Contents „ EDITORIAL ƒ Meibomian Gland Dysfunction (MGD) Sameera Irfan -------------------------------------------------------------------------------------------------------------------------------------- 49 „ OPHTHALMIC SECTION / ORIGINAL ARTICLES ƒ Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort Tayyaba Gul Malik et al ------------------------------------------------------------------------------------------------------------------------------ 52 ƒ A Study of Prevalence of Risk Factors in Patients with Non- ArteriticAnterior Ischemic Optic Neuropathy (Na- Aion) Akhunzada Muhammad Aftab et al --------------------------------------------------------------------------------------------------------------- 56 ƒ Dacryocystorhinostomy - is Endonasal Endoscopic Approach A Viable Option? Khawaja Khalid Shoaib et al ------------------------------------------------------------------------------------------------------------------------ 59 ƒ Ocular and systemic Complications of Intravitreal Bevacizumab (Avastin) therapy Akhunzada Muhammad Aftab et al --------------------------------------------------------------------------------------------------------------- 62 ƒ Incidence of Intraocular Foreign Body in Penetrating Trauma presented to a Tertiary Care Hospital of Khyber Pakhtun Khwa and its Visual Outcome Mohammad Idris et al -------------------------------------------------------------------------------------------------------------------------------- 66 ƒ To Determine the Efficacy of Tattoo Ink in Changing the Color of Rabbit’s Iris Mehdi Soltanifar et al -------------------------------------------------------------------------------------------------------------------------------- 69 ƒ Incidence of Hepatitis B & C among Admitted Eye Patients in Tertiary Care Hospital of Peshawar Bilal Bashir et al --------------------------------------------------------------------------------------------------------------------------------------- 72 ƒ Visual Outcome & Complications of Scleral-fixation Posterior Chamber Intraocular Lenses Mir Ali Shah Aftab et al ---------------------------------------------------------------------------------------------------------------------------- 75 ƒ Prevalence and Density of Amblyopia in Strabismic Patients of School Age Children Mohammad Alam et al ------------------------------------------------------------------------------------------------------------------------------- 79 ƒ Tuberous Sclerosis Complex Hussain Ahmad Khaqan et al ----------------------------------------------------------------------------------------------------------------------- 82 ƒ Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus Mohammad Kashif et al ----------------------------------------------------------------------------------------------------------------------------- 85 ƒ Intraocular Pressure Control after Cataract Extraction with Posterior Chamber Intraocular Lens Implantation in Phacomorphic Glaucoma Prof. Laal Mohammad et al ------------------------------------------------------------------------------------------------------------------------- 90 ii Ophthalmology Update Vol. 13. No. 2, April-June 2015 ƒ Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults Mohammad Kashif et al ------------------------------------------------------------------------------------------------------------------------------ 93 ƒ Intraocular Pressure Control after The Efficacy of Limbal Based Conjunctival Flap in Patients Undergoing Trabeculectomy with Intra-operative Mitomycin C Hasan Yaqoob et al ---------------------------------------------------------------------------------------------------------------------------------- 100 ƒ Normal Tension Glaucoma & Cerebral Ischemia / Brain Atrophy Akhunzada Muhammad Aftab et al ------------------------------------------------------------------------------------------------------------- 104 ƒ Complications & Results of External Dacryocystorhinostomy in Chronic Dacryocystitis