy and dilated and non‐responsive pupil in the left eye. Funduscopy was unremarkable. He was kept in observation and 45 min later he was reexplored: ptosis, extraocular movements and pupil size improved; 2 h later exploration was completely normal.Conclusions: To conclude, we wanted to remember some of the possible complications of retrobulbar block and the importance of its conscious selection. Above all, we wanted to highlight this infrequent reaction on the fellow eye about which we have found very little evidence.

Role of Radiotherapy in Thyroid-Related Ophthalmopathy: A Case Series

Purpose To explore the role of radiotherapy (RT) in management of moderate to severe thyroid-related eye disease in terms of efficacy, treatment outcome, and response. Material and methods A case series of 5 patients with moderate to severe Graves Ophthalmopathy treated with orbital RT between July 2020 and March 2021. Patient symptoms and ophthalmic findings prior to RT and after 6 months post RT were analyzed. Computed tomography was performed before and after RT to compare orbital (muscles) volume change. Endpoints including improvement in ocular symptoms such as diplopia, proptosis, extraocular movement were compared. Acute and long-term complications were documented to assess its safety and treatment response. Results Addition of RT improved diplopia, visual acuity, proptosis, and color vision significantly. RT also decreased upper lid edema, optic nerve compression, and reduced intraocular muscle bulk. Extraocular muscles diameter reduced significantly. Patients experienced relief of symptoms and significant reduction in diplopia clinically. Conclusion External beam radiation is a safe and effective intervention in thyroid ophthalmopathy. Our study demonstrated that radiation is effective in decreasing inflammatory signs, symptoms, and muscle bulk. This treatment modality is well tolerated, and long-term complications are tolerable.

Clinical Results According to Inferior Oblique Manipulation in Patients with Inferomedial Blowout Fracture Involving the Orbital Strut.

Detachment of the inferior oblique muscle may be necessary under certain circumstances to repair a large inferomedial orbital fracture involving the orbital strut. This study aimed to evaluate the outcomes of patients who underwent surgeries with and without inferior oblique muscle reattachment after its detachment to repair the orbital wall fractures. Forty patients who underwent repair of combined floor and medial orbital wall fracture involving the orbital strut at a single tertiary institution between January 2014 and December 2020 were reviewed. Groups 1 and 2 comprised 20 patients each, who underwent surgery with inferior oblique muscle detachment without and with reattachment, respectively, and were followed up for at least 6 months postoperatively. Enophthalmos, Goldmann diplopia test, alignment test, ocular motility test, and orbital inferomedial angle ratio were the outcome measures. Statistically significant improvement was observed in ocular motility, diplopia, and enophthalmos postoperatively at the 1- and 6-month follow-up (p < 0.01). The mean postoperative inferomedial angle ratio (102.28 ± 10.62%) was improved significantly compared with the preoperative inferomedial angle ratio (115.61 ± 4.38%) (p = 0.004) in all patients. After surgery, inferior oblique muscle underaction was observed in seven and six patients in groups 1 and 2, respectively, which was associated with preoperative extraocular movement limitation and strabismus. Two patients showed diplopia in both groups at the last follow-up; they had inferior oblique muscle underaction but no enophthalmos. Orbital fracture repair with or without inferior oblique muscle reattachment was clinically effective and safe; however, patients with preoperative strabismus and extraocular motility limitation should be informed of the increased risk of postoperative complications.

Oculomotor and trochlear nerve neuritis following botulinum toxin injection for masseter hypertrophy - a case report with literature review.

