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Purpose: Isolated acquired superior rectus palsy (ASRP) is extremely rare. The goal of this report is to describe the clinical manifestations and surgical protocols for treatment of isolated traumatic ASRP., Design: Retrospective observational case series., Method: Records of patients presenting with traumatic isolated ASRP from 2011 to 2020 were retrospectively reviewed. Variables analyzed included nature of the damage, ocular alignment, ocular motility, binocular vision, fundus photography, imaging and surgical treatment., Result: Of the 23,498 strabismus surgeries performed, 16 (0.07%) were identified as being attributable to traumatic isolated ASRP. Iatrogenic injury during orbital/brain tumorectomy was the most common cause for ASRP, followed by injury resulting from a sharp object, blunt instrument, car accident, dog bite, accidental fall and explosion. The main clinical features were hypotropia and deficient supraduction of the affected eye, accompanied by exotropia, extorsion, decreased vision and ptosis. The imaging examination showed the superior orbital wall fracture in 3 cases and superior rectus rupture in 7 cases. Inferior rectus recession and/or superior rectus resection comprised the major surgical procedures employed for these cases. Vertical deviations were reduced from 45.60 ± 17.52 PD preoperatively to 12.20 ± 12.97 PD postoperatively after an average of 22.70 months at follow-up, with a success rate of 50%., Conclusion: Traumatic isolated ASRP comprised only 0.07% of cases receiving strabismus surgery at our hospital. Orbital imaging is essential to identify whether muscle rupture, orbital fractures and/or other possible disorders are present. Superior rectus resection and inferior rectus recession represented the most frequently used surgical procedures., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In our practice at our department, we have encountered two clinical cases involving the complete loss of vision and ophthalmoplegia after craniotomy on the vascular pathology of the brain. Both patients underwent microsurgery via bifrontal skin incision. In the first case, the subfrontal craniotomy on the right side was made, and then microsurgical resection of an arteriovenous malformation of the right frontal lobe was performed. In the second case, a fronto-basal interhemispheric craniotomy was made for aneurysm surgery. This surgery included an intracranial anastomosis in a side-to-side fashion between the A3 segments of both anterior cerebral arteries, and a clip was applied proximal to a fusiform aneurysm located in the A2 segment of the anterior cerebral artery. The intracranial part of the procedure was uneventful. However, upon awakening from anesthesia after surgical treatment, both patients developed bilateral amaurosis and ophthalmoplegia.A thorough morbidity and mortality (M&M) analysis of these cases was performed, including a retrospective analysis of the clinical condition of patients and their ophthalmological status prior to surgery. Video recordings of the surgery and of anesthesia management and its records were carried out. Intraoperative iatrogenic direct damage to the cranial nerves and arteries was excluded.From the data obtained, a putative intraoperative explanation of the decisive causative factor was highlighted: direct pressure on the eyeballs from the retracted skin flap during both surgeries., (© 2025. The Author(s).)

Oculomotor nerve schwannoma in children not associated with neurofibromatosis is a rare disease, with 26 pediatric cases reported so far. There is no established treatment plan. A 7-year-old girl presented with oculomotor nerve palsy. Surgical reduction of the tumor combined with postoperative gamma knife surgery preserved the oculomotor nerve, improved oculomotor nerve function, and achieved tumor control during the observation period of 20 months. The combination of partial surgical resection and gamma knife surgery as a treatment strategy for oculomotor nerve schwannoma resulted in a good outcome., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Previous reports revealed that patients with acquired paralytic strabismus caused by central nervous system diseases are primarily affected by the etiology and treatment of the condition. Strabismus correction for these acquired paralytic strabismus should be performed as soon as the primary disease has been stabilized for 6 months in order to archive a favorable surgical outcome., Case: We followed an infrequent case of longer-lasting supranuclear ophthalmoplegia secondary to brain stem cavernoma., Observation: A 25-year-old Chinese Han female developed aberrant head posture and ipsilateral conjugate gaze palsies 8 years after the first brainstem hemorrhage caused by pontine cavernoma. The patient was diagnosed with supranuclear ophthalmic palsy and brain stem cavernoma after surgery. A resection-recession procedure along with a rectus muscle transposition was performed. The patient's abnormal head position disappeared, with a normal primary position., Conclusion: Resection-recession procedures combined with rectus muscle transposition works very well for longer duration large-angle strabismus caused by brain stem cavernoma., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

BACKGROUND Mitochondrial neurogastrointestinal encephalopathy syndrome (MNGIE) is an autosomal recessive disease caused by thymidine phosphorylase deficiency leading to progressive gastrointestinal dysmotility, cachexia, ptosis, ophthalmoparesis, peripheral neuropathy and leukoencephalopathy. Although liver transplantation corrects thymidine phosphorylase deficiency, intestinal deficiency of the enzyme persists. Retrospective chart review was carried out to obtain clinical, biochemical, and pathological details. CASE REPORT We present a case of liver and subsequent intestine transplant in a 28-year-old man with MNGIE syndrome with gastrointestinal dysmotility, inability to walk, leukoencephalopathy, ptosis, cachexia, and elevated serum thymidine. To halt progression of neurologic deficit, he first received a left-lobe partial liver transplantation. Although his motor deficit improved, gastrointestinal dysmotility persisted, requiring total parenteral nutrition. After exhaustive intestinal rehabilitation, he was listed for intestine transplantation. Two-and-half years after liver transplantation, he received an intestine transplant. At 4 years after LT and 20 months after the intestine transplant, he remains off parenteral nutrition and is slowly gaining weight. CONCLUSIONS This is the first reported case of mitochondrial neurogastrointestinal encephalomyopathy to undergo successful sequential liver and intestine transplantation.