without Intubation (Review of 107 Cases.) Mohammad Alam et al ----------------------------------------------------------------------------------------------------------------------------- 107 ƒ Recurrence of Retinal Detachment after Silicone Oil Removal Bilal Khan et al -------------------------------------------------------------------------------------------------------------------------------------- 110 ƒ Choroidal Melanoma in a Young Patient Hussain Ahmad Khaqan et al ---------------------------------------------------------------------------------------------------------------------- 113 „ GENERAL SECTION / ORIGINAL ARTICLES ƒ Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting with Non-variceal Upper Gastrointestinal Bleeding Imran Yahaya et al ---------------------------------------------------------------------------------------------------------------------------------- 115 ƒ Meatal Mobilization Technique for Childhood Hypospadias Repair, an Early Experience at Lady Reading Hospital, Peshawar Muhammad Ayub Khan et al ---------------------------------------------------------------------------------------------------------------------- 120 „ OPHTHALMOLOGY NOTEBOOK ƒ Obituary- Forever Loved - Forever Missed ---------------------------------------------------------------------------------------- 123 ƒ Murree: The Queen of Mountains - A Shining Pearl of Pakistan (Malika-e-Kohsaar) ------------------------ 124 Ophthalmology Update Vol. 13. No. 2, April-June 2015 iii Meibomian Gland Dysfunction (MGD) (Current Concept) Meibomian Gland Dysfunction, also referred to face which can glide and spread the tear film from the as the posterior blepharitis, is a very common cause of tear meniscus in the lower conjunctival fornix, evenly a myriad of symptoms in the general population, par- over the cornea, giving it its polished appearance.4 Bac- ticularly after the age of 45 years which is often neglect- teria (staphlococci which are the normal flora of the ed and under-diagnosed by the ophthalmic fraternity.1 eyelid) invade the meibomian glands and produce li- Many ocular disorders, including evaporative dry eye, pases which break down the waxy esters in meibum blepharitis, sties, chalazia and ocular rosacea have been to short chain free fatty acids.5 These fatty acids are linked to abnormal function of the meibomian glands2. toxic to the ocular surface and causes its irritation. The Health professionals in the USA have now been alert- lack of waxy esters result in excessive evaporation of ed that MGD is a major contributing factor in ocular aqueous component of the tear film. The abnormally surface disease in at least 50 - 75% cases. According functioning glands may over secrete toxic meibum, to the International Workshop on Meibomian Gland under secrete or get blocked, with underlying changes Dysfunction in 2011, sponsored by the Tear Film and to the eye. Normally the meibum is in a fluid state at Ocular Surface Society, USA,2 there is a paradigm shift normal body temperature but these short chain fatty in the treatment of dry eyes. As a result of this report, acids clump together making the meibum viscid.6 This ophthalmologists are now evaluating the lids more thick, opaque secretion blocks the meibomian gland carefully, and more often when seeing patients with orifices, dries up and plugs them (seen in the top pic). dry-eye complaints. MGD has also been known to be When the gland becomes obstructed by thick, inspis- an important cause contact lens intolerance.3 sated secretion, the glandular epithelium degenerates Pathogenesis: Normally there are 40 meibomian and stops functioning altogether, leading to minimal or glands in the upper lid and 20 in the lower. As the nonexistent production of meibum and loss of meibo- glands make meibum, it is normally pushed outward mian glands. The areas where the meibomian glands with each blink by the contraction of Riolan’s muscle have atrophied appears as notches at the grey line (seen (pre-tarsal orbicularis) on to the surface of eyelids and in the bottom picture). Meibomian gland secretion is spreads over the lid margin making it a smooth sur- controlled by androgens, mainly testosterone. Its defi- Ophthalmology Update Vol. 13. No. 2, April-June 2015 49 E DITORIAL ciency is particularly seen as a part of normal ageing v) Note the tear-film break up time: this gets reduced process. Hence, dry eye syndrome and MGD is more with worsening of the disease. Normal being >10 mm. commonly seen in post-menopausal women.7 vi) Punctate keratopathy at the inferior limbus and in- MGD causes two problems: Firstly, eyelid inflamma- ferior conjunctival staining due to irritation by toxic tion and secondly, excessive evaporation of tears and meibum at the lid margin. consequently dry eyes. The tears become hyperosmoler vii) Transilluminate the tarsal plate by a pen-torch held which then stimulate corneal nerves resulting in ocular on the skin side of a fully everted lid to look for evi- irritation, dryness, tearing, redness, a foreign body sen- dence of atrophy, loss or degeneration of the meibomi- sation or intermittent blurring of vision. an glands. Examination: In every adult patient who has come to viii) Check for aqueous deficiency of tear film with you with any eye complaint, try to assess for MGD and Schirmer’s 2 test. look for the following first: ix) Check the tear osmolarity if possible. i) The lids may look normal but the lid margin has to be x) In severe MGD, check lipid profile/ Blood Sugar. everted a little bit and the meibomian gland orifices ex- Don’t assume patients will voluntarily mention their amined; normally the meibum is a clear secretion that symptoms. Be proactive, and ask every adult patient flows easily out of the orifices with a tiny pressure at about ocular irritation and whether it is worse in the the lid margin with a cotton-tip applicator. However, morning which points to MGD. A dry eye due to an opaque secretion is abnormal. Or, the glands could aqueous deficiency is worse in the evening. be completely blocked / plugged with thick white se- Treatment: cretion which cannot be expressed with pressure on the a) Highest on the list is getting the patient to play an lid margin. Scarred and notched grey line indicates loss active role by scrubbing the lid margins with a baby of glands. Hence, there are different stages of meibo- shampoo twice a day to remove excess oil. mian gland disease. b) Mobilize the oils 8 out of the lids onto the eye where ii) Grades of MGD: you do want them. Achieve this through the use of lid Grade 0: Normal, no MGD: clear, thin secretion at the compresses, which are believed to melt plugs com- gland orifices, squirts out of orifices with a little pres- posed of dried secretions blocking the gland orifice; sure on the lid margin. Apply hot fomentation to the lids with a hot towel to Grade 1: a viscid secretion flows out easily with mini- melt the thick secretions/plugs and then expressing mum pressure. meibomian glands on a daily basis by massaging the Grade 2: an opaque secretion flows after exerting a lot lower lid upwards and upper lid downwards with a of pressure. finger or a Q-tip. this should be done 2-3 x per day. This Grade 3: gland orifices are plugged/capped and no se- will not work in Grade 4 disease in whom there are no cretion flows or it comes out like a tooth-paste or a froth secretions at all due to atrophic glands. is present at the lid margins (due to saponification of c) Addressing the source of any inflammation; avoid fatty acids by bacterial lipases). aminoglycocides topically as they worsen MGD. Find Grade 4: atrophic/scarred gland orifices. out and treat any allergies. Topical tetracycline eye NOTE: Toxic secretions cause an inferior conj / corneal ointment massaged into the id margins twice per day. staining. If the ducts are blocked with thick meibum Systemic doxycycline9 can interfere with the lipases plugs, or have atrophied, then