DOCSLIB.ORG

Lid Nystagmus As a Sign of Intrinsic Midbrain Disease

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Lid Nystagmus As a Sign of Intrinsic Midbrain Disease Journal of Neuro-Ophthalmology 15(4): 236-240, 1995. i 1995 Lippincott-Raven Publishers, Philadelphia Lid Nystagmus as a Sign of Intrinsic Midbrain Disease Michael C. Brodsky, M.D. and Frederick A. Boop, M.D. A 6-year-old boy with signs and symptoms of ocular The terms "lid nystagmus," "upper lid jerks," myasthenia gravis had lid nystagmus evoked by hori­ and "lid hopping" have been applied to a rare zontal gaze. MR imaging demonstrated an intrinsic mid­ neuro-ophthalmic phenomenon in which a series brain lesion, which was diagnosed by biopsy as a low- grade astrocytoma. In the setting of ocular myasthenia of rapid, rhythmical, upward jerking movements gravis, the finding of lid nystagmus may serve as a use­ of the upper lids occur alone or in conjunction with ful clinical sign of intrinsic midbrain disease. specific movements of the eyes or head (1-14). Key Words: Lid nystagmus—Ocular myasthenia— Clinical reports suggest that this phenomenon oc­ Ophthalmoplegia—Midbrain tumor. curs in the setting of posterior fossa disease (1). We describe a child with bilateral ptosis and diffuse ophthalmoplegia suggestive of ocular myasthenia gravis in whom the atypical finding of lid nystag­ mus led to the diagnosis of midbrain astrocytoma. CASE REPORT A healthy 6-year-old boy was referred for eval­ uation of gradually progressive exotropia and bi­ lateral upper eyelid ptosis of 6 months duration. His mother stated that the ptosis was usually mild upon awakening and worse as the day progressed. There was no history of headaches, nausea or vomiting, mental status changes, decreased motor strength, or difficulty swallowing or chewing. There was no family history of ptosis or ophthal­ moplegia. Facial examination demonstrated a severe bilat­ eral ptosis and a large exotropia (Fig. 1). Corrected visual acuity was 20/20 in each eye. The pupils were equal in size and normally reactive to light, with no afferent pupillary defect. Extraocular movements were mildly limited in all fields of gaze with a severe adduction deficit in the right eye as shown in Fig. 2. Horizontal and vertical sac- Manuscript received July 18, 1994. cades were slow in all directions. The patient was From the Department of Ophthalmology (M.C.B.), and Neu­ unable to converge his eyes. He had no nystagmus rosurgery (F.A.B.), University of Arkansas for Medical Sci­ when he looked straight ahead in his exotropic po­ ences, Little Rock, Arkansas, U.S.A. This study was supported in part by a grant from Research to sition of gaze, but developed a gaze-evoked Prevent Blindness, Inc. nystagmus in horizontal and vertical gaze. He usu­ Address correspondence and reprint requests to Dr. Michael ally fixated objects of interest with his left eye C. Brodsky, Arkansas Children's Hospital, 800 Marshall, Little Rock, AR 72202, U.S.A. which necessitated a compensatory right face 236 LID NYSTAGMUS 237 drift to the original ptotic position. During hori­ zontal pursuit movements, the lids jerked at a fre­ quency of approximately one cycle per second. Careful examination of videotapes disclosed no as­ sociated vertical movement of the eyes. In sus­ tained lateral gaze, the lid nystagmus continued as a horizontal gaze-paretic nystagmus supervened. During attempted upgaze, the lid nystagmus in­ creased in amplitude and coincided with a large- amplitude, synchronous upbeating nystagmus. Attempted upgaze produced no visible retraction movements of the globes. During fixation of a sta­ tionary object, an occasional spontaneous upward jerk of the lids was observed. The patient had a positive Cogan's lid twitch sign. He displayed equivocal levator fatigability; however, his ptosis improved noticeably after 30 