To report a rare complication of oculomotor and trochlear nerve neuritis following botulinum toxin injection for masseter hypertrophy. A previously healthy 31-year-old man presented with a two-week history of left eye (OS) ptosis and diplopia, following botulinum toxin injection over the masseter area for masseter hypertrophy at an aesthetic centre. He had no proptosis or facial asymmetry. Visual acuity was 6/6 in the right eye (OD) and 6/9 in the OS. There was anisocoria, with pupils measuring 3 mm in the OD and 5 mm in the OS but no relative afferent pupillary defect. OS appeared hypertropic in primary gaze with impaired intorsion. Extraocular movement of the OS was restricted in all gazes, except for laevoversion; that of the OD was normal. This was associated with diplopia in all gazes except on laevoversion. Both eyes' anterior and posterior segment examinations were otherwise unremarkable. Besides the oculomotor and trochlear nerve, the other cranial nerves and neurological examinations were normal. Investigations including blood and cerebrospinal fluid, magnetic resonance imaging and angiography of the brain, were normal. Our impression was left oculomotor and trochlear nerve neuritis secondary to botulinum toxin injection. He was started on oral prednisolone 1 mg/kg daily and tapered by 5 mg per week. His condition improved gradually with no residual ptosis or anisocoria after three months. Extraocular movements normalised except for minimal residual restriction on depression. Oculomotor and trochlear nerve neuritis can occur following botulinum toxin injection over the masseter area. Healthcare professionals should be aware of this potential complication before offering the injection.

Movement disorders in hereditary spastic paraplegia (HSP): a systematic review and individual participant data meta-analysis

BackgroundHereditary spastic paraplegia (HSP) is a rare genetic disorder associated with mutations in > 80 loci designated SPG (SPastic parapleGia). The phenotypic spectrum of HSP can extend to include other neurologic features, including movement disorders. Our aim was to investigate genotype–phenotype associations in HSP with a focus on movement disorders.MethodsWe performed a systematic review and individual participant data (IPD)-level meta-analysis by retrieving publications from Medline/EMBASE/Web of Science on HSP with a SPG genotype. Studies were included only if individual-level information was accessible and at least one patient with a movement disorder was reported for that genotype. Out of 21,957 hits, 192 manuscripts with a total of 1413 HSP cases were eligible. Data were compared between two HSP groups: manifested with (HSP-MD, n = 767) or without (HSP-nMD, n = 646) a movement disorder.ResultsThe HSP-MD group had an older age of onset (20.5 ± 16.0 vs. 17.1 ± 14.2 yr, p < 0.001) and less frequent autosomal dominant inheritance (7.6% vs. 30.1%, p < 0.001) compared to HSP-nMD. SPG7 (31.2%) and SPG11 (23.8%) were the most frequent genotypes in the HSP-MD group. HSP-MD with SPG7 had higher frequency of later onset during adulthood (82.9% vs. 8.5%), ataxia (OR = 12.6), extraocular movement disturbances (OR = 3.4) and seizure (OR = 3.7) compared to HSP-MD with SPG11. Conversely, SPG11 mutations were more frequently associated with consanguinity (OR = 4.1), parkinsonism (OR = 7.8), dystonia (OR = 5.4), peripheral neuropathy (OR = 26.9), and cognitive dysfunction (OR = 34.5).ConclusionThis systematic IPD-level meta-analysis provides the largest data on genotype–phenotype associations in HSP-MD. Several clinically relevant phenotypic differences were found between various genotypes, which can possibly facilitate diagnosis in resource-limited settings.

307 Phenotypic-genotypic expansion of plectinopathy in a patient with muscular dystrophy and immune-mediated myasthenia gravis

A 26-year-old female presented with blistering skin lesions since infancy, hair loss, proximal motor weakness, nasal tone speech, swallowing problem, and droopy eyes. Upon neurological examination, normal cognition, inability to walk unassisted, bilateral ptosis with a full range of extraocular movements, weak gag reflex, generalized muscle atrophy, and decreased deep tendon reflexes were detected. Her electromyography revealed small polyphasic muscle unit action potentials, minimal insertional activities, myopathic changes, motor, and sensory increased latency, decreased amplitude, reduced velocity, and normal F wave.

