Extraocular Muscle Movement Research Articles

Index of Suspicion

Index of Suspicion

Multidisciplinary Approach in Managing Orbital Tumors in Ibadan, Nigeria

Patient A. O., an 8-year-old school pupil presented to the Eye Clinic of the University College Hospital, Ibadan with a 3 year history of gradual painless protrusion of the left eye. She lost vision in the eye 4 months before presentation. The general examination was normal. No features of neurofi bromatosis were found. The visual acuity were 6/5 and NLP in the right and left eyes respectively. There was a non-axial proptosis of about 18 mm in the left eye. The deviation was down and out. No palpable mass was felt, and the orbital rim was smooth. The proptosis was not tender, non-retropulsive, non-pulsatile and no bruit was heard over the eyeball. The extra ocular muscle movements were full in all directions of gaze (Fig. 1A). An afferent pupillary defect was present in the left eye. Dilated fundoscopy showed left optic atrophy. The right eye was normal. A cranial CT scan showed a fusiform enlargement of the left optic nerve compressing the eyeball. No intracranial extension was seen. (Fig. 1B) An assessment of left optic nerve glioma was made. Differential diagnosis of unilateral proptosis in the young includes orbital cellulitis, orbital tumors such as Burkitt’s lymphoma, myeloid leukemia and secondaries. Further evaluation and investigations supported an optic glioma. Case 2 Patient A.B, 47 year old woman with 10 year history of gradual painless proptosis of the right eye. Examination showed right visual acuity of 6/12, non axial proptosis, superotemporal fi rm, non tender orbital mass, mild ophthalmoplegia, and choroidal folds on fundoscopy. The right optic disc was normal. Regional lymph nodes were not palpably enlarged. The left eye was normal at presentation. Cranial computerized tomography scan showed a circumscribed superolateral orbital mass, with no intracranial extension. An assessment of a lacrimal gland tumour was made. The two patients had lateral orbitotomy in conjunction with the maxillofacial surgeons. At surgery, a C shaped skin incision was made just lateral to the lateral orbital rim, Hemostasis was secured. Subcutaneous tissue and temporalis muscle were dissected to gain access to the lateral orbital rim. Periosteal elevator was used to expose the fronto zygomatic suture, and with the aid of a drill, two bore holes were drilled on either sides of the suture to facilitate the removal of a bone window by a rotating electric saw (Fig. 1D).

Stroke and Visual Rehabilitation

Many patients will experience some type of visual dysfunction following a stroke. The visual changes associated with stroke can be categorized as sensory (visual acuity and visual field), motor (extraocular muscle motility), and perceptual. These disturbances affect the patient’s quality of life and can impede overall rehabilitation. Many of these impairments can be addressed by simple yet effective techniques. As a result, vision rehabilitation specialists are becoming an important part of the multidisciplinary stroke rehabilitation team.

Index of Suspicion

Index of Suspicion

Tetracycline delays ocular motility decline in chronic progressive external ophthalmoplegia

Chronic progressive external ophthalmoplegia (CPEO) is a mitochondrial cytopathy characterized by bilateral ptosis during adolescence, followed later by limitation of extraocular muscle movement and diplopia.1 The biochemical defect consists of mutations or deletions of mitochondrial DNA genes that encode respiratory chain enzymes involved in adenosine triphosphate (ATP) generation and its subsequent translocation from the mitochondria.1 To date, there is no definitive treatment that reverses or halts the progression of the muscle weakness. Herein, we report improvement in ocular motility in a patient with CPEO following treatment with tetracycline. The retrospective review was approved by the institutional review board. A 47-year-old woman, with bilateral upper eyelid ptosis since childhood, underwent ptosis repair in 1987, at age 28. There was a gradual return of the ptosis over the ensuing years. By age 33, she began experiencing diplopia. She had otherwise enjoyed excellent health. Her family history was significant for six brothers and three sisters with ptosis. We initially evaluated her in October 1997, at age 38, for diplopia and ptosis. Her visual acuity was 20/20 for both eyes. There was 6- to …