Purpose: To quantify typical disease characteristics for patients with congenital fibrosis of the extraocular muscles (CFEOM) including pre-and post-surgical ocular alignment and head positioning as well as average improvement with surgical intervention., Patients and Methods: This investigation is a systematic review and meta-analysis. All studies detailing surgical intervention in cohorts of individuals with CFEOM were included. Ocular alignment and head positioning before and after surgery was recorded. Meta-analyses were performed to quantify these findings along with other patient characteristics across all included studies., Results: The estimated average improvement in vertical alignment for patients with unilateral and bilateral CFEOM was 34.8 pd (prism diopters) and 21.27 pd, respectively. For horizontal alignment, patients with unilateral and bilateral CFEOM improved an average of 25.39 pd and 10.99 pd after surgery, respectively. There was no significant difference between the two most common surgeries used to address hypotropia and blepharoptosis in this patient population. The estimated proportion of patients with post-surgical head alignment within 5-9° was 60.64% and was 28.25% for patients with<5° of alignment., Conclusion: This study was able to illuminate many characteristic features of patients with CFEOM. Surgical intervention for the ocular alignment and head positioning of these patients demonstrates promising utility.

Idiopathic Intracranial Hypertension (IIH) typically occurs in obese (BMI >30 kg/m 2 ) females of childbearing age in the absence of any apparent intracranial space-occupying lesion. Patients typically present with headache, nausea, vomiting, tinnitus, and blurry vision secondary to increased intracranial pressure, with more severe cases involving cranial neuropathies and ophthalmological manifestations. Complete ophthalmoplegia is a rare event in IIH. In such cases, aggressive management with pharmacological, endovascular, and surgical intervention is essential to hasten recovery and limit long-term neurological and visual deficits. Herein, we present a rare case of a patient with IIH associated with third, fourth, and sixth cranial nerve palsies, resulting in complete unilateral ophthalmoplegia, who underwent dural sinus stenting and 2.5-year follow-up revealed complete resolution with full extraocular movements. We also perform a systematic literature review of complete and partial ophthalmoplegia secondary to IIH, highlighting the associated presentations, pathophysiology, management, and outcomes., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The cavernous sinus area is the second most common location for intracranial dural fistulas. Although these spontaneous dural cavernous fistulas are self-limited, a sizeable number of patients will develop progressive vision loss, diplopia, or intractable glaucoma, which warrant interventional therapy. 1 , 2 We present the case of a 54-year-old male with hypertension and type 2 diabetes, who presented with a red right eye associated with progressive exophthalmos, ophthalmoparesis, and deterioration of visual acuity. The angiotomography showed the exophthalmos with an ingurgitated superior ophthalmic vein, with early filling in the arterial phase. A digital angiography was made, and a diagnosis of dural cavernous fistula, Barrow type D was made. 3 Considering several transvenous approaches, alternatives included inferior petrosal sinus, access through the superior ophthalmic vein, and an open approach. 4 In this particular case the inferior petrosal sinus was not present, so we tried to catheterize through the facial vein and also puncture the ophthalmic vein. Both procedures were unsuccessful. We decided to perform, then, an open approach with the oculoplastic surgery team (Video 1). Through an eyelid dissection, we localized the superior ophthalmic vein and then canalized it by direct visualization. 5 With this approach, we were able to perform the cavernous sinus packing with coils and achieved a complete occlusion of the fistula. We reproduced the direct approach to the superior ophthalmic vein in a cadaveric specimen and schematized it step by step with 3-dimensional photographs. 6 ., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Pituitary apoplexy (PA)-induced oculomotor palsy, although rare, can be caused by compression on the lateral wall of the cavernous sinus. This study aimed to visualize PA-induced oculomotor nerve damage using diffusion tensor imaging (DTI) tractography., Materials and Methods: We enrolled 5 patients with PA-induced isolated oculomotor palsy (patient group) and 10 healthy participants (control group); all underwent DTI tractography preoperatively. Fractional anisotropy (FA) and mean diffusion (MD) values of the cisternal portion of the bilateral oculomotor nerve were measured. DTI tractography was repeated after the recovery of oculomotor palsy., Results: While no statistical difference was observed in FA and MD values of the bilateral oculomotor nerve in the control group (P>0.05), the oculomotor nerve on the affected side was disrupted in the patient group, with a statistical difference in FA and MD values of the bilateral oculomotor nerve (P<0.01). After the recovery of oculomotor palsy, the FA value of the oculomotor nerve on the affected side increased, whereas the MD value decreased (P<0.01). Meanwhile, no significant difference was observed in FA and MD values of the bilateral oculomotor nerve (P>0.05). DTI tractography of the oculomotor nerve on the affected side revealed restoration of integrity. Furthermore, the symptoms of oculomotor palsy improved in all patients 7 days postoperatively., Conclusion: DTI tractography could be a helpful adjunct to the standard clinical and paraclinical ophthalmoplegia examinations in patients with PA; thus, this study establishes the feasibility of DTI tractography in this specific clinical setting.

