Outcomes of half-width vertical rectus transposition augmented with posterior fixation sutures for sixth cranial nerve palsy

AIM: To describe the experience with half-width vertical muscles transposition (VRT) augmented with posterior fixation sutures. METHODS: The clinical charts of all patients, who underwent half-width VRT augmented with posterior fixation sutures for sixth cranial nerve palsy from January 2003 to December 2018, were retrospectively reviewed. For each patient, pre- and post-operatively, the largest measured angle was used for the calculations, usually resulting with the angle for distance, except in young infants, where measurements were made at near fixation using the Krimsky test. RESULTS: Fifteen patients met the inclusion criteria for the study, of them 9 (60.0%) had also medial rectus muscle recession at the time of surgery. Mean follow-up period was 21.4±23.2mo (range 1.5-82mo). Preoperative mean esotropia was 51.3±19.7 prism diopter (PD; range 20-90 PD). Postoperative mean deviation on final follow-up was 7.7±20.2 PD (range -40 to 35 PD; P=0.018). In all patients with preoperative abnormal head position, improvement was noted. Ten (66.7%) patients had improvement in abduction and 10 (66.7%) patients reported improvement in their diplopia, by final follow-up. The addition of medial rectus recession was correlated with a larger change in postoperative horizontal deviation compared to baseline (P=0.026). Two (13.3%) patients developed a vertical deviation in the immediate postoperative period which had resolved in one of them. CONCLUSION: Half-width VRT augmented with posterior fixation suture, with or without medial rectus muscle recession, is an effective and safe procedure for esotropia associated with sixth cranial nerve palsy. A major improvement in the angle of deviation is expected. Most patients will have improvement in their abnormal head position and diplopia.

A Rare Case of Dengue Fever with Abducens Nerve Palsy

Dengue fever is one of the most common vector borne disease which is a viral infection transmitted by aedes mosquