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Jonathan M Holmes - One of the best experts on this subject based on the ideXlab platform.
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incidence and etiology of presumed Fourth cranial Nerve Palsy a population based study
American Journal of Ophthalmology, 2018Co-Authors: Sarah R Hatt, David A Leske, Eniolami O Dosunmu, David O Hodge, Jonathan M HolmesAbstract:Purpose To determine the incidence of isolated, presumed Fourth Nerve Palsy in a defined population, and to report the frequency of each cause. Design Retrospective, population-based case series. Methods A population-based database was used to identify all cases of isolated Fourth Nerve Palsy in Olmsted County, Minnesota, USA diagnosed over a 15-year period (January 1, 1978 to December 31, 1992). The most likely etiology was determined by review of the entire medical record by 2 ophthalmologists. A priori definitions were applied for assigning cause. The incidence of Fourth Nerve Palsy and the frequency of each etiology were calculated. Decade of life at presentation was recorded. Results Seventy-three patients (74 episodes, 70 [95%] unilateral) were identified. Mean age at presentation was 41.8 (range 3.3–81.6) years. The age- and sex-adjusted annual incidence rate was 5.73 per 100 000 per year (95% confidence interval [CI] 4.31–7.14). The most common etiology was presumed congenital (49%), followed by hypertension (18%) and trauma (18%). One patient (1%) had Fourth Nerve Palsy owing to a known intracranial neoplasm. For 3 patients (4%) the cause of Fourth Nerve Palsy was undetermined. The most common decade of presentation overall was the Fourth decade, including for presumed congenital cases. Conclusions In this population-based study, the majority of isolated Fourth Nerve palsies were presumed congenital, even though they presented throughout adulthood. Other etiologies such as hypertension and trauma were less frequent, and in no case was an isolated Fourth Nerve Palsy the presenting sign of an intracranial tumor.
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one versus two muscle surgery for presumed unilateral Fourth Nerve Palsy associated with moderate angle hyperdeviations
American Journal of Ophthalmology, 2017Co-Authors: David L Nash, Brian G Mohney, Sarah R Hatt, David A Leske, Laura May, Erick D Bothun, Michael C Brodsky, Jonathan M HolmesAbstract:Purpose To compare 1-muscle vs 2-muscle surgery for moderate-angle hyperdeviations owing to presumed unilateral Fourth Nerve Palsy. Design Retrospective chart review. Methods Seventy-three patients (aged 5–86 years) underwent either 1- or 2-muscle surgery at our institution for moderate hyperdeviation owing to presumed unilateral Fourth Nerve Palsy, measuring 14–25 prism diopters (PD) in straight-ahead gaze at distance fixation. Six-week and 1-year motor success was defined as zero vertical deviation or 1–4 PD undercorrection at distance, overcorrection as any reversal of hypertropia, and undercorrection as >4 PD. Diplopia success was defined as no diplopia, or only rarely for distance straight ahead and reading. Results Twenty-eight patients underwent 1-muscle surgery, and 45 patients underwent 2-muscle surgery. Motor success was similar (64% vs 67%, P > .99 at 6 weeks; 47% vs 55%, P = .8 at 1 year, n = 46), but there were more undercorrections at 6 weeks with 1-muscle surgery (36% vs 16%, P = .09) and more overcorrections at 6 weeks with 2-muscle surgery (0% vs 18%, P = .02). Diplopia success was also somewhat similar between 1- and 2-muscle surgery at 6 weeks (73% vs 60%, P = .5) and 1 year (45% vs 59%, P = .5). Conclusion For moderate-angle hyperdeviations owing to presumed unilateral Fourth Nerve Palsy, there appears no clear advantage of 2-muscle surgery for motor outcomes. Diplopia success was similar between 1- and 2-muscle surgery, owing to a greater number of less symptomatic undercorrections with 1-muscle surgery and a smaller number of more symptomatic overcorrections with 2-muscle surgery.
