Abstract

Purpose:

In patients referred with blepharoptosis, the possibility of an underlying systemic cause for their ptosis can warrant a more detailed evaluation. The purpose of this study is to determine both the incidence and demographic characteristics associated with different types of ptosis in patients referred to the oculoplastics division at a tertiary care center.

Methods:

A retrospective chart review was performed on all patients referred to the oculoplastics division between 2007 and 2010. Final etiology for each patient's ptosis was determined based on history, standard eyelid measurements, and ancillary testing. Based on etiology, ptosis was categorized as aponeurotic, neurogenic, myogenic, traumatic, congenital, or mechanical. Demographics, including median age and sex were analyzed for patients in each category of ptosis.

Results:

Of the 251 patients, aponeurotic ptosis was the most common type of ptosis (60.2%), followed by traumatic (11.2%), congenital (10.4%), mechanical (8.8%), neurogenic (5.6%), and myogenic (4.0%). Of the neurogenic group, 35.7% of patients had cranial nerve 3 (CN 3) palsy, 28.6% had myasthenia gravis, 14.3% had aberrant regeneration, and 7.1% had Horner's syndrome. Thirty percent of the myogenic group had chronic progressive external ophthalmoplegia (CPEO). The congenital group had the youngest median age (10.5 years), yet the aponeurotic group had the oldest (62 years).

Conclusions:

A significant proportion of patients referred with ptosis had more serious conditions such as neurogenic or myogenic ptosis. Thus, clinicians should maintain a high degree of suspicion and thoroughly evaluate all patients with ptosis in order to properly assess for underlying systemic associations.

To investigate the expressions of EphrinB2 and VEGF in nasopharyngeal carcinoma and their relationships with clinic pathological factors.The expressions of EphrinB2 and VEGF in 136 cases of nasopharyngeal carcinomas, and 20 cases of nasopharyngitis tissues were detected by SP method immunohistochemistry.1) The positive rates of EphrinB2 and VEGF were 63.2% and 67.6% respectively in 136 cases of nasopharyngeal carcinomas. Their positive rate in nasopharyneal carcinoma tissues was significantly higer than those in nasopharyngitis tissues (P<0.01). 2) Iniensity of the expression of EphrinB2 and VEGF protein was related to lymphnodes metabasis, cranial nerve palsy, basalis encroachment, clinical stage respectively (P<0.01). 3) The expression of EphrinB2 in nasopharyngeal carcinoma tissues and was positively correlated with VEGF (P< 0.01).Ephrinbeta2 and VEGF may play important roles in invasiveness, metastasis and angiogenesis of nasopharyngeal carcinoma. There may be certain interregulation mechanism between them and they are hoped to become new biologic parameters to judge the pathogenesis, development and prognosis of nasopharyngeal carcinoma and to guide the treatment.

To determine incidence of diplopia after glaucoma drainage device (GDD) surgery and to report treatment outcomes.Financial claims data were used to identify patients who underwent GDD surgery (CPT [Current Procedural Terminology] 66180) at the Bascom Palmer Eye Institute from January 2, 1991, through December 31, 2005. After a second claims data search, the medical records of patients diagnosed with diplopia (International Classification of Diseases, 9th Revision code 368.2) and those who underwent extraocular muscle surgery (CPT-4 code 67311-67335) after GDD implantation were reviewed retrospectively.A total of 2,661 patients underwent GDD surgery during the study period. Charges were submitted for 59 patients for strabismus surgery or office visits relating to diplopia. Of these, 27 patients were excluded because medical records did not document diplopia or included pre-existing diplopia, cranial nerve palsy, or diplopia attributed to another ocular procedure. The remaining 32 patients developed diplopia secondary to GDD. Superotemporal quadrant GDDs were identified in 23 eyes and inferonasal quadrant placement in 9 eyes. The 1-year cumulative incidence of diplopia was 1.4%. No patient developed diplopia after 1 year. The mean follow-up after diagnosis for patients with diplopia was 48 ± 27 months (range, 1-124 months). The mean time of onset of diplopia after GDD implantation was 66 ± 62 days, with median onset of 42 days (range, 8-278 days). Treatment of diplopia included prisms in 17 cases (53.1%), no treatment in 13 (40.6%), other therapies in 2 (6.3%), and surgery after prismatic treatment failed in 3 (9.4%).The incidence of diplopia after GDD surgery is low, and most patients are treated with prisms.

BACKGROUND:

Third, fourth, and sixth cranial nerve (CN3, CN4, and CN6) palsies are not uncommon in neuro-ophthalmology. The time and quality of recovery depend on the causes of the cranial nerve palsy. The purpose of our study was to evaluate the causes and outcome of acquired paralytic strabismus (PS) in a southern Taiwan population.

