Painful Eye Movements Research Articles

Recurrent Idiopathic Orbital Myositis: Two Case Reports

Idiopathic orbital myositis is a subtype of idiopathic orbital inflammatory diseases characterized by inflammation of the extraocular muscles. The diagnosis of the disease is made clinically and radiologically. Clinically characterized by periorbital edema, ptosis, propitosis, diplopia and painful eye movements. The diagnosis is made by observing the enlargement of the involved muscles in the orbital CT. The most common differential diagnosis is thyroid ophthalmopathy. In this study, we presented two patients with idiopathic orbital myositis who were referred to our clinic with complaints of eye rash, eye movement pain, bilateral visual acuity. Idiopathic orbital myositis was diagnosed and 1 mg/kg/day oral prednisolone was started. Symptoms of the patients regressed with oral corticosteroid therapy.

Pediatric preseptal and orbital cellulitis: A 10-year experience

ObjectiveCharacterize clinical features, epidemiology and treatment of hospitalized pediatric cases of preseptal and orbital cellulitis. MethodsRetrospective study of children/adolescents admitted to a central hospital with preseptal and orbital cellulitis between 2007 and 2017. ResultsA total of 122 cases were included, 80.3% with preseptal cellulitis and 19.7% with orbital cellulitis. Patients had a median age of 5 years. Sinusitis was the most common predisposing factor (40.2%), followed by dental abscess (20.4%) in preseptal cellulitis and by external ocular infections (12.5%) in orbital cellulitis. Sinusitis (p < 0.001) was associated with orbital cellulitis, whereas patients with dental abscess (p = 0.007) and trauma (p = 0.040) were most likely to have preseptal cellulitis. Fever, photophobia, ocular pain, painful eye movements, proptosis, rhinorrhea and vison impairment were related with orbital cellulitis. Leukocytosis was present in 34.4% of patients, and associated with orbital cellulitis (p = 0.001). Nearly half of patients (49.2%) had a CT-scan performed. Systemic corticosteroids were used in 19.7%. Complications occurred in 13 patients. Imaging revaluation through CT was performed in 6.6%, with no patients showing deterioration; 1.6% of patients required surgery. ConclusionsIdentification of orbital involvement signs suggested orbital cellulitis. We emphasize the impact of dental abscess as a predisposing factor for preseptal cellulitis. Repeated imaging had no impact on treatment or outcome. A high percentage of patients was treated with steroids despite their controversial use.

Clinical manifestations of orbital lesion in granulomatosis with polyangiitis

To study the clinical course and prognosis of orbital lesions of various localization in GPA patients. Material and me-thods. The study included 226 patients with GPA, 74 of them with orbital lesion. Ophthalmic examination consisted of visual acuity test, biomicroscopy, ophthalmoscopy, exophthalmometry and ocular mobility test. Visualization was done using multislice computed tomography and/or magnetic resonance tomography and/or ultrasound examination. Among the patients of the study group, in 35.1% the lesion was limited to dacryoadenitis, in 4.0% of patients - to myositis, and 70.8% had extensive inflammatory orbital masses. Patients with orbital masses had systemic disease in 51.1%, compared to 7.7% in dacryoadenitis (p=0.00). Clinical progression in patients with orbital masses was characterized by severe exophthalmos, periorbital swelling and hyperemia. Patients with dacryoadenitis, on the contrary, had only mild symptoms. Patients with orbital masses had unfavorable prognosis. There were only three patients with myositis in the study group, so the data on them is limited; their clinical symptoms included light periorbital swelling, exophthalmos, strabismus, painful binocular diplopia and eye movement restriction. The disease was recurring in two cases. Patients with orbital involvement in GPA may have different course of the disease depending on the localization of inflammation.

