Ntm2004

First International Scientific Teleconference "New Technology in Medicine" Saint-Petersburg, Russia, March 2004 P.K.Sodhi1 et.al., 2004.
P.K.Sodhi1, J.L.Goyal 2, S.K.Ratan3
CURRENT PRESENTATIONS OF OCULAR MOTOR NERVES PALSIES
1Department of Ophthalmology, Safdarjung Hospital, New Delhi, India 2Maulana Azad Medical College and allied Guru Nanak Eye Centre, New Delhi, India 3Department of Paediatric Surgery, Safdarjung Hospital, New Delhi, India Abstract
Background: Ocular motor nerve palsies, in addition to being of visual inconvenience, might additionally point to a grave systemic
disease. Though the ocular condition needs conservative treatment mainly, the underlying systemic condition might require emergent
and/or prolonged treatment measures.
Patients and Methods: The aim of the present study was to find the current pattern of ocular motor nerve palsies. We retrospectively
reviewed the case records of ninety-nine patients who presented to us with ocular motor nerve palsies. In addition to performing the
appropriate examination and routine investigations, the radiological studies and specific investigations were performed where ever
indicated.
Results: We found the abducens nerve to be most frequently paralysed followed by oculomotor nerve and trochlear nerve. Next to
idiopathic ocular motor nerve palsies, trauma and vascular causes formed a common cause for ocular motor nerve involvements. Multi-
ple cranial nerves were involved in 32% subjects. Bilateral affection was seen in 15% subjects. The vascular abnormalities were the
most frequently found positive finding on radiological scans.
Conclusions: Our findings were, by and large, similar to those reported by other authors. Unlike previous authors we found a higher
incidence of vascular causes and thereby vascular abnormalities on radiological scans; and lower incidence of neoplasms in our patients
of oculomotor nerve palsies. We discovered optic atrophy to be a very common clinical feature in these patients. A baseline knowledge
of the current pattern of ocular motor nerve palsies not only would help us to make a probable diagnosis of the underlying disease con-
dition but also would be helpful in prescribing the appropriate investigation modalities for these patients.
Keywords: Ocular motor nerve palsies, Trochlear nerve palsy, Oculomotor nerve palsy,
INTRODUCTION
involved in third and fourth and other nerve paralysis. Ocular motility disturbance can be caused by various These patients presented with ocular complaints like causes like myogenic, neurogenic, inflammatory, endocrine diplopia, ptosis, diminution of vision and proptosis after a or restrictive pathologies. Out of these causes, a neurogenic varying duration of their onset that is fifteen days to two pathology, forms an important cause for ophthalmoplegias.1 months. Diplopia was the commonest complaint in patients There are a few studies in literature which describe different who had fourth nerve, sixth nerve or other nerve palsies patterns of ocular motor nerve involvement in terms of fre- while ptosis was commonest in patients having third nerve quency, presentations, associated systemic conditions and paralysis. The systemic complaints with which they pre- radiological findings.1-10 We conducted a retrospective study sented included fever, headache, convulsions and uncon- on 99 patients who presented to us with ocular motility dis- sciousness; among which headache followed by fever were orders. The aim of this study was to identify the pattern of ocular motility disorder in our clinical set up. The sixth nerve was the most frequently affected one MATERIALS AND METHODS
(62%) and this was followed by third nerve involvement A retrospective study was conducted on 99 patients (57%) and fourth nerve affection (27%). Thirty two patients diagnosed to have ocular motility disturbance at Neuro- had multiple cranial nerve involvement. Out of these, 18 had Ophthalmology Clinic of Guru Nanak Eye Centre, New a combination of third, fourth and sixth nerve affection; 6 Delhi between January 1999 to December 1999. History for had third and fourth nerve involvement; 5 had third and presenting ocular symptoms like diplopia, ptosis, diminution sixth nerve affection; 2 had sixth and seventh nerve paraly- of vision and proptosis; systemic complaints like fever, sis; and one had concurrent third, fourth and seventh nerve headache, convulsions, unconsciousness; duration of these involvement. We did not find a concurrent third and fourth complaints; systemic diseases like diabetes, hypertension, nerve involvement. The visual acuity in these patients tuberculosis, etc.; or trauma was elicited. An ophthalmologi- ranged from 6/6 to 6/60 with no notable pattern of distribu- cal examination for assessment of visual acuity, anterior tion in groups of patients with different ocular motor nerve segment and posterior segment status, pupil