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adjustable bilateral superior oblique tendon advancement for bilateral Fourth Nerve Palsy
American Journal of Ophthalmology, 2017Co-Authors: Bashar M Bata, David A Leske, Jonathan M HolmesAbstract:Purpose Bilateral Fourth Nerve Palsy may be symmetric or asymmetric with combined vertical and excylotropic deviations and so there may be an advantage to independent adjustment of vertical and torsional components. We report a surgical technique that allows such independent adjustment. Design Retrospective interventional case series. Methods Fifteen patients, aged 17–73 years, underwent adjustable bilateral superior oblique tendon advancements for bilateral Fourth Nerve Palsy: 11 symmetric (≤2 prism diopters [pd] hyperdeviation in straight-ahead gaze) and 4 asymmetric. Motor alignment was assessed with double Maddox rods and prism and alternate cover tests preoperatively, pre- and postadjustment, and 6 weeks postoperatively. Results Preoperative torsion ranged from 7 to 30 degrees excyclotropia (mean 17 ± 7 degrees) and hyperdeviation from 0 to 10 pd. Preadjustment torsion ranged from 5 degrees excyclotropia to 40 degrees incyclotropia, and hyperdeviation from 0 to 8 pd. Twelve of the 15 patients (80%) were adjusted to a target of 0 pd hyperphoria and 10 degrees incyclotropia (actual mean 9 degrees incyclotropia, range 2–13 degrees incyclotropia). At 6 weeks postoperatively there was expected excyclodrift (to mean 4 degrees excyclotropia, range 0 degrees incyclotropia to 15 degrees excyclotropia), but 13 (87%) had 5 degrees or less excyclotropia and 14 (93%) had 2 pd or less hyperdeviation. Mean torsional correction from preoperative to preadjustment was 31 ± 14 degrees ( P P Conclusions Adjustable bilateral superior oblique tendon advancement allows independent control of torsional and vertical components of the deviation, and therefore may be useful in cases of bilateral superior oblique Palsy.
George Mariatos - One of the best experts on this subject based on the ideXlab platform.
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Acute Bilateral Ophthalmoparesis with Pupilary Areflexical Mydriasis in Miller-Fisher Syndrome Treated with Intravenous Immunoglobulin
2013Co-Authors: Theocharis Papanikolaou, Cath Gray, Bernard Boothman, Gerald Naylor, George MariatosAbstract:Copyright © 2010 Theocharis Papanikolaou et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Miller-Fisher syndrome (MFS) is a rare condition characterized by the classical triad of ophthalmoplegia, ataxia, and areflexia (Fisher, 1956). It is considered a variant of Guillain-Barré syndrome (GBS) with which it may overlap, or it can occur in more limited forms. We report a case of a thirty-five-year-old male who presented with a six-day history of diplopia, following a recent chest infection. On examination, he was found to have bilateral sixth Nerve Palsy, bilateral Fourth Nerve Palsy, bilateral areflexical mydriasis, ataxia and total absence of reflexes. After excluding other conditions, a diagnosis of Miller-Fisher syndrome was made. The patient was administered intravenous immunoglobulin and made an uneventful recovery. 1. Case Report A thirty-five-year-old male patient presented to our department complaining of diplopia of 6 days duration. He was generally fit and well with no significant past medical history. Ten days previously, he had suffered a chest infection for which he had a course of antibiotics and had made a goo
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acute bilateral ophthalmoparesis with pupilary areflexical mydriasis in miller fisher syndrome treated with intravenous immunoglobulin
Journal of Ophthalmology, 2010Co-Authors: Theocharis Papanikolaou, Cath Gray, Bernard Boothman, Gerald Naylor, George MariatosAbstract:Miller-Fisher syndrome (MFS) is a rare condition characterized by the classical triad of ophthalmoplegia, ataxia, and areflexia (Fisher, 1956). It is considered a variant of Guillain-Barre syndrome (GBS) with which it may overlap, or it can occur in more limited forms. We report a case of a thirty-five-year-old male who presented with a six-day history of diplopia, following a recent chest infection. On examination, he was found to have bilateral sixth Nerve Palsy, bilateral Fourth Nerve Palsy, bilateral areflexical mydriasis, ataxia and total absence of reflexes. After excluding other conditions, a diagnosis of Miller-Fisher syndrome was made. The patient was administered intravenous immunoglobulin and made an uneventful recovery.
Eric Eggenberger - One of the best experts on this subject based on the ideXlab platform.