Sphenoid sinus carcinoid tumour causing ectopic ACTH syndrome

A thirty-eight year old patient presented with a gradual increase in weight and Cushingoid facies of two years duration. He also had orbital congestion, with puffy eyelids and corkscrew conjunctival vessels, associated with painful eye movements. An endocrine evaluation revealed raised cortisol and ACTH. Head imaging was performed which showed an enhancing tumour arising from the sphenoid sinus, with osseous erosion of the sphenoid sinus, extending to the nasopharynx, sellar and a small amount extending intracranially. He underwent an endoscopic endonasal resection of the tumour and histology revealed a low-grade carcinoid tumour with ACTH staining. The patient also underwent radiotherapy for the intracranial extension. He is currently in his fourth year of follow-up and imaging has showed a small, stable intracranial remnant. His anterior pituitary hormonal profile remains normal.

How long does it take to diagnose patients with neuromyelitis optica (NMO) using the 2006 diagnostic criteria?

Background and purposeA few reports studied the time use to diagnose patient with neuromyelitis optica (NMO). The Aim of the study is to evaluate the interval from disease onset to the time when patients fulfilled the NMO diagnostic criteria 2006 in Thai. Method: A retrospective study of the NMO patients visiting the MS clinic and related disorders at Siriraj hospital was reviewed. Results: There were 42 definite NMO. All were female. The most common first presentations were optic neuritis (ON) (45.2%), transverse myelitis (TM) (35.7%), ON and TM (9.5%) and brainstem symptoms (9.5%), respectively. The mean age at onset of their ON and TM attack was 33.4 and 38.4 years, respectively. Anti-AQP4 antibody was presented in 82% using cell based assay. For those presented with ON, 7.1% reported painful eye movements and 33.3% had bilateral involvement. Brain MRI not compatible with MS was found in 94.87%. In who presented with TM, 87.8% revealed long extensive transverse myelitis (LETM) in spinal MRI. The presence of CSF-oligoclonal band (CSF-OCB) was found in 14.6%. Our NMO patients had the average number of the attack of 1.5 times before the diagnosis could be made. Nearly fifty-five percent of NMO patients fulfilled the NMO diagnostic criteria 2006 within 1 year after disease onset and 90.5% within 5 years Conclusion: About half of Thai patients with definite NMO were diagnosed within 1 year and approximately 90% within 5 years from their disease onset.

The diagnostic value of orbital magnetic resonance imaging T2-Mapping in patients with active Graves' ophthalmopathy

Objective To study the clinical value of orbital magnetic resonance imaging(MRI) in diagnosis and making a judgment about the curative effect of glucocorticoid in patients with Graves' ophthalmopathy(GO). Methods A total of 106 patients with GO were divided into active GO group or inactive GO group according to whether clinical activity score(CAS)≥3 or not, respectively. T2 relaxation times(T2RTs)(ms) and areas(mm2) of four extra-ocular muscles (EOMs) (superior, inferior, medial, and lateral rectus) were directly measured by MRI T2-Mapping. Correlation analysis of T2RTs and areas with eyeball motility, diplopia, exophthalmus, visual acuity and intraocular pressure(IOP) were also performed. The T2RTs and areas of EOMs before and after intravenous methylprednisolone(iv MP) pulse therapy were recorded, respectively. Results The mean T2RTs(88.9±13.8) and mean areas(58.1±23.8) of EOMs in active GO were significantly greater than those in inactive GO(80.6±10.0 and 46.2±18.6, respectively), bing both significantly greater than those in volunteers with normal eyes(76.2±4.7 and 30.3±6.1, respectively)(P<0.01). Maximal T2RTs and maximal areas of EOMs showed significant positive correlation(P<0.01), and both were positively correlated weakly with CAS, reduced movement of eyeball, diplopia, exophthalmus and loss of visual acuity(P<0.01). On the contrary, maximal T2RTs and maximal areas of EOMs showed negative correlation or no correlation with spontaneous retrobulbar pain, painful eye movement, redness of eyelids and abnormal IOP. Even if 1≤CAS<3, ophthalmic symptoms and signs also showed a positive responses to iv MP in patients with moderate to severe GO as long as prolonged T2RTs occurred at least in one of EOMs. The maximal T2RTs, maximal areas, mean T2RTs and mean areas of EOMs were significantly decreased at the end of iv MP treatment, meanwhile ophthalmic symptoms and signs were obviously improved. Conclusions Prolonged T2RTs, especially accompanied by enlarged area on the identical EOMs is an remarkable symbols of acute inflamed muscles. The findings suggested that the use of prolonged T2RTs can improve diagnostic sensitivity and predict the curative effect of iv MP in patients with moderate to severe GO and CAS≥1. (Chin J Endocrinol Metab, 2015, 31: 327-332) Key words: Graves' ophthalmopathy; Magnetic resonance imaging; Methylprednisolone

