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ARTICLES
Year : 1979  |  Volume : 27  |  Issue : 4  |  Page : 96-98

Surgical management of a case of post-encephalitis ophthalmoplegia


Patney's Eye Hosp. "Alankar" Condal Rd. Rajkot-2, India

Correspondence Address:
Sudha Awasthi Patney
Patney's Eye Hosp. "Alankar" Condal Rd. Rajkot-2
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Patney SA, Patney H L. Surgical management of a case of post-encephalitis ophthalmoplegia . Indian J Ophthalmol 1979;27:96-8

How to cite this URL:
Patney SA, Patney H L. Surgical management of a case of post-encephalitis ophthalmoplegia . Indian J Ophthalmol [serial online] 1979 [cited 2020 Apr 7];27:96-8. Available from: http://www.ijo.in/text.asp?1979/27/4/96/32587

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A girl aged 16 years, came to us in Sept. 1975 with bilateral palsies of mutiple muscles following encephali­tis in May-June 75. A report was given by civil hospital, Rajkot where she was treated. This report stated that at first there was right divergent strabisonus with limitation of vertical movements in up and down gazes, in both eyes along with a weak lateral movement (abduction in left eye and adduction in right eye). Pupils were semi-dilated and fixed. This picture developed into a total 3rd nerve palsy in right eye and a partial 3rd nerve palsy in left eye. The fundi remained normal. The father of the girl said that for the first few days, she could not see anything. Gradually the vision recovered to 6/6 in both eyes after treatment with anti biotics and corticosteroids.

On first examination: She had a large divergent deviation with marked right hypertropia, although she could alternate. Examination of ocular movements revealed gross limitatian of right eye in dextro and levodepression along with a limitation and marked upshoot in adduction. In left eye the main feature was a limitation of. elevation mainly in levo-elevation. There was also a slight limitation of left eye in levo­version. No in-torsion was seen on attempted depres­sion in right eye. Vision, pupillary reactions, fundi and fields were normal. She was given more vitamins B 1 , B1 2 and kept under observation till June 76. During the first four months, there was partial spontaneous recovery. Next three months showed no further change, therefore, it was decided to operate. She was warned that several operations may be needed to achieve straight eyes in primary position. She wanted to wait till June when 1st stage surgery was carried out as follows, Rt. lateral rectus recession-9 mm. & rt. interior oblique myectomy.

The pre and post-operative orthoptic reports were as follows:­

Pre-operative-V.A. 6/6 B. E.

Cover test: Rt.-Alternating exotropia with hyper­tropia for near and distance.

Ocular movements

In levo-version-F.R.E.-down shoot and slight limitation of L.E. : F.L.E.limitation and marked up­shoot of R.E.

In dextro-version-F.R.E.-slight downshoot of L.E. F.L.E.-slight upshoot of R.E.

In levo-evelation-over action of R.E. under-action of L.E.

In dextro-elevation-slight over action of R.E. and under-action of L.E.

In levo and dextro-depression-Gross under-action of L.E.

Synoptophore:-No simultaneous perception. Pic­tures crossed at-11 R/L 12-20 Prisms. Fusion absent.

Diplopia chart showed: L/R images with crossed diplopia in all positions with maximum vertical separa­tion in levo elevation and maximum horizontal separation in levo-version.

Post-operative report after 7 days:

C.T.-F.R.E.SI.L.D.S. with left hypotropia

F.L.E.-Rt. hypertropia.

(Vertical angle much less)

Ocular movements-Limitation of both eyes in levo­version as before and over action of R.E. in dextro­elevation. Depression of R.E. and L.E. movements as before.

Synoptophore: Objective angle of deviation by flash­ing F.R.-1R/14-6, F.L.-2R/L8. No. binocular functions.

Her cosmetic appearance was very much better but the eyes were not perfectly straight in any position.

In the following months the picture changed some­what.

Second stage surgery was carried out in Oct. 76, as follows:

1. Rt. superior rectus recession-4 mm.

2. Rt. medial rectus recession-5 mm.

3. Rt. inferior rectus recession-5 mm.

Pre-operative reports were as under:

CT-R.D.S. with rt. hypcrtropia can alternate.

O.M.-In levo-version-limitation of rt. eye with slight upshoot. In dextro-version-slight limitation of R.E. and downshoot of I.e. In leavo-elevation-marked limitation of B.E. 19 Dexiro-elevation-Over-action of R.E., slight limitation of I.e

In depression-marked limitation of R.E.

Synoptophore S.M.P. was now present at: F.R E.­11R/L23 F.L.E.-9R/Ll9

Fusion now present at-9R/L20, Add. to-6, abd. to­12. Steropsis-absent.

Diplopia test-Crossed with L/R images, maximum horizontal separation in leavo-version, vertical in leavo­elevation.

Second post-operative report after 7 days:

C.T.-No deviation-slight exophoria in P.P. for near and distance.

O.M. Limitation of R.E. in elevation and depression, more in depression slight limitation of R.E. in abduc­tion. L.E.-same as before.

Synoptophore: S.M.P.-F.E.E. 0 L/R i.5, Fusion at OL/R 1.5 Adducts to-9, abducts to-5, with K.S., S.V.

absent.

Convergence-12-14 cm. with effort.

After 18 days: O.M.-elevation equal but limited in both eyes. First field of B.S.V.-50-56.

Synoptophore: Range of fusion now increased to 18 degrees­

After 2 months: The main feature was a return of ctertopsis. O.M.-depression now seems limited in both eyes ..Ithough more so in R.E.

Another striking feature was an increase in the field of B.S V. which now measured 70 0 (vertical) x 80 (horizontal).

After 3 months cover test showed a return of slight divergence. With correct head posture (C.H.P.)-(slight face turn to left) exophoria for N. and D. Without C.H.P.intermittent exotropia for near.

A small-angle it. exotropia for distance.

Convergence-18-20.

Field of B.S.V.-60° (horiz.)x70° (vert.)

After 7-1/2 months--Field of B.S.V.-V75°xH69°.

After 10 months:

C.T.:
F.R.E.-No. deviation for near-slight exophoria

F.L.E.-Exophoria with slight left hyperphoria.

For distance-F.R.E.-slight exophoria

F.L.E.-slight exophoria.

Ocular movements

Limitation of R.E. in dextro and levo-elevation.

Slight limitation of L.E. in levo-elevation.

Slight limitation of both eyes in dextro and levo­depression.

Synoptophore: S.M.P.-F.R.E. L/R2∆, F.L.E.­L/R3

Fusion-at L/Rt.3, Adducts to +7°. abducts to-6°.

Stereopsis-present.

Field of B.S.V.-Vert. 60°xHoriz. 55° (attached).

Remarkable features of this case are:

  1. Unlike most of the cases of post-encephalitic ophthalmoplegia this one did not recover to any great extent and surgery had to be carried out.
  2. Even after ten months of reasonably straight eyes in primary position, fusion and convergence re­mained weak inspite of orthoptic excercises.
  3. There was a circular nystagmus in upwards gazes which is still persisting after a year.
  4. There was a lid-lag in depression which dis­appeared after the second operation.
  5. Responded well to surgery.
  6. Excellent cosmetic result and fairly good functional result.




 
 
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