Ocular Motility Dysfunction Research Articles

Subclinical Ocular Motility Dysfunction and Extraocular Muscle Changes in Inactive Graves' Orbitopathy.

This study aimed to investigate the presence of structural and functional changes in extraocular muscles (EMs) among patients with inactive Graves' orbitopathy (GO) classified according to the Clinical Activity Score (CAS). Sixty-seven patients with Graves' disease (GD) and inactive GO were included. The data collected included clinical parameters, thyroid function, autoantibody levels, EOM morphology via orbital ultrasound (US), and ocular motility. Patients were stratified into Red Filter Test (RFT)-positive or RFT-negative groups based on the presence or absence of latent diplopia during the RFT examination. Thirty-three patients (49.25%) exhibited latent diplopia on the RFT, despite not reporting double vision during standard ocular motility tests. Significant differences were observed between the two groups in terms of age, disease duration, intraocular pressure (IOP) elevation in up-gaze, and medial rectus muscle thickness (p < 0.05). No significant differences were found in thyroid status, TRAb and ATA levels, CASs, exophthalmos, or lateral rectus thickness between the two groups. This study revealed that in inactive GO, subclinical EM dysfunction and morphological changes may be present, which might not be apparent through routine ocular examinations. The RFT is effective in detecting latent diplopia, highlighting its utility in identifying subtle ocular motility issues and subclinical muscle involvement. Comprehensive evaluations combining functional tests like the RFT and imaging are essential for early detection of GO-related abnormalities, enabling tailored and prompt management and improving patient outcomes.

Understanding Visual Disorders through Correlation of Clinical and Radiologic Findings.

Patients presenting with visual disturbances often require a neuroimaging approach. The spectrum of visual disturbances includes three main categories: vision impairment, ocular motility dysfunction, and abnormal pupillary response. Decreased vision is usually due to an eye abnormality. However, it can also be related to other disorders affecting the visual pathway, from the retina to the occipital lobe. Ocular motility dysfunction may follow disorders of the cranial nerves responsible for eye movements (ie, oculomotor, trochlear, and abducens nerves); may be due to any abnormality that directly affects the extraocular muscles, such as tumor or inflammation; or may result from any orbital disease that can alter the anatomy or function of these muscles, leading to diplopia and strabismus. Given that pupillary response depends on the normal function of the sympathetic and parasympathetic pathways, an abnormality affecting these neuronal systems manifests, respectively, as pupillary miosis or mydriasis, with other related symptoms. In some cases, neuroimaging studies must complement the clinical ophthalmologic examination to better assess the anatomic and pathologic conditions that could explain the symptoms. US has a major role in the assessment of diseases of the eye and anterior orbit. CT is usually the first-line imaging modality because of its attainability, especially in trauma settings. MRI offers further information for inflammatory and tumoral cases. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Cranial nerves palsy in pituitary apoplexy outcome post emergent surgery

Introduction:pituitary apoplexy (PA), an uncommon clinical condition brought on by rapid bleeding or infarction. The primary symptom, a sudden, severe headache, is occasionally accompanied by vision abnormalities or ocular palsy. Aim of the study :to assess the benefit of an emergent trans sphenoidal approach and its results, as well as the deficit of cranial nerves other than the optic nerve in the recovery from pituitary apoplexy.Patient and methodsA prospective study of cranial nerve deficit in pituitary apoplexy and their prognosis in patients with apoplexy followed up on 16 patients from 2018 to 2020 who had cranial nerve deficits throughout their hospital stays and for up to two years following release.Results :Oculomotor nerve intracavernous segment has more predilection to involve in pituitary apoplexy cavernous invasion in our study we include other cranial nerves to expel the presenting oculomotor nerve palsy in comprise to other cranial nerves and even with mixed cranial nerve involvement, the cranial nerve involvement and cavernous extension and the volume of tumor effect additional compression on cranial nerve. Only one patient with 3rd cranial nerve palsy and one patient with mixed palsy is not recovered after six-month postoperative fellows while the majority retrieve their function during 1st three months.Conclusion:Patients with pituitary apoplexy who experienced ocular motility dysfunction due to cranial nerve palsies had favorable prognoses.Keywords: Pituitary apoplexy, cranial nerve palsy, pituitary adenoma