LYME DISEASE MASQUERADING AS AN OPTIC NEURITIS

Optic Neuritis is a rare manifestation of Neuroborreliosis and we present the only case in the literature diagnosed by the gold standard two-tier testing procedure of ELISA and Immunoblot. A...

A rare presentation of orbital complication of invasive fungal sinusitis in an immunocompetent young boy-a rare case

We present a case of allergic fungal sinusitis (AFS) in a 24 -year old man with history of left sided nasal obstruction and discharge since few years. Since few months he developed epiphora in the left eye associated with discomfort on eye movements. Patient was examined and CT with contrast was done. CT contrast showed an enhancing lesion in Left maxillary and ethmoid sinuses and erosion of the inferior bony wall of the orbit and medial wall of maxillary sinus. Though most patients of fungal sinusitis are immunocompromised but this patient was young male immunocompetent and made an unusual presentation with visual epiphora and painful eye movements. CT showed bony erosion of the Left inferior Bony wall of the Orbit and medial wall of Maxillary Sinus. After through examination and specific investigations, the patient was posted for surgery. We planed for Cald well –Luc’s Surgery and Endoscopic excision of the mass .Histological examination was reported as non malignant and microscopy showed Fungal Hyphae. After the surgery patient was discharged satisfactorily within couple of days and followed up regularly. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 48-51 DOI: http://dx.doi.org/10.3126/jcmsn.v8i1.6826

A decade of experience managing orbital and periorbital cellulitis in children in the post-Hib vaccination era

<h3>Introduction</h3> Infections of the soft tissues around the eye, with redness and swelling, cause significant morbidity and have the potential to develop serious complications. Periorbital cellulitis, where the position and function of the eye is unaffected, is the result of preseptal soft tissue infection, and occurs more frequently than orbital cellulitis. Orbital cellulitis, with proptosis, painful eye movements and occasionally visual loss is a less common, though potentially much more serious condition. Early recognition, prompt management and appropriate referral are crucial. <h3>Objectives</h3> Routine immunisation against Hib was introduced in the UK in 1992. The incidence and epidemiology of pre and postseptal cellulitis in the post Hib vaccination era has not been studied extensively. We reviewed the clinical features, management, complications and follow up of patients with orbital and periorbital cellulitis in the post-immunisation era. <h3>Methods</h3> We retrospectively reviewed medical notes of 50 children with orbital and periorbital cellulitis admitted to our paediatric department between 2000 and 2010. We looked at age, gender, month of admission, number of days of illness before admission, clinical features, inflammatory response including temperature, WCC, CRP on/during admission, immunisation status, blood culture results, microbiology studies, radiology findings, antibiotics, complications, duration of hospital stay and follow up. <h3>Results</h3> 45 (90%) patients had periorbital cellulitis and 5 (10%) had orbital cellulitis. 9 (18%) were aged less than 1 year and 27 (54%) were aged 1-7. 27 (54%) were female. 23 (46%) admissions were between December and February. 22 (44%) had ENT symptoms. 40 (80%) patients were apyrexial, 13 (26%) had a CRP &gt;60 mg/L and 5 had a WCC of &gt;20×106/L. 43 (86%) had blood cultures, with one positive growth of Micrococcus. Eye swabs were performed in 12 patients and 3 had a positive growth of Staphylococcus aureus. Most of the patients were seen by ophthalmologists and had radiology studies; all received antibiotics. Surgery was required for six patients. We had the immunisation record for 36 patients and only 2 of those were not fully immunised. <h3>Conclusions</h3> In the post Hib-vaccination era bacteraemia and sepsis are now rarely seen in acute orbital/periorbital infections. Upper respiratory tract infection and conjunctivitis remain important predisposing factors. Significant complications can still occur when periorbital cellulitis is present.