minutes of sleep. In­ tramuscular injection of neostigmine 0.8 mg pro­ duced no visible change in his ptosis or ophthal­ FIG. 1. Facial photograph demonstrating bilateral up­ moplegia. Results of a neurological examination per eyelid ptosis and exotropia. were otherwise normal. A magnetic resonance (MR) scan of the head turn and a slight chin elevation. He had 45 diopt­ demonstrated a 2-cm mass with low signal inten­ ers of exotropia in all fields of gaze except for left sity on Tl -weighted images and high signal inten­ gaze where his exotropia increased to greater than sity on T2-weighted images within the midbrain 90 diopters. tegmentum (Fig. 3). There was mild enlargement Horizontal pursuit movements or saccades in ei­ of the ventricular system with sparing of the fourth ther direction evoked a large-amplitude upper lid ventricle secondary to compression of the aque­ nystagmus that lasted for the duration of horizon­ duct of Sylvius. Results of a stereotactic biopsy re­ tal gaze. Each abnormal lid movement consisted of vealed a low-grade astrocytoma. a rapid, conjugate, upward jerk of both lids that The patient was treated with radiation therapy was followed immediately by a slower downward consisting of 5,400 cGy over a 6-week period. Two FIG. 2. Versions in secondary positions of gaze demonstrating diffuse ophthalmoplegia with marked adduction lag in the right eye. / Neuro-Ophthalmol, Vol. 25, No. i, 1995 238 M. C. BRODSKY AND F. A. BOOP FIG. 3. MR images demonstrating intrinsic midbrain lesion. Left: T2-weighted (TR = 2500; TE = 90) axial MR image demonstrating large intrinsic hyperintense midbrain glioma. Right: T1-weighted (TR = 700; TE = 11) sagittal image (postgadolinium) demonstrating the rostrocaudal extent of the tumor. years after initial presentation, he is attending ers and coworkers (4) described convergence- public school and appears to be functioning nor­ induced lid nystagmus induced by convergence in mally except for mild speech impairment. His par­ a patient with a cerebellar sarcoma that filled the ents state that his ptosis has resolved, but his ex- fourth ventricle. Safran and coworkers (5) de­ otropia persists. scribed convergence-induced lid nystagmus in two patients cerebellar system disease and speculated DISCUSSION that a phasically initiated instability of cerebellar origin might disrupt the normal physiological in­ Upper lid nystagmus is considered pathological crease in levator tonus that occurs during conver­ when it occurs in the absence of synchronous ver­ gence. As an alternative hypothesis, they sug­ tical movements of the globes. Nystagmus-like gested that convergence-evoked lid nystagmus jerking of the upper lids has been described in nu­ might also represent the effect of gaze-evoked merous pathological conditions. In each case, the nystagmus of cerebellar origin upon the normal abnormal lid movements have been evoked by physiological eyelid retraction evoked by conver­ specific movements of the eyes or head. Most pre­ gence. Salisachs and Lapresle (6) noted conver­ viously reported cases can be subdivided into lid gence-evoked lid nystagmus in patient with Miller nystagmus evoked by convergence (Pick's sign) Fisher syndrome. Howard described the same and lid nystagmus evoked by horizontal gaze. phenomenon in a patient with a pontomedullary Convergence-evoked lid nystagmus was first re­ angioma (7). ported in 1916 by Pick (2) in a patient who had Gaze-evoked lid nystagmus was first reported in multiple sclerosis and spastic quadriparesis. The 1916 by Popper (8) in an alcoholic patient with a lid nystagmus was observed in primary gaze in the left-beating vestibular nystagmus. Sittig (9) and absence of bulbar nystagmus. The lid movements Wilbrand and Saenger (10) subsequently described became accentuated during convergence and also gaze-evoked lid and ocular nystagmus