Cases reported "Diplopia"

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1/15. Thyroid ophthalmopathy presenting as superior oblique paresis.

    Six patients with thyroid ophthalmopathy presented with what appeared to be a unilateral superior oblique paresis by the three-step test, which was eventually followed by more typical findings of thyroid disease. This early motility defect in thyroid ophthalmopathy may be caused by a restrictive process due to involvement of the inferior rectus muscle. Clues to the proper diagnosis included an increase in vertical deviation in upgaze, elevation of intraocular tension in upgaze, and the lack of excyclodeviation. These features should be assessed in patients with isolated superior oblique paresis.
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2/15. A case of hypothyroid Graves' disease following external radiation therapy to the cervical region.

    A case of hypothyroid Graves' disease occurred following external radiation therapy to the cervical region is described. Severe hypothyroidism developed in a 56-year-old man 6 months after external radiation therapy for submandibular cancer. Serological evaluation of thyroid autoimmunity revealed the presence of antithyroid antibodies and thyrotropin-binding inhibitory immunogloblins (TBII). diplopia, limitation of downward gaze, and palpebral edema developed 2 years after levothyroxine replacement therapy. Ocular magnetic resonance imaging revealed marked hypertrophy of the bilateral extraocular muscles with signal hyperintensity on T2-weighted images. This infiltrative ophthalmopathy showed marked improvement after additional treatment with high-dose methylprednisolone and orbital radiation, in parallel with a decrease in TBII. These results suggest that radiation-associated thyroidal injury might be associated with the etiology of hypothyroid Graves' disease.
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keywords = ophthalmopathy
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3/15. Differential diagnosis and management of acquired sixth cranial nerve palsy.

    BACKGROUND: Cranial nerve VI innervates the lateral rectus muscle. A lesion will result in esotropia greater at distance and an ipsilateral abduction deficiency. After the age of 50 years, vascular diseases are the most commonly known causes. CASE REPORT: A 55-year-old white man reporting a 2-week history of horizontal diplopia that was worse at distance was found to have a left sixth cranial nerve paresis. The patient was diagnosed with hypertension and placed on medications. At the 4-week follow-up visit, the abduction deficiency had resolved. DISCUSSION: The incidence of sixth nerve palsy is 11.3 in 100,000. A lesion anywhere along the course of the nerve, from the pons to the orbit, can cause a paresis or palsy. After ruling out trauma and non-neurological problems, cases should be classified into neurologically isolated or non-neurologically isolated cases. Neurologically isolated sixth nerve palsies are associated most commonly with vascular disease. Non-neurologically isolated sixth nerve palsies typically are associated with more grave conditions. CONCLUSION: A sixth nerve palsy of vascular or undetermined causes typically resolves within 6 to 8 weeks. If resolution does not occur within 2 to 3 months, the condition progresses, or if additional neurologic signs or symptoms develop, imaging studies are indicated.
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4/15. magnetic resonance imaging in diagnosis and follow-up of minimal thyroid ophthalmopathy.

    We report a case of minimal thyroid ophthalmopathy treated with intravenous methylprednisolone, in which precise identification of the involved muscle was possible with the use of surface coil magnetic resonance (MR) imaging. Intravenous methylprednisolone was more effective than the oral prednisolone as judged by orbital MR imaging. MR imaging is one of the useful tools in the diagnosis and assessment of treatment in this field.
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keywords = ophthalmopathy
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5/15. Concomitant euthyroid Graves' ophthalmopathy and isolated ocular myasthenia gravis.

    A 44 year old diabetic woman presented with diplopia and bilateral ptosis and mild exophthalmos. The patient was clinically euthyroid, the baseline thyroid function tests were normal, but the thyroid stimulating hormone response to thyrotrophin releasing hormone was flat. Computed tomographic scan and magnetic resonance imaging of the orbits showed left medial and inferior rectus muscle thickening, more prominent on the left side, consistent with Graves' disease. The tensilon stimulation test resulted in resolution of the ptosis and partial improvement of the ophthalmoplegia. The single fibre electromyography was consistent with a defect in neuromuscular transmission. However, forced duction test was normal and anti-acetylcholine receptor antibodies were undetectable. Significant improvement of the extraocular muscle function and resolution of the right ptosis had resulted from anticholinesterase therapy. These findings and the clinical response to therapy were consistent with concomitant euthyroid Graves' ophthalmopathy and ocular myasthenia gravis. Coexistent isolated ocular myasthenia gravis and Graves' ophthalmopathy is rare and should be considered in patients with findings of ocular myasthenia and extraocular muscle dysfunction.
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6/15. Necrotizing scleritis following strabismus surgery for thyroid ophthalmopathy.

