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
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3. Richards BW, Jones FR, Younge BR. Causes and prognosis in
Kobashi et al however, found trochlear nerve palsy to be
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We did not encounter any patient with a concurrent third
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Ganka Gakki Zasshi (Acta Soc Ophthalmol Jpn).1969;73:577-588.
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