|Year : 1980 | Volume
| Issue : 1 | Page : 13-16
V Rama, J Vimala, M Chandrasekhar, C Anjaneyulu, I Dinakar
Department of Neurosurgery, Government General Hospital & Kurnool Medical College Kurnool, Andhra Pradesh, India
deptt. of Neurosurgery Medical College, Kurnool A.P.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rama V, Vimala J, Chandrasekhar M, Anjaneyulu C, Dinakar I. Ophthalmoplegia. Indian J Ophthalmol 1980;28:13-6
|How to cite this URL:|
Rama V, Vimala J, Chandrasekhar M, Anjaneyulu C, Dinakar I. Ophthalmoplegia. Indian J Ophthalmol [serial online] 1980 [cited 2020 Oct 22];28:13-6. Available from: https://www.ijo.in/text.asp?1980/28/1/13/31039
Paralysis of extraocular muscles singly or in various combinations always interest the clinician and provide the basis for an exercise in differential diagnosis. While the etiology varies considerably, in quite a few instances it remains unknown. There have been very few reports on this subject from our country,.
| Methods and materials|| |
Ninety cases of ophthalmoplegia encountered during a five year period (1973-1978) have been reviewed. Detailed clinical assessment and routine examination of blood, urine cerebrospinal fluid and skiagrams of the skull were done in all the cases. Contrast investigations such as carotid angiography, ventriculography and pneumoencephalography were performed wherever required to arrive at a diagnosis. The diagnosis was confirmed histologically in relevant cases. The aetiology has been established in 84 cases and remains unknown in six.
| Observations|| |
The observation have been shown in [Table - 1],[Table - 2],[Table - 3].
| Discussion|| |
The nerve or nerves involved and their causative factors are summarised in [Table - 2],[Table - 3]. The third cranial nerve alone was affected in 28 cases. Carotid angiography was done in 18 of them. The procedure was not done in the 8 cases of trauma and 2 cases of congenital ophthalmoplegia. The solitary instance of isolated fourth nerve palsy was found in a case of brain stem tumour. Sixth nerve paralysis alone was found in 29 cases. A total opthalmoplegia (3, 4 and 6 nerves) was found in 24 cases. The third and sixth nerves were involved together in six cases and the 3rd and 4th together in two cases. The incidence of third nerve involvement appears to be the same in both Indian and American series (about 30%). The fourth and sixth nerve affection is lower in both Indian series [Table - 3]. The incidence of combined nerve lesions is higher in our series than in those of both the other series.
The causes of ocular palsy are summarised in the [Table - 2]. Those due to Neurotuberculosis including tuberculomas comprised 19 cases. Intracranial neoplasms and head injury accounted for 16 each. Vascular diseases consisted of 13 cases. The etiology was unknown in 6 cases while in 13 cases miscellaneous causes were found.
It is an entity which accounts for over a third of neurological problems in our region (Rayalaseems area i.e., former Ceded Districts) of Andhra Pradesh. It is not surprising therefore that 19 of the 90 cases were caused by this infection in its varied manifestations. Five of them were tuberculomas and 14 cases belonged to tuberculous meningitis group.
Head injury is one of the common causes of ocular palsy. Rucker found 168 of 1000 cases due to trauma i.e., about 17%, a figure close to ours (18%). The pathogenesis of oculomotor palsy in head injury in sufficiently well documented to need repetition.,,
Vascular lesions are less frequent in this series due to both atherosclerosis and aneurysms being much less prevalent in this region. In this series, one case was an aneurysm of posterior communicating artery, two were due to cavernous sinus thrombosis and in the other ten, atherosclerosis was found to be responsible. Two of them had hypertension. The third nerve was involved in 5 and the sixth alone in one. The third and fourth were affected together in one case and all the three were involved in six cases. Diabetes mellitus was present in 3 of these. There were four I.C. aneurysms (2.2%) among 180 cases of Krishna.
