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BackgroundOcular motor nerve palsies (OMNP) frequently cause patients to present in an emergency room. In the following study, we report the differential diagnosis of OMNP by use of magnetic resonance imaging (MRI) and CSF examination as a standard.MethodWe performed a data analysis of N = 502 patients who presented with oculomotor, trochlear, and/or abducens nerve palsy in the emergency room of the Department of Neurology, University of Ulm, between January 2006 and December 2019. We report clinical and MRI scan findings in all patients; furthermore, the CSF of 398 patients has been analysed.ResultsAbducens nerve palsies were most common (45%), followed by palsies of the oculomotor (31%) (CNP III) and trochlear nerve (15%). Multiple OMNPs were seen in 9% of our cohort. The most common causes included inflammations (32.7%), space-occupying lesions, such as aneurysms or neoplasms (17.3%), diabetes mellitus (13.3%), and brainstem infarctions (11%). Still 23.4% of the patients could not be assigned to any specific cause after differential diagnostic procedures and were described as idiopathic. One of three patients with an inflammation and 39% of the patients with space-occupying lesions showed additional cranial nerve deficits.ConclusionInflammation and space-occupying processes were the most frequent causes of OMNP, although brainstem infarctions also play a significant role, in particular in CNP III. The presence of additional CNPs increases the probability of an inflammatory or space-occupying cause.

PurposeTo describe the causes of third, fourth, and sixth cranial nerve palsies in children and adolescents.MethodsIn this retrospective case series, a total of 66 patients aged 0–19 years with third, fourth, and sixth cranial nerve palsies seen in strabismus and neuro-ophthalmic practice from 2010 to 2017 were included. Causes of palsies were determined based on clinical assessment, high-resolution magnetic resonance imaging (MRI), and laboratory work-up.ResultsThirty-five patients had sixth cranial nerve palsy, 14 patients had third cranial nerve palsy (7 partial, 7 complete), 13 patients had fourth cranial nerve palsy, and 4 patients had combined cranial nerve palsies in this study. Neoplasia involving central nervous system was one of the most common causes of third, fourth, and sixth cranial nerve palsies both in children (age: 0–14 years) and adolescents (age: 15–19 years) (20% and 31%, respectively). Overall, neoplasia (23%) was the most common cause of acute third, fourth, and sixth cranial nerve palsies, followed by idiopathic cause (14%), inflammation (11%), and non-aneurysmal vascular contact (11%). Neoplasia was also the most common cause of sixth and third cranial nerve palsies (25% and 29%, respectively). The most common cause of fourth cranial nerve palsy was late decompensation in congenital fourth cranial nerve palsy (46%).ConclusionsA substantial proportion of pediatric and juvenile patients had serious pathologies for third, fourth, and sixth cranial nerve palsies. If nerve palsies are indicated, prompt diagnosis of etiologies using high-resolution MRI with contrast and laboratory work-up are important for this disease population.

We report two adult cases of abducens nerve palsy presenting immediately (within weeks) after they received the first dose of Covishield vaccination. Magnetic resonance imaging (MRI) of the brain obtained after the onset of diplopia demonstrated demyelinating changes. The patients had associated systemic symptoms. Post-vaccination demyelination typically known as acute disseminated encephalomyelitis (ADEM) associated with several vaccines is more common in children. Although the mechanism of the nerve palsy remains unclear, it is suspected to be related to the post-vaccine neuroinflammatory syndrome. Cranial nerve palsies and ADEM-like presentations may represent part of the neurologic spectrum following COVID-vaccination in adults, and ophthalmologists should be aware of these sequelae. Although cases of sixth nerve palsy following COVID vaccination are already reported, associated MRI changes have not been reported from India.

To evaluate the surgical outcomes of a combined modified Nishida's procedure with medial rectus (MR) recession augmented with lateral rectus (LR) plication in patients with long-standing complete sixth nerve palsy presenting with large-angle esotropia (ET). This retrospective interventional case series included three patients with chronic traumatic complete sixth nerve palsy and large-angle ET (70 to 75 prism diopters [PD]). Postoperatively, two patients achieved orthophoria at distance and near and one patient had a small residual ET of 5 PD at 6 months. The combination of modified Nishida's procedure with MR recession and LR plication appears to be an effective single-stage surgical approach for large-angle esotropia (approximately 70 PD) associated with complete sixth nerve palsy. The technique provides substantial alignment correction, improved abduction, resolution of diplopia, and a reduced risk of anterior segment ischemia compared to full-tendon vertical rectus transposition.