Case report: papillitis as the sole ocular sign in Lyme disease

BackgroundLyme disease is a spirochetal disease responsible for a multitude of ocular and systemic manifestations, and patients may present to ophthalmologists and general clinicians with a wide variety of generalized and ocular signs which can result in chronic and disabling sequelae. Here we report two cases of patients suffering with Lyme disease who developed a rare associated papillitis.MethodsA 48-year-old Scottish man presented with diminished visual acuity, painful ocular eye movements, photophobia, and mild ataxia. Fundus examination revealed bilateral disc swelling with associated hemorrhages in the right eye. Following exclusion of raised intracranial pressure as the cause of the findings, enzyme-linked immunosorbent assay and Western blot serology confirmed a positive result for Borrelia burgdorferi which, along with ophthalmic signs and exposure to an endemic area, confirmed the diagnosis of Lyme disease. A 79-year-old gentleman presented with intermittent short-duration “gray film” in his left eye. Fundus examination revealed left optic disc swelling. He was positive for Lyme’s serology and his condition was treated with 2 weeks of intravenous ceftriaxone.ResultsThe first patient’s inflammation resolved and visual acuity returned to normal following a course of high-dose steroids and intravenous ceftriaxone, followed by oral doxycycline. The second patient’s condition improved with high-dose intravenous ceftriaxone.ConclusionThese patients highlight the fact that Lyme disease should be considered as a differential diagnosis for patients presenting with papillitis. With the incidence of this disease rising and more cases being reported, practitioners in Lyme-endemic areas need to be aware of the various manifestations so that appropriate referrals for treatment can be made.

A case of relapsing flitting bilateral idiopathic orbital inflammation

Idiopathic orbital inflammation (IOI) is defined as a benign non-infective clinical syndrome characterized by features of non-specific inflammation of the orbit without identifiable local or systemic causes. This can be called orbital myositis if the inflammation is predominantly in the orbital muscles. It is a diagnosis of exclusion based on clinical, radiological, and if necessary, histological findings. The most commons symptoms are swelling, ptosis, proptosis and painful eye movements. To our knowledge, this patient is the first with IOI to demonstrate relapsing flitting bilateral involvement of several individual extra-ocular muscles.

