Fisher syndrome (FS) is characterized by acute extraocular muscle paralysis, ataxia, and absent tendon reflexes, along with positive anti-GQ1b antibodies. However, incomplete forms of the syndrome, in which only some of the symptoms are present, are known to exist. In this report, we present two cases of incomplete Fisher syndrome with unilateral ocular motor dysfunction. Both patients were positive for anti-GQ1b antibodies and exhibited mild ataxia as the only other neurological symptom, but improved without treatment intervention. This case report highlights the need to recognize that incomplete forms of this syndrome, presenting with unilateral ocular muscle paralysis, exist within the disease spectrum.

Background: Cobras (Naja sp.) are medically important snakes in Thailand. Envenoming by the monocled cobra (N. kaouthia) often causes neurotoxicity, most notably ptosis, ophthalmoplegia, local tissue necrosis and progressive paralysis leading to respiratory failure. Early antivenom administration and respiratory support are medically significant for effective treatment. Methods: In this study, we determined the association between the time course of cobra envenoming and related neurotoxic outcomes using the clinical profiles of cobra envenomed patients. We also demonstrated histopathological changes in the neuromuscular junction of the diaphragm in experimentally envenomed rats. Results: A retrospective study of 69 cases of cobra envenoming in Central and Southern Thailand shows that delayed arrival beyond one hour at hospital was common among younger adults (47.0% aged 10-29) and associated with more severe neurotoxicity, including higher rates of ptosis (41.2%, p = 0.032) and referrals (41.2% vs. 15.4%, p = 0.040). Antivenoms (22 Monovalent and 1 Polyvalent) were administered to 23 (33.3%) envenomed victims and caused adverse reactions in 9 cases (39.1%). Neurotoxicity following cobra envenoming in the clinical section correlated with histopathological examination of envenomed rat diaphragms. Transmission electron microscopy (TEM) revealed degeneration of the neuromuscular junction and diaphragm within 1 h following experimental cobra envenomation, which worsened by 4 h. Intravenous administration of antivenom at recommended doses reduced diaphragmatic damage but failed to prevent presynaptic degeneration after 90 min of envenoming. Conclusions: Clinically, extraocular muscle paralysis was the earliest manifestation. Early monitoring and prompt administration of antivenom are essential to reduce neurotoxicity and relevant complications.

In skull base surgery, preservation of the cranial nerve function of III and VI is an important consideration for maintaining the visual function and quality of life of patients. Nevertheless, intraoperative neurophysiological monitoring is not generally performed, mainly because of the technical difficulties in accurately inserting recording electrodes into the inferior rectus and lateral rectus muscles, which involve cranial nerves III and VI, respectively. In this case, electromyography (EMG) was monitored by inserting 25-mm insulated needle electrodes into the inferior rectus and lateral rectus muscles. As a result, clear EMG waveforms could be stably observed in both muscles. The patient recovered without extraocular muscle paralysis after surgery. This case shows that intraoperative extraocular muscle monitoring can help evaluate the function of the third and sixth cranial nerves, and suggests that monitoring with a 25-mm insulated needle electrode is an effective method.

To observe the effect of the direct stimulation of acupuncture at extraocular muscle attachment point on acquired extraocular muscle palsy. Thirteen patients with acquired extraocular muscle palsy were treated with acupuncture directly at extraocular muscle (paralytic muscle) attachment point. Firstly, the intraocular conjunctival sac drops of topical anesthetic (procaine hydrochloride eye drops) were administered, 0.2 mL each time, once every 10 minutes, for a total of 3 times. Acupuncture was delivered immediately after the third drop. The sterile acupuncture needle for single use, 0.25 mm×25 mm, was inserted at the anatomical location of the corneal limbal attachment of paralytic extraocular muscle, with an angle of 10° to 15° formed between the needle tip and extraocular muscle, and a depth of 0.3 mm to 0.5 mm. Pivoted by the needle tip, the eyeball was moved passively towards the direction of normal action of orbital muscle, 30 to 50 times until the patient felt soreness of the eyeball; afterwards, the needle was removed. After acupuncture, levofloxacin eye drops were administered once (0.2 mL) at the affected eye. The treatment was given twice a week, and completed when diplopia disappeared. Before and after treatment, the diplopia and the synoptophore circumference were observed respectively. After 7 to 24 (15.46±5.56) times of direct stimulation with acupuncture at extraocular muscle attachment point, the symptoms of diplopia disappeared in 13 patients, the eye position restored to orthophoria, and the circumference of synoptophore was reduced to be (4.04±0.82)° from (19.38±3.98)° detected before treatment (P<0.05). Acupuncture directly at extraocular muscle attachment can attenuate diplopia and improve ocular muscle function in patients with acquired extraocular muscle palsy.