in patients upgaze, where a synchronous upbeating nystag­ clinical signs of brainstem dysfunction without fur­ mus appeared. Pick (2) hypothesized that lid ther clinical or pathological localization. Daroff and nystagmus may reflect abnormal excitation within colleagues (11) described a patient with lateral the oculomotor nuclei radiating to the cell bodies medullary syndrome who had lid nystagmus that that control levator function. Rohmer and col­ was evoked by lateral gaze and inhibited by con­ leagues (3) noted convergence-induced lid nystag­ vergence. mus in a patient with a posttraumatic dorsal mid­ The fact that our patient's lid nystagmus oc­ brain syndrome and a left third nerve palsy. Sand­ curred in the absence of any visible vertical move- / Neuro-Ophthalmol, Vol. 15, No. 4, 1995 LID NYSTAGMUS 239 ment of the globes led us to conclude that the ab­ was characterized by a momentary elevation or normal lid movements somehow resulted from the fluttering of the ptotic eyelid as the patient visually abnormal innervational milieu created by his pursued an object from one position of lateral gaze slowly growing tegmental tumor. In upgaze, the to another. The ptosis resolved following radiation amplitude of the lid nystagmus increased as a therapy to the tumor. Ragge and Hoyt (23) attrib­ large-amplitude upbeating nystagmus super­ uted the patients neuro-ophthalmic signs to "mid­ vened, suggesting that the observed lid move­ brain myasthenia" and hypothesized that tumor ments in upgaze were, at least in part, secondary infiltration within the midbrain may have critically to the ocular nystagmus. reduced acetylcholine levels at centrally located The pathophysiology of lid nystagmus in un­ acetylcholine synapses (most likely at the synapses known. In this case, however, its neuroanatomical between supranuclear pathways in the brainstem substrate can clearly be localized to the midbrain and the nuclear complex of the third nerve), result­ tegmentum. Our patient's neuroophthalmic find­ ing
Load more

Recommended publications
  • Neuromyelitis Optica in Patients with Myasthenia Gravis Who Underwent Thymectomy
    ORIGINAL CONTRIBUTION Neuromyelitis Optica in Patients With Myasthenia Gravis Who Underwent Thymectomy Ilya Kister, MD; Sandeep Gulati, MD; Cavit Boz, MD; Roberto Bergamaschi, MD; Guiseppe Piccolo, MD; Joel Oger, MD; Michael L. Swerdlow, MD Background: Myasthenia gravis (MG) and neuromy- Patients: Four patients with MG who underwent elitis optica (NMO, also known as Devic disease) are rare thymectomy. autoimmune disorders, with upper-limit prevalence es- timates in the general population of 15 per 100 000 and Interventions: None. 5 per 100 000, respectively. To our knowledge, an asso- ciation between these diseases has not been previously Results: The prevalence of MG within the published co- reported. hort of patients with NMO is more than 150 times higher than that in the general population. Objectives: To describe 4 patients with MG who de- Conclusion: Dysregulation of B-cell autoimmunity in my- veloped NMO after thymectomy and to analyze possible asthenia, possibly exacerbated by loss of control over au- causes of apparent increased prevalence of NMO among toreactive cells as a result of thymectomy, may predis- patients with MG. pose patients to the development of NMO. Design: Case series. Arch Neurol. 2006;63:851-856 EUROMYELITIS OPTICA REPORT OF CASES (NMO) is characterized by 1 or more attacks of CASE 1 optic neuritis (ON) and myelitis. It can be dif- An African American woman with mild Nferentiated from multiple sclerosis (MS) asthma, distant history of smoking and with the aid of magnetic resonance imag- cocaine snorting, and family history of ing (MRI),1-3 cerebrospinal fluid anal- MS in her mother developed symptoms ysis4-8 and NMO-IgG antibody.9 The of ocular myasthenia at age 38 years.