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differentiating acute and subacute vertical strabismus using different head positions during the upright supine test
JAMA Ophthalmology, 2018Co-Authors: Joao Lemos, Adnan Subei, Cesar Nunes, Christopher C Glisson, Eric Eggenberger, Luis Cunha, Mário SousaAbstract:Importance: Accurate clinical differentiation between skew deviation and Fourth Nerve Palsy (4NP) is critical in the acute and subacute settings. Objective: To determine the sensitivity and specificity of the upright-supine test to detect vertical misalignment changes using different head positions for the diagnosis of acute or subacute skew deviation vs 4NP. Design, Setting, and Participants: This multicenter study enrolled consecutive patients from Coimbra University Hospital Centre, Coimbra, Portugal, and Michigan State University, Lansing, within 2 months of presenting with vertical diplopia and diagnosed as having skew deviation or acquired unilateral 4NP. The study used nonmasked screening and diagnostic test results from June 1, 2013, to December 31, 2016. Data were analyzed from January 1, 2017, to June 30, 2017. Main Outcomes and Measures: A 50% or greater change in vertical misalignment between the upright and supine positions, with the head centered and tilted to either side. Measurements included the alternate prism and cover (APC) test, the double Maddox rod test, the APC test change index ([measurement upright - measurement supine] / [measurement upright + measurement supine]), and the APC test sensitivity and specificity. Results: Of the 37 included patients, the mean (SD) age was 58 (14) years, and 26 (70%) were male. We enrolled 19 patients (51%) with skew deviation and 18 (49%) with 4NP. Eighteen patients with skew deviation (95%) showed additional ocular motor and/or neurological signs. When moving to the supine position, only 1 patient with skew deviation (5%) showed more than a 50% decrease of hypertropia with the head centered (APC test: sensitivity, 5%; specificity, 100%). Three patients with 4NP (17%) showed more than a 50% decrease of hypertropia with the head tilted toward the hypertropic eye, and 10 patients with 4NP (56%) showed more than a 50% increase of hypertropia with the head tilted toward the hypotropic eye. Change indexes were different between the skew deviation and 4NP groups for head tilt to the hypotropic eye (difference, -0.33 prism diopters; 95% CI, -0.43 to -0.20; P < .001). Cyclotorsion worsened in the supine position only in patients with skew deviation (hypertropic eye: difference, -7.6 prism diopters; 95% CI, -13.00 to -0.75; P = .01; hypotropic eye: difference, 8.2 prism diopters; 95% CI, 0 to 15.75; P = .03). Conclusions and Relevance: The upright-supine test with the head centered is not a sensitive method to separate acute or subacute skew deviation from 4NP. Conversion of an incomitant vertical deviation in the upright position to a comitant vertical strabismus in the supine position in all head positions, as well as the absence of additional ocular motor and/or neurologic signs, may constitute a more useful clue.
Theocharis Papanikolaou - One of the best experts on this subject based on the ideXlab platform.
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Acute Bilateral Ophthalmoparesis with Pupilary Areflexical Mydriasis in Miller-Fisher Syndrome Treated with Intravenous Immunoglobulin
2013Co-Authors: Theocharis Papanikolaou, Cath Gray, Bernard Boothman, Gerald Naylor, George MariatosAbstract:Copyright © 2010 Theocharis Papanikolaou et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Miller-Fisher syndrome (MFS) is a rare condition characterized by the classical triad of ophthalmoplegia, ataxia, and areflexia (Fisher, 1956). It is considered a variant of Guillain-Barré syndrome (GBS) with which it may overlap, or it can occur in more limited forms. We report a case of a thirty-five-year-old male who presented with a six-day history of diplopia, following a recent chest infection. On examination, he was found to have bilateral sixth Nerve Palsy, bilateral Fourth Nerve Palsy, bilateral areflexical mydriasis, ataxia and total absence of reflexes. After excluding other conditions, a diagnosis of Miller-Fisher syndrome was made. The patient was administered intravenous immunoglobulin and made an uneventful recovery. 1. Case Report A thirty-five-year-old male patient presented to our department complaining of diplopia of 6 days duration. He was generally fit and well with no significant past medical history. Ten days previously, he had suffered a chest infection for which he had a course of antibiotics and had made a goo
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acute bilateral ophthalmoparesis with pupilary areflexical mydriasis in miller fisher syndrome treated with intravenous immunoglobulin
Journal of Ophthalmology, 2010Co-Authors: Theocharis Papanikolaou, Cath Gray, Bernard Boothman, Gerald Naylor, George MariatosAbstract:Miller-Fisher syndrome (MFS) is a rare condition characterized by the classical triad of ophthalmoplegia, ataxia, and areflexia (Fisher, 1956). It is considered a variant of Guillain-Barre syndrome (GBS) with which it may overlap, or it can occur in more limited forms. We report a case of a thirty-five-year-old male who presented with a six-day history of diplopia, following a recent chest infection. On examination, he was found to have bilateral sixth Nerve Palsy, bilateral Fourth Nerve Palsy, bilateral areflexical mydriasis, ataxia and total absence of reflexes. After excluding other conditions, a diagnosis of Miller-Fisher syndrome was made. The patient was administered intravenous immunoglobulin and made an uneventful recovery.
Joao Lemos - One of the best experts on this subject based on the ideXlab platform.