Transient Cortical Blindness Following Cervical Transforaminal Epidural Injection

Purpose: To report a case of transient cortical blindness following cervical transforaminal epidural injection.Case summary: A 58-year-old diabetic and hypertensive male was referred to the ophthalmology department with sudden-onset bilateral visual disturbances after cervical transforaminal epidural injection for neck pain. During the procedure, an intravascular contrast medium was injected into the left vertebral artery. Immediately after the injection, the patient complained of bilateral visual disturbances, mild headache, and dizziness. Twelve hours after the procedure, his visual acuity was reduced to hand motion perception in both eyes. Anterior segment and fundus examinations were unremarkable. Pupillary light reflexes and extraocular muscle movements were normal. Brain magnetic resonance imaging, magnetic resonance angiography, and fluorescein angiography showed no significant findings. There were no other neurological abnormalities. The patient was treated conservatively with intravenous dexamethasone and nimodipine based on a provisional diagnosis of transient cortical blindness. The symptoms gradually improved 2 days after the procedure; visual acuity recovered to 20/20 by the third day.Conclusions: Although contrast-induced transient cortical blindness is rare, it should be considered in patients with bilateral visual loss after transforaminal epidural injection. It is a benign and reversible condition but requires a prompt diagnosis.

Workplace Trauma with Massive Intraorbital Foreign Body, A Dramatic Outcome

Background: Intra-orbital foreign bodies [IOFB] are considered a rare condition, and an enormous challenge to surgeons, as it might be difficult to diagnose in some cases even with the current advances in imaging technology. Retained IOFB can be a cause of major visual morbidity and blindness, especially in the working population. Purpose: In this article, we report a case of IOFB that occurred as a result of workplace related trauma while drilling ceramic. Methods: Case report and literature review using PubMed. Case Presentation: we present a case of a 30 years old male, not known to have any medical illness, the patient presented to the emergency department after getting trauma while drilling ceramic. Orbital computed tomography [CT] showed multiple high-density objects situated in a circumferential pattern around the globe. Results: The patient underwent lateral canthotomy and cantholysis in the emergency department, followed by three exploratory operations to remove intraorbital foreign bodies [FBs] . Luckily, the patient in our case regained a 0.5 visual acuity, with an impressive improvement in the extraocular muscle motility, with only mild restriction in the upper and lower gazes. The patient was followed up for 2 years after the incident, he was stable during that period. Conclusions: IOFB is an ophthalmological emergency, careful history, examination, and investigations are important steps in diagnosing IOFB since it can be easily missed when depending solely on imaging. Timely management is crucial to prevent irreversible complications.

PSAT355 A Case Report Identifying Graves’ Ophthalmopathy in a Myasthenia Gravis Crisis and Response to Teprotumumab