METHODS:

This study involved a retrospective chart review of patients at Kaohsiung Veterans General Hospital from January 2006 through July 2009. A total of 196 patients were enrolled. Outcomes and recovery times were recorded for the patients who exhibited C3, C4, and C6 palsies. The patients were categorized into four etiologic groups: vascular, idiopathic, traumatic, and neoplastic. The onset of PS, its continuing medical management, recovery, and other outcomes were followed up in these patients over a period of up to 10 years.

RESULTS:

The mean age of the 196 patients enrolled was 58.35 ± 17.60 years (range 11-90 years), and the mean follow-up time was 13.6 months. Seventy-seven patients (39.29%) had CN3 palsy, 38 patients (19.39%) had CN4 palsy, and 81 patients (41.33%) had CN6 palsy. The most common causes were vascular diseases (35.20%), followed by trauma (33.67%), and idiopathic causes (21.94%). About 50% of the patients recovered within 6 months. Among the four etiologic groups of patients, the vascular group showed the best recovery: about half of the patients recovered within 3 months. Longer recovery periods were necessary for patients in the neoplastic group than for those in the traumatic, vascular, and idiopathic groups (p = 0.01; p < 0.001; p < 0.001, respectively).

CONCLUSION:

The prognosis for patients with PS depended mostly on the cause of their disease. Patients with PS attributable to a vascular cause had a better prognosis than the other patients, and those in the neoplastic group required the longest time to recover.

A 7-year-old boy developed a left ventricular aneurysm with massive hemopericardium 3 years ago due to a fall from a fourth-floor window. He had mild neurological sequelae including cranial nerve III palsy and abnormal electroencephalography findings at that time. He had no chest pain until recently when he presented with chest tightness and abdominal pain for 2 days prior to admission. Chest X-ray showed marked cardiomegaly. Echocardiography revealed massive pericardial effusion and a large left ventricular aneurysm. The massive hemopericardium was surgically drained, and the aneurysm was resected under cardiopulmonary bypass. He was discharged uneventfully 1 week after operation. Because symptoms and signs can vary in patients with ventricular aneurysm, we strongly suggest a close clinical follow-up, preferably with chest X-ray or echocardiography, for patients experiencing a blunt chest trauma.

Tuberculous meningitis (TBM) and acute bacterial meningitis (ABM) cause substantial mortality and morbidity in both children and adults. Identification of poor prognostic factors at patient's admission could prepare physicians for more aggressive monitoring of patients with meningitis. The objective of this study was to determine the predictive value of neurological features to differentiate ABM and TBM. A retrospective study was conducted between patients affected with ABM or TBM admitted to three teaching hospitals during the last 14 years in Zahedan the central city of Sistan and Balouchestan province (Iran). The neurological features include seizure, level of consciousness, stroke, focal neurologic deficit and cranial nerve palsy at the time of admission. Mean age for patients with TBM and ABM were 41 ± 22.4 and 24 ± 18.5 years respectively. In univariate analysis, all measured variables revealed significant difference between ABM and TBM patients except for seizure episodes. Multivariate logistic regression analysis showed positive predictive effect of cranial nerve palsy (AOR=1.980, CI 95%: 1.161-3.376) on the diagnosis of TBM. In our study cranial nerve palsies was the most important neurological predictor factor to differentiate TBM from ABM.

BACKGROUND::

In treating cavernous sinus dural arteriovenous fistulas (CSdAVFs), transvenous embolization of the whole affected sinus is usually performed, which may result in the disturbance of normal venous drainage, or permanent cranial nerve palsy.

Objective:

To describe superselective shunt occlusion (SSSO) of CSdAVFs.

METHODS::

Between July 2005 and August 2011, we experienced 20 consecutive CSdAVFs. In 14 cases (70%), we could detect the restricted locus of arteriovenous shunts by way of three-dimension rotational angiography (3-D RA) and/or superselective arteriography. After navigating the microcatheter to the shunt segment, consecutive superselective arterio-venography was performed to confirm the location of the microcatheter at the proper position.

RESULTS::

In 12 of 14 cases (85.7 %) in which the shunt was restricted, coiling only in the small venous pouch or compartment, which was just downstream of the shunt point, led to complete disappearance of the shunt without obliterating the entire sinus. No recurrence or permanent cranial nerve palsy was observed during the follow-up period with a mean of 46 (3 to 69) months in 12 cases treated by SSSO.

CONCLUSION:

: This technique, which enables complete extirpation of shunts by small amounts of coils, is a feasible way to treat CSdAVFs with excellent mid- to long-term results. Understanding of the angioarchitecture by 3-D RA and consecutive superselective arterio-venography was useful. This method should be considered before sinus packing or mere obliteration of dangerous venous outlets.