size and reac- palsies. Optic atrophy (46%) was the most common fundus tions was undertaken. The ocular motor nerve paralysis was finding in all the three groups though papilledema and fun- detected by objective examination techniques like Hess dus edema were also found. The field changes were seen charting and diplopia charting. The computed tomography scan or magnetic resonance imaging scan of head and orbit While idiopathic ocular motor nerve palsies (57.0%) formed the largest number in all the three nerves’ involve- The subjects were conservatively managed with medical ment, trauma (20.1%) followed by diabetes (16.8%) were measures like multivitamins (Tablet neurobion or syrup the next most common causes responsible for these palsies. polybion) and/or systemic prednisolone. For diplopia, the Other systemic conditions associated were tuberculosis patients were given occlusion or prismatic correction (with (8.7%), hypertension (8.0%), chronic suppurative otitis me- glass prisms). The subjects were reexamined at successive dia (1.3%), herpes zoster ophthalmicus (2.0%), meningitis intervals of two week. The duration for partial or complete (2.0%), meningioma (2.0%), epilepsy (1.3%), tumors (2.0%) recovery of healthy ocular motility status was noted. Bilateral involvement i.e. ocular motor nerve palsy in 99 patients including 59 males and 40 females in the age both eyes simultaneously, was seen in 15% patients and out range of 1 year to 81 years who presented to us with ocular of these five patients had all the three nerve affected, five motility disturbance were enrolled in this study. Ten patients subjects had only sixth nerve involvement; one patient had belonged to the age group of 12 years or less while 46 pa- only fourth nerve involvement and four patients had in- tients were in the age group of 35 years or more. Though we volvement of third nerve only. Out of these patients, one did not find any predilection for right or left side, right eye patient had tumor, one had tuberculosis and in the rest the was found to be more frequently involved in sixth nerve affections and left eye was found to be more commonly Though the radiological studies either through comput- First International Scientific Teleconference "New Technology in Medicine" Saint-Petersburg, Russia, March 2004 erized tomographic scan or through magnetic resonance im- work up for the patients having combined palsies without aging scan were usually found normal, vascular abnormali- ties were the most commonly encountered positive finding. We found that vascular abnormalities were the most fre- In almost all the patients these nerves took more than two quently detected positive finding on the radiological scans of months for appearance of any sign of recovery of their func- our patients. Previous workers have noted a decline in aneu- rysm related cases probably because of timely diagnosis due DISCUSSION
to better diagnostic techniques.2,4 Richards et al state that While some authors have found that ocular motor nerve since younger patients are more likely to have tumors and palsies are more common in subjects above 35 years of sustain trauma diagnostic approach should be more aggres- age,1,2 others have seen this disease condition more common between 18-74 years.3 In our study too, the mean age of the The patients with isolated palsies and those with vascular patients was about 35 years. Different studies have reported causes for involvement recovered at a higher rate,3 while the males to be more often affected,1,3 a trend seen by us too. prognosis was poor in patients having multiple cranial nerve Unlike us, the previous workers have not noticed any side palsies.2 Prognosis was the best in vascular group, and better than 50% in all groups except tumors.1,2,3 The patients with The diagnosis for location and cause of lesion for appear- palsies caused by aneurysms, trauma and undetermined ance of motor nerve palsy can more certainly be made for causes were predictably less likely to recover1,2,3 though patients having additional neurological symptoms.3 Diplopia those with neoplasms had the worst prognosis.3 The highest is the most common presentation in trochlear palsy 6 and this spontaneous recovery rate was found to be that for abducens nerve (38%) followed by trochlear nerve(34%) while it was The abducens nerve has been found to be the commonest significantly low for oculomotor nerve.1 The mean recovery to be involved, followed by oculomotor and trochlear nerve time was 5.4 months while the range was from less than one while multiple cranial nerve palsies were the least commonly month to 48 months. In our study, though the patients with found.2,3,7 The incidence of abducens nerve involvement has ocular motor palsies due to vascular causes recovered almost been found to lie between 29.13%1 to 41.9%;2 of oculomotor all of them took more than two months for recovery. We