Background: The Oculomotor nerve (OCN) lies in a close relationship with large arteries inside the basal cisterns. Therefore, it may be compressed by vascular malformations or aneurysms. Nevertheless, the compression is not always related to pathologic conditions. Indeed, some cases of neurovascular conflicts of the OCN have been described in the literature., Methods: A case of neurovascular conflict of the OCN resolved after steroid treatment is reported. Additionally, a systematic literature review of those cases was performed., Results: OCN palsy due to a neurovascular conflict has been described as acute or chronic persistent palsy, or with an intermittent presentation. Symptoms result from compression, although asymptomatic compression is not uncommon. Surgical treatment, pharmacological treatment, and observation have been reported as options in the literature. Microvascular decompression was employed effectively in some cases of OCN neurovascular conflict. Nevertheless, other cases were treated successfully with steroids (persistent presentation) and carbamazepine (intermittent presentation). A management algorithm based on the results of the literature review is proposed., Conclusions: Treatment options for OCN neurovascular conflicts and their results are heterogeneous. Based on the literature review, the pharmacological treatment seems to be the most appropriate first-line approach, reserving surgery for refractory cases. Collecting clinical information about new cases will allow defining treatment standards for this rare condition., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Simple, complex or syndromic craniosynostosis may be responsible for ocular and especially oculomotor pathologies. Among simple craniosynostosis, anterior plagiocephaly is the most frequently associated with oculomotor disorders. Oculomotor disorders encountered in craniosynostosis are specific to this pathology. They may be related to orbital deformities or oculomotor muscle malformations. Early craniofacial surgery reduces the onset and severity of these oculomotor disorders which is very important for ophtalmological patient care. Indeed, these oculomotor disorders are difficult to treat for the ophthalmologist with most of the time several surgeries needed, and lead to amblyopia if neglected., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Paradoxical convergence movements on attempted side gaze have been rarely reported in horizontal gaze palsy. The authors report the clinical manifestation of right-sided facial colliculus syndrome in a 9-year-old girl who manifested convergence, miosis, and myopic shift on attempting right gaze that was treated with strabismus surgery, and provide a comprehensive literature review. [J Pediatr Ophthalmol Strabismus. 2020;57:e15-e18.]., (Copyright 2020, SLACK Incorporated.)

Purpose: Congenital fibrosis of the extraocular muscles (CFEOM) is a rare nonprogressive disorder characterized by bilateral ptosis, with severely limited ocular motility. We report the treatment outcomes and problems in 3 cases of pediatric CFEOM in which extraocular muscle surgery was performed., Cases: All the cases showed bilateral ptosis and a chin-up abnormal head posture (AHP). Case 1 A 6-year-old girl. Both eyes were fixed downward with esotropia and could not elevate above the horizontal midline. She underwent simultaneous bilateral inferior rectus (IR) and medial rectus (MR) recession. Postoperatively, 8-prism-diopter (PD) exotropia was observed, and the AHP were improved, but MR advancement in the right eye was necessary because A-pattern exotropia became prominent starting about 10 months postoperatively. Case 2 A 7-year-old girl. Both eyes were fixed downward and did not elevate over the midline. She underwent bilateral IR recession. Postoperatively, 8-PD exotropia was observed; however, A-pattern exotropia became prominent gradually at about 1 year and 7 months postoperatively, and bilateral lateral rectus (LR) recession was added. Case 3 A 6-year-old girl. Both eyes were fixed downward but could be elevated above the horizontal midline by upward effort. She underwent bilateral IR recession, which resulted in improvement of the AHP and ptosis. About 8 months postoperatively, exotropia was evident only in the downward gaze., Conclusions: Bilateral IR recession in pediatric patients with CFEOM was effective in improving AHP, but postoperative exotropia appeared to be inevitable owing to the diminished adducted function caused by IR recession. Thus, horizontal strabismus surgery should be planned after the results of IR recession become evident.

Purpose: To evaluate the finding of anomalous superior oblique muscles in congenital fibrosis of the extraocular muscles (CFEOM), a feature not previously emphasized in this condition., Methods: The medical records of all patients clinically or genetically diagnosed with CFEOM at Boston Children's Hospital between 2010 and 2018 were reviewed retrospectively. Those who underwent strabismus surgery during the study period were included in the analysis. Baseline patient characteristics, type of CFEOM, results of genetic testing, and intraoperative features of the superior oblique muscle or tendon were recorded., Results: Of 24 patients identified (age range, 1 month to 62 years), 10 (42%) had genetically confirmed CFEOM, and 22 underwent strabismus surgery, 14 (64%) involving the superior oblique muscle. Of these, 7 (50%) had anomalously inserted tendons (most commonly attached nasal to the superior rectus muscle), whereas 7 (50%) had increased superior oblique muscle tension., Conclusions: Half of CFEOM patients who underwent superior oblique surgery had abnormally inserted superior oblique tendons, and 50% had tight muscles or abnormally thin tendons, findings that have not been well-characterized in this condition. The findings suggest that abnormal insertion of the superior oblique muscles and tendons are additional features of the disease process in CFEOM that have not been described previously. These features may contribute to the severe upgaze limitation in CFEOM and highlight the importance of superior oblique tenotomy in surgical management., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To detail surgical strategy and strabismus outcomes in a genetically defined cohort of patients with congenital fibrosis of the extraocular muscles (CFEOM)., Methods: A total of 13 patients with genetically confirmed CFEOM (via genetic testing for mutations in KIF21A, PHOX2A, and TUBB3) were retrospectively identified after undergoing strabismus surgery at Boston Children's Hospital and surgical outcomes were compared., Results: Age at first surgery ranged from 11 months to 63 years, with an average of 3 strabismus procedures per patient. Ten patients had CFEOM1, of whom 9 had the KIF21A R954W amino acid substitution and 1 had the M947T amino acid substitution. Of the 3 with CFEOM3, 2 had the TUBB3 E410K amino acid substitution, and 1 had a previously unreported E410V amino acid substitution. CFEOM1 patients all underwent at least 1 procedure to address chin-up posture. Chin-up posture improved from 24° ± 8° before surgery to 10.0° ± 8° postoperatively (P < 0.001). Three CFEOM1 patients developed exotropia after vertical muscle surgery alone; all had the R954W amino acid substitution. Postoperatively, 1 CFEOM1 patient developed a corneal ulcer. All CFEOM3 patients appeared to have underlying exposure keratopathy, successfully treated with prosthetic replacement of the ocular surface ecosystem (PROSE) lens in 2 patients., Conclusions: CFEOM is a complex strabismus disorder for which surgical management is difficult. Despite an aggressive surgical approach, multiple procedures may be necessary to achieve a desirable surgical effect. Knowledge of the underlying genetic diagnosis may help to inform surgical management., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Congenital fibrosis of the extraocular muscles (CFEOM) is caused by abnormal development of the innervation of extraocular muscles. We update the recent literature regarding the clinical, anatomic, genetic, and molecular characteristics of CFEOM. Surgical considerations are addressed., Recent Findings: CFEOM is broken down into three main subtypes, CFEOM1, CFEOM2, and CFEOM3. Several recent reports of individuals, as well as family pedigrees, highlight the phenotypic heterogeneity of CFEOM. Intracranial and intraorbital radiologic findings have enhanced our understanding of the disease pathophysiology. Molecular genetics research has increased our understanding of the development of extraocular muscles and their innervation as well as pathophysiology of CFEOM., Summary: Our understanding of the pathophysiology of CFEOM has increased with the recent contributions from neuroimaging, molecular genetics, and pedigree analysis. Surgical management of patients with CFEOM continues to be challenging.