Congenital Sudoriferous Cyst within the Orbit Followed by Esotropia

PurposeTo report a case of congenital sudoriferous cyst of the orbit with esotropia.MethodsA 20-day-old male, born prematurely presented with a palpable lump on left upper lid. Orbital ultrasonography including color doppler image and orbital magnetic resonance image were performed to evaluate the lid lesion. The mass was excised and histologically examined. Complete ocular examination including visual acuity, duction, version, and the presence of strabismus were performed.ResultsA well circumscribed round cystic mass, measuring 1.4×1.3 cm was noted at medial superior aspect of the left orbit. It compressed and displaced the left globe to inferior posterior position with intact optic nerve. Histopathologic examination showed the lesion to be a solitary sudoriferous cyst lined by two layers of cuboidal epithelial cells with eosinophilic cytoplasm. After the excision of the mass, limitations of extraocular muscle movements, esotropia, and amblyopia were noted.ConclusionsIf an orbital cyst affects the globe or extraocular muscles, it should be excised as soon as possible to prevent strabismus and amblyopia especially in infant.

Eosinophilic Lymphogranuloma (Kimura's Disease) of Lacrimal Gland-A Case Report

Purpose: To report an unusual presentation of orbital Kimura's disease in an elderly patient. Method: Case report. Result: A 78-year-old male presented with a slowly protruding left eyeball that had developed over 7 months. Extraocular muscle motility was mildly limited. Orbital CT scan revealed an enhanced tumor arising from the lacrimal gland, occupying almost the whole retrobulbar space. Chest X-ray revealed a pulmonary nodule over the right upper lung field. Under the impression of orbital lymphoproliferative disorder or metastatic lung cancer, he received diagnostic biopsy through lateral orbitotomy. Histological examination demonstrated follicular hyperplasia of lymphoid tissue with variable interollicular eosinophil infiltration and proliferation of thin wall vessels. A complete set of immunocytochemical analysis helped to reach a diagnosis of Kimura's disease. Immunostaining of CD3 and CD20 demonstrated structures of lymphoid follicles. Absence of CD10 and bcl-2a reactivity excluded the suspicion of lymphoid malignancy. Treatment with oral prednisolone, starting from 15mg per day, gradually stabilized the proptosis. Conclusion: This is a case of orbital Kimura's disease with the oldest-aged patient reported in Taiwan. Diagnosis was based on histopathological findings with complete immuno-histological analysis.

Slow-release lanreotide in Graves’ ophthalmopathy: A double-blind randomized, placebo-controlled clinical trial

SS analogs are an attractive alternative in treating Graves' ophthalmopathy (GO). Most of the previous studies were uncontrolled and enrolled few patients. The present study was conducted as a larger scale, prospective, randomized controlled study to determine the effectiveness of a slow-release formulation of lanreotide in GO. Sixty patients with active GO received an im injection every two weeks of either lanreotide 30 mg or placebo for 12 weeks. They were then followed and further treated in the traditional way if necessary. The Clinical Activity Score (CAS) was the primary efficacy criterion. Proptosis, diplopia, corneal erosion or ulcer, visual acuity, extraocular muscle movement and intraocular pressure were also evaluated. At the end of the 12 weeks, the mean CAS was not significantly decreased in the lanreotide group compared to the placebo group. The overall mean difference of proptosis between these two groups also did not reach significance at 12 weeks. Only diplopia at downward gaze had significant improvement for the lanreotide- treated group vs placebo group (p = 0.03). No differences were observed between the two groups compared to other outcome measures. During the 24-month follow-up after the clinical trial, 14 patients received eye surgery in the placebo group compared with 10 patients in the lanreotide group (p = 0.29). Six patients received methylprednisolone pulse therapy in the placebo group and two patients in the lanreotide group (p = 0.25). In conclusion, lanreotide treatment had no significant effects on GO compared with placebo.

