Cases reported "Diplopia"

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1/32. Convergence retraction nystagmus: a disorder of vergence?

    The pathological mechanism of convergence retraction nystagmus (CRN) is not known. To determine whether CRN is a disorder of vergence or of the saccadic system, the scleral search coil technique was used to record binocularly the three-dimensional components of CRN in a patient with a left mesencephalic infarction involving the nucleus of the posterior commissure and the rostral interstitial nucleus of the medial longitudinal fascicle. CRN had disconjugate horizontal and torsional components. The horizontal amplitude/velocity relationship of CRN aligned with the main sequence of vergence responses of normal control subjects but not with that of saccades. Vergence responses of the right eye and left eye were not asynchronous. The slow phases of CRN showed an exponential decay with a time constant of 70 milliseconds. Thus, CRN is probably a disorder of vergence rather than of opposing adducting saccades.
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2/32. diplopia from skew deviation in Ramsey-Hunt syndrome. A case report.

    OBJECT: Presentation of a 34-year-old pregnant woman with skew deviation due to peripheral vestibular dysfunction caused by herpes zoster oticus. methods: A multidisciplinary approach (neuroophthalmology, otorhinolaryngology, neuroradiology) revealed the diagnosis of Ramsey-Hunt syndrome. CASE REPORT: The patient presented with painful herpes zoster vesicles of the left ear, associated with a rotatory vertigo and hearing loss. Otorhinolaryngological examination showed a unilateral peripheral vestibular loss, a nystagmus towards the unaffected right side, no facial nerve dysfunction and a left perception hearing loss, mainly in the frequencies between 2-6 KHz. The patient was treated with Zovirax IV. Neuroradiological examination (MRI without contrast) revealed no abnormalities. Vertical diplopia from skew deviation was noted /- 10 days after onset of herpes zoster oticus. Neuroophthalmological and orthoptic examination showed a comitant right hypertropia of 6 diopters and a spontaneous nystagmus to the right. CONCLUSION: Skew deviation can be caused by a sudden unilateral cochleo-vestibular loss as described by A.B. Safran. (4,6,7,8).
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3/32. Ahhh, that's a strange eye movement.

    A 57-year-old woman presents with sudden onset of horizontal diplopia following surgical repair of a ruptured posterior fossa aneurysm. Neuro-ophthalmic examination revealed a left gaze palsy, right abducens palsy, bilateral facial nerve palsy, reverse ocular bobbing and oculopalatal myoclonus. These findings can be localized to the anterior pons caused by damage to the midline perforator vessels resulting in anterior pontine pathology. A video demonstration of the oculopalatal myoclonus and other types of vertical nystagmus is provided. The etiology and characteristics of these forms of nystagmus is discussed.
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4/32. Combined pharmacologic and surgical approach to acquired nystagmus due to multiple sclerosis.

    PURPOSE: To describe a combined pharmacological and surgical approach to treating acquired nystagmus in a patient with multiple sclerosis. DESIGN: Interventional case report. methods: A 40-year-old patient with acquired horizontal and vertical nystagmus and severe oscillopsia secondary to multiple sclerosis had combined treatment with gabapentin and a vertical Kestenbaum-type procedure. RESULTS: After gabapentin treatment (3,000 mg orally daily) the horizontal nystagmus was significantly reduced, and the patient developed a marked chin-up position. The vertical nystagmus remained unchanged, dampening on downgaze. A recession of both inferior rectus muscles reduced the nystagmus significantly in primary position, the abnormal head position disappeared, and oscillopsia completely resolved. Treatment increased visual acuity from 6/24 in the right eye and 6/60 in the left eye to 6/9 in both eyes. CONCLUSIONS: Acquired nystagmus in multiple sclerosis can be significantly improved by using a combined pharmacological and surgical approach.
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5/32. Ocular tilt reaction due to a mesencephalic lesion in juvenile polyarteritis nodosa.