A four-year-old child with a clinical diagnosis of unilateral congenital fibrosis of extraocular muscles (CFEOM) was planned for inferior and medial rectus muscle recession surgery, adjusted with the status of forced duction test. Due to pathological changes within the muscles subsequent to innervational abnormality, intraoperatively the inferior rectus muscle was pulled into two following the insertion of muscle hook. Moreover, the snapped muscle fibers could not be identified, thus further surgery was abandoned and an observation was commenced. At the end of 6 weeks, there was a significant reduction in the amount of hypotropia but clinically significant perverted convergence with esotropia necessitated further surgical intervention. A second surgical intervention consisting of medial rectus transposition to superior rectus with 3 mm recession was performed to achieve acceptable results in the primary gaze., Competing Interests: None

Purpose: To compare the outcome of inferior oblique disinsertion and myectomy in patients with unilateral congenital superior oblique palsy., Methods: In this prospective study, consecutive patients with superior oblique palsy underwent either myectomy or disinsertion of the inferior oblique muscle. Success was defined as postoperative hypertropia of ≤5 Δ in primary position and no hypotropia. In cases with preoperative hypertropia of ≤5 Δ , success was defined as improved hypertropia and resolution of abnormal head position (AHP)., Results: A total of 62 patients were included: 34 underwent myectomy; 28, disinsertion. Preoperative primary position hypertropia was 15.8 Δ ± 7.4 Δ in the myectomy group and 14.5 Δ ± 7.3 Δ in the disinsertion (P = 0.756). AHP was present in 85.3% and 85.7% of patients, respectively (P = 1). Mean follow-up was in the myectomy group 7.5 ± 6.7 months and 6.9 ± 3.0 months in the disinsertion group (P = 0.637). Correction of hypertropia in primary position was more pronounced in the myectomy group (14.3 Δ  ± 7.4 Δ vs 10.0 Δ  ± 5.4 Δ ; P = 0.013). Success was achieved in 91.2% of myectomy and 60.7% of disinsertion patients (P = 0.006). Persistence of AHP did not differ between groups (8.8% in the myectomy group vs 7.1% in the disinsertion group [P = 1]). Comparison of patients with preoperative hypertropia of ≤15 Δ revealed nonsignificant differences between groups in rate of success (100% vs 81.3% [P = 0.226]) and correction of primary position hypertropia (8.8 Δ  ± 3.2 Δ vs 7.6 Δ  ± 4.0 Δ [P = 0.336])., Conclusions: In our study cohort, inferior oblique myectomy had a greater effect in reduction of primary position hypertropia; however, disinsertion proved as effective as myectomy if preoperative vertical deviation was ≤15 Δ . Both procedures effectively corrected AHP and demonstrated self-adjustment., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: The clinical feature of unilateral decompensating strabismus sursoadductorius (dSSA; often called congenital superior oblique palsy, CSOP) is not an etiologically uniform entity. Hypotrophy of the superior oblique muscle (HMOS) is a frequent and immediate cause of dSSA/CSOP. In this study, clinical characteristics of dSSA/CSOP with and without HMOS are compared., Patients and Methods: Twenty-five consecutive patients (age 14 - 69 years; median 43 years) were included in this study, 14 with 3T MRI-proven HMOS (group 1) and 11 without HMOS (group 2). HMOS was defined as a reduction of the medio-lateral (ML) as well as based on ML and cranio-caudal (CC) diameter calculated area = (ML · CC/4) · π of the affected superior oblique muscle (SOM) < 80% in comparison to the contralateral SOM (measured on the single coronal image on which the muscle has its greatest extent). The two groups were compared in terms of head tilt, cyclo- and vertical deviation and the Bielschowsky head tilt test. Patients were classified according the Knapp's classification., Results: Both the incidence of head tilt with 14/14 vs. 5/11 (χ 2  = 0.003) and its degree: 11.1 ± 4.5° vs. 3.2 ± 4.1° (p < 0.001) was higher in group 1 than in group 2, as well as the Bielschowsky head tilt test: 9.3 ± 4.3° vs. 3.8 ± 4.9° (p = 0.008). The average amount of hypertropia was larger in group 1 than in group 2 during adduction: 16.7 ± 5.3° vs. 9.3 ± 3.4° (p < 0.001) as well as during adduction and downgaze of the affected eye: 14.6 ± 7.1 vs. 7.2 ± 3.7° (p = 0.03). In the sagittal plane, the increase of vertical deviation was larger in group 1 than in group 2: 2.8 ± 7.8 vs. - 2.4 ± 4.2 (p = 0.04); the excyclodeviation was larger in group 1 in all three planes (sagittal plane, adduction and abduction) in comparison to group 2: 1.3 ± 4.1 vs. - 2.9 ± 2.8 (p = 0.006), 2.4 ± 5.2 vs. - 2.2 ± 2.9 (p = 0.01), 0.5 ± 3.8 vs. - 2.7 ± 3.9 (p = 0.05). Knapp's class II was found in 6 of 15 patients in group 1 and only in this patient group (χ2 = 0.03)., Conclusions: In both groups, the vertical deviation showed a great dispersion. In patients without HMOS (group 2), vertical deviation in adduction did not exceed 15°. Patients with HMOS (group 1) do not show the typical features of a later acquired trochlear palsy due to an early developed compensating innervation. A vertical deviation in adduction of more than 15°, increasing excyclodeviation towards downgaze in all three planes (sagittal plane, adduction and abduction) and Knapp's class II are relatively reliable predictors of a hypoplasia of the SOM. An internationally uniform term for this group of patients, such as superior oblique weakness or superior oblique hypotrophy, would be desirable., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Surgical management-depending upon the severity of the ophthalmoplegia-ranges from restorative to palliative. In paresis with reasonable residual muscle function and ductions, the goal of the surgery is not only to restore single vision in primary position but also to provide a relatively normal field of single binocular vision. With complete paralysis of a single muscle or more than one muscle served by a single cranial nerve (third), in addition to conventional recess or resect surgery, the transposition of still-functioning muscles is often needed to obtain a durable result and restore at least some field of single binocular vision. In complete ophthalmoplegia, the benefits of the surgery are limited; but even in these cases, surgery can often reduce the need for an awkward head posture and improve appearance.