Stability of gold bead tissue markers

Significant soft tissue features in the orbit and elsewhere are not resolved by MRI or any other imaging method. We describe a new method that uses tiny ( approximately 0.1 mm diameter) gold beads as markers to visualize movements of such tissues with high spatial resolution ( approximately 100 microm) and moderate temporal resolution ( approximately 100 ms). We describe bead fabrication, implantation, imaging, and image processing to extract three-dimensional bead coordinates. We then present results of an experiment to determine the stability of gold bead tissue markers (GBTMs) over time in normally moving orbital tissues. Most beads (76%) implanted in sclera, muscle, tendon, and connective tissue were highly stable over the 6-month measurement period. Beads that were judged unstable drifted only a few 100 microm. Bead flows with gaze suggested that posterior Tenon's capsule moves with the globe, that the lateral rectus belly may sideslip, producing "bridle forces," and that the posterior medial rectus pulley sling moves freely anteriorly and posteriorly, but hardly vertically, as required by the "coordinated active pulley" hypothesis. The GBTM method seems applicable to study such short time course phenomena as extraocular muscle (EOM) and connective tissue movement as a function of gaze and such long time course phenomena as myopic eye growth.

Comparison of Different Surgical Management Approaches in the Treatment of Strabismus in Dysthyroid Ophthalmopathy

the Treatment of Strabismus in Dysthyroid Ophthalmopathy Scott M. Thomas, Oscar A. Cruz; Saint Louis University School of Medicine, St. Louis, MO Introduction: Surgical management of strabismus caused by dysthyroid ophthalmopathy has a history of variable outcomes ranging from 44 to 74%. However, in 2002, Nguyen et al. showed that correcting the restricted duction seen in thyroid eye disease, rather than the deviation as is done in other types of strabismus surgery, resulted in improved success rates. This important observation changed the way many strabismus surgeons approach surgical management in dysthyroid ophthalmopathy. Methods: Retrospective nonrandomized comparative trial. Results: Eighty-six patients were enrolled in this study, including 52 in the deviation correction group (controls) and 34 in the duction correction group (cases), with 73 control and 47 case operations. A successful outcome, defined as postoperative deviation less than or equal to 5 PD, was seen in 71% of controls and 66% of cases (P 0.55). Discussion: The marked improvement in postoperative outcomes described by Nguyen et al. convinced many surgeons to adapt this alternative technique. Furthermore, it seemed logical that the restrictive nature of the strabismus seen in thyroid eye disease warranted a different surgical approach than is used for other strabismus etiologies. We have demonstrated, however, no statistically significant difference exists between these two methods. Conclusions: There was no difference in outcome between surgical corrections of restricted duction versus deviation. Surgeons may choose from either operation, depending on their preference, and may expect similar results. Reference: 1. Nguyen VT, Park DJJ, Levin L, et al. Correction of restricted extraocular muscle motility in surgical management of strabismus in Graves’ ophthalmopathy. Ophthalmology 2002;109:384-8.

Literature review regarding the methodology of assessing third nerve paresis associated with non-ruptured posterior communicating artery aneurysms

The association of third cranial nerve palsy subsequent to an enlarging posterior communicating artery (P-Com A) aneurysm has been well described. In our current communication, we review the relevant literature and propose a classification system for the severity of the third cranial nerve palsy, correlating it to the postoperative recovery. Our four grade scale (I-IV) included the degree of the levator palpebrae muscle paresis, the presence of pupillary reaction and the impairment of the third nerve mediated extraocular muscle movement. We evaluated five patients with third nerve palsy secondary to non-ruptured, P-Com A aneurysm. Patients were re-evaluated at 2, 4, 8, 24 weeks postoperatively. Four of the five patients had complete recovery within 4-8 weeks after surgery. One patient had grade II third nerve paresis and complete resolution of the third nerve symptoms within 4 weeks, whereas three patients with grade III and IV had complete resolution 4-8 weeks after surgery. The fifth patient, with grade IV paresis, had minimal (grade III) improvement 6 weeks after surgery, and incomplete recovery (grade I) 6 months postoperatively. Our simple grading system of third nerve palsy associated with P-Com A aneurysms, can be a helpful tool for the initial evaluation and for the monitoring of recovery in these patients.