Abstract Background Thyroid disease is relatively common in patients with Myasthenia Gravis (MG), affecting 5%–10% of patients, conversely, the prevalence of MG in patients with Graves’ disease is 0.14%. Of thyroid diseases seen in MG, Graves’ Disease (GD) is the most common. Graves ophthalmopathy (GO) is a known complication associated with GD, however, in patients with MG, its identification may be difficult, as both GD and MG may present with similar ocular signs and subtle differences. This case identifies GO in a MG crisis and its response to teprotumumab. Clinical Case A 53-year-old-woman with MG presented with one year of worsening bilateral eye and arm weakness, fatigue, eye pain, headaches and palpitations. Examination revealed bilateral ptosis, eyelid edema, and ⅘ bilateral upper extremity strength. Workup revealed suppressed TSH (&amp;lt;0.010, n 0.5-5.0 ml U/L) and elevated antibodies: Thyroid Stimulating Immunoglobulin (4.86, n &amp;lt;0.54 IU/L) and Thyrotropin Receptor Antibodies (TRAb) (8.08, n ≤1.75 IU/L). Thyroid ultrasound showed several bilateral cystic nodules and increased thyroid parenchyma vascularity without thyromegaly, suggestive of GD. Thyroid Uptake and Scan showed diffusely elevated 24-hour uptake (71%, n 10-30%) consistent with GD. Treatment was initiated with methimazole 5 mg daily. At follow up, she had symptoms of eyelid weakness, diplopia, headaches, and muscle weakness. Graves’ Ophthalmopathy Clinical Activity Score (CAS) was 5/10. Examination showed bilateral ptosis with eyelid edema, proptosis, conjunctival redness, and chemosis. Extraocular muscle movements intact without pain, normal pupils and visual fields. Ophthalmology review and orbital CT showed bilateral exophthalmos with extraocular muscle thickening consistent with thyroid eye disease (TED). The classic coke-bottle-sign of the anterior tendon of the inferior rectus muscles was noted. Given her presentation, clinical course and progression of TED, she commenced a teprotumumab treatment trial. Clinical improvement of GO was noted upon follow-up assessment after 5 doses of teprotumumab: CAS 2/10, decreasing proptosis on exam, and TRAb (3.86, n ≤1.75 IU/L). Conclusion This case highlights the potentially misleading clinical findings and difficult diagnoses of coexisting GO and MG. Although muscular weakness is common in GD, concomitant MG is rare and may cause profound additional morbidity. Ocular signs in both diseases may cause diagnostic confusion, although ptosis is more consistent with MG and lid retraction with GD alone. GO can mimic some of the neuromuscular and ophthalmologic signs of MG and can be easily missed or mistakenly attributed to either MG or GD. This may result in a delayed diagnosis/inappropriate treatment of GO, thus, clinicians should maintain suspicion for coexisting diagnoses. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Evaluation of Streamed Hardware-to-Software Telemedicine Strabismus Consultations Utilizing Video Glasses.

While video glasses have been shown to be an effective tool for real-time pediatric strabismus telemedicine consultations, the high cost of the hardware-to-hardware conferencing system and bandwidth limitations may present barriers to accessibility and widespread adoption. This study evaluates the use of video glasses with a more affordable hardware-to-software video conferencing system for real-time strabismus consultations across multiple graders. A pediatric ophthalmologist (Grader 1) wearing video glasses simultaneously performed and recorded strabismus examinations in primary gaze, with and without correction, both at distance and near. Recorded parameters included strabismus category, angle measurements, and ocular motility. Three years later, four pediatric ophthalmologists (Graders 1-4) reviewed and graded streamed video feed transmitted at 1 megabit per second (Mbps) from a hard-wired codec to software. Agreement between streamed and gold standard in-person findings was determined by weighted kappa (κ) for categorical variables, intraclass correlation coefficient (ICC) for continuous variables, and percent agreement. Eighteen patients aged 4-11 years (median, 7 years) were included. Agreement in strabismus category between in-person and streamed examinations was perfect for both horizontal and vertical deviations (κ=1.0). Almost perfect agreement was found for degree manifest (tropia vs intermittent tropia vs phoria) across graders (κ=0.91, range 0.86-0.97). Agreement for angle measurements was excellent across graders (ICC = 0.97, range 0.97-0.98). Extraocular motility agreement was 90% for all graders combined, with Grader 1 having 100% agreement between her in-person and streamed examinations. Feed obtained from video glasses streamed through a hardware-to-software video conferencing system at 1 Mbps is a reliable tool for pediatric strabismus telemedicine evaluations.

ODP590 Combined Orbital Irradiation and Systemic Steroids in the Management of Progressive Thyroid Eye Disease

Abstract We present a case of a 62-year-old female with Multinodular Toxic Goiter who later developed Grave's Ophthalmopathy. She had an elevated baseline TRAb with an orbital MRI that showed bilateral proptosis with enlarged bilateral medial and lateral recti and extraocular muscles of the superior complex. She was initially treated with oral steroids which led to resolution of her visual complaints. However, due to recurrence of an active ophthalmopathy, she was subsequently given pulsing corticosteroid therapy. This was followed by radiotherapy due to minimal improvement in double vision. After completion of treatment, inflammatory ophthalmologic signs and symptoms were significantly improved. Radiotherapy in combination with glucocorticoids, particularly in the presence of diplopia or restriction of extraocular motility, should be considered in the management of active thyroid associated orbitopathy. Presentation: No date and time listed