    [Show full text]
  • Targeting the Rare Co-Occurrence of Myasthenia Gravis and Graves’ Disease with Radioactive Iodine Therapy
    ID: 21-0046 -21-0046 A E S Arcellana and others Myasthenia gravis, Graves’ ID: 21-0046; July 2021 disease association DOI: 10.1530/EDM-21-0046 Dual attack: targeting the rare co-occurrence of myasthenia gravis and Graves’ disease with radioactive iodine therapy Correspondence Anna Elvira S Arcellana 1, Karen Joy B Adiao2 and Myrna Buenaluz-Sedurante1 should be addressed to A E S Arcellana 1Division of Endocrinology, Diabetes and Metabolism, Department of Medicine and 2Department of Neurosciences, Email University of the Philippines-Manila, Philippine General Hospital, Manila, Philippines [email protected] Summary Occasionally, autoimmune disorders can come in twos. This double trouble creates unique challenges. Myasthenia gravis co-existing with autoimmune thyroid disease occurs in only about 0.14–0.2% of cases. The patient is a 27-year- old man with a 2-month history of bilateral ptosis, diplopia, with episodes of easy fatigability, palpitations, and heat intolerance. On physical exam, the patient had an enlarged thyroid gland. Myasthenia gravis was established based on the presence of ptosis with weakness of the intraocular muscles, abnormal fatigability, and a repetitive nerve stimulation studyindicatedneuromuscularjunctiondisease.Episodesoffluctuatingrightshoulderweaknesswerealsonoted.He wasalsofoundtohaveelevatedFT3,FT4,andasuppressedTSH.Thyroidultrasoundrevealedthyromegalywithdiffused parenchymal disease. Thyroid scintigraphy showed increased uptake function at 72.4% uptake at 24 h. TRAb was positive at4.1U/L.Patientwasstartedonpyridostigminewhichledtoasignificantreductioninthefrequencyofocularmuscle weakness.Methimazolewasalsoinitiated.Radioactiveiodineat14.9mciwasinstitutedforthedefinitivemanagementof hyperthyroidism. After RAI, there was abatement of the hyperthyroid symptoms, as well as improvement in the status of the myasthenia gravis, with ptosis, diplopia, and right arm weakness hardly occurring thereafter despite the reduction of the pyridostigmine dose based on a symptom diary and medication intake record.
    [Show full text]
  • Strabismus: a Decision Making Approach
    Strabismus A Decision Making Approach Gunter K. von Noorden, M.D. Eugene M. Helveston, M.D. Strabismus: A Decision Making Approach Gunter K. von Noorden, M.D. Emeritus Professor of Ophthalmology and Pediatrics Baylor College of Medicine Houston, Texas Eugene M. Helveston, M.D. Emeritus Professor of Ophthalmology Indiana University School of Medicine Indianapolis, Indiana Published originally in English under the title: Strabismus: A Decision Making Approach. By Gunter K. von Noorden and Eugene M. Helveston Published in 1994 by Mosby-Year Book, Inc., St. Louis, MO Copyright held by Gunter K. von Noorden and Eugene M. Helveston All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the authors. Copyright © 2010 Table of Contents Foreword Preface 1.01 Equipment for Examination of the Patient with Strabismus 1.02 History 1.03 Inspection of Patient 1.04 Sequence of Motility Examination 1.05 Does This Baby See? 1.06 Visual Acuity – Methods of Examination 1.07 Visual Acuity Testing in Infants 1.08 Primary versus Secondary Deviation 1.09 Evaluation of Monocular Movements – Ductions 1.10 Evaluation of Binocular Movements – Versions 1.11 Unilaterally Reduced Vision Associated with Orthotropia 1.12 Unilateral Decrease of Visual Acuity Associated with Heterotropia 1.13 Decentered Corneal Light Reflex 1.14 Strabismus – Generic Classification 1.15 Is Latent Strabismus
    [Show full text]
  • Myasthenia Gravis
    A Guide for Patients and Families What is... Myasthenia Gravis Myasthenia gravis (MG) is a chronic autoimmune MG is not inherited, and it is not contagious. Although disease — a disease that occurs when the immune MG is not hereditary, genetic susceptibility appears to system mistakenly attacks the body’s own tissues. play a role in it. Occasionally, the disease may occur in more than one member of the same family. In MG, the immune system attacks and interrupts the connection between nerve and muscle, called the MG causes weakness in muscles that control the neuromuscular junction (NMJ). This causes weakness eyes, face, neck, and limbs. Symptoms include partial in the skeletal muscles, which are responsible for paralysis of eye movements, double vision, and droopy breathing and moving parts of the body. eyelids, as well as weakness and fatigue in neck and jaws with problems in chewing, swallowing, and holding In most cases of MG, the immune system targets the up the head. acetylcholine receptor — a protein on muscle cells that is required for muscle contraction. Muscle weakness in MG gets worse with exertion and improves with rest. About 85 percent of people with MG have antibodies against the acetylcholine receptor in their blood. The Approximately 10-20 percent of people with antibodies target and destroy many of the acetylcholine MG experience at least one myasthenic crisis, an receptors on muscle. Consequently, the muscle’s emergency in which the muscles that control breathing response to repeated nerve signals declines with time, weaken to the point where the individual requires a and the muscles become weak and tired.