Posttraumatic abducens to oculomotor nerve misdirection

Paradoxical patterns of extraocular muscle, eyelid, or pupillary movements can occur following injury between divisions of the oculomotor nerve, trigeminal and abducens nerves, and trigeminal and oculomotor nerves. We report three cases of unusual ocular motility and eyelid movements that are a result of aberrant connections between the abducens and oculomotor nerves. Three patients with unusual eye movement abnormalities after trauma were studied. A complete ophthalmic examination plus neuroradiologic evaluation were performed. Each patient manifested an aberrant connection between the 6th and 3rd cranial nerves resulting in third nerve function during sixth nerve stimulation. Two patients demonstrated complete third nerve palsies except for adduction on attempted abduction. The third showed improved bilateral ptosis on abduction. The neuroanatomical abnormalities involve intraorbital structures in one patient and central nervous system pathways in the others. Explanations such as retrograde regeneration, ephaptic transmission, or denervation supersensitivity do not appear to explain these unusual eye movements. The most likely mechanism involves some form of peripheral neuronal misdirection. These rare sixth to third nerve misdirection cases add support to the "neuronal misdirection hypothesis" of aberrant eye movements after trauma.

CT of orbital trauma.

In a patient with acute orbital trauma, visual acuity and extraocular muscle motility are the two most important ophthalmologic functions to be evaluated emergently. The assessment of these capabilities may sometimes be difficult due to the severity of the head injury, the extent of periorbital soft tissue edema, inadequate cooperation in alert patients, and a reduced level of consciousness in obtunded individuals. Consequently, computed tomography (CT) has come to play a major role in the orbital examination of acute trauma patients. In this study, in conjunction with clinical evaluation, we have sought to utilize CT to determine the various prevalences of the causes of decreased visual acuity and extraocular muscle motility resulting from orbital trauma. We retrospectively reviewed the records of all patients admitted to our emergency facility who, having suffered head trauma, underwent a CT study for diagnosis. CT examinations of the head using a multidetector scanner were performed from the base of the skull to the vertex at 5-mm intervals. Orbital CT was obtained when a routine CT of the head showed periorbital soft tissue edema and/or facial bone fractures. The orbital CT examination was performed using axial 1-mm and coronal 3-mm slices. Coronal reformation images were prepared if the patient was unable to tolerate the prone position for direct coronal imaging. The imaging findings were correlated with ophthalmologic observations. The orbit floor was the most common and the orbital roof the least common site of fracture of the bony coverings of the eye. Twenty-three patients suffered decreased visual acuity. In order of declining frequency, the causes of reduced vision consequent to trauma were retrobulbar hemorrhage, optic nerve thickening presumably secondary to edema, intraorbital emphysema, optic nerve impingement, detached retina and ruptured globe. Five patients had visual impairment without demonstratable radiographic abnormalities. The most common finding associated with diminished extraocular muscle motility was muscle impingement by fracture fragments, followed in decreasing frequency by thickened muscle due to edema or contusion, intraconal emphysema, muscle entrapment, and retrobulbar fat herniation. Six patients with decreased extraocular muscle activity had no abnormalities demonstrated on CT images. The overwhelming majority of patients with decreased visual acuity or reduced extraocular muscle motility consequent to trauma had abnormalities demonstrated by orbital CT. Hence, CT examinations should play a major role in the evaluation of the intraorbital contents in patients with orbital trauma.

Correction of restricted extraocular muscle motility in surgical management of strabismus in graves’ ophthalmopathy

Objective To compare the success rates for strabismus surgery designed to correct limitation of duction with surgery designed to correct deviation in patients with Graves’ ophthalmopathy. Design Retrospective nonrandomized comparative trial. Participants One hundred thirty-seven patients with Graves’ ophthalmopathy who had undergone at least one extraocular muscle surgery were divided into two groups: those whose first surgery occurred before June 1997 (control group) and those whose first surgery occurred in June 1997 or thereafter (case group). Interventions Extraocular muscle surgery primarily directed at either correcting deviation (control group) or correcting limitation of ductions (case group). Main outcome measures Postoperative deviations in the primary position were measured in prism diopters 30 to 180 days after surgery. A postoperative deviation of less than 5 diopters was considered a successful surgical outcome. Results Patients undergoing strabismus surgery specifically designed to correct limitation of duction achieved a 74% success rate compared with a 44% success rate in the control group (P < 0.01). Furthermore, the rate of reoperation in this group was only 27% compared with 44% in the control group (P < 0.04). Conclusions Compared with surgery aimed primarily at the correction of deviation, extraocular muscle surgery tailored to address restriction of ductions in patients with Graves’ ophthalmopathy is associated with improved surgical success of initial realignment and with a lower rate of reoperation

Management of the trochlea of the superior oblique muscle in the repair of orbital roof trauma