Background: Idiopathic intracranial hypertension (IIH) is a disorder of young obese females and characterized by headache, papilledema with raised intracranial pressure in the absence of known pathological cause. However, ophthalmoplegia is common presentation of IIH, limb weakness is rare and may led to misdiagnosis and poor outcome., Case: We report female patient presented with acute onset of quadriparesis, headache and ophthalmoplegia, the fundus examination showed papilledema, the MRI brain showed no detectable abnormal finding.The intracranial pressure (ICP) was elevate. Nerve conduction study revealed sever radiculopathy. Our provisional diagnosis was fulminant idiopathic intracranial hypertension versus Gulliane Barre syndrome. The patient was submitted to CSF shunting which resulted in improvement of her symptoms. conclusion quadreparesis is a rare presentation of idiopathic intracranial hypertension, which may delay diagnosis and affect outcome. And urgent lumbo-peritoneal shunt was critical in saving patient vision and regaining ability to walk., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: None declared.

Objective: Recovery of oculomotor nerve palsy after microsurgical and endovascular treatment has been studied in numerous small series of predominantly ruptured aneurysms. Little consideration has been given to the distinction between ruptured and unruptured aneurysms. This study examines the influence of treatment modality on oculomotor palsy recovery as a result of unruptured posterior communicating artery aneurysms., Methods: Patients who presented between 2003 and 2015 with an oculomotor palsy secondary to an unruptured posterior communicating artery aneurysm were identified from the hospital database. A keyword search for "posterior communicating artery aneurysm" and "oculomotor nerve palsy OR third nerve palsy" using the PubMed database was performed for the narrative review., Results: The cohort study and narrative review identified 15 and 179 eligible patients, respectively. Surgically treated patients in the cohort study did not have a significantly better rate of complete palsy resolution than those who had been coiled (P = 0.08). In the review, clipping of the aneurysm resulted in a higher rate of complete palsy resolution (70.0%; 95% confidence interval [CI], 60.7%-79.3%) than did coiling (46.5%; 95% CI, 36.0%-57.0%). Patients who presented with an aneurysm <7 mm had a higher rate of complete palsy resolution compared with aneurysms >7 mm (68.6%; 95% CI, 57.7%-79.5% vs. 44.3%; 95% CI, 32.7%-55.9%). Patients presenting with a complete palsy (49.4%; 95% CI, 38.6%-60.2%) had a lower rate of recovery than did those with a partial palsy (71.4%; 95% CI, 60.2%-82.6%)., Conclusions: In this narrative review, surgical clipping of unruptured posterior communicating artery aneurysms was associated with a higher rate of associated oculomotor palsy recovery than was endovascular treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Orbital fractures are injuries frequently related to traumas of the midface. These fractures can be associated with ocular lesions, ranging from small abrasions on the cornea to serious complications such as hyphema and ocular globe rupture. Diplopia and ophthalmoplegia are common findings in orbital fractures. They can be caused by mechanical factors as bone fragments or muscle imprisonment. The aim of this study was to report a case of a 40-year patient, male showing diplopia and ophthalmoplegia due to the orbital fracture. The patient was treated by general anesthesia. It was performed a supra orbital approach and the fragments were removed. A titanium mesh to restore the orbital anatomy was installed. After 40 days of follow-up, the patient has no aesthetic or functional complaints. In orbital traumas, the ophthalmological evaluation should be performed carefully aiming to avoid ocular sequelaes. In surgical patients, the surgery should be done as early as the clinical conditions permit, to restore the ocular function.