    [Show full text]
  • Autoimmune Diseases, Treatment, and Contact Lens Wear
    Autoimmune Diseases, Treatment, and Contact Lens Wear Content written by: June Smith-Jeffries – FCLSA, NCLE, COT Content originally published in the Summer 2015 edition of The Eighth Line Table of Contents • Introduction • Autoimmune Diabetes o Type 1 Diabetes Mellitus o Latent Autoimmune Diabetes of Adulthood (LADA) • Sjögren’s Syndrome • Fibromyalgia • Rheumatoid Arthritis (RA) • Systemic Lupus Erythematosus (SLE) • Ankylosing Spondylitis (AS) • Systemic Sclerosis (Scleroderma) • Raynaud’s Phenomenon • Sarcoidosis • Multiple Sclerosis (MS) • Myasthenia Gravis • Ulcerative Colitis • Corticosteroids and Dilated Eye Exams • Post Test Introduction Autoimmune diseases occur when a person’s immune system does not distinguish between healthy tissue and antigens. An antigen is any substance foreign to the body that evokes an immune response. As a result, the body sets off a reaction that destroys normal tissues. Normally the white blood cells in the body’s immune system help to protect against harmful substances such as bacteria, viruses, toxins, cancer cells and blood and tissue from outside the body. These substances contain antigens. The immune system produces antibodies against these antigens that enable it to destroy these damaging substances. 1 | Page An autoimmune disease may affect one or more organ and various types of tissue. Areas often affected by autoimmune diseases include: connective tissues, joints, muscles, blood vessels, the skin and endocrine glands. There is significant overlap in endocrine and autoimmune diseases because many autoimmune diseases originate in an endocrine gland, for instance, type 2 diabetes, thyroid diseases and Addison’s disease. Autoimmune diseases have been found in virtually every organ system in the body. Most autoimmune diseases continue for the lifetime of the patient because there are no cures.
    [Show full text]
  • Ice Pack Test for Myasthenia Gravis LETTER to the EDITORS
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by RERO DOC Digital Library J Neurol (2003) 250:883–884 DOI 10.1007/s00415-003-1121-1 LETTER TO THE EDITORS Adam Czaplinski countries. According to previous we cooled the more affected eye. Andreas J. Steck publications local cooling improves The ice pack was then removed af- Peter Fuhr neuromuscular transmission, ter 2 minutes. After 10 minutes, whereas warming has the opposite three i. v. injections, one containing effect [1]. However, the precise 10 mg edrophonium and two Ice pack test for mechanism of this effect is unclear. placebo, were administered in a myasthenia gravis Reduction or inhibition of the ac- double blinded fashion by a nurse. tivity of acetylcholinesterase by Photographs were taken immedi- A simple, noninvasive and safe lowering temperature is a possible ately after cooling or 1 minute after diagnostic method mechanism [8]. The purpose of the injection. All pictures were re- present article is to be a reminder viewed by a blinded observer. Out- Received: 24 January 2003 of an alternate method to tensilon come measure was the effect of ice Accepted: 27 February 2003 testing that is simple and safe but or edrophonium on ptosis. seems to have fallen into oblivion Results: Five subjects improved in the neurological literature. with the ice test; however, in one of Sirs: Intravenous injection of the Design/Methods: Five patients them the edrophonium test was acetylcholinesterase inhibitor edro- with ptosis from previously undi- negative. All subjects with positive phonium (tensilon) is commonly agnosed myasthenia gravis and five response to orbital cooling were used in the diagnosis of myasthe- with non-myasthenic ptosis were subsequently shown to have myas- nia gravis (MG), because of rapid studied with the use of tensilon thenia gravis by other tests (ele- onset and short duration of its ef- testing, orbital cooling, and other vated titers of anti-acetylcholine fects.