Intermittent Manual Carotid Compression as a Treatment Option for Indirect Low Flow Carotid Cavernous Fistula

ABSTRACT Purpose To evaluate the efficacy of intermittent manual carotid compression (IMCC) in the management of low-flow carotid cavernous fistulae (CCF). Materials and methods Patients diagnosed with low-flow CCF and treated with IMCC over a period of 13 years were retrospectively analyzed. Data analyzed included demographic details, clinical features, type of CCF, and response to therapy. Outcomes were categorized as complete cure, partial cure, and no cure or worsening. Patients with complete and partial cure were grouped as good outcome whereas those with no cure or worsening as poor outcome. Results A total of 44 patients were advised IMCC for low-flow CCF, of whom five were lost to follow-up. Results of the remaining 39 patients were analyzed, of whom 21 (53.8%) were males. The mean age at presentation was 54.38 ± 14.54 years. The median duration between the onset of symptoms and presentation was 5.0 ± 4.10 months. The common presenting features were episcleral congestion and proptosis (89.7%), extraocular motility restriction (66.7%), and diplopia (48.7%). Most common CCF type was type D (34, 87.2%). All patients were advised to undergo IMCC. Good outcome was seen in 35 patients (89.7%, 95% CI: 80.2% to 99.2%), whereas poor outcome was seen in four (10.3%) patients. The mean duration of follow-up was 15.91 ± 21.87 months. Conclusion The present study found a good outcome with IMCC in 89.7% cases of indirect low-flow CCF with no major complications. It should be considered the management of choice in patients who are systemically unfit or cannot afford endovascular embolization.

Macular pigment optical density of hyperopic anisometropic amblyopic patients measured by fundus reflectometry.

PurposeHyperopic anisometropia is a major cause of amblyopia and may be associated with macular pigment optical density (MPOD) reduction. To explore whether the MPOD changes in hyperopic anisometropic amblyopia, we measured the MPOD using fundus reflectometry in eyes with hyperopic anisometropic amblyopia and normal vision.MethodsThis was a cross-sectional study conducted from January 2017 to June 2017. Forty subjects (25 males and 15 females) between the ages of 6 and 10 years were recruited. The subjects' eyes were divided into two groups: amblyopic eyes (best-corrected visual acuity (BCVA) not more than 20/25 or BCVA of two eyes differing by two or more lines) and fellow eyes. All enrolled subjects underwent a comprehensive ophthalmic examination, including extraocular motility assessment, cover-uncover testing, and refractive error (noncycloplegic), BCVA, axial length (AL), macular foveal thickness (MFT) and MPOD (Visucam® 200, Carl Zeiss Meditec AG, Germany).ResultsThe MPOD of amblyopic and fellow eyes was 0.12 ± 0.03 log units and 0.13 ± 0.04 log units, respectively, with a significant difference (P = 0.026). The MFT of amblyopic and fellow eyes was 241.28 ± 13.95 and 237.13 ± 16.02 μm, respectively, revealing that the MFT was significantly higher in amblyopic eyes than in fellow eyes (P = 0.028). Conversely, there was no correlation between the MPOD and MFT in the two groups.ConclusionsThis study is the first to report that the MPOD is decreased in hyperopic anisometropic amblyopia. In this study, no correlation between the MPOD and MFT was found. In the future, factors that induce a decrease in the MPOD in eyes with hyperopic anisometropic amblyopia should be explored in a large-sample study with follow-up observation.