    PURPOSE: To describe a case of ocular tilt reaction caused by vasculitic lesions in the midbrain in a child with polyarteritis nodosa. DESIGN: Observational case report. methods: A 5-year-old girl with a chronic illness developed diplopia associated with a left head tilt, right hypertropia, torsional nystagmus, slowed vertical saccades and poor convergence. Fundoscopic examination demonstrated conjugate leftward torsion of the eyes consistent with a sustained ocular tilt reaction.Renal angiography confirmed polyarteritis nodosa and cerebral magnetic resonance imaging demonstrated mesencephalic pathology. CONCLUSIONS: polyarteritis nodosa is a difficult condition to diagnose in a child and can cause brainstem lesions. This rare case of ocular tilt reaction of midbrain origin highlights that a sustained head tilt in a child can be due to brainstem pathology, rather than a fourth nerve palsy.
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keywords = nystagmus
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6/32. arnold-chiari malformation.

    arnold-chiari malformation is a congenital malformation of the skull near the foramen magnum in which the cerebellum and the medulla are caudally displaced. This herniation of the brainstem causes down-beat nystagmus and oscillopsia, the most commonly presenting sign and symptom, respectively. Differential diagnoses for the arnold-chiari malformation include, but are not limited to, demyelinating disease, tumor, and vascular disorders. Symptoms will generally worsen with time and may even be brought on during exercise or valsalva maneuvers. A correct diagnosis can lead to timely surgical intervention which can improve the quality of eye movements. Treatment generally involves the surgical decompression of the surrounding spinal tissue.
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7/32. Familial positional downbeat nystagmus and cerebellar ataxia: clinical and pathologic findings.

    A family with progressive cerebellar ataxia is reported. The earlier signs of cerebellar dysfunction was positional downbeat nystagmus (PDBN). An autopsy of one member with PDBN, who died early in the disease of unrelated causes, showed loss of purkinje cells primarily in the nodulus.
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8/32. Isolated vertical diplopia as the initial manifestation of presumed pretectal and anterior hypothalamic germinomas.

    A 21-year-old man with a 5-month history of diplopia caused by isolated vertical ocular misalignment had normal laboratory studies, including brain magnetic resonance imaging (MRI). Eight months after the onset of diplopia, he reported dry mouth, polydipsia, polyuria, and absent sweating. Examination now disclosed light-near dissociation of the pupillary responses, convergence-retraction nystagmus, and upgaze palsy. MRI revealed enhancing suprasellar and pretectal masses presumed to be germinomas. Two years after brain irradiation and systemic chemotherapy, no lesions are apparent on MRI and hypothalamic dysfunction has partially resolved. In a young patient with isolated vertical diplopia and normal brain imaging, one should consider an early pretectal syndrome and inquire after manifestations of hypothalamic dysfunction.
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ranking = 0.2
keywords = nystagmus
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9/32. Downbeating nystagmus and muscle spasms in a patient with glutamic-acid decarboxylase antibodies.

    PURPOSE: To report the ophthalmic findings and response to treatment in a patient with glutamic-acid decarboxylase antibodies. DESIGN: Case report. methods: A 55-year-old woman developed progressive, painful, low back muscle spasms, vertical diplopia, downbeating nystagmus, and asymmetric appendicular ataxia. RESULTS: Downbeating nystagmus was present in primary gaze with an alternating skew deviation in lateral gaze. serum and cerebrospinal fluid GAD antibodies were detected. Treatment with diazepam led to resolution of spasticity, whereas repeated courses of intravenous immunoglobulin improved cerebellar function, including appendicular ataxia and downbeating nystagmus. CONCLUSIONS: patients with GAD antibodies may have elements of both stiff-person syndrome (muscle rigidity and spasms) and prominent cerebellar dysfunction. Treatment with diazepam rapidly improved Stiff-person symptoms, whereas IVIg was partially effective at the early stage of cerebellar dysfunction.
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ranking = 1.4
keywords = nystagmus
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10/32. Pineal germinoma with granulomatous reaction: case report.

    A 20-year-old man presented with diplopia. Neurological examination revealed mild skew deviation and upbeat nystagmus. Computed tomography showed a clover-shaped isodense mass in the pineal region with homogeneous enhancement. The lesion was isointense on both T(1)- and T(2)-weighted magnetic resonance (MR) imaging with homogeneous enhancement by gadolinium-diethylenetriaminepenta-acetic acid. cerebral angiography showed no tumor staining. serum and cerebrospinal fluid were negative for beta-human chorionic gonadotropin, alpha-fetoprotein, and placental alkaline phosphatase. Open biopsy was performed using a right occipital transtentorial approach. Histological examination revealed a tumor consisting of clusters of germinoma cells, but with prominent infiltration of lymphocytes, plasma cells, and macrophages, and proliferation of small vessels. The histological diagnosis was germinoma with granulomatous reaction. MR imaging showed complete disappearance of the tumor after chemoradiotherapy. Neurosurgeons should be aware of this rare tumor to avoid misdiagnosis as granulomatous inflammation.
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ranking = 0.2
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