Purpose To compare the effectiveness of three procedures: modified Nishida procedure alone vs modified Nishida procedure combined with medial rectus recession (MRc) vs modified Nishida procedure combined with MRc and botulinum toxin (BT) for severe unilateral sixth nerve palsy. Design Consecutive, interventional case series. Methods The medical records of a consecutive series of patients with severe unilateral sixth nerve palsy who underwent modified Nishida procedure in multiple centres were reviewed. Surgical technique was decided preoperatively at the surgeon’s discretion. The preoperative and postoperative findings were compared. Results Of the 43 patients with abducens palsy that received the procedure, 32 were included (mean age 38.6 ± 19.8 years). Mean preoperative deviation was 63.0 ± 27.3 prism dioptres (PD) and mean limitation of abduction −4.5 ± 1.2. Five patients underwent a modified Nishida procedure alone, 24 patients had an additional MRc and 3 patients were also injected with BT. Overall, the average correction of modified Nishida technique by itself was 29.4 ± 6.6 PD (range 20–36) and adding a MRc corrected 62.6 ± 23.8 PD (range 24–120). Modified Nishida procedure, MRc and BT altogether corrected 95.0 ± 18.0 PD (range 75–110). No postoperative complications were observed in any of the patients. Conclusions Excellent outcomes with fewer complications are obtained with modified Nishida procedure alone. The need for additional procedures such as MRc and BT which increase the effect in primary position can be determined depending on passive duction and preoperative horizontal deviation.

Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy,\" \"vertical rectus transposition for abducens palsy,\" \"superior rectus transposition,\" \"inferior rectus transposition,\" and \"Hummelsheim procedure.\" References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy.

Abducens palsy is one of the commonly encountered cranial nerve palsies in strabismus clinic. For large-angle esotropia, due to complete abducens palsies, various vertical recti transposition (VRT) procedures have been described. Hummelsheim and Jensen's procedure are especially popular among them. Risk of anterior segment ischemia and induced vertical deviation postVRT prompt to search for better procedures to correct the esotropia and also improve the abduction. Modified Nishida's procedure (no split, no tenotomy transposition) is one of the newly described procedure in this direction. We describe three cases of complete abducens nerve palsy treated by this procedure.

Nephrotic syndrome (NS) is a common glomerular disease characterised by massive proteinuria, hypoalbuminaemia, oedema and hyperlipidaemia. Cerebral venous sinus thrombosis (CVST) is a rare complication in children with NS. Here, we report a case of relapsing NS on steroid therapy, in a male in early childhood who presented with symptoms of headache, vomiting and double vision. On prism cover test there was 25 PD esotropia with abduction restriction in the left eye. Fundus examination showed bilateral papilloedema. He was diagnosed as sixth cranial nerve palsy of left eye. Neuroimaging reported dense CVST. He was managed with subcutaneous low molecular weight heparin and steroids. After 2 months of treatment, there was a complete resolution of esotropia and optic disc oedema. This case highlights the importance of early diagnosis of acute onset esotropia and sagittal sinus thrombosis in a case of NS.

To study the binocular alignment and ocular motility in patients with large-angle esotropia due to sixth nerve palsy treated with double augmented vertical recti transposition. This was a prospective interventional study. Fifteen patients with non-resolving sixth nerve palsy who underwent surgical correction were included in the study. Fourteen patients also underwent an additional medial rectus recession. Two patients with an associated small vertical deviation had a selective augmentation of one vertical rectus muscle. Binocular alignment, ocular motility, duction limitation, improvement in head posture, induced vertical deviations, and field of diplopia-free binocular single vision (when possible) were analyzed. Successful outcome was defined as a residual horizontal deviation of 10 prism diopters (PD) or less with no vertical deviation at final follow-up (6 months). The double augmented Hummelsheim procedure improved esotropia from 58.3 ± 10.8 PD preoperatively to 7.2 ± 5.1 PD postoperatively (P = .001). Three (20%) patients had residual deviation of greater than 10 PD, of which 1 patient had diplopia and was treated with prisms. Postoperative binocular field of vision was performed in 6 patients, the mean of which was 20° for abduction and 45° for adduction. Three of 6 patients had elimination of face turn and the rest had residual head posture of less than 5°. Two patients had an induced vertical deviation of less than 4 PD. In patients who had selective augmentation, the vertical deviation was completely corrected. The patients operated on with double augmentation of the Hummelsheim procedure combined with medial rectus recession had reduced mean primary esotropia and improved diplopia-free field of vision postoperatively. [J Pediatr Ophthalmol Strabismus. 2016;53(6):369-374.].

The aim of this work is to elucidate underlying etiologies, lesion locations, and outcomes of inferior rectus (IR) palsy of acquired origin. Retrospective search identified 44 patients with acquired IR palsy between April 2006 and May 2011 from four Neurology and two Ophthalmology Clinics in Korea. We analyzed clinical features, the results of radiological and laboratory evaluation, and prognosis. The most common causes were vascular ( n  = 16, 36 %) and trauma ( n  = 12, 27 %). Vascular disorders included microvascular ischemia ( n  = 10, 23 %), cerebral infarction ( n  = 5, 11 %), and dural arterio-venous fistula ( n  = 1, 2 %). Other causes were inflammation ( n  = 7, 16 %), myasthenia gravis ( n  = 5, 11 %), and thyroid ophthalmopathy ( n  = 1, 2 %). We were unable to determine the etiology in the remaining three patients (7 %). Most patients (95 %) showed a complete recovery with or without treatment. Acquired IR palsy mostly occurs with brainstem or orbital lesions, and has an excellent prognosis.