Voriconazole in the treatment of invasive aspergillosis of orbit

BackgroundThe aim of the study was to evaluate the outcomes of voriconazole in terms of functional recovery and response on imaging in the management of invasive aspergillosis of orbit. MethodsThis was a prospective non-comparative interventional study. Diagnosed cases of invasive orbital aspergillosis were studied in a tertiary care hospital. Intravenous voriconazole followed by oral treatment was given. Sinus debridement was done, where needed. The response to treatment was assessed clinically and on radiology. ResultsA total of 10 diagnosed cases of invasive orbital aspergillosis were studied. Nine cases (90%) occurred in immunocompetent patients. Predisposing sinus infection was seen in 8 patients (80%). The most common presenting complaint was the protrusion of eye. On voriconazole treatment, there was a statistically significant improvement in vision and extraocular movements from first week onwards (p = 0.01 and p = 0.02, respectively) and reduction in proptosis from second week onwards (p = 0.003). Imaging was done at three months follow-up which revealed a good response to treatment in 90% of patients. All patients tolerated the drug well except one who had transient hepatic dysfunction. The mean follow-up was 5.8 months (range: 3–12 months). There was no recurrence of disease till the last follow-up. ConclusionInvasive orbital aspergillosis commonly presents as sino-orbital disease, mostly in immunocompetent adult patients. Voriconazole is a safe and effective drug with good short-term clinical outcome.

S2757 Eye-BD—A Rare Case of Orbital Myositis as an Extra-intestinal Manifestation of Crohn’s Disease

Introduction: Crohn’s Disease (CD) is often associated with a diverse array of extra-intestinal manifestations (EIMs). The estimated prevalence of EIMs in patients with CD is 25-70%. The estimated prevalence of ocular manifestations in patients with CD is 3.5-6.8%. Orbital myositis (OM), characterized by inflammation of the extraocular muscles, is a rare ocular EIM associated with CD. Case Description/Methods: A 22-year-old female with CD on ustekinumab for maintenance therapy in remission presented with three days of right eye swelling and pain with extraocular movements. CT of the orbits reported minimal pre-septal tissue swelling, without evidence of orbital cellulitis. She was started on NSAIDs. A week later, the patient presented to the Ophthalmology clinic with resolution of her right eye symptoms but with new, similar symptoms in her left eye, including diplopia, restriction of lateral and medial gaze, and chemosis of the lateral conjunctiva. She denied symptoms concerning for a Crohn’s flare or other EIMs. The initial CT of the orbits was reviewed, and an addendum was made, reporting subtle enlargements of multiple extra-ocular muscles in the right orbit. She was diagnosed with bilateral OM. Infectious, endocrine, and autoimmune work-up was performed which were unrevealing and her OM was likely an EIM of her CD. She was started on prednisone 40 mg daily, which resulted in complete resolution of her symptoms at one-week follow-up. She was kept on ustekinumab maintenance therapy as she remained in clinical remission without evidence of other EIMs and completed her steroid taper without further complication. The patient was informed of the high recurrence rate of CD-associated OM and close follow-up was arranged. (Figure) Discussion: Overall, our patient’s OM was a likely EIM of her CD, as further laboratory work-up for commonly implicated etiologies to include thyroid disease, vasculitides, sarcoidosis, and IgG4-related disease was all negative. This case illustrates a rare EIM of CD in a patient believed to be in clinical remission, emphasizing the point that certain EIMs may occur independently of gastrointestinal luminal disease activity. Given that a high index of suspicion was necessary to reach the diagnosis given the subtle exam and imaging findings, this case also reiterates the importance of timely diagnosis and early management to minimize morbidity risk, which can be best accomplished through multidisciplinary coordination among subspecialty providers.Figure 1.: Orbital CT, Coronal- Asymmetric enlargement of the medial rectus in the RT orbit.