Objective/Background To describe an innovative endoscopic technique to treat prepontine epidermoid cysts. These cysts are typically resected in a microsurgical fashion and can be associated with significant risks and complications. This report is the first description of an endoscopic-assisted removal of an epidermoid cyst without the use of the operative microscope and evaluates the operative findings, technique, and postoperative course.Study Design Retrospective review at tertiary referral center.Methods Two patients, one with rapidly progressive headache and ataxia, and another with trigeminal neuralgia were found to have mixed-intensity cystic lesions of the prepontine region consistent with an epidermoid cyst. A detailed description of the preoperative preparation, surgical approach, intraoperative technique, pre- and post-operative imaging findings and monitoring outcomes are emphasized.Results Both patients underwent resection of the epidermoid cyst using an endoscope-assisted technique. The procedures were 3 and 4 hours in duration with an estimated blood loss of 50 cc in both operations. No intraoperative complications occurred. The patients were discharged from the hospital on postoperative days 2 and 3, respectively. Postoperative imaging revealed no edema of the cerebellum and complete resolution of the cyst. Neurological examination revealed improvement of preoperative symptoms with complete resolution of headache and ataxia of case 1, with resolution of trigeminal neuralgia in case 2. Case 2 did develop an ipsilateral cranial nerve (CN) VI paresis postoperatively that resolved over a 3-week period. The patient from case 1 remains symptom free after 24-months with magnetic resonance imaging (MRI) consistent with gross-total resection of the epidermoid cyst. Case 2 has continued resolution of trigeminal neuralgia and CN VI palsy with 12-month follow-up MRI consistent with gross total resection.Conclusions The use of the endoscope as the sole means to access the posterior fossa to treat prepontine cystic lesions affords the surgeon excellent visualization with minimal cerebellar retraction and can be done in a safe and effective manner with little to no morbidity.

Herpes zoster ophthalmicus is a manifestation of herpes zoster when the ophthalmic division of the trigeminal nerve becomes involved. Ocular symptoms are varied and mainly due to inflammatory mechanisms. Total, external and/or internal ophthalmoplegias, as well as isolated third, fourth and sixth cranial nerve palsies have all been reported as complications. In a minority of cases, concurrent pupillary paralysis has been documented. The presentation of complete paralytic mydriasis as the sole cranial nerve complication following herpes zoster ophthalmicus infection is a rare finding. The postulated pathophysiologic aetiology is a partial third nerve palsy with the pupillary fibres for light and accommodation-convergence affected and motor fibres spared. The mechanism responsible for the postulated lesion is speculative.

To study an effective method for surgical management of vertebral and basilar artery aneurysms.Forty-one patients with 43 aneurysms of the vertebral and basilar arteries were managed by microsurgical clipping. Cerebral angiography revealed basilar apex aneurysms in 17 patients, basilar trunk in six patients, vertebrobasilar (VB) junction aneurysms in three patients and vertebral aneurysms in 15 patients. One patient had two basilar aneurysms, and another had bilateral vertebral artery aneurysm.We used a pterional approach in basilar apex aneurysms (n = 17 patients), orbitozygomatic and its variants in upper basilar trunk aneurysms (n = 2 patients), combined petrosal and far-lateral approach in mid basilar trunk aneurysms (n = 4 patients), far-lateral and transcondylar approach for the aneurysms at VB junction (n = 3 patients) and transcondylar approach for the vertebral aneurysms (n = 15 patients). Bypass graft was performed in 14 patients with fusiform and wide neck aneurysms, to prevent potential cerebral ischemia due to prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice.Neurological outcomes were measured on the basis of Glasgow Outcome Score (GOS). The rate of back-to-normal life after surgery in basilar tip aneurysm, basilar trunk aneurysms, VB junction aneurysms and vertebral artery aneurysms was 15/17 (82.5 %), 5/6 (83 %), 3/3 (100 %) and 14/15 (93.3 %), respectively. Thirty-six (87.8 %) patients had uneventful postoperative courses. Two patient with basilar apex aneurysm suffered severe neurological deficits related to midbrain ischemia, two patient with occipital artery (OA) graft bypass had postoperative partial lower cranial nerve palsy, and one death with basilar trunk aneurysm occurred after the 20th day of surgery. Thirty-nine patients accepted postoperative digital subtraction angiography (DSA) and eight patients accepted computed tomography (CT) angiogram, whereas two patient denied either one. All the images demonstrated afferent and efferent vessels without aneurysm in situ. Out of 14 patients with graft bypass, 11 patients on cerebral angiographies disclosed the aneurysm clip and the graft bypass patency, one patient on angiography had unidentified graft bypass patency but no symptom related to the graft bypass patency, and two patients denied the postoperative cerebral angiographies. In 40 patients with a mean follow-up of 3.4 years, 37 patients had good outcome, two patients needed assistance for daily living, and one death occurred due to brainstem infarction related to surgery.Selection of proper cranial base approach with adequate exposure is effective in clipping VB aneurysms, minimizing the postoperative complications. Graft bypass may avoid parent artery sacrifice and its branches occlusion in patients with fusiform and wide neck aneurysms.