To develop different machine learning models to train and test diplopia images and data generated by the computerized diplopia test. Diplopia images and data generated by computerized diplopia tests, along with patient medical records, were retrospectively collected from 3244 cases. Diagnostic models were constructed using logistic regression (LR), decision tree (DT), support vector machine (SVM), extreme gradient boosting (XGBoost), and deep learning (DL) algorithms. A total of 2757 diplopia images were randomly selected as training data, while the test dataset contained 487 diplopia images. The optimal diagnostic model was evaluated using test set accuracy, confusion matrix, and precision-recall curve (P-R curve). The test set accuracy of the LR, SVM, DT, XGBoost, DL (64 categories), and DL (6 binary classifications) algorithms was 0.762, 0.811, 0.818, 0.812, 0.858 and 0.858, respectively. The accuracy in the training set was 0.785, 0.815, 0.998, 0.965, 0.968, and 0.967, respectively. The weighted precision of LR, SVM, DT, XGBoost, DL (64 categories), and DL (6 binary classifications) algorithms was 0.74, 0.77, 0.83, 0.80, 0.85, and 0.85, respectively; weighted recall was 0.76, 0.81, 0.82, 0.81, 0.86, and 0.86, respectively; weighted F1 score was 0.74, 0.79, 0.82, 0.80, 0.85, and 0.85, respectively. In this study, the 7 machine learning algorithms all achieve automatic diagnosis of extraocular muscle palsy. The DL (64 categories) and DL (6 binary classifications) algorithms have a significant advantage over other machine learning algorithms regarding diagnostic accuracy on the test set, with a high level of consistency with clinical diagnoses made by physicians. Therefore, it can be used as a reference for diagnosis.

The current study aims to report cases of immune reconstitution inflammatory syndrome (IRIS) following Cushing's syndrome (CS) treatment and elucidate various presentations of IRIS and its management. A single-centre study was conducted in individuals with endogenous CS who presented with immune reconstitution inflammatory syndrome after CS remission. A literature review was also conducted to describe the previous reporting of IRIS. Nine cases from the author's centre were identified. Out of 9 cases, one case was ectopic CS, who presented with CNS vasculitis following excision of the primary lesion. Other 8 cases were Cushing's disease (CD) presented with diverse IRIS manifestations in the form of thyroiditis, oculomotor neuritis, extraocular muscle palsy, episcleritis, bell's palsy, rheumatoid arthritis (RA) and Charcot neuroarthropathy, with the time of presentation from less than 1 month till 24 months. The most common IRIS described in the literature is thyroid dysfunction, and the time of presentation of IRIS is variable from less than one month to 5 years. Immune reconstitution inflammatory syndrome is a unique and rare post-operative complication after CS remission, affecting various organ systems due to rebound immunity.

Incomplete Miller-Fisher syndrome (MFS) is a rare autoimmune disorder affecting the nervous system. In contrast to classical MFS, its clinical manifestations are often atypical and may be characterized by the absence of certain features, such as extraocular muscle paralysis and the loss of tendon reflexes. The presence of anti-GD3 antibodies is infrequently observed in these patients. This case report describes a patient diagnosed with incomplete MFS who exhibited positive anti-GD3 antibody results and presented with pyramidal tract signs. This suggests that anti-GD3 antibodies may play a role in the pathogenesis of some atypical forms of MFS, warranting attention in clinical practice.