AN UNUSUAL PRESENTATION OF ORBITAL PSEUDOTUMOR

The term orbital pseudotumor refers to a broad category of non-specic idiopathic inammations of the orbit, which may affect any orbital structure. A 28-year-old female presented with swelling in the right upper eyelid for 1 month associated with pain and mild redness of the eye. She was previously been seen by other ophthalmologists and diagnosed as Hordeolum Internum prescribed oral antibiotics and advised incision and drainage. She visited our OPD for secondary opinion and surgical treatment. Best Corrected Visual Acuity- R/E- 6/9, LE -6/6P. No Proptosis. No Limitation of Extra Ocular Movements. Considering the clinical presentation of the patient Computed Tomography orbit was advised, revealed abnormal soft tissue density in lateral aspect of right orbit within extraconal compartment suggestive of Orbital Pseudotumor. The patient was started on oral steroids and had a favourable outcome with no recurrence till date.

Clinical correlations of extraocular motility limitation pattern in orbital fracture cases: a retrospective cohort study in a level 1 trauma centre

ABSTRACT Purpose Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits. Methods This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval. Results 278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3–27.2) and 5.22 (95%CI: 1.9–13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161). Conclusions OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma.

Pearls & Oy-sters: Deep Phenotyping of Abnormal Eye Movements Advances the Detection of Gerstmann-Sträussler-Scheinker Syndrome.

A 58-year-old previously healthy woman presents with 3 years of rapidly progressive ataxia, parkinsonism, dysautonomia, peripheral neuropathy, leg weakness, spasticity, hyperreflexia, and mild vertical-gaze palsy. She has a matrilineal family history of neurodegenerative diseases. She was initially postulated to have spinocerebellar ataxia or atypical parkinsonism with cerebellar features. However, on closer inspection, her abnormal extraocular eye movements suggested rare mimicking disorders such as prion disease as part of the differential diagnosis, requiring further evaluation. This case highlights how deep phenotyping can open new diagnostic considerations, inform additional workup, and yield the precise diagnosis of Gerstmann-Sträussler-Scheinker syndrome (GSS).

Acute Cognitive Dysfunction in a Patient With Traumatic Brain Injury: A Clinical Vignette.

Acute Cognitive Dysfunction in a Patient With Traumatic Brain Injury: A Clinical Vignette.

LESI NERVUS OKULOMOTOR INVOLVED PUPIL ET CAUSA ANEURISMA PADA PASIEN DENGAN STROKE SUBARACHNOID HEMORRHAGIC DAN SYSTEMIC LUPUS ERITHEMATOSUS

Introduction: Oculomotor nerve palsy is an pathological condition caused by microvascular injury, head injury, compression due to neoplasm or aneurysm, and also oculomotor nerve palsy can be caused by autoimmune prosses. Peripheral neuropathy is one of the clinical manifestations in patient with SLE, Oculomotor nerve palsy is one type of cranial neuropathy seen with SLE patient. Patient with SLE have a higher risk of serebrovascular event than general population. Case Illustration: Female 34 years old complained drop of the eyelid on the left eye and double vision when see with both eyes since 1 mounth before examination. Patient with history of headace and diagnosed with SLE since 2006 with regular treatment. From the examination, pupil anisocor, on the right eye pupil was 3 mm in diameter with positif direct and indirect reflex. On the left eye pupil was 6 mm with negative direct and indirect reflex. Extraocular movement on the left eye was limited except abduction movement. CT-Scan examination shows bilateral subarachnoid hemorrhage and from CT-Angiography shows dilatation of the left siphon carotid artery. Patient was diagnosed with oculomotor nerve palsy involving pupil caused by aneurysm with SAH and SLE. Discussion: Oculomotor nerve palsy mostly caused by aneurysm compression in posterior communicating artery (PCoA) and internal carotid artery (ICA). Cerebrovascular imaging, MRA and CTAngiography, can showing the aneurysm and its location. Risk of cerebrovascular event increased in patient with SLE than general population. Management patient with oculomotor nerve palsy with SLE nowadays is with pulse dose corticosteroid. Conclusion: SLE with oculomotor nerve palsy will increase risk of cerebrovascular event. Key Words : Oulomotor Nerve Palsy, Subarachnoid Hemorrhage, Systemic Lupus Erithematosus