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differentiating acute and subacute vertical strabismus using different head positions during the upright supine test
JAMA Ophthalmology, 2018Co-Authors: Joao Lemos, Adnan Subei, Cesar Nunes, Christopher C Glisson, Eric Eggenberger, Luis Cunha, Mário SousaAbstract:Importance: Accurate clinical differentiation between skew deviation and Fourth Nerve Palsy (4NP) is critical in the acute and subacute settings. Objective: To determine the sensitivity and specificity of the upright-supine test to detect vertical misalignment changes using different head positions for the diagnosis of acute or subacute skew deviation vs 4NP. Design, Setting, and Participants: This multicenter study enrolled consecutive patients from Coimbra University Hospital Centre, Coimbra, Portugal, and Michigan State University, Lansing, within 2 months of presenting with vertical diplopia and diagnosed as having skew deviation or acquired unilateral 4NP. The study used nonmasked screening and diagnostic test results from June 1, 2013, to December 31, 2016. Data were analyzed from January 1, 2017, to June 30, 2017. Main Outcomes and Measures: A 50% or greater change in vertical misalignment between the upright and supine positions, with the head centered and tilted to either side. Measurements included the alternate prism and cover (APC) test, the double Maddox rod test, the APC test change index ([measurement upright - measurement supine] / [measurement upright + measurement supine]), and the APC test sensitivity and specificity. Results: Of the 37 included patients, the mean (SD) age was 58 (14) years, and 26 (70%) were male. We enrolled 19 patients (51%) with skew deviation and 18 (49%) with 4NP. Eighteen patients with skew deviation (95%) showed additional ocular motor and/or neurological signs. When moving to the supine position, only 1 patient with skew deviation (5%) showed more than a 50% decrease of hypertropia with the head centered (APC test: sensitivity, 5%; specificity, 100%). Three patients with 4NP (17%) showed more than a 50% decrease of hypertropia with the head tilted toward the hypertropic eye, and 10 patients with 4NP (56%) showed more than a 50% increase of hypertropia with the head tilted toward the hypotropic eye. Change indexes were different between the skew deviation and 4NP groups for head tilt to the hypotropic eye (difference, -0.33 prism diopters; 95% CI, -0.43 to -0.20; P < .001). Cyclotorsion worsened in the supine position only in patients with skew deviation (hypertropic eye: difference, -7.6 prism diopters; 95% CI, -13.00 to -0.75; P = .01; hypotropic eye: difference, 8.2 prism diopters; 95% CI, 0 to 15.75; P = .03). Conclusions and Relevance: The upright-supine test with the head centered is not a sensitive method to separate acute or subacute skew deviation from 4NP. Conversion of an incomitant vertical deviation in the upright position to a comitant vertical strabismus in the supine position in all head positions, as well as the absence of additional ocular motor and/or neurologic signs, may constitute a more useful clue.
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Differentiating Acute and Subacute Vertical Strabismus Using Different Head Positions During the Upright-Supine Test.
JAMA ophthalmology, 2018Co-Authors: Joao Lemos, Adnan Subei, Cesar Nunes, Christopher C Glisson, Luis Cunha, Mário Sousa, Eric R. EggenbergerAbstract:Importance Accurate clinical differentiation between skew deviation and Fourth Nerve Palsy (4NP) is critical in the acute and subacute settings. Objective To determine the sensitivity and specificity of the upright-supine test to detect vertical misalignment changes using different head positions for the diagnosis of acute or subacute skew deviation vs 4NP. Design, Setting, and Participants This multicenter study enrolled consecutive patients from Coimbra University Hospital Centre, Coimbra, Portugal, and Michigan State University, Lansing, within 2 months of presenting with vertical diplopia and diagnosed as having skew deviation or acquired unilateral 4NP. The study used nonmasked screening and diagnostic test results from June 1, 2013, to December 31, 2016. Data were analyzed from January 1, 2017, to June 30, 2017. Main Outcomes and Measures A 50% or greater change in vertical misalignment between the upright and supine positions, with the head centered and tilted to either side. Measurements included the alternate prism and cover (APC) test, the double Maddox rod test, the APC test change index ([measurement upright − measurement supine] / [measurement upright + measurement supine]), and the APC test sensitivity and specificity. Results Of the 37 included patients, the mean (SD) age was 58 (14) years, and 26 (70%) were male. We enrolled 19 patients (51%) with skew deviation and 18 (49%) with 4NP. Eighteen patients with skew deviation (95%) showed additional ocular motor and/or neurological signs. When moving to the supine position, only 1 patient with skew deviation (5%) showed more than a 50% decrease of hypertropia with the head centered (APC test: sensitivity, 5%; specificity, 100%). Three patients with 4NP (17%) showed more than a 50% decrease of hypertropia with the head tilted toward the hypertropic eye, and 10 patients with 4NP (56%) showed more than a 50% increase of hypertropia with the head tilted toward the hypotropic eye. Change indexes were different between the skew deviation and 4NP groups for head tilt to the hypotropic eye (difference, −0.33 prism diopters; 95% CI, −0.43 to −0.20;P Conclusions and Relevance The upright-supine test with the head centered is not a sensitive method to separate acute or subacute skew deviation from 4NP. Conversion of an incomitant vertical deviation in the upright position to a comitant vertical strabismus in the supine position in all head positions, as well as the absence of additional ocular motor and/or neurologic signs, may constitute a more useful clue.