there will be no toxic se- produced by Staphlococci that break down the fatty cretions; however, if few ducts are open, then a little components to free fatty acids- a common regimen is bit of corneal staining will be there. Hence seeing cor- doxycycline 100 mg od or b.i.d. for four to six weeks, neal staining with open ducts is Grade 2 disease. See- in severe cases. An alternative is Azithromycin 500 mg ing corneal staining + majority of ducts being capped/ bid or 1 Gm od per week for 3 consecutive weeks. Simi- blocked is grade 3 disease. If grey line shows notching, larly, cyclosporin10 eye drops 0.5% - 0.75% twice a day then trans-illumination confirms atrophic glands at the have the same anti-inflammatory affect. site of a notch (Grade 4 disease). d) Neutralize toxic secretions with artificial tears; drops iii) Oily debris floating in tear film or foam present at during day and lubricating ointment at night. the lid margins indicate hyper-secretion; the fatty acids e) Some patients are beyond the point of no return. undergo saponification by bacteria and produce toxic They don’t have any glands left, or the ones they have foam. aren’t functioning. For them, heating and massaging iv) Look for Rosacea / recurrent chlazia which indicate won’t do anything. They can be given Lipid-based ar- MGD. tificial tears. 50 Ophthalmology Update Vol. 13. No. 2, April-June 2015 EDITORIAL f) Oral Omega 3 Fatty acids11 to restore the balance be- blepharitis. Invest Ophthalmol Vis Sci.1986;27(4):486–491. 6. Foulks GN. The correlation between the tear film lipid layer tween good and bad lipids. and dry eye disease. Surv Ophthalmol.2007;52(4):369–374. g) Intra-ductal probing12 of blocked meibomian glands 7. Sullivan DA, Sullivan BD, Evans JE. Androgen deficiency, mei- has been found to be effective in removing dried secre- bomian gland dysfunction, and evaporative dry eye. Ann New York Academy Sciences 2002;966:211-222 tion. 8. Olson MC, Korb DR, Greiner JV. Increase in tear film lipid Recommendation: MGD is a very common eye prob- layer thickness following treatment with warm compresses lem; try to look for it in every adult who presents at the in patients with meibomian gland dysfunction. Eye Contact Lens. 2003;29(2):96–99. ophthalmic clinic. Every patient should be specifically 9. Dougherty JM, McCulley JP, Silvany RE, Meyer DR. The role of asked for symptoms of ocular irritation. An eye exami- tetracycline in chronic blepharitis. Inhibition of lipase production nation should commence from the lids. in staphylococci. Invest Ophthalmol Vis Sci. 1991;32(11):2970– 2975. It is important to familiarize with the normal meibo- 10. Rubin M, Rao SN. Efficacy of topical cyclosporine 0.05% mian secretion by examining the lids of teenagers first in the treatment of posterior blepharitis. J Ocul Pharmacol and trying to squirt out meibum with a gentle squeeze Ther. 2006;22(1):47–53. 11. Macsai MS. The role of omega-3 dietary supplementation in on the lid margin. blepharitis and meibomian gland dysfunction (an AOS the- REFERENCES sis) Trans Am Ophthalmol Soc. 2008;106:336–356. 1. Bron AJ, Tiffany JM. The contribution of meibomian disease to 12. Maskin SL. Intraductal meibomian gland probing relieves dry eye. Ocul Surf. 2004;2(2):149–165. symptoms of obstructive meibomian gland dysfunction. Cor- 2. The definition and classification of dry eye disease: report of nea. 2010;29(10):1145–1152 the Definition and Classification Subcommittee of the Interna- tional Dry Eye WorkShop (2007) Ocul Surf. 2007;5(2):75–92. Dr. Sameera Irfan, FRCS 3. Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am Optom Assoc. 1980;51(3):243– Consultant Oculoplastic Surgeon & Strabismologist 251. Mughal Eye Trust Hospital, Lahore, Pakistan 4. McCulley JP, Shine WE. The lipid layer of tears: dependent on Website: www.sameerairfan.com meibomian gland function. Exp Eye Res 2004;78:361-5. 