nerve varies between 24.91%1 to 29%2 and of trochlear in- found more quick recovery in patients having sixth nerve volvement ranged from 7.2%4 to 17.2%.2 We found the sixth palsy followed by those having fourth or third nerve palsy nerve to be involved in 62% of our subjects and this was while other authors noted somewhat different pattern.2 Rich- followed by third nerve involvement (57%) and fourth nerve ards et al also studied the recurrence rate and found that the affection (27%). Maruo and Kubota, however, state that ocu- patients with vascular causes and those having palsies of lomotor nerve palsy is the most frequent one;8 while Kobashi idiopathic origin and in children recovered inspite of recur- et al found trochlear nerve palsy to be the most commonly rences.3 We did not determine the recurrence rate of ocular Usually the largest group of patients with ocular motor Once the clinician comes across the ocular motor nerve nerve palsies have been found to be idiopathic2,3,4,5 and the palsy, it is not mandatory to perform the complete neuro- incidence of idiopathic cases varies from 14-28%.2,3,4,5 Fol- ophthalmologic evaluation and clinical judgement has to be lowing this, vascular causes, trauma and tumors form the used to reach the diagnosis if possible.3 In patients with ocu- next common group.5 While abducens nerve has been found lar motor nerve paralysis, baseline measurement for the ocu- to be more commonly associated with tumors, trochlear nerve lar motor nerve function should be done. Conservative man- has been found to be paralysed in patients with a history of agement has been recommended for elderly patients who are trauma.1,3,6 We made a similar observation. Though visual relatively symptomless and have no systemic disease; and in acuity in our patients varied from 6/6 to 6/60, we cannot those having diabetes or hypertension but without obvious relate the vision to motor nerve involvement alone as these neurological problem.3 However, a close watch should be patients had concurrent presence of refractive errors, and made for any accompanying problem like aneurysm.3 While diseases like cataract, glaucoma, age related macular degen- waiting for recovery, complete or partial occlusion of specta- eration, etc. Previous workers have not described the fundus cle lenses is helpful.3 Later on some surgical procedure or changes and field changes in their patients. We however, prism therapy might ultimately be needed to restore binocu- found the optic atrophy to be the commonest fundus finding. The incidence of bilateral ocular motor nerve palsy has REFERENCES
been found to be 8% by Rush and Younge2 and 5% reported 1. Kobashi R, Ohtsuki H, Hasebe S. Clinical studies of ocular motil- by Shrader and Schleringer).9 Like other studies,2 among the ity disturbances. Jpn J Ophthalmol. 1996;40:502-510. patients with a bilateral involvement we found sixth nerve 2. Rush JA, Younge BR. Paralysis of cranial nerves III, IV and VI. Arch Ophthalmol.1981;99:76-79. 3. Richards BW, Jones FR, Younge BR. Causes and prognosis in Kobashi et al however, found trochlear nerve palsy to be 4278 cases of paralysis of the oculomotor, trochlear and abducens cranial nerves. Am J Ophthalmol. 1992; 113:489-496. The incidence of multiple cranial nerve involvement 4. Rucker CW. The cause of paralysis of the third, fourth and sixth which has been previously reported is about 11.9%.2 The cranial nerves. Am J Ophthalmol.1966;61:1293-98. most frequently seen pattern of cranial nerve involvement in 5. Rucker CW. Paraysis of the third, fourth, and sixth cranial nerves. multiple affections is the palsy of all the three ocular motor nerves,1,2 which was what we also found. 6. Mansour AM and Reinecke RD. Central trochlear palsy. Surv Ophthalmol.1986;30:279. We did not encounter any patient with a concurrent third 7. Senou K, Kiribuchi T, Maruo T. Incidence of congenital and ac- and fourth nerve involvement a combination which other quired ophthalmoplegia. Rinsaho Ganka (J Jpn clinical Ophthalmol- authors encountered.1 Though other authors found tumors like infratentorial neoplasms, metastatic tumors and pituitary 8. Maruo T& Kubota N. Statistical study of ophthalmoplegia. Nihon adenomas to be the most common cause for a multiple cra- Ganka Gakki Zasshi (Acta Soc Ophthalmol Jpn).1969;73:577-588. nial nerve involvement,2 we found idiopathic cases followed 9. Shrader EC, Schlezinger NS. Neuroophthalmologic evaluation of by those caused by diabetes to be the commonest. Almost abducens nerve paralysis. Arch Ophthalmol. 1960;63:84-91. 40% patients with multiple cranial nerve palsies remit par- 10. Gabianelli EB, Klingele TG and Burde RM. Acute oculomotor tially or completely.2 Richards et al recommend extensive nerve palsy in childhood. Is arteriography necessary? J Clin Neuro-Ophthalmol.1989;9:33. E-mail:- [email protected]

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