Letters to the Editor

30 August 2007 Dear Editor, ORBITAL MYOSITIS FOLLOWING STREPTOCOCCAL PHARYNGITIS Idiopathic orbital myositis is an inflammatory process involving the extra ocular muscles. It not only occurs most frequently in young to middle-aged adults with a 2:1 female predominance, but also occurs in children. The cause is unknown, however, it has been considered that an immunopathogenic mechanism is likely.1 There have been two previously reported cases in a 36-year-old woman2 and a 13-year-old boy where orbital myositis has followed streptococcal pharyngitis.3 We now report a third case. A 9-year-old girl presented with a 40-h history of pain on movement of the right eye and several hours of swelling and purplish discolouration of the right upper eyelid. She had diplopia on lateral gaze. An initial diagnosis of periorbital cellulitis was made and she was treated with 3 days of intravenous cefotaxime and then discharged on oral cephalosporin. She re-presented 3 days after discharge with photophobia and continuing pain on eye movement. On examination, there was slight proptosis of the right eye. The right upper eye lid was swollen and there was diplopia on extreme lateral gaze. Her visual acuity was normal. Six weeks prior to the presentation, she had had an episode of severe tonsillitis with a right-sided tonsillar abscess which had been treated in hospital with intravenous penicillin for 5 days. Investigations at the second presentation showed a white cell count of 18.6 × 109/L, 14.1 × 09/L neutrophils, ESR 47, ASOT 560 iu/mL (normal < 200), anti-DNAse B 160 (normal < 20). Creatinine phosphokinase and thyroid function tests were normal. A computerized tomography (CT) scan of the orbits showed a uniform thickening of the right medial rectus muscle which enhanced after contrast administration (Fig. 1). The paranasal sinuses were normal. Computerized tomography scan showing enlargement of R medial rectus muscle. Treatment was commenced with oral prednisolone 1 mg/kg and within 48 h of starting prednisolone she was afebrile and the eyelid oedema had resolved. The steroid dose was gradually reduced over 8 weeks. On review at 4 weeks, she had no ocular symptoms. The clinical findings are typical of orbital myositis with painful eye movement, diplopia, mild proptosis and some periorbital oedema. The CT scan showed the typical muscle enlargement in the medial rectus. Orbital myositis has been described following upper respiratory tract infections.2 There are two previous cases of orbital myositis following serology or culture proven streptococcal pharyngitis. The first was a 36-year-old woman who developed periorbital myositis 2 weeks after culture proven streptococcal pharyngitis.2 There was a rapid resolution of symptoms in 5 days following institution of oral prednisolone. The second was a 13-year-old boy who developed orbital myositis in the lateral and medial recti muscles following streptococcal pharyngitis. He was treated with non-steroidal anti-inflammatory drug therapy and the symptoms resolved approximately 7 weeks after presentation.3 There are a number of post-infective complications recorded following Group A streptococcal pharyngitis which are considered to have an immunopathogenic basis. In addition to rheumatic fever and glomerulonephritis, these include post-streptococcal reactive arthritis,4 paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections,5 uveitis, erythema nodosum, tenosynovitis of the superior oblique tendon sheath and polymyalgia. Post-streptococcal polymyalgia consists of muscle pain, fever, raised antistreptolysin O titres, neutrophilia, raised inflammatory markers and normal muscle enzymes.6 Myopathic abnormalities have been observed on electromyography.6 The fever and tenderness associated with post-streptococcal polymyalgia improves within a few days of treatment with prednisolone and somewhat more slowly following non-steroidal anti-inflammatory medication. This clinical course and response to medication is similar to that observed in the present case and the other two reported cases of orbital myositis following streptococcal pharyngitis. The occurrence of polymyalgia indicates that post-streptococcal inflammatory syndromes can involve skeletal muscle tissue. This case highlights that orbital myositis is a cause of painful eye movements and mild proptosis in children and provides further support for the possibility that an immune-mediated post-streptococcal inflammation of ocular muscle is one cause.

Case 2: Rash, fever and headache….first, do no harm

A 16-year-old healthy boy presented with a two-day history of pruritic painful rash involving his left abdomen and back in a T9 to T10 distribution. In addition, he had a fever, blurry vision, painful eye movements and a headache. The patient had a history of varicella-zoster virus infection without complications when he was eight years of age, and his past medical history was unremarkable. There were no sick contacts, and his vaccinations were current. He had not received the varicella vaccine.

Retrobulbar pain, diplopia and exophthalmus as manifestations of an isolated ocular myositis in a 15 year old boy

Aims: The idiopathic orbital Myositis is a rare disease. Typical symptoms are retrobulbar pain with painful eye movements, diplopia on deviation of eyeball, swelling of eyelid, exophthalmus and conjunctival redness. Vision, pupil reactions, fundus and intraocular pressure are always normal. Single or multiple muscle affection and uni- or bilateral eye affection have been described. Infectious causes like Herpes zoster, Borreliosis, Tuberculosis, cysticercosis, infections of the airways and autoimmune diseases like SLE, Crohn disease and paraneoplasitc syndromes should be considered in the differential diagnoses.