5. Dougherty JM, McCulley JP. Bacterial lipases and chronic Cell: 03364500901 ELECTION RESULT OPHTHALMOLOGICAL SOCIETY OF PAKISTAN (Federal Branch, Islamabad) Following members have been elected as the office bearers of the Ophthalmological Society of Pakistan, Federal Branch, in a recent election held in Islamabad for the year 2015-16. President Dr. Waheed Afzal President Elect Prof Farooq Afzal General Secretary Dr Shahzad Saeed Treasurer Prof Nadeem Qureshi Joint Secretary Prof B. A. Naeem Executive Council: Prof. Jahangir Akhter, Dr. Izzat Ali Khan, Prof. Brig. Amer Yaqub, Prof. Imran Azam Butt Prof. Mazhar Ishaq, Prof. Syed Imtiaz Ali, Prof. Wajid Ali Khan, Prof. Naqaish Sadiq Prof. Shakaib Anwar, Dr. Tariq Mirza, Dr. Amir Israr, Dr Intisar-Ul-Haq, Lt. Gen (R) M K Akbar, Dr. Naeem Qadir, Dr. Shahzad Iftikhar, Dr. Ali Raza, Dr. Javed Malik, Dr. Mazhar Qayyum Ophthalmology Update Vol. 13. No. 2, April-June 2015 51 OPHTHALMIC SECTION ORIGINAL ARTICLE Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort Tayyaba Gul Tayyaba Gul Malik FCPS1, Prof. Khalid Farooq FCPS (Diagnostic Radiology)2 Muhammad Khalil FCPS3 ABSTRACT: Objective: To determine neuro-imaging patterns of ocular motor nerve palsies in a Pakistani cohort and to compare with other populations. Study Design: Descriptive, retrospective study. Study period: 2010 to 2014 Subjects and settings: 50 Patients of ocular motor nerve palsies from two different centers of Lahore were included in the study. History charts and neuro-imaging reports were reviewed. The data considered for the study was age, sex, ocular manifestations, neuro-ophthalmological findings and imaging reports (CT scans, MRI, MRA and MRV). Results: Female to male ratio was 1.6:1. Age ranged from 13 years to 74 years (average 44.18). 66% (n=33) patients had isolated sixth nerve palsy and 34% (n= 17) had isolated third nerve palsy. None of our patients had fourth nerve palsy. 42% patients had normal neuro-imaging. Sinusitis and brain infarcts were commonest cause of third nerve palsy while demyelination was more common in patients with sixth nerve palsy. Other neuro-etiologies were space-occupying lesions, parasellar tumours, multiple sclerosis, aneurysm and meningitis. Conclusion: Third nerve palsy is the commonest ocular motor nerve palsy. There are certain cases where neuro-imaging shows normal scans and the cause of palsy remains undetermined. Key words: Ocular motor nerve palsy, trochlear palsy, oculomotor palsy, abducent palsy, Parasellar tumours, neuro-imaging. INTRODUCTION Very interestingly, idiopathic palsies constitute a large Ocular motor nerves are comprised of Oculomo- percentage in clinical practice. Acoustic neuroma, basal tor (supplying Medial Rectus, Superior Rectus, Inferior skull fractures, naso-pharyngeal tumours and raised Rectus, Inferior Oblique), Trochlear (innervating Supe- intracranial pressures are culprits of sixth nerve pathol- rior Oblique) and Abducent (nerve to the Lateral Rec- ogies2. Cavernous sinus pathologies give rise to multi- tus). Ocular motor nerve palsies are either supra nucle- ple cranial nerve palsies (oculomotor, trochlear, abdu- ar or infra nuclear. Associated neurological signs and cent, ophthalmic and maxillary divisions of trigeminal symptoms help us determine the site of lesion. Fascicu- nerves). This study reviews the neuro-imaging patterns lar palsies of third nerve are associated with different of ocular motor nerve palsies in a selected group of pa- syndromes (Benedikt, Weber, Nothnagel and Claude). tients from two tertiary care hospitals of Pakistan. Similarly, fascicular lesions of sixth nerve are associat- SUBJECTS AND METHODS ed with Foville and Millard-Gubler syndromes.1 Fourth It was a descriptive retrospective study. 