    [Show full text]
  • Strabismus Developing After Unilateral and Bilateral Cataract Surgery in Children
    Eye (2016) 30, 1210–1214 © 2016 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0950-222X/16 www.nature.com/eye CLINICAL STUDY Strabismus developing R David, J Davelman, H Mechoulam, E Cohen, I Karshai and I Anteby after unilateral and bilateral cataract surgery in children Abstract Purpose To evaluate the prevalence and common in children with poor final visual risk factors of strabismus in children acuity. undergoing surgery for unilateral or bilateral Eye (2016) 30, 1210–1214; doi:10.1038/eye.2016.162; cataract with or without intraocular lens published online 29 July 2016 implantation. Methods Medical records of pediatric Introduction patients were evaluated from 2000 to 2011. Children undergoing surgery for unilateral The rate of strabismus associated with cataract or bilateral cataract with at least 1 year of in children has been reported to range from follow-up were included. Children with 20.5 to 86%.1 Strabismus is more prevalent in ocular trauma, prematurity, or co-existing children who have been operated for cataract systemic disorders were excluded. The than in the general pediatric population.2–8 following data were evaluated: strabismus Moreover, it occurs more frequently in patients pre- and post-operation; age at surgery; with unilateral than bilateral cataract.1 The post-operative aphakia or pseudophakia; association between timing of surgery or the use and visual acuity. of intra ocular lens (IOL) with development of Results Ninety patients were included, 40% strabismus is still not fully understood. had unilateral and 60% had bilateral cataracts. The main purpose of this study is to evaluate Follow-up was on average 51 months (range: the prevalence and risk factors of strabismus 12–130 months).
    [Show full text]
  • Ocular Myasthenia: Evaluationof Tensilon Tonography And
    J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.33.5.639 on 1 October 1970. Downloaded from J. Neurol. Neurosurg. Psychiat., 33, 1970, 639-646 Ocular myasthenia: evaluation of Tensilon tonography and electronystagmography as diagnostic tests M. J. CAMPBELL, E. SIMPSON, A. L. CROMBIE, AND J. N. WALTON From the Department of Neurology, Regional Neurological Centre, The General Hospital, and the Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne SUMMARY The value of electronystagmography (ENG) and of tonography in monitoring the beneficial effect of edrophonium chloride (Tensilon) on the extraocular muscles in myasthenia gravis has been assessed. Studies were performed on 17 patients with myasthenia gravis and on 18 control subjects, of whom nine had extraocular muscle weakness due to myopathic or neurogenic lesions. Electronystagmography recorded the repetitive following movements of the eyes elicited during guest. Protected by copyright. optokinetic nystagmus. Neuromuscular fatigue with the subsequent beneficial response to Tensilon was clearly seen in 50 % of patients with myasthenia. False positive responses were not seen in control subjects but in many of these, as in the remaining myasthenic patients, the amplitude and rate of nystagmus seen in the ENG was very variable. These difficulties suggest that the ENG is of limited value as a diagnostic test in myasthenia gravis. Tonography, recording the intraocular pressure of the eye continuously over four minutes, was found to be of considerable value. We found that the intraocular pressure fell on average by 1-6 to 1-8 mm Hg over a one minute period in the control recordings but increased by a mean of 1 6 mm Hg in patients with myasthenia, with a peak effect 35 seconds after Tensilon.