Idiopathische hypertrophische kraniale Pachymeningitis

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a chronic inflammatory disease of unknown origin that is morphologically characterized by a local fibrotic thickening of the dura mater with a sterile lymphocytic infiltrate. Patients usually present with chronic headache, ataxia and cranial nerve palsies. Because of the great diversity of symptoms and the fact that IHCP can be associated with many other disorders, there is often a long time between the occurrence of clinical features and making the diagnosis. During this time symptoms can further increase. In addition, this is the third case report describing bone involvement in this disorder. In May 2000, a 51-year-old woman presented with reduced visual acuity on both eyes, complete palsies of the fourth and sixth cranial nerve, a partial palsy of the third cranial nerve and numbness and pain concerning the area of the fifth cranial nerve on the left side, painful eye movement on the left side, headache, and numbness and palsies on the left side of her body. Magnetic resonance imaging of the brain showed a focal gadolinium-enhanced small thickening of the dura mater close to the left hemisphere and a homogeneous bone thickening in the same area close to the thickened dura mater. Cerebrospinal fluid analysis revealed an elevated cell count (lymphocytic pleocytosis), routine blood counts and serum chemistry showed an elevated white blood count, an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Therapy with corticosteroids resulted in a complete remission in November 2000 except for a persistent numbness of the left side of her face and body and reduced visual acuity on both sides. The following three years were characterized by repeated clinical deteriorations followed by a temporary increase of the daily steroid dose. Altogether, daily oral steroid therapy could slow down the progression of disease and improve the visual acuity when compared with the first examination. Chronic headache, ataxia and cranial nerve palsies in combination with inflammation and dural thickening should call to mind idiopathic hypertrophic cranial pachymeningitis. In principle, every ophthalmological or neurological symptom can be associated with IHCP.

291 Orbital Myositis Presenting as Cluster Headache

Background. Cluster headache affects men in the third decade of life. Episodes centers in and around eye, start acutely, last 1 to 2 hours, and occur several times a day. Associated features are ipsilateral conjunctival hyperemia, lacrimation, ptosis, miosis, and facial sweating. Orbital myositis belongs to the group of idiopathic orbital inflammatory syndromes. Clinical picture involves proptosis, conjunctival hyperemia, lid edema, and painful eye movements. Case report. We report on a 13 year-old girl presenting with recurrent and alternating orbital myositis mimicking a cluster headache. At the age of 10 years she first experienced an episode of ocular pain, diplopia, and palpebral edema involving the right eye. Lacrimation, conjunctival hyperemia, nasal rhinorrhea and headache were also observed. The episode lasted 1 month. Neurological examination was normal. Further four episodes affecting the right and the left eyes, alternatively, occurred during a period of 18 months. Cluster headache was initially diagnosed. Neither FANS nor tryptans were able to control clinical symptoms. Magnetic resonance imaging of the orbits showed evident edema and thickening of the correspondent rectus lateralis which subsided after corticosteroids. Idiopathic ocular myositis was therefore diagnosed. The following investigations were performed in several occasions and resulted normal or negative. They included: (i) levels of complement factors and of immunoglobulins; (ii) Raitest and Waaler-Rose test; (iii) research of antinuclear antibody, antibody to ds-DNA, antibodies to extractable nuclear antigens (RNP, Sm, SS/A, SS/B), antisynthetasis (Jo1), antineutrophil cytoplasmic antibody (IFI, antiproteinase 3, antimyeloperoxidase, antilactoferrin). Thyroid function was normal. Viral and bacterial infections were also excluded. Orbital myositis may clinically mimic cluster headache. Conclusions. Orbital myositis should be considered in those patients with atypical cluster headache signs such as painful eye movements and ocular pain which do not resolve after 3–4 hours. An early diagnosis is necessary to plan a proper therapeutic strategy.

What do we know about the mechanism of action of disease-modifying treatments in MS?