50 pa- tients with acquired isolated Ocular motor nerve (Oc- nerve palsies are usually congenital in nature. ulomotor, Trochlear and Abducent) palsies were se- Different causes of isolated nerve palsies are men- lected (from two centers of Lahore City). Study period tioned in literature. These include vascular diseases spanned over 2010 to 2014. like Diabetes and Hypertension. In Oculomotor palsy Inclusion criteria: associated with Diabetes and Hypertension, pupils • Patients with acquired isolated third, fourth or are usually spared. Aneurysms and trauma are other sixth cranial nerve palsies important causes of isolated nerve palsies. Tumours, • Patients whose, complete clinical and radiological neurosyphilis and Giant cell arteritis are rare causes. data was available. 1Associate Professor of Ophthalmology, 2Professor, Department of Exclusion criteria: Radiology, 3Associate Professor of Ophthalmology, Lahore Medical • Patients with multiple cranial nerve palsies and Dental College, Tulspura, North Canal Bank,Canal Road, Lahore • Patients with incomplete clinical and imaging data Correspondence: Dr. Tayyaba Gul Malik FCPS, Associate Professor We reviewed clinical and imaging charts of se- of Ophthalmology, Lahore Medical and Dental College, Lahore E.mail: [email protected], Mob: 0300-4217998 lected patients and medical records were analyzed. Clinical data included history, visual acuity, color vi- Received: January 2015 Accepted: February 2015 sion and slit lamp examination. Special attention was 52 Ophthalmology Update Vol. 13. No. 2, April-June 2015 Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort given to pupillary reactions, extra ocular movements, aging. 11 patients with normal scans had uncontrolled cover/un-cover tests and fundoscopy. Neuro-imaging diabetes. Details of neurological scans are shown in tests included Computerized tomography with both graphs 1,2 and 3. The commonest etiologies of third plain and post contrast images, MRI with T2 and T1 nerve palsy (with positive neuro-imaging results) were weighted plain and post contrast images, (Gd-DTPA brainstem infarcts and maxillary sinusitis while demy- used for post contrast component), magnetic resonance elinating disease was major cause of sixth nerve palsy. arteriography and venography. Data was compiled, re- sults deduced and descriptive statistical analysis was done. RESULTS Fifty patients, 31 females and 19 males (female: male ratio, 1.6:1) were included in the study. Age ranged from 13 years to 74 years (mean 44.18 years). 66 % (n= 33) patients had isolated third nerve palsy and 34% (n= 17) had isolated sixth nerve palsy. None of our patients had fourth nerve palsy. Headache (34%, n= 17) and diplopia were the commonest symptoms at presen- tation. 58% of the patients had right sided nerve palsies and 42% had left sided involvement. None of our pa- tients had bilateral palsies. Normal imaging scans were Graph-3: Comparison of Oculomotor and Abducent nerve palsies seen in 44% patients. 13 out of 33 (39.39%) patients with oculomotor nerve palsy had negative scans. The pa- tients with normal MRI and third nerve palsy had nor- mal pupils. 9 out of 17 (52.9%) patients with Abducent nerve palsy showed no positive findings on neuro-im- Figure-1: Solid homogeneously enhancing extra axial mass (meningioma) with significant mass effect on left side of mid rain Graph-1: Neuro-imaging in patients of third nerve palsy Figure-2: Right para sellar meningioma (T2 and T1) coronal /axial post contrast images showing significant mass effect on right cavernous sinus, pituitary stalk and optic chiasm. Graph-2: Neuroetiology of sixth nerve palsy Ophthalmology Update Vol. 13. No. 2, April-June 2015 53 Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort Parasellar meningioma pressing on the cavernous sinus es. Our ability to collect detailed information was lim- was the commonest space occupying lesion leading to ited by the retrospective study and we had to rely on oculomotor ( 6%, n= 2/33) and abducent nerve palsies the available data. But this study can provide grounds (5.88, n= 1/17). Only one case of Acoustic neuroma had on which prospective follow-up studies can be done. sixth nerve palsy. The patient had developed palsy as CONCLUSION a complication of neurosurgery for Acoustic neuroma. Third nerve palsy is the commonest ocular motor One of our patients with third nerve palsy had multiple nerve palsy. There are certain cases where neuro-imag- tuberculomas in parasellar region. ing shows normal scans and the cause of palsy remains undetermined. DISCUSSION REFERENCES Out of twelve pairs of cranial nerves, three pairs 1. Kim SH, Lee KC, Kim SH. Cranial nerve palsies accompanying supply extra ocular muscles of eyeball. Diabetes, Hy- pituitary tumour. J Clin Neurosci. 