    Necrotizing scleritis with inflammation of the right eye developed after bilateral eye muscle surgery for thyroid ophthalmopathy. Debilitating pain, delay in onset, and involvement of the sclera distinguish this condition from anterior segment ischemia. The surgery may have acted as a nonspecific trigger in an eye at risk for scleritis. Necrotizing scleritis has occurred infrequently after other types of eye surgery but, to our knowledge, has not been previously reported as a complication of eye muscle surgery.
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keywords = ophthalmopathy
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7/15. Fadenoperation for the management of complicated incomitant vertical strabismus.

    We reviewed retrospectively the records of 17 patients with incomitant vertical diplopia secondary to an underacting inferior rectus muscle who had been treated by surgically weakening the contralateral inferior rectus muscle with a posterior fixation suture (fadenoperation). This was the sole procedure in four patients with blowout fractures and in two patients with restriction secondary to scleral buckling procedures. It was combined with horizontal or vertical muscle surgery in 11 patients. The procedure was particularly useful in preventing diplopia on downgaze after excessive weakening of a tight inferior rectus muscle in seven patients with thyroid ophthalmopathy. In three patients it was used in anticipation of an iatrogenic incomitancy in downgaze secondary to a large recession of a tight inferior rectus muscle. All patients were markedly improved after surgery and no complications were encountered.
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keywords = ophthalmopathy
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8/15. multiple sclerosis, euthyroid restrictive Grave's ophthalmopathy, and myasthenia gravis. A case report.

    A 53-year-old physician with a 13-year history of multiple sclerosis presented with the subacute onset of an atypical, restrictive, euthyroid Grave's ophthalmopathy. The hypotropia and monocular upgaze restriction responded to a course of systemic and local steroids. Three months later, the patient developed ocular and systemic features of myasthenia gravis. This is the second reported case of coincident multiple sclerosis, myasthenia gravis, and thyroid-related disease complex.
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keywords = ophthalmopathy
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9/15. Use of computerized axial tomography (CAT scan) in evaluating therapy of orbital pseudotumor.

    Two patients with orbital pseudotumor, demonstrated by computerized axial tomography (CAT scan), are presented. This radiological technique was further used to demonstrate the complete resolution (Case 1) and marked regression (Case 2) of the orbital masses after steroid therapy. CAT scan characteristics of orbital pseudotumor were discussed and contrasted with the findings in thyroid ophthalmopathy. It is our recommendation that patients with CAT scan and clinical characteristics of orbital pseudotumor should be treated with systemic steroids and resolution of the inflammatory lesion should be corroborated by a repeat scan in atypical cases. Orbital surgery and other invasive studies should be used in those patients in whom there is no objective improvement in the disease process.
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keywords = ophthalmopathy
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10/15. cyclophosphamide in the management of advanced Graves' ophthalmopathy. A preliminary report.

    Three patients with advanced Graves' ophthalmopathy were treated with cyclophosphamide. All had proptosis and diplopia. One patient had disabling iatrogenic Cushing's syndrome from steroid treatment of the ophthalmopathy and had undergone bilateral orbital decompression before cyclophosphamide therapy; steroids could not subsequently be withdrawn. When cyclophosphamide was administered to the cushingoid patient, withdrawal of glucocorticoid therapy was then possible. diplopia completely resolved in two patients and improved in the third coincident with administration of cyclophosphamide. Deteriorating visual acuity resolved in one patient. Chemosis improved in the two affected patients. Proptosis was unchanged in all three patients. cyclophosphamide deserves further study as a therapeutic agent in Graves' disease.
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