Screen Time and Developmental Eye Movement Testing in Middle School Students

Background: Screen time continues to increase among children and youth, yet little is known about its potential effects on oculomotor development and function. The aims of the current study were to (a) compare oculomotor function in children today to those tested before smartphone use and (b) explore correlations between screen time use and oculomotor function among children today. Method: A retrospective comparison was conducted comparing normative data published in the Developmental Eye Movement (DEM) Test manual in 1990, prior to the invention of smart devices, to data collected in 2020. Correlations between screen time and DEM variables were also explored within the current sample. Results: Sixty middle school students reported spending on average 45.5 hours/week on screens with approximately 18.5 hours/week on iPhones, 14.5 hours/week on television and 10.5 hours/week on computers. Surprisingly, DEM performance was not significantly improved in the current sample compared to the historical sample. There were also no significant correlations between any screen time variables and oculomotor metrics within the current sample. Conclusion: Despite the significant increase in screen time usage since 1990, DEM performance was replicable among 6th, 7th, and 8th grader students tested 30 years later. A statistically significant difference was found among 7th graders on DEM Vertical, where the 2020 students performed slower however, this difference may not be clinically significant. Importantly, DEM Ratio, a key variable for identifying ocular motility dysfunction (OMD), was also not significantly different between 1990 and 2020. Moreover, screen time in the current sample did not correlate with any DEM variables. This study provides preliminary evidence indicating that as measured by the DEM Test, increased screen time may not affect ocular motility. Further research is warranted using more finite methods for measuring saccade and smooth pursuit eye movements during the use of screened devices.

CLINICAL EVALUATION OF USING CORTICAL LAMINA XENOGRAFT IN RECONSTRUCTION OF ORBITAL FLOOR

Background: The orbital floor is one of the most frequently injured areas during facial trauma. Their proper treatment is crucial for prevention of orbital complications as diplopia, limitation of ocular motility and enophthalmos. Cortical lamina is a collagenated cortical bone of heterologous origin that is used in grafting of non-load-bearing areas. Objective: To evaluate clinically the use of cortical lamina in the reconstruction of orbital floor defects. Materials and Methods: Ten patients with orbital floor defects less than 2cm were associated with one or more of the following complications; binocular diplopia, enophthalmos, limitation of ocular motility or infra orbital nerve dysfunction, were indicated for orbital reconstruction using cortical lamina xenograft. The follow-up schedule was 1week and 1, 3, 6 months postoperatively. Results: Orbital complications had been resolved in all patients. Only infra orbital nerve dysfunction continued in 7 patients where 3 of patients recovered after 3 months and the other 4 have recovered after 6 months. Conclusions: Cortical lamina xenograft is a good alternative for the reconstruction of orbital floor defects less than 2cm due to its plasticity and biocompatibility without any donor site morbidity.

Collapsin Response-Mediator Protein 5–Associated Retinitis, Vitritis, and Optic Disc Edema

Collapsin response-mediator protein 5 (CRMP5) immunoglobulin G (IgG) has been associated with paraneoplastic optic neuritis, vitritis, retinitis, or a combination thereof, but few reports of these findings exist in the literature. We reviewed the neuro-ophthalmic findings and visual outcomes in a large series of CRMP5 IgG-positive patients to characterize further its clinical phenotype and response to treatment. Retrospective case series. Seventy-six patients with CRMP5 autoimmunity examined at the Mayo Clinic, Rochester, Minnesota. Single academic medical center chart review of all CRMP5 IgG-positive (serum titer, >1:240) patients seen between 2001 and2017. Neuro-ophthalmic manifestations and outcomes of CRMP5 autoimmunity, coexisting neural autoantibody presence and paraneoplastic associations, and the impact of immunosuppressant therapy. Twenty-nine of 76 patients (38%) demonstrated neuro-ophthalmic manifestations. Of the 29 patients with neuro-ophthalmic findings, the median age was 67 years (range, 33-88 years) and 20 (69%) were women. Cancer was diagnosed in 62% of the patients (small-cell carcinoma in 83%). Neuro-ophthalmic symptoms occurred before the diagnosis of cancer in 72%. Seventeen of 29 patients (59%) showed ocular (i.e., anterior visual pathway or intraocular) manifestations; presenting median visual acuity was 20/50 (range, 20/20-counting fingers) and the final median visual acuity was 20/40 (range, 20/20-hand movements). Fourteen of 17 patients (82%) demonstrated optic neuropathy, with 12 of these patients also showing retinitis or uveitis. Three of 17 patients (18%) showed retinitis or uveitis without optic neuropathy. All 12 patients with optic neuropathy and a documented fundus examination at visual symptom onset demonstrated optic disc edema. No patients showed optic nerve enhancement on magnetic resonance imaging. Twelve of 29 patients (41%) demonstrated ocular motility dysfunction consisting of central nystagmus and diplopia. Among those receiving immunosuppressive therapy, visual function improved in 50%. In our cohort of 29 CRMP5 IgG-positive patients with neuro-ophthalmic manifestations, optic neuropathy presented with optic disc edema, often associated with uveitis, retinitis, or both. The combination of retinitis, vitritis, and optic disc edema without optic nerve enhancement should prompt serologic testing for CRMP5 IgG to expedite vision-sparing immunosuppressant therapy and a targeted search for a systemic cancer.

Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy

Pituitary apoplexy (PA) often presents with acute headache and neuro-ophthalmic manifestations, including ocular motility dysfunction (OMD) from cranial nerve palsies (CNPs). Our goal was to describe the epidemiology and outcomes of OMD in a large, single-center series of patients with PA. We conducted a retrospective chart review of all patients with PA seen in our pituitary center between January 1995 and December 2012. Presenting neuro-ophthalmic, endocrine, and radiologic data, as well as neuro-ophthalmology follow-up data, were collected. We identified 235 patients with PA, 59 of whom (25%) had OMD. Twenty-seven of those 59 patients underwent neuro-ophthalmic evaluation. Preoperatively, 23 of these 27 patients had unilateral OMD, 18 (78%) with a single CNP and 5 (22%) with multiple CNPs. Bilateral OMD was present in 4 of the 27 patients. Postoperatively, 24 of the 27 patients with OMD had follow-up (median duration, 7 months; interquartile range [IQR], 3-17 months). At the last postoperative follow-up, 7 of these 24 patients (29%) had OMD (5 unilateral, 2 bilateral). OMD resolved in 3 of the 24 patients (12%) within 1 month, in 13 of 21 patients (62%) within 6 months (3 lost to follow-up), and in 17 of 19 patients (89%) within 1 year (2 lost to follow-up). Surgery was performed at ≤14 days after presentation in 16 of 18 (89%) resolved cases and in 4 of 6 (67%) unresolved cases. Patients with OMD were more likely than those without OMD to have larger tumors (2.6 vs. 2.0 cm; P<0.001), panhypopituitarism (31% vs. 14%; P= 0.005), and necrosis (58% vs. 37%; P= 0.03). OMD from CNPs is common in PA, occurring in one-quarter of patients, and is frequently associated with certain radiologic, endocrinologic, and pathological features. The prognosis is excellent, with 90% of cases of OMD resolving by 1 year after early pituitary surgery.

Invasive fungal disease of the sinus and orbit: a comparison between mucormycosis and Aspergillus

Background/aimsInvasive fungal infections of the head and neck are rare life-threatening infections where prompt diagnosis and intervention is critical for survival. The aim of this study is to determine the...

Eye tracking detects disconjugate eye movements associated with structural traumatic brain injury and concussion.

Disconjugate eye movements have been associated with traumatic brain injury since ancient times. Ocular motility dysfunction may be present in up to 90% of patients with concussion or blast injury. We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 sec and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen. We prospectively eye tracked 64 normal healthy noninjured control subjects and compared findings to 75 trauma subjects with either a positive head computed tomography (CT) scan (n=13), negative head CT (n=39), or nonhead injury (n=23) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion. Tracking metrics were then correlated to the clinical concussion measure Sport Concussion Assessment Tool 3 (SCAT3) in trauma patients. Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to noninjured control subjects. Only one of five vertical disconjugacy measures was significantly increased in brain-injured patients relative to controls. Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total Standardized Assessment of Concussion score. Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects observed in follow-up. Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury.

Complications of vision loss and ophthalmoplegia during endoscopic sinus surgery

ObjectiveTo describe two rare cases of concurrent vision loss and external ophthalmoplegia following powered endoscopic sinus surgery (ESS).DesignObservational case report.ResultsThe records of two patients who underwent powered ESS and developed multiple concurrent ophthalmic complications were retrospectively reviewed for clinical history, neuro-ophthalmologic examination, and imaging findings. Patient 1 developed a retinal vascular occlusion and complete loss of adduction. Patient 2 developed an orbital hemorrhage, optic neuropathy, and a restrictive global ophthalmoplegia. Similar published case reports were also reviewed.ConclusionDespite advances in powered ESS technique and instrumentation, serious ophthalmic complications can still occur. Inadvertent entry into the medial orbital wall can result in a combination of blindness and ocular motility dysfunction. The variety of mechanisms responsible for these complications underscores the importance of thorough pre- and postoperative clinical examination and review of imaging studies.