Clinical symptoms of monocled cobra (Naja kaouthia) envenoming include the paralysis of extraocular muscles, local tissue necrosis and death through respiratory failure. These neurotoxic outcomes are mainly due to the inhibitory action of postsynaptic neurotoxins to nicotinic acetylcholine receptors. However, injuries involving respiratory muscles have rarely been investigated. In this study, we determined the effect of N. kaouthia envenoming on morphological changes in the rat diaphragm. The efficacy of cobra monovalent antivenom in neutralising the histopathological effects of N. kaouthia venom was also evaluated. The intramuscular (i.m.) administration of N. kaouthia venom (2 mg/kg) caused skeletal muscle fibre atrophy and ruptures of myofibrils shown via a light microscope study. Transmission electron microscopy (TEM) revealed the zig-zagging of the Z-band, mitochondrial damages and degeneration of the synaptic fold of the neuromuscular junction following experimental cobra envenoming for 4 h. Intravenous administration of cobra antivenom at manufacturer-recommended doses diminished histopathological changes in the diaphragm following the administration of cobra venom. The expression of NF-kB and MuRF1 in the experimentally N. kaouthia-envenomed diaphragm indicated inflammation and tissue atrophy in the immunofluorescence analysis, respectively. In this study, we found that there were respiratory muscle injuries following N. kaouthia envenoming. The early administration of monovalent N. kaouthia antivenom is capable of neutralising neurotoxic outcomes following cobra envenoming.

ABSTRACT Intrroduction Sixth nerve palsy is the most common type of extraocular muscle palsy. The therapy options in sixth nerve palsies include monitoring with or without conservative treatment, botulinum toxin injections or strabismus surgery. The aim of this retrospective study was to compare botulinum toxin (BT) injections into the medial rectus to conservative treatment in sixth nerve palsies. The rate of patients improved after intervention and treatment outcomes for the two treatment options were be evaluated at a German tertiary referral center. Methods A service evaluation was conducted on adult patients with sixth nerve palsy. Patient files were reviewed and data including abduction deficit and size of deviation were collected retrospectively. Patients which presented between January 1987 and April 2022 were considered. Patients were allocated into two treatment groups: BT injected into medial rectus or conservative treatment, which included observation, providing occlusion and Fresnel prisms. Inclusion criteria were attendance of two visits with orthoptic assessment. Exclusion criteria included presence of further oculomotor palsies, strabismus, strabismus surgery and suppression. Non-parametric statistical analysis was conducted using IBM® SPSS Statistics. Results A total of 606 adult patients with unilateral or bilateral sixth nerve palsy attended during the named period. A total of 137 adult patients met the inclusion criteria. Of which, 36 had a bilateral palsy, 101 had a unilateral palsy. 45.26% (n = 62) were treated with BT injections and 54.75% (n = 75) were treated conservatively. The median initial abduction deficit was greater in the BT group, (−4 to −5 after Scott and Kraft) than in the conservative treatment group (−1). The initial angle of deviation at distance was significantly larger in the BT group than in the conservative treatment group (p = <0.001). The rate of improvement in the BT group was 24.19% (n = 15) and 20% (n = 15) in the conservative treatment group. When excluding longstanding palsies rates of improvement in both groups increased to 28.85%. The improvement of the angle of deviation at distance in all patients was greater in the BT group (p = <.001). The improvement of abduction in bilateral palsies were greater in the BT group (p = .016), but in unilateral palsies, there was no significant difference in abduction improvement in the two treatment groups (OD p = .3, OS p = .406). Conclusion This service evaluation found that BT injection into medial rectus in unilateral and bilateral sixth nerve palsies did not increase the rate of improvement compared to conservative treatment. But BT injections reduced the angle of deviation to a greater extent than conservative treatment. Additionally, BT was able to improve abduction in bilateral palsies to a greater extent than conservative treatment. It is recommended a BT injection is considered in symptomatic bilateral sixth nerve palsies to enable fixation and improved ocular motility. More research is needed to verify reliable clinical guidelines for the use of BT in sixth nerve palsies.

BACKGROUND Miller fisher syndrome (MFS) is a variant of Guillain-Barré syndrome, an acute immune-mediated peripheral neuropathy that is often secondary to viral infections. Anti-ganglioside antibodies play crucial roles in the development of MFS. The positive rate of ganglioside antibodies is exceptionally high in MFS patients, particularly for anti-GQ1b antibodies. However, the presence of other ganglioside antibodies does not exclude MFS. CASE SUMMARY We present a 56-year-old female patient who suddenly developed right blepharoptosis and progressively worsening vision in both eyes. There were flu symptoms prior to onset, and a coronavirus disease 2019 test was positive. On physical examination, the patient exhibited bilateral extraocular muscle paralysis, weakened reflexes in both limbs, and impaired coordination. The cerebrospinal fluid examination results showed no obvious abnormalities. Bilateral peroneal nerve F-waves were not extracted. Serum anti-GD1b IgG and anti-GT1a IgG antibodies were positive. The patient received intravenous methylprednisolone (1000 mg/day), with the dosage gradually decreased. Additionally, intravenous high-dose immunoglobulin treatment was administered for 5 days (0.4 g/kg/day) from day 2 to day 6 of hospitalization. The patient’s symptoms improved after treatment with immunoglobulins and hormones. CONCLUSION Positive ganglioside antibodies may be used as supporting evidence for the diagnosis; however, the diagnosis of MFS is more reliant on clinical symptoms.