    [Show full text]
  • Ocular Myasthenia Gravis Associated with Autoimmune Thyroid Disease
    Case Report OCULAR MYASTHENIA GRAVIS ASSOCIATED WITH AUTOIMMUNE THYROID DISEASE Aylin Yaman, M.D.* / Hakan Yaman, M.D., M.S.** * Departm ent o f neurology, İsparta State Hospital, İsparta, Turkey. ** Fam ily Physician, School o f Medicine, Suleyman Dem irel University, İsparta, Turkey. ABSTRACT pathologies is a rare condition but should be taken into consideration. The coincidence of thyroid ophthalmopathy and ocular myasthenia gravis is a defined but rather rare condition. Key Words: Myasthenia gravis, Graves’ disease, Ophthalmopathy, Ocular involvement, A 30-year-old female patient was admitted with Thyrotoxicosis, Thymectomy complaints of weight loss, sweating, palpitation and tremor of both hands for about 4 months. She was diagnosed as having Graves' disease INTRODUCTION with elevated thyroid hormone levels, diffuse hyperplastic thyroid gland with increased iodine, Graves’ disease and myasthenia gravis are both 131 uptake and positive antithyroid antibodies. autoimmune diseases and the coexistence of Two months after the diagnosis of thyroid these two diseases is well recognised. disease, she developed diplopia and in the Myasthenia Gravis is more frequent in patients following days, bilateral ptosis. Orbital magnetic with thyroid disease. It is seen in less than one resonance imaging showed that the lateral and percent of patients with Graves’ disease, and inferior rectus muscles were thickened indicating approximately five percent of myasthenic the infiltration of those muscles. She had positive patients are thyrotoxic at some time (1). response to the prostigmine test and elevated Moreover thyroid diseases occur more frequently acetylcholine receptor antibody levels supporting in close relatives of patients with myasthenia the diagnosis of myasthenia gravis. She had gravis than in the general population (2).
    [Show full text]
  • Adult Strabismus Overview Common Types Esotropia Exotropia
    Gregory Ostrow, M.D. Scripps Clinic/Scripps Green Hospital Grand Rounds Wednesday, Mar. 18, 2009 Overview • Common Types of Strabismus • Indications for Strabismus Surgery • Common Procedures Adult Strabismus • Psychosocial Benefits Gregory Ostrow M.D Pediatric Ophthalmology and Adult Strabismus Scripps Clinic Medical Group 3811 Valley Centre Drive San Diego, CA 92130 Esotropia Common Types Exotropia www.scripps.org/clinicrss Scripps Conference Services & CME www.scripps.org/conferenceservices 1 P: (858) 652-5400 E: [email protected] Gregory Ostrow, M.D. Scripps Clinic/Scripps Green Hospital Grand Rounds Wednesday, Mar. 18, 2009 • There are many different Indications for Strabismus presentations of strabismus Surgery • Most can be corrected surgically Classically Taught Benefits of Other Benefits Strabismus Surgery • Develop binocular vision • Improve visual • Restore binocular vision field • Eliminate diplopia • Eliminate torticollis www.scripps.org/clinicrss Scripps Conference Services & CME www.scripps.org/conferenceservices 2 P: (858) 652-5400 E: [email protected] Gregory Ostrow, M.D. Scripps Clinic/Scripps Green Hospital Grand Rounds Wednesday, Mar. 18, 2009 Insurance accepted indications Surgical Procedures for strabismus surgery •Diplopia • Weaken (recession) • Asthenopia (eye strain) • Strengthen (resection or tuck) • Any misalignment of the eyes that • Alter vector forces (transposition) cannot be corrected non-surgically – this is where some prodding is occasionally required Recession (weakening) www.scripps.org/clinicrss Scripps Conference Services & CME www.scripps.org/conferenceservices 3 P: (858) 652-5400 E: [email protected] Gregory Ostrow, M.D. Scripps Clinic/Scripps Green Hospital Grand Rounds Wednesday, Mar. 18, 2009 Resection (tightening) Psychosocial Benefits of Strabismus Surgery www.scripps.org/clinicrss Scripps Conference Services & CME www.scripps.org/conferenceservices 4 P: (858) 652-5400 E: [email protected] Gregory Ostrow, M.D.