Endovascular and surgical techniques are conventional options for treating intracranial aneurysms, but criteria for selecting an optimal approach for individual patients remain variable across practitioners and institutions. While endovascular and surgical approaches are generally used alone, both modalities combined in single patients can produce efficacious outcomes. The aim of this study was to evaluate outcomes of combined, concomitant endovascular and surgical modalities in the treatment of multiple and/or complex aneurysms in single patients. Indications, sequencing rationale, and categorization for multimodality treatments are reviewed. All intracranial aneurysms treated at our institution from 2004 to 2014 were reviewed. Single patients who had undergone concomitant endovascular and surgical treatments were eligible for participation in our study. Demographic data and clinical presentation parameters, including location, size, and morphological features of lesions, treatment sequencing, and outcomes were recorded. Our cohort consisted of 27 patients with 57 aneurysms who received concomitant endovascular and surgical treatment of their aneurysm(s). One patient arrived to us after he had an aneurysm clipped at an outside institution and then required treatment for a contralateral ruptured aneurysm. 66.7% of patients were diagnosed with subarachnoid hemorrhage. These were subdivided according to therapeutic approach: clipping and coiling (CL+CO), clipping and stenting (CL+ST), bypass and endovascular parent vessel occlusion (PVO) (BY+PVO), attempted clipping then stenting, and bypass followed by stenting. Glasgow Outcome Scale was as follows: CL-CO-Multiple, 4.17 (five in unruptured patients, 3.75 in ruptured); CO-CL-Multiple, five (all patients had a ruptured aneurysm); CL-CO-Single, three (all patients had a ruptured aneurysm); CO-CL-Single, five (all patients had a ruptured aneurysm). No patients suffered a new neurological deficit as a result of treatment. A total of two mortalities were documented. Concomitant, mutimodality endovascular and surgical therapy may offer a safe and potentially more effective paradigm than single modality approaches for the management of multiple, complex, or "failed" aneurysm treatments in selected patients.

Rationale: The Lambert-Eaton myasthenic syndrome (LEMS) is a neuromuscular disease; its unique symptoms of LEMS include dry mouth with a metallic taste, constipation, and erectile dysfunction. As it is quite rare, isolated ocular muscle impairment associated with LEMS east to ignore., Patient Concerns: A 65-year-old man presented with alternating ptosis and diplopia. Isolated ocular muscle impairment had lasted for 6 years, and the patient was initially diagnosed with ocular myasthenia gravis (MG). Treatment with azathioprine only slightly improved symptoms over the first 2 months; long-term treatment was not effective., Diagnoses: Dynamic observation of chest computed tomography images revealed a slowly progressing nodule in the lower lobe of the left lung. The subsequent pathologic examination following mass resection confirmed a diagnosis of lung adenocarcinoma., Interventions: The patient was ultimately diagnosed with the Lambert-Eaton myasthenic syndrome associated with pulmonary adenocarcinoma., Outcomes: Resection of the lung tumor relieved all symptoms., Lessons: Other causes of ocular MG symptoms should be considered when standard MG therapy is ineffective, especially the Lambert-Eaton myasthenic syndrome.

Purpose: To discuss surgical intervention strategies among patients with horizontal gaze palsy with concurrent esotropia., Methods: Five consecutive patients with dorsal pontine lesions are presented. Each patient had horizontal gaze palsy with symptomatic diplopia as a consequence of esotropia in primary gaze and an anomalous head turn to attain single binocular vision., Results: Clinical findings in the first 2 patients led us to presume there was complete loss of rectus muscle function from rectus muscle palsy. Based on this assumption, medial rectus recessions with simultaneous partial vertical muscle transposition (VRT) on the ipsilateral eye of the gaze palsy and recession-resection surgery on the contralateral eye were performed, resulting in significant motility limitation. Sequential recession-resection surgery without simultaneous VRT on the 3rd patient created an unexpected motility improvement to the side of gaze palsy, an observation differentiating rectus muscle palsy from paresis. Recession combined with VRT approach in the esotropic eye was abandoned on subsequent patients. Simultaneous recession-resection surgery without VRT in the next 2 patients resulted in alleviation of head postures, resolution of esotropia, and also substantial motility improvements to the ipsilateral hemifield of gaze palsy without limitations in adduction and vertical deviations., Conclusions: Ocular misalignment and abnormal head posture as a result of conjugate gaze palsy can be successfully treated by basic recession-resection surgery, with the advantage of increasing versions to the ipsilateral side of the gaze palsy. Improved motility after surgery presumably represents paresis, not "paralysis," with residual innervation in rectus muscles., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of superior oblique tucking on the Bielschowsky head tilt test., Methods: A retrospective analysis of 22 patients with congenital unilateral superior oblique palsy, who underwent tucking of the superior oblique tendon in Tianjin Eye Hospital, depending on vertical deviation in the primary position, ocular motility, objective cyclotorsion and abnormal head posture. Bielschowsky head tilt test was evaluated quantitatively by the prism cover test. Α positive Bielschowsky head tilt test was defined as one in which the vertical deviation when the head tilt to the side of the paresis was at least 5. 0(△) greater than that on tilt to the uninvolved side. The follow-up period ranged from 3 to 12 months (mean 4.6 months). Kolmogorov-Smirnov (K-S), Rank sum test and Spearman correlation analysis statistical methods were used in this study., Results: All patients had vertical deviation and significant abnormal head posture before operation. After the procedure of superior oblique tucking,vertical deviation and symptom of unacceptable abnormal head posture were ameliorated or disappeared. OBJECTIVE torsion was 15.62°±7.36° before the surgery, 9.91°±10.09°1d after the surgery and 11.25°±9.17°at the last follow-up visit, respectively (P<0.05). We found that there were positive correlations between the objective cyclotorsion and the vertical deviation difference value between the paralyzed side and uninvolved side at 1 d after the surgery and last follow-up visit(P<0.05). The vertical deviation of the paresised eye when the head tilted to the side of paresis side and uninvolved side difference were 5.00(△)-17.00(△), average 8.68(△)±3.23(△), 1.00(△)-8.00(△),average 3.36(△)±2.01(△) and 0.00(△)-14.00(△),average 3.77(△)±3.01(△), preoperatively, 1d after the surgery and at the last follow-up visit respectively. Using Rank sum test, the pre-and postoperative difference was statistically significant (Z=-4.64, P<0.01). A positive Bielschowsky head tilt test was found in all cases preoperatively. The results of Bielschowsky tilt test was still positive in 5 cases and negative in 17 cases (77.3%)., Conclusions: In most cases with unilateral superior oblique paresis, the results of Bielschowsky tilt test became negative after superior oblique tucking. The long-standing results is worthy of observation. (Chin J Ophthalmol, 2016, 52: 589-595).