Comparison of 4% articaine and 0.5% levobupivacaine/2% lidocaine mixture for sub-Tenon’s anaesthesia in phacoemulsification cataract surgery: a randomised controlled trial

Backgound/aims:The aim of this study was to compare the efficacy and safety of 4% articaine with a mixture containing equal volumes of 2% lidocaine and 0.5% levobupivacaine without hyaluronidase for...

Orbital complications of functional endoscopic sinus surgery: MR and CT findings

To describe the radiological findings of ophthalmic complications during functional endoscopic sinus surgery (FESS) and correlate them with the clinical manifestations and mechanisms of injury. This was a retrospective review of the clinical and cross-sectional imaging findings of 9 patients with orbital complications during FESS. The most common site of entry into the orbit during FESS was the lower medial orbital wall (7 of 9), followed by the inferior orbital wall, resulting in injury to the medial rectus (4 of 9) and, less frequently, the inferior rectus (2 of 9) or superior oblique muscles (1 of 9). Extensive scarring on imaging (3 of 9) was associated with global ocular motility dysfunction. In contrast, localized scarring (3 of 9) or extraocular muscle trauma (6 of 9) resulted in disturbance of eye movement in the direction of gaze from the injured site. Orbital magnetic resonance and computed tomography findings correlate very well with the abnormal eye movements clinically observed, and can assist in clarifying the cause of injury and guide surgical corrective management of patients suffering orbital complications from FESS. Radiologists should be familiar with the recent developments in FESS instrumentation as well as with the most commonly injured structures within the orbit.

Ocular motility dysfunction associated with chemotherapeutic agents

Two articles in this issue discuss strabismus associated with vincristine. Chemotherapeutic toxicity is an uncommon cause of ocular motility disturbance and one that could easily be overlooked by oncologists, strabismus surgeons, and primary care providers alike. In addition, ophthalmologists use chemotherapeutic agents infrequently, and drug-induced ocular side effects related to their use are uncommon. Still, it is important to be aware of potential ocular side effects from this class of medication. Reported here is a summary of reports of ocular motility disorders caused by chemotherapeutic agents. It is hoped that clinicians will recognize this association in select patients and diagnose the condition and treat their patients accordingly. We reviewed information from the National Registry of Drug-Induced Ocular Side Effects (NR) at Casey Eye Institute (Portland, Oregon), as well as the World Health Organization’s (WHO; Uppsala, Sweden) database of adverse drug reactions. We also performed a literature search for articles describing ocular motility dysfunction in this setting. 1-5 We included reports of diplopia, strabismus, ptosis, and myasthenia-like effects, but we specifically excluded nystagmus because this condition is both frequently reported and poorly characterized throughout the literature. Most reports of strabismus or diplopia were associated with extraocular muscle paresis, although several drugs are known specifically to be myotoxic. Similarly, strabismus and diplopia normally occurred together but are sometimes reported independently. Our findings are presented in Tables 1 and 2. In this review, we distinguish between drug effects reported to the NRor the WHO and those reported in the scientific literature. Furthermore, the adverse drug reactions contained in these databases have been reviewed to determine the strength of the association. It is often unclear whether an observed side effect can be attributed to a specific agent or whether it could have been caused by

Ocular motility complications after endoscopic sinus surgery with powered cutting instruments

Objective: The purpose of this study was to describe 2 unique cases of ocular motility dysfunction after powered endoscopic sinus surgery and identify potential risk factors for extraocular muscle injury. Study Design: Interventional case series. Results: Patient 1 developed a restrictive global ophthalmoplegia after inadvertent entry into the medial orbit during powered endoscopic sinus surgery. Patient 2 had complete loss of adduction of the left eye as a result of transection of the medial rectus muscle by a powered cutting instrument. Conclusions: Despite advances in endoscopic sinus surgery technique and instrumentation, serious ophthalmic complications may still occur. Inadvertent entry into the medial orbital wall can result in ocular motility complications. Furthermore, it is possible that attraction of orbital contents into the tip of a powered cutting instrument may occur without significant entry into the orbital cavity. Significance: It is important for endoscopic sinus surgeons to be aware of the intimate anatomical relationship between the orbit and sinuses, as well as the potential risks of the current instruments used in endoscopic sinus surgery. (Otolaryngol Head Neck Surg 2001;125:501-9.)