2007;14(12):1158-62. pertension, aneurysms, trauma and brain tumours are 2. Hung CH, Chang KH, Chu CC,et al. Painful ophthalmoplegia with normal cranial imaging. BMC Neurol. 2014; 14: 7 the most commonest causes of these nerve palsies. There 3. Chiu EK, Nicholas JW: Sellar lesions and visual loss: key are certain cases where cause cannot be found and they concepts in neuro-ophthalmology. Expert Rev Anticancer are considered under the heading of idiopathic. In this Ther 2006; 6(9):23-29 4. Wilker SC, Rucker JC, Newman NJ, et al. Pain in Ischemic Ocu- particular study third nerve palsy was the common- lar Motor Cranial Nerve Palsies. Br J Ophthalmol. Dec 2009; est among all ocular motor palsies. It was consistent 93(12): 1657–1659. with the findings of Kim et al,3 Chih-Hsien Hung4 and 5. Rowe F and VIS group. Prevalence of ocular motor cranial nerve palsy and associations following stroke. Eye (Lond). Jul Chiu EK5 Contrary to that, many other researchers had 2011; 25(7): 881–887. preponderance of sixth nerve palsy in their studies.4,5,6 6. Zafar A, Irfan M. Lateral rectus palsy: An important sign in di- Male to female ratio was 1.6:1 in a study by Shawn C in agnosing tuberculous meningitis. KUST Med J 2011; 3(1): 10-14. his cohort with an average age of 66.9 years.4 The ratio 7. Kumar MP, Vivekanand U, Umakanth S, Yashodhara BM. A study of etiology and prognosis of oculomotor nerve paralysis. was reverse in our study (1:1.6) Edorium J Neurol 2014;1:1–8. In this particular study, 22% patients (n=11) were 8. Rucker CW. The causes of paralysis of the third, fourth and idiopathic. It was very much similar to the figures sixth cranial nerves. Am J Ophthalmol 1966;61(5 Pt 2):1293–8. 9. Krishna AG, Mehkri MB. India Neurol 1973 Suppl. IV. Vol 20: given by Kumar9, Rucker et al.10 And Krishna et al.11 584). While this percentage was quite high by Berlit P12. The 10. Berlit PJ. Isolated and combined pareses of cranial nerves III, IV incidence of ocular palsy associated with pituitary tu- and VI. A retrospective study of 412 patients..Neurol Sci. 1991 May;103(1):10-5. mors is reported to be between 4.6 and 32%.11 We had 11. Greenman Y, Stern N. Non-functioning pituitary adenomas. parasellar meningiomas leading to ocular motor palsy Best Practice & Research Clinical Endocrinology & Metabo- but none of our patients had pituitary adenoma. Later- lism 2009, 23:625-638. ality of palsies is also interesting. 52% of our patients 12. Nair AG, Ambika S, Noronha VO, Gandhi RA. The diagnostic yield of neuroimaging in sixth nerve palsy - Sankara Nethra- had right sided palsy which was very much consistent laya Abducens Palsy Study (SNAPS): Report1. Indian J Oph- with an earlier study.12 Headache and diplopia were thalmol. Oct 2014; 62(10): 1008–1012. the commonest presenting complaints of ocular motor 13. Tamhankar MA, Biousse V, Ying GS. Isolated Third, Fourth and Sixth Cranial Nerve Palsies From Presumed Microvascular palsies in our study similar to earlier researchers.13 Versus Other Causes: A Prospective Study. Ophthalmology. There are many cases where MRI or other arterial Nov 2013; 120(11): 10. and venous scans show negative results. Controversy 14. Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Inci- dence, associations, and evaluation of sixth nerve palsy using still exists whether to perform scans in every patient a population-based method. Ophthalmology. 2004;111:369–75. with isolated ocular motor nerve palsy. One school of 15. Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and thought in the absence of other neurological signs is to acute ocular motor mononeuropathies: a prospective study.. have a close follow up of the patient. If neurological Arch Ophthalmol. 2011;129(3):301-5. 16. Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated findings develop, neuro-imaging should be performed sixth nerve palsies. Neuroradiology. 2001 Sep;43(9):742-5. 16,17. Others have suggested to perform neurological im- 17. Kanski JJ. Neuro-ophthalmology. In: Clinical Ophthalmology: aging in all patients even if there is evidence of vascu- a systematic approach. 7th Edi. Elsevier Butterworth Heine- mann; 2011. p 1055 lopathy18. In fact, every patient should be thoroughly 18. Kanski JJ. Neuro-ophthalmology. In: Clinical Ophthalmology: investigated and neuro-imaging should be performed a systematic approach. 7th Edi. Elsevier Butterworth Heine- depending upon history, age and examination find- mann; 2011. p 1063 19. Kim SH, Lee KC, Kim SH. Cranial nerve palsies accompanying ings. pituitary tumour. J Clin Neurosci. 2007;14(12):1158-62. This study has certain limitations. Small sample 20. Hung CH, Chang KH, Chu CC,et al. Painful ophthalmoplegia size could be the cause of absent fourth nerve palsy cas- with normal cranial imaging. BMC Neurol. 2014; 14: 7 21. Chiu EK, Nicholas JW: Sellar lesions and visual loss: key 54 Ophthalmology Update Vol. 13. No. 2, April-June 2015 Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort concepts in neuro-ophthalmology. Expert Rev Anticancer 29. Greenman Y, Stern N. Non-functioning pituitary adenomas. Ther 2006; 6(9):23-29 Best Practice & Research Clinical Endocrinology & Metabo- 22. Wilker SC, Rucker JC, Newman NJ, et al. Pain in Ischemic Ocu- lism 2009, 23:625-638. lar Motor Cranial Nerve Palsies. Br J Ophthalmol. Dec 2009; 30. Nair AG, Ambika S, Noronha VO, Gandhi RA. The diagnostic 93(12): 1657–1659. yield of neuroimaging in sixth nerve palsy - Sankara Nethra- 23. Rowe F and VIS group. Prevalence of ocular motor cranial laya Abducens Palsy Study (SNAPS): Report1. Indian J Oph- nerve palsy and associations following stroke. Eye (Lond). Jul thalmol. Oct 2014; 62(10): 1008–1012. 2011; 25(7): 881–887. 31. Tamhankar MA, Biousse V, Ying GS. Isolated Third, Fourth 24. Zafar A, Irfan M. Lateral rectus palsy: An important sign in di- and Sixth Cranial Nerve Palsies From Presumed Microvascular agnosing tuberculous meningitis. KUST Med J 2011; 3(1): 10-14. Versus Other Causes: A Prospective Study. Ophthalmology. 25. Kumar MP, Vivekanand U, Umakanth S, Yashodhara BM. A Nov 2013; 120(11): 10. study of etiology and prognosis of oculomotor nerve paralysis. 32. Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Inci- Edorium J Neurol 2014;1:1–8. dence, associations, and evaluation of sixth nerve palsy using 26. Rucker CW. The causes of paralysis of the third, fourth and a population-based method. Ophthalmology. 2004;111:369–75. sixth cranial nerves. Am J Ophthalmol 1966;61(5 Pt 2):1293–8. 33. Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and 27. Krishna AG, Mehkri MB. India Neurol 1973 Suppl. IV. Vol 20: acute ocular motor mononeuropathies: a prospective study. 584). Arch Ophthalmol. 2011;129(3):301-5. 28. Berlit PJ. Isolated and combined pareses of cranial nerves III, IV 34. Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated and VI. A retrospective study of 412 patients..Neurol Sci. 1991 sixth nerve palsies. Neuroradiology. 2001 Sep;43(9):742-5. May;103(1):10-5. 40 years with no co-morbids with the presentation as in pictures. It started a year back with recurrent redness and swellings. Now this picture for last 20 days in RE and beginings in LE as well. DD. cavernous sinus thrombosis, Chemosis, bleeding orbital varices Curtesy: Dr. Muhammad Rashad Qamar Rao FCPS, FRCS Associate Professor of Ophthalmology QAMC, Bahawalpur, Pakistan E-mail: [email protected] Ophthalmology Update Vol. 13. No. 2, April-June 2015 55