In cavernous sinus (CS) surgery, venous complication may occur in some types of venous drainage. The sphenobasal vein (SBV) drains from the superficial middle cerebral vein (SMCV) to the pterygoid venous plexus at the temporal skull base. A frontotemporal epi- and interdural approach (Dolenc approach), which is one of the CS approaches, may damage the SBV's route. We report a case of intracavernous trigeminal schwannoma that contained the SBV and discuss our modified surgical procedure that combined epi- and subdural approaches to preserve the SBV. A 64-year-old man complained of right progressive oculomotor palsy and was referred to our hospital for surgery. MR images revealed a hemorrhagic tumor in the right CS. Three-dimensional venography revealed that the SMCV drained into the pterygoid venous plexus via the SBV. After identifying the first branch of the trigeminal nerve epidurally, we incised the dura linearly along the sylvian fissure and entered the subdural space to visualize the SBV. The incision was continued to the meningeal dura of the lateral wall of the CS along the superior margin of the first branch of the trigeminal nerve, and the Parkinson's triangle was opened from the subdural side. The tumor was grossly totally removed, and the SBV was preserved. In conclusion, a frontotemporal epi- and subdural approach to the intracavernous trigeminal schwannoma can effectively preserve the SBV.

Objective: to identify and give an objective assessment of all changes in the periorbital region in paralysis orbicularis oculi muscle., Methods: With physical, laboratory and instrumental methods of research, we analyzed the survey of 33 patients with paralytic lagophthalmos. This survey has allowed us to identify the symptoms of periorbital changes characteristic of paralysis orbicularis oculi involved in lagophthalmos development., Results: After analyzing the results of a survey of 33 patients with paralytic lagophthalmos, we identified 15 symptoms of changes in the periorbital region., Conclusion: In our opinion, lagophthalmos should be considered as a syndrome, including certain symptom in a particular case. For adequate closure of the optic fissure and obtaining a good aesthetic result is necessary to simultaneously remove more of the symptoms.

Background: Paralytic ectropion is a significantly functional and esthetic problem leading to problems with lacrimation, corneal exposure, and poor palpebral closure. Limitations with traditional corrective procedures include poor apposition of the lid to the globe, suboptimal medial canthal position, and high recurrence rates., Objective: The objective of this study was to develop a technique of lower-lid suspension using transnasal wiring for the long-term maintenance of lid position., Methods: Twenty-three consecutive patients with complete unilateral facial nerve paralysis underwent the procedure, and they were followed up for a median of 27 months (1-73 months)., Results: Fifteen of 18 patients maintained their intraoperative lower-lid position beyond the 12-month follow-up. Three patients had a minimal scleral show at 3 months. One of these patients also developed lid laxity seen on the snap test. No perioperative complications were experienced., Conclusions: Transnasal wiring of the lower-lid tendon suspension provides consistent results that are maintained over time., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: To describe clinical features of patients with unilateral isolated inferior rectus (IR) muscle paralysis along with type of surgical treatment and results after surgery., Methods: Patients diagnosed with unilateral isolated IR muscle palsy between 2009 and 2012 that required surgical treatment were included in the study. Diagnosis of IR muscle palsy was done by hypertropia with the largest angle in depression and abduction and inferior rectus muscle underaction., Results: Twenty-two patients remained in the study; 17 patients (77.3%) had left eye involvement. IR muscle paresis was traumatic in 12 patients (54.5%), congenital in 9 patients (40.9%), and vascular in 1 patient (4.5%). Limitation of duction in the gaze of IR muscle was -2 to -3 in all cases. 3 patients, paradoxically, had contralateral compensatory head tilt (compensatory head tilt to the opposite side of IR muscle palsy). Intraoperatively, we did not detect any gross abnormalities in the IR muscles. The surgical plan at the first operation was IR muscle resection alone in 13 patients (59.1%). At the last follow-up visit, 15 patients (68%) had no deviations in primary position and downgaze. Three cases needed reoperation., Conclusion: The presence of both ipsilateral and contralateral compensatory head postures in our patients showed that three-step or head-tilt test is not helpful in the diagnosis of IR muscle palsy. In comparison with other studies, more patients in our study were treated with IR muscle resection alone. Also, our reoperation rate was lower than other studies. Absence of gross abnormality in the IR muscles at the operation and partial nature of the paresis may explain these good results. Thus, a considerable number of IR muscle palsy cases with the above characteristics may be treated successfully by one muscle surgery (IR muscle resection).

Aim: Some of cases suffering from subarachnoid hemorrhages (SAHs) in grade V on World Federation of Neurologic Surgeons (WFNS) grading can gain a good prognosis. The outcome of patients of SAH in grade V on WFNS grading in their institute was here investigated., Methods: Between April 2007 and July 2012, consecutive 37 patients had SAH diagnosed on CT scan and were classified in grade V on WFNS grading in Kosei General Hospital. There were seventeen male and twenty female patients. We were assigned to patients with spontaneous respiration and without oculomotor palsy (N group, N.=11), and patients with oculomotor palsy (O group, N.=26). Patients were evaluated by mRS., Results: The prognosis in N group was significantly better than in O group (P<0.001)., Conclusion: Surgical treatments should be considered for SAH patients without oculomotor palsy. It is necessary to make subgroups in grade V on WFNS grading in order to decide operative indication and evaluate the treatment results of SAH in grade V.

Isolated inferior oblique muscle palsy is the least common of all extra-ocular muscle palsies and very few reports are available in the literature. It can present a formidable therapeutic challenge to the ophthalmologist, as treatment options need to be titrated on an individual basis. A patient of 60 years old of idiopathic right inferior oblique palsy who underwent an adjustable superior rectus recession in his left eye, with a satisfactory surgical outcome and symptomatic resolution of diplopia is reported.