Purpose: This study evaluated whether reattachment of the trochlea is necessary to assure normal postoperative extraocular muscle movements after orbital roof exploration and trochlea detachment.Patients and Methods: This was a retrospective review of 889 operative records of one surgeon practicing at a level I trauma center between January 1, 1992 and December 31, 1998. Three hundred twenty-four of these cases were trauma related, 97 of which involved the upper facial third or upper midface. From this group, 15 patients required orbital roof exploration with trochlea detachment. Age, gender, cause of injury, form of craniofacial injury, method of repair, materials used, date of first notation of intact extraocular movement, and date of last follow-up were recorded and analyzed.Results: From among the 15 patients requiring orbital roof exploration and repair, 14 (93%) were male, with a mean age of 34.7 ± 15.2 years. Eight (53%) were involved in motor vehicle accidents, 3 (20%) in motorcycle accidents, and 4 (27%) in high-energy impacts. Most (95%) had injuries that included the frontal sinus, the naso-orbital-ethmoid region (60%), and the orbital rims (60%). After bitemporal flap reflection, careful subperiosteal dissection, supraorbital and supratrochlear nerve repositioning, and trochlea detachment, simple reapproximation of the orbital soft tissues to the reconstructed orbit resulted in satisfactory extraocular muscle movements in all cases.Conclusions: When careful subperiosteal dissection is used, simple reapproximation of the soft tissues adjacent to the reconstructed orbital roof, without reattachment of the trochlea, is all that was necessary to assure satisfactory extraocular muscle movements postoperatively.

Management of the trochlea of the superior oblique muscle in the repair of orbital roof trauma

<h2>Abstract</h2> <b>Purpose:</b> This study evaluated whether reattachment of the trochlea is necessary to assure normal postoperative extraocular muscle movements after orbital roof exploration and trochlea detachment. <b>Patients and Methods:</b> This was a retrospective review of 889 operative records of one surgeon practicing at a level I trauma center between January 1, 1992 and December 31, 1998. Three hundred twenty-four of these cases were trauma related, 97 of which involved the upper facial third or upper midface. From this group, 15 patients required orbital roof exploration with trochlea detachment. Age, gender, cause of injury, form of craniofacial injury, method of repair, materials used, date of first notation of intact extraocular movement, and date of last follow-up were recorded and analyzed. <b>Results:</b> From among the 15 patients requiring orbital roof exploration and repair, 14 (93%) were male, with a mean age of 34.7 ± 15.2 years. Eight (53%) were involved in motor vehicle accidents, 3 (20%) in motorcycle accidents, and 4 (27%) in high-energy impacts. Most (95%) had injuries that included the frontal sinus, the naso-orbital-ethmoid region (60%), and the orbital rims (60%). After bitemporal flap reflection, careful subperiosteal dissection, supraorbital and supratrochlear nerve repositioning, and trochlea detachment, simple reapproximation of the orbital soft tissues to the reconstructed orbit resulted in satisfactory extraocular muscle movements in all cases. <b>Conclusions:</b> When careful subperiosteal dissection is used, simple reapproximation of the soft tissues adjacent to the reconstructed orbital roof, without reattachment of the trochlea, is all that was necessary to assure satisfactory extraocular muscle movements postoperatively. © 2000 American Association of Maxillofacial Surgeons

Measuring Eye Movements in Graves?? Ophthalmopathy

Background: The current grading of class IV (extraocular muscle involvement) of the NO SPECS classification for Graves ophthalmopathy is subjective and, in practice, virtually limited to three grades (grade c rarely occurs). The subjectiveness results in a high degree of observer disagreement, as illustrated by kappa values of 0.48 to 0.64 for the agreement between the authors in grading of class IV changes in 13 patients. Methods: The authors investigated the significance of a quantitative approach in assessing eye motility and modified a hand perimeter to measure the monocular eye movements in degrees. Results: The mean maximal excursions in the four main directions of gaze, obtained with this device in 40 healthy control subjects (5 men and 5 women from each decade between 20 and 60 years of age), were as follows: elevation=34°, depression=58°, adduction=48°, and abduction=46°. The ductions showed an age-related decline. The intraobserver and interobserver variations were assessed in 12 and 18 patients with Graves ophthalmopathy, respectively, by calculating the coefficients of repeatability, which varied from 5° to 8°. The authors compared the current grading of NO SPECS class IV with quantitative measurements of elevation in 11 patients by calculating the kappa values for agreement. These were found to be 0.57 and 0.80, respectively. Conclusions: The quantitative measurement of eye movements with a modified perimeter appears to be precise and reproducible. In addition, it should replace the current grading of the extraocular muscle movements of Graves ophthalmopathy patients in the NO SPECS classification, which is less reliable, as evidenced by a higher degree of observer disagreement.