    [Show full text]
  • Refraction of 1-Year-Old Children After Atropine Cycloplegia R
    Br J Ophthalmol: first published as 10.1136/bjo.63.5.343 on 1 May 1979. Downloaded from British Journal of Ophthalmology, 1979, 63, 343-347 Refraction of 1-year-old children after atropine cycloplegia R. M. INGRAM From the Kettering and District General Hospital, Kettering SUMMARY The refractions of 1648 children aged 11 to 13 months are reported. Atropine % was used for cycloplegia. 11 83% of the children had bilateral hypermetropia of +2O00 or more D. 13-23 % of them had + 1 50 or more D astigmatism in one or both eyes, and 6 5 % had anisometropia. Anisometropia was significantly (P=0-000 001 %) associated with bilateral hypermetropia, but even more significantly (P=0000000 4%) associated with astigmatism of +1 50 or more D in one or both eyes. Cyclopentolate was used in our pilot study (Ingram month of their birth, but some children born late et al., 1979) for reasons of convenience, but its in the month were refracted early in that month cycloplegic effect has not been proved (Davidson, and others, for one reason or another, attended 1976). Atropine is accepted generally as the most during the following month. Thus their ages ranged efficient cycloplegic drug, and the true range of from 11 to 13 months inclusive. refractions at age 1 year would be more accurately All the refractions were carried out by the recorded after 'atropinisation'. This is a report of author. When cycloplegia was obviously incomplete, the refractions of 1648 1-year-old children examined for example, the pupils were mobile or when the after 'full atropinisation'.
    [Show full text]
  • Myasthenia Gravis Diagnosis and Management
    MyastheniaMyasthenia GravisGravis DiagnosisDiagnosis andand managementmanagement Dr.Dr. ThaninThanin AsawavichienjindaAsawavichienjinda,, M.D.M.D. MyastheniaMyasthenia GravisGravis • A neuromuscular disorder characterized by weakness and fatigability of skeletal muscles • The underlying defect: A decrease in the number of available acetylcholine receptors (AChRs) at neuromuscular junctions due to an antibody-mediated autoimmune attack. •• PreferablePreferable name:name: AutoimmuneAutoimmune myastheniamyasthenia • Treatment now available for MG is highly effective, although a specific cure has remained elusive Harrison 2001 MyastheniaMyasthenia Gravis:Gravis: EpidemiologyEpidemiology •• InIn thethe USA,USA, thethe prevalenceprevalence isis 14.214.2 cases/1cases/1 millionmillion peoplepeople •• AppearAppear atat anyany ageage •• InIn women,women, thethe onsetonset betweenbetween 2020 andand 4040 yearsyears ofof ageage •• AmongAmong men,men, atat 4040--6060 • Overall, women are affected more frequently than men, in a ratio of approximately 3:2. •• FamilialFamilial occurrenceoccurrence isis rarerare JOAO 2004 MyastheniaMyasthenia Gravis:Gravis: EpidemiologyEpidemiology •• AnnualAnnual incidence:incidence: 0.250.25--2/100,0002/100,000 •• SpontaneousSpontaneous remission:remission: 20%20% •• WithoutWithout treatment,treatment, 2020--30%30% diedie inin 1010 yearsyears •• MGMG isis aa heterogeneousheterogeneous disorderdisorder –– 90%90% nono specificspecific causecause •• Genetic predisposing factor: HLA association; HLA-BW46 in chinese ocular
    [Show full text]