Multiple sclerosis (MS), a chronic inflammatory disorder of the central nervous system (CNS), 2 results in damage to axons and their surrounding myelin sheath. The exact cause of inflammation remains unclear, but an autoimmune response directed against CNS antigens is suspected. MS can affect the brain, optic nerve and spinal cord, thus causing many neurological symptoms. These can include limb numbness or weakness, sensory or motor changes, ataxia, blurry vision, painful eye movements, bladder and bowel dysfunction, decreased memory, fatigue and effective disorders. This article will include a concise overview of the pathogenesis of MS in order to set the stage for subsequent discussion of the mechanisms of action of disease-modifying treatments, and whether these should influence our treatment choices. Although the exact pathogenesis of MS is not fully understood, current knowledge has already led to the development of effective treatments, namely interferon (IFN) 3 and glatiramer acetate, both of which have been shown to reduce relapse rates, while IFN 3- 1 a also reduces confirmed disability progression. Further increases in our understanding of the pathogenesis of MS are likely to assist in the identification of new targets for disease-modifying therapies and in the optimisation of current treatments..

Orbital myositis posing as cluster headache.

Arch Neurol. 2002;59:635‐636.OBJECTIVE: To describe the case of a patient with recurrent orbital myositis who was thought to have cluster headaches for 6 years. DESIGN AND SETTING: Case report in an outpatient neuro‐ophthalmology clinic. PATIENT: A 24‐year‐old man developed unilateral supraorbital pain, lacrimation, conjunctival hyperemia, nasal congestion, proptosis, and painful eye movements. The pain intensity varied over the course of each day and disappeared after 1 month. He had multiple attacks responsive to prednisone that were separated by months over the ensuing 6 years. Neuroimaging revealed an enlarged extraocular muscle. CONCLUSIONS: Overlap in symptoms between recurrent orbital myositis and cluster headache delayed the diagnosis in this patient. Orbital myositis should be considered in patients with atypical cluster headache characterized by proptosis, painful eye movements, and pain that does not completely resolve after 3 hours. Comment: Cluster has numerous mimics. Because of this, I favor one good imaging study for each patient with presumed cluster. SJT

Intramuscular hydatid cyst of the medial rectus muscle

PurposeTo describe a unique case of orbital hydatid cyst that was located solely within the medial rectus muscle. DesignRetrospective, interventional case report. MethodsA 20-year-old woman presented with right periocular pain induced by ocular movements. Magnetic resonance imaging studies showed a focal, well-circumscribed intramuscular cystic lesion of the right medial rectus muscle. The cyst was completely extirpated from the muscle, but some of the fluid content escaped into the surrounding tissues. Irrigation with hypertonic saline was performed. ResultsHistopathologic examination showed an acellular cyst wall with inner germinal layer, diagnostic for hydatid cyst. Two cycles of oral albendazole were administered with no recurrence. ConclusionsIn the orbit, hydatid cyst may be localized primarily within an extraocular muscle and produce painful eye movements. Hydatid cyst must be considered in the differential diagnosis of solitary cystic enlargements of extraocular muscles.

Tobacco-alcohol amblyopia. Clinical course in 33 patients

The clinical data of 33 patients with tobacco-alcohol-amblyopia are described. Usually, the visual disturbance concerned both eyes and was not associated neither with headache nor with painful eye movements. The fundus was very often normal. In the static perimetry mostly relative or absolute central scotomas were found, sometimes centrocoecal scotomas and very seldom paracentral scotomas. The colour vision was very often disturbed, usually the red-green discrimination. In the rule the amplitudes of the visual evoked potentials were diminished, the P-100 latency was delayed in 39%. A follow-up of 25 patients revealed that the visus and the results of the static perimetry improved in 72% during vitamin substitution (B1, B2, B6, B12, folic acid). In a few cases this improvement could be observed even though the alcohol drinking was not ceased. In most cases the disturbance of the colour vision and the pathologic visual evoked potentials, however, did not change.