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LETTER TO THE EDITOR |
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Year : 2020 | Volume
: 68
| Issue : 6 | Page : 1230-1231 |
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Reply to comments on: Acute isolated medial rectus palsy due to infarction as a result of a hypercoagulable state
Arvind K Morya
Associate Professor & Unit Head, Department of Ophthalmology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
Date of Web Publication | 25-May-2020 |
Correspondence Address: Dr. Arvind K Morya Associate Professor & Unit Head, Department of Ophthalmology, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/ijo.IJO_2414_19
How to cite this article: Morya AK. Reply to comments on: Acute isolated medial rectus palsy due to infarction as a result of a hypercoagulable state. Indian J Ophthalmol 2020;68:1230-1 |
Respected Sir,
Firstly, we would like to thank you for your interest in our paper.[1],[2] In the letter to the editor written by you, we would like to clarify certain points. We would like to begin with the fact that although the clinical picture of this patient at presentation was rather a confusing one while describing the clinical features rather being parsimonious we have described the exact turn of events that occurred. The diagnosis of internuclear ophthalmoplegia did not occur at the initial presentation since there was no evidence of nystagmus in the other eye at presentation. Hence, instead of presuming the diagnosis, we advised a review of reports of MRI being conducted elsewhere and were reported to be normal. As per the discussion with the radiologist, we came to the conclusion that the previous MRI had thick slices and completely ruled out any pathology hence, repeat MRI with the smaller cuts was required. Therefore, the patient was subjected to a repeat MRI. Meanwhile, the patient was examined multiple times by the ophthalmologists and the neurologist. In addition, the patient was started on corticosteroid suspecting inflammatory etiology. However, after the reports were available the steroids were tapered off. We did not have a higher-end machine-like oculography and hence, we relied on our clinical examinations. The extraocular movements were examined by multiple ophthalmologists in normal and in slow motion, and video recording of all the movements was also taken. However, we could not detect any nystagmus. In the literature search, we came across the reports of isolated medial rectus palsy that could relate to our case.[3],[4],[5],[6] As rightly mentioned by you, the subtle findings of nystagmus, ocular tilt reaction, or skew deviation could have been easily missed. Nevertheless, as we could not base our diagnosis on presumption, we considered a differential diagnosis of both. The comment on whether it was nuclear fascicular in nature again cannot be based completely on the clinical findings, as the case was atypical in presentation. We did exclude all the other risk factors of ischemia stating why hypertension, dyslipidemia, and smoking were considered a risk factor since none of their histories were positive and were not being mentioned previously. Considering the clinical feature, we preferred the diagnosis of isolated MR palsy to partial or unilateral INO, as there was no supporting evidence for the same.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References | | |
1. | Pandey PK, Kishore D, Saraf P, Chaudhary RB, Sachdeva N, Muni I. Comments on: Acute isolated medial rectus palsy due to infarction as a result of hypercoagulable state: A case report and literature review. Indian J Ophthalmol 2020;68:1229-30. [Full text] |
2. | Morya AK, Jangid K, Naidu A, Bhandari S, Prakash S, Gogia S. Acute isolated medial rectus palsy due to infarction of as a result of hypercoagulable state; A case report and literature review. Indian J Ophthalmol 2019;67:1898-900. [ PUBMED] [Full text] |
3. | Al-Sofiani M, Lee Kwen P. Isolated medial rectus nuclear palsy as a rare presentation of midbrain infarction. Am J Case Rep 2015;16:715-8. Published 2015 Oct 8. doi: 10.12659/AJCR.893875. |
4. | Bal S, Lal V, Khurana D, Prabhakar S. Midbrain infarct presenting as isolated medial rectus palsy. Neurol India 2009;57:499-501. [ PUBMED] [Full text] |
5. | Rabadi MH, Beltmann MA. Midbrain infarction presenting isolated medial rectus nuclear palsy. Am J Med 2005;118:836-7. |
6. | Yao Y, Hong W, Fan Z, Li D, Chang X, Fan W. Isolated medial rectus palsy: Rare presentation of mesencephalon infarction. J Stroke Cerebrovasc Dis 2017;26:e53-4. |
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