Two patients, a mother and a daughter had congenital ptosis. One patient had total opthaimoplegia due to oculo-pharyngeal myopathy who later developed tuberculous meningitis. In two patients there was congenital abductor palsy-one of them had spinal compression due to congenital stenosis of spinal canal as well. The pupils were normal in all these cases.
There were 16 cases of intracranial neoplasm. Seven were gliomas, two were meningiomas and two were acoustic tumors. Three were unverified and one each was a pituitary tumour and secondary.
One of these was a vascular hamartoma in boy with all the ocular muscles affected and the other was an intraorbital meningioma with an abducens palsy.
Herpes Zoster causing abducens palsy is uncommon and there was one case in our series. Three cases were categorised as Tolosa-Hunt syndrome based on investigations and response to therapy.,, Two cases of III nerve palsy were due to Horner's syndrome, both associated with cervical cord lesions. Purulent meningitis accounted for two cases of ophthalmoplegia and Myasthenia gravis and neurosyphilis were responsible for one each. Abducens palsy was caused by pseudotumor cerebri in 3 cases. Rucker listed syphilis, meningitis, multiple sclerosis and pseudotumor cerebri among the miscellaneous causes of paralysis of cranial nerves.
In every series a proportion of cases remains whose pathogenesis is unkown. In six of our patients the etiology could not be established. The third nerve alone was affected in three of them, while the third and sixth were involved in one and there was a total ophthalmoplegia in two. Rucker found 211 of 1000 cases (21%) while Krishna and Mehkri found 18% due to undetermined etiology. The incidence in our series is lower. No definite explanation could be offered for this.
A comparative study of the main causes of ophthalmoplegia [Table - 4] between the American (Rucker, 1966) and the South Indian (Krishna, et al)' series does not lend itself for any clear cut conclusions to be drawn as there are significant differences in the pattern of disease in the areas covered. For example, the incidence of tuberculosis is high in our area and this disease accounted for 21% of the cases. lntracranial neoplasms were less frequent in our series than that of Rucker while being double that of Krishna's series. The incidence of vascular group is about 4% less than that of the American figures. It is significant that the incidence of aneurysm as a cause of ophthalmoplegia was very high (7.7%) in Rucker's series whereas we had only a single case. Krishna and Mehkri whose report is from the adjacent State of Karnataka also found only 4 cases (2.2%). It is generally the experience of workers from this region that intracranial aneurysms are less frequent. This low figure however does not reflect the true incidence of aneurysm in general as there have been other cases who manifested mainly as subarachnoid haemorrhage. This single case was the one who presented during the period covered, with opthalmoplegia.
| Summary|| |
An analysis of ninety cases of Opthalmoplegia of varied etiology is presented. Two thirds of the cases belong to the age group of 11 to 40 years. The third and sixth nerves are involved in a large proportion of cases. Isolated trochlear involvement is rare. Intracranial neoplasms, neurotuberculosis and cranial trauma are the common causes. Among those due to vascular disease, atherosclerosis and thrombosis are the common. Aneurysm is a rare cause of ophthalmoplegia in this region.
| Acknowledgements|| |
We are grateful to the Superintendent, Government General Hospital, Kurnool for permission to use Hospital records. We are thankful to Mr. Esa, Steno for Secretarial assistance.
| References|| |
Dinakar, I, 1976. Neurol. India 24: 159.
Duke-Elder, S 1971 Neuro-ophthalmology, in System of ophthalmology. Ed. Henry & Kimptom, London, VOL. XII 1972. p-780 Part II.
Hooper, R.S. 1951. Brit. J. Surg. 39: 126
Krishna, A.G. and Mehkri, M.B. 1973 Neurol. India Suppl. IV. Vol 20: 584.
Mathew, N T. and Chandy, J. 1970 J. Neurol. Sci. 11: 243
Rucker, C.W. 1958. Amer. J. Ophthmol. 46: 787
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Vimala, J; Seetharam, Wand Dinakar, I 1978. Ind. J. Ophthalmol. 26: 46-48.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]