Measuring Eye Movements in Graves Ophthalmopathy

The current grading of class IV (extraocular muscle involvement) of the NO SPECS classification for Graves ophthalmopathy is subjective and, in practice, virtually limited to three grades (grade c rarely occurs). The subjectiveness results in a high degree of observer disagreement, as illustrated by kappa values of 0.48 to 0.64 for the agreement between the authors in grading of class IV changes in 13 patients. The authors investigated the significance of a quantitative approach in assessing eye motility and modified a hand perimeter to measure the monocular eye movements in degrees. The mean maximal excursions in the four main directions of gaze, obtained with this device in 40 healthy control subjects (5 men and 5 women from each decade between 20 and 60 years of age), were as follows: elevation = 34 degrees, depression = 58 degrees, adduction = 48 degrees, and abduction = 46 degrees. The ductions showed an age-related decline. The intraobserver and interobserver variations were assessed in 12 and 18 patients with Graves ophthalmopathy, respectively, by calculating the coefficients of repeatability, which varied from 5 degrees to 8 degrees. The authors compared the current grading of NO SPECS class IV with quantitative measurements of elevation in 11 patients by calculating the kappa values for agreement. These were found to be 0.57 and 0.80, respectively. The quantitative measurement of eye movements with a modified perimeter appears to be precise and reproducible. In addition, it should replace the current grading of the extraocular muscle movements of Graves ophthalmopathy patients in the NO SPECS classification, which is less reliable, as evidenced by a higher degree of observer disagreement.

Peribulbar Anesthesia Effect of Bicarbonate on Mixtures of Lidocaine, Bupivacaine, and Hyaluronidase with or without Epinephrine

The pH-adjustment of local anesthetic solutions with sodium bicarbonate may shorten onset time and improve spread of neural blockade. The authors undertook a prospective, double-masked, randomized study to see if a pH-adjusted mixture of lidocaine, bupivacaine, and hyaluronidase had faster and more complete onset of neural blockade, when used for peribulbar anesthesia. Eighty patients were randomly assigned to four groups and received a peribulbar block with one of four mixtures: group 1 (L) = 2% lidocaine, group 2 (LPH) = 2% lidocaine with 0.06 meq/ml sodium bicarbonate, group 3 (LE) = 2% lidocaine with 1:100,000 epinephrine (commercially prepared), or group 4 (LEPH) = 2% lidocaine with 1:100,000 epinephrine with 0.06 meq/ml sodium bicarbonate. To 5 ml of each of the preceding groups, 5 ml of 0.75% bupivacaine and 150 units of hyaluronidase was added. After each block, extraocular muscle movement was followed in each quadrant until akinesia developed. In the event of incomplete akinesia, blocks were supplemented at 20 minutes. The LPH group had the fastest onset to complete akinesia (7.0 ± 2.0 minutes, mean ± SEM) when compared with the onset time of all other groups (group 1 = 11.5 ± 1.9 minutes, group 4 = 13.1 ± 1.4 minutes, and group 3 = 16.0 ± 1.8 minutes, significance greater than 95% by analysis of variance). Furthermore, when compared with group 3 by analysis of variance, group 4 had a faster onset time. The authors conclude that pH-adjustment of solutions with bicarbonate of either Lidocaine/bupivacaine/hyaluronidase or commercially prepared lidocaine with epinephrine/bupivacaine/hyaluronidase decreases the onset time of peribulbar anesthesia.

91. 高速 CT 装置よる眼球動態スキャン (EOM スキャン) について(第 46 回総会学術大会会員研究発表予稿)

91. 高速 CT 装置よる眼球動態スキャン (EOM スキャン) について(第 46 回総会学術大会会員研究発表予稿)