We reported a case of cavernous sinus aspergillosis. A 62-year-old man complained of trigeminal neuralgia in the right V1 region. Neurological examination on admission showed ptosis, loss of light reflex and ophthalmoplegia externa in the right side. MRI enhanced with gadolinium demonstrated sphenoid sinusitis and mass lesion in the right cavernous sinus. MRA revealed right internal carotid artery occlusion. An open biopsy using the extradural temporopolar approach was performed. Pus discharge was observed from the cavernous sinus and histological examination showed hypha of Aspergillus. With early voriconazole treatment, the patient had improvement in headache, ptosis and ophthalmoplegia externa. Cavernous sinus aspergillosis is often found after sphenoiditis. It results in invasion to an internal carotid artery and worsens the patient's prognosis by cerebral infarction, so early diagnosis and treatment are important. We should consider aspergillosis as one of the differential diagnoses of a mass in the cavernous sinus. The epidural approach to this lesion was available to obviate aspergillus dissemination into the medullary cavity.

Objective: To investigate surgical approach for paralytic strabismus with lateral rectus muscles paralysis and evaluate its clinical effects., Methods: Design retrospective, observational case series. 28 patients (31 eyes) who underwent augmented partial rectus muscle transposition (APRMT) in the treatment of paralytic strabismus with lateral rectus muscles paralysis from May 2009 to May 2011 at Eye & ENT Hospital of Fudan University were included in this study. The following data were analyzed: (1) The procedure that was performed, (2) The angle of deviation of primary position, (3) The presence of compensatory head posture, (4) The presence of diploma in the primary position, (5) The binocular single visual fields, (6) The motility of the affected eye., Results: According to the results of rectus muscle forced traction test and examination before and after operation, among 31 eyes in 28 patients, 8 eyes were treated with APRMT, 10 eyes were treated with recession of antagonistic muscle of paralytic rectus muscle combined with APRMT, 7 eyes were treated with APRMT and recession of yoke muscle, 6 eyes were treated with APRMT and recession of yoke muscle combined with recession of antagonistic muscle. 17 among 28 patients were orthotopic in the primary position while others were in mild under correction with deviation no more than 10 prism degrees during 5 months (range: 3-8 months) follow-up in average. The diploma and abnormal head posture were eliminated in 26 patients except one patient who was appeared with 10 prism degrees under correction postoperatively and was resolved by wearing prisms thereafter. Binocular single visual fields were extended from 27.0° ± 6.4 ° preoperatively to 40.5° ± 4.8 ° postoperatively (t = -34.692, P < 0.001). Ocular movement was improved from -4.9 ± 0.4 to -2.9 ± 0.9 postoperatively (t = -13.418, P < 0.001)., Conclusions: APRMT can safely and effectively correct the primary position in paralytic strabismus with lateral rectus muscles paralysis, eliminate the presence of diploma in primary position and abnormal head posture, and improve the ability of the ocular movement, furthermore, significantly expand the scope of binocular single visual fields. The results also demonstrate that rectus muscle forced traction test is a key measurement to determine the surgical procedure.

Purpose: To evaluate the correlation between hypertropia and excyclotorsion in acquired superior oblique palsy (SOP)., Methods: Thirty-one patients with acquired unilateral SOP were recruited for this study. The torsional angle of each patient was assessed via one objective method (fundus photography) and two subjective methods (double Maddox rod test and major amblyoscope). The patient population was divided into two groups (concordance group, n = 19 and discordance group, n = 12) according to the correspondence between the hypertropic eye (paralytic eye) and the more extorted eye (non-fixating eye), which was evaluated by fundus photography., Results: The mean value of objective torsion was 5.09° ± 3.84°. The subjective excyclotorsion degrees were 5.18° ± 4.11° and 3.65° ± 1.93° as measured by double Maddox rod test and major amblyoscope, respectively. Hypertropia and the excyclotorsional angle did not differ significantly between the groups (p = 0.257). Although no correlation was found in the discordance group, the concordance group showed a significant and positive correlation between hypertropia and excyclotorsion (p = 0.011)., Conclusions: Torsional deviation was not related to hypertropia. However, in the concordance patients in whom the hypertropic eye showed excyclotorsion, a significant positive correlation was found between hypertropia and excyclotorsion.

Object: The aim of this study was to provide information about long-term functional outcome in patients with isolated oculomotor nerve palsy following minor head injury and to discuss surgical treatment of these patients, especially those with accompanying sphenoid fracture., Methods: A retrospective analysis was made of 26 patients with traumatic isolated oculomotor nerve palsy. The severity of oculomotor nerve palsy and the functional recovery were evaluated based on extraocular muscle movement, eyelid movement, and pupil size. On average, patients were evaluated 3.6 days after the initial injury, and the average follow-up period was 14.2 months (range 3 months-2 years)., Results: Twenty men and six women were enrolled in this study. The most common cause of trauma was motor vehicle accident in 17 (65.4%) of 26. Among all the recorded symptoms, internal ophthalmoplegia was most frequently seen. The recovery rates of ptosis, external ophthalmoplegia, and internal ophthalmoplegia were 95% (19 of 20 patients), 83.3% (15 of 18 patients), and 50% (13 of 26 patients), respectively. The 6 patients with sphenoid fracture underwent surgical decompression of the superior orbital fissure, after which all patients experienced recovery from ptosis and external ophthalmoplegia and 66.7% (4 of 6 patients) recovered from internal ophthalmoplegia., Conclusions: Limited eye movement may be a major factor that negatively affects functional recovery after mild head injury. Sphenoid fracture might be one of the potential mechanisms involved in traumatic isolated oculomotor nerve palsy after mild head injury. Surgical decompression should be considered when there is evidence of bone compression of the superior orbital fissure.