Peribulbar anesthesia is a common regional block in intraocular surgeries with an excellent safety profile. We report a rare case of contralateral loss of accommodation and extraocular muscle palsy following peribulbar block (PBB). A patient with right-eye pterygium was planned for pterygium excision with conjunctival autograft under PBB. After PBB, the patient developed blurring of vision and loss of extraocular muscle movements in the contralateral eye. Contrast-enhanced computed tomography scan of the brain and orbit was unremarkable. The patient was stabilized, and surgery was deferred. The patient’s vision and extraocular movements returned spontaneously after 4–5 hours.

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.

Spanish physicians have made important contributions to the nosology of headaches by describing various syndromes. In 1954, Eduardo Tolosa Colomer published the first case of Tolosa-Hunt syndrome, a clinical picture characterized by orbital pain and paralysis of extraocular muscles due to the presence of granulomatous inflammation in the cavernous sinus. In 1980, José Félix Martí Massó described pseudomigraine with cerebrospinal fluid pleocytosis, which manifests with episodes of migraine-type headache, transient neurological deficits, and elevated lymphocytes in the cerebrospinal fluid, usually with a benign prognosis. Since 2002, Juan Pareja and his group have identified several entities including: nummular headache, characterized by pain localized in a small coin-shaped area of the skull; primary trochlear headache, originating in the trochlea, in the superointernal angle of the orbit; epicrania fugax, which manifests with episodes of paroxysmal pain radiating along the surface of the head, following a linear or zigzag trajectory, and idiopathic ophthalmodynia and rhinalgia, which present with pain in the eyeball or nose with no apparent cause. Juan Pareja has also described several trigeminal terminal branch neuralgias, which are characterized by pain limited to the corresponding cutaneous territory and which typically respond to anesthetic blockade of the nerve. Finally, paroxysmal pressing headache, described by the same author, is manifested by brief episodes of unilateral pressing pain without accompanying symptoms. All these descriptions have been documented in scientific publications, and most of them have had a significant impact on clinical practice.

To evaluate the impact of Medpor implantation on extraocular muscle function, eye movement disorders, and diplopia in patients with orbital wall fracture. A retrospective study was conducted on 98 patients (98 eyes) who underwent Medpor implantation surgery at Bethune International Peace Hospital from January 2019 to December 2022. The degree of eyeball enophthalmos and total fracture area in patients before and after surgery, as well as orbital volume were measured. The relationship between enophthalmos severity and total fracture area was analyzed. Changes in extraocular muscle function, eye movement, and diplopia were assessed before and after surgery. Before operation, enophthalmos severity was correlated with the total fracture area (r = 0.323, P = 0.001). After surgery, there was no significant correlation (r = -0.053, P = 0.630). Compared with preoperative measurements, both orbital volume and the volume difference improved significantly after surgery (both P < 0.05). Among the patients who received surgery within 3 weeks, the cure rates for rectus muscle restriction and extraocular muscle paralysis were 94.12% and 100.00%, respectively, higher than those in patients who underwent surgery after 3 weeks (67.27% and 65.62%) (P < 0.05). In comparison of preoperative conditions, notable improvements were observed in both ocular motility disorders and diplopia after operation (both P < 0.05). The total improvement rates in ocular motility disorders at 1, 3 and 6 months of follow-up were 84.69%, 90.82%, 96.94%, respectively, while these rates in diplopia were 89.79%, 91.84% and 95.92%, respectively. Abnormal maxillofacial sensations also improved significantly at 1-, 3-, and 6-month post-surgery (all P < 0.05). Medpor implantation effectively restores extraocular muscle function in patients with orbital wall fractures, significantly alleviating diplopia, eye movement disorders, and maxillofacial abnormalities.