Surgical management of V-pattern strabismus and oblique dysfunction in craniofacial dysostosis

Introduction: Strabismus affects as many as 60% to 70% of patients with craniofacial dysostosis. V-pattern strabismus with severe oblique muscle dysfunction is the most common ocular motility problem seen and can be difficult to manage. Few studies have reported on the results of strabismus surgery in this condition. Methods: We retrospectively reviewed the surgical management and outcomes of 14 patients with craniofacial dysostosis who underwent 16 operations to determine the optimal surgical procedure and to report on extraocular muscle anomalies noted at the time of surgery. Operations performed included medial rectus muscle infraplacement (n = 2), inferior oblique (IO) recession (n = 3), IO myectomy (n = 3), IO anterior transposition (n = 3), and IO denervation/extirpation (n = 5). Results: All patients had significant residual ocular motility dysfunction postoperatively. No beneficial effect was noted after IO anterior transposition or after medial rectus muscle infraplacement. Modest improvement of the V-pattern and oblique muscle dysfunction was noted after denervation/extirpation and myectomy of the IO muscle. Bilateral absent or anomalous superior oblique tendons were noted in 8 of 9 patients in whom the superior oblique tendon was examined at surgery. Conclusions: Strabismus in craniofacial dysostosis is complex and difficult to cure with surgery. Denervation/extirpation and myectomy of the IO muscle offered modest benefits, though neither procedure resulted in normalization of ocular motility. Agenesis of the superior oblique tendon may be causally related in a large proportion of affected patients. (J AAPOS 2000;4:338-42)

The Effect of Mitomycin-C on the Healing Process in Rabbit Extraocular Muscle Surgery

One of the most serious complications following extraocular muscle surgery is formation of postoperative adhesions that may result in restrictive ocular motility dysfunction. The effect of mitomycin-C (MMC) on postoperative wound healing in extraocular muscle surgery was investigated. Sixteen albino rabbits (24 eyes) were used and anesthetized with ketamine and xylazine. These rabbits were divided into 3 groups; (1) control group (balanced salt solution (BSS) exposure for 5 minutes), (2) Group 1 (0.5 mg/ml MMC exposure for 1 minute) and (3) Group 2 (0.5 mg/ml MMC exposure for 5 minutes). After 3 mm recession of superior rectus muscle, MMC or BSS was applied using Weck-Cel sponge (Solan, Jacksonville, FL). The reduction of fibroblast and collagen fiber proliferation were evaluated histopathologically with light microscope at 1, 2, 4 and 8 weeks after operation. We also evaluated the amount of basic fibroblast growth factor (bFGF) by immunohistochemical study at the same time. Histopathologically, there was a more significant reduction of fibroblast and collagen fiber proliferation in Group 1 and 2 than the control group. Immunohistochemically, Group 1 and 2 showed lesser expression of bFGF than the control group. But, there was no difference between Group 1 and 2. Topical intraoperative application of mitomycin C in extraocular muscle surgery may reduce postoperative adhesions.

Evaluation of mitomycin to limit postoperative adhesions in strabismus surgery.

Ocular motility dysfunction following strabismus surgery may be the result of postoperative scarring or the formation of adhesions. Mitomycin C (MMC) has been used with encouraging results as an adjunct to standard treatment of hypertrophic conjunctival scars after strabismus surgery. It has been demonstrated that MMC does not inhibit muscle reattachment and might inhibit adhesions and scar formation in the rabbit. We investigated in a rabbit model effectiveness of MMC in reducing the formation of postoperative adhesions following reoperations and the tensile strength of the new musculo-scleral junction. A prospective, masked-observer, controlled study was performed in rabbits. Symmetrical bilateral recessions of the superior and inferior rectus muscles were performed on each rabbit. A reoperation was performed 6 weeks later, in which the muscles were advanced back to their original insertion. During the reoperation, one eye served as the control while the other was treated with a 5-minute intraoperative exposure to topical mitomycin. Mitomycin reduced the formation of adhesions and the amount of postoperative scarring. The tensile strength of the musculo-scleral junction was reduced in the mitomycin-treated eyes but exceeded the force generated during extraocular ductions. MMC may be an effective adjunctive therapy in the treatment of strabismus associated with pre-existing adhesions or scarring.