Ophthalmoplegia, a condition marked by paralysis or weakness of extraocular muscles, leads to impaired eye movement and associated visual disturbances. This comparative review focuses on ophthalmoplegia through detailed case studies, aiming to deepen our understanding of the diverse presentations, underlying causes, and treatment responses of the condition. By examining cases of different types of ophthalmoplegia, such as isolated oculomotor nerve palsy, progressive chronic external ophthalmoplegia, and ophthalmoplegia associated with systemic or genetic conditions, this review highlights the range of patient outcomes. The emphasis is on diagnostic strategies, treatment approaches, and patientcentered care. The findings suggest that customized treatment, based on a precise etiological diagnosis and severity, can significantly improve prognosis and quality of life. The review concludes with recommendations for optimizing diagnostic tools and exploring future therapeutic options, including advancements in gene therapy and neurorehabilitation.

BackgroundSepticemia that leads to ocular involvement mostly presents as endophthalmitis or panophthalmitis. Contrarily, septicemia without intraocular involvement, known as hematogenous orbital cellulitis (HOC), involves only the orbit and is an extremely rare complication of septicemia and a rare type of orbital cellulitis.Case presentationFour male patients with septicemia presented with orbital involvement without intraocular infection were described in this study. They were 22 (case 1), 15 (case 2), 79 (case 3), and 30 (case 4) years old, with a mean age of 29.75 years. All patients were immunocompromised except for case 2. Cases 1 and 3 had a history of steroid use, whereas case 4 was in a post-chemotherapy myelosuppression phase. Septicemia in case 1 was community-acquired, cases 3 and 4 were hospital-acquired, and case 2 was secondary to acne squeezing. Blood cultures from cases 1, 2, and 3 were positive for Candida albicans, methicillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae, respectively. Case 4 had negative cultures; however, next-generation sequencing reported the presence of Enterococcus faecalis and Rhizopus oryzae. Case 1 had right eye involvement, and both eyes were involved in the other three cases. According to Chandler’s classification, case 1 was type 2, case 2 was type 2 (OD) and type 4 (OS), and cases 3 and 4 were type 1 orbital infections. All patients had eyelids erythema, and cases 1 and 2 had mildly decreased visual acuity, proptosis, and painful and restricted ocular motility. Hospital stays ranged from 13 to 43 days (mean, 24 days). All patients received systemic antibiotic therapy based on drug sensitivity and next-generation sequencing results, in combination with multidisciplinary treatment, resulting in complete recovery of ocular and systemic signs and symptoms; no ocular surgical interventions were performed. Extraocular muscle palsy was the last symptom to resolve.ConclusionHOC is predominantly seen in immunocompromised individuals with a high proportion of hospital-acquired infections and positive cultures for pathogens. Infection control using systemic antibiotics targeted at the causative organism guarantees a favorable prognosis.

Diabetes mellitus which is a multi systemic disease is a common public health problem which can affect children, young people, adults and older people due to uncontrolled hyperglycemia. Ocular and other systemic complications of diabetes are becoming the most significant cause of visual impairment and other morbidities and are either preventable or curable with early detection and prompt treatment. Its prevalence is increasing globally with sight threatening ocular manifestations. The most of the published articles highlighted that the common ocular manifestations were diabetic retinopathy, snow flake cataract, primary open angle glaucoma, corneal lesions, recurrent stye, Chalazion and extraocular muscle palsies. Treatment options for diabetic retinopathy are laser photocoagulation and intravitreal injection of steroids. Expert opinion is always required in a case with glaucoma, cataract, optic nerve disorders and cranial nerve palsies. Control of blood sugar level, proper nutrition and adequate physical exercise and periodic eye examination can play a crucial role for its prevention.

For example, hypertension leads to cerebrovascular sclerosis and peripheral artery nerve compression, resulting in extraocular muscle paralysis in patients, and then diplopia appears.

Moebius syndrome is a rare congenital neurological disorder whereby there is an underdevelopment or absence of cranial nerve VI (abducens) and cranial nerve VII (facial), leading to weakness or paralysis of facial and extraocular muscles. Abnormalities can also occur in other cranial nerves including the 3rd, 5th, 8th, 9th, 11th and 12th. This article will focus upon the ocular manifestations of Moebius syndrome.

以头痛伴单侧眼外肌麻痹的非典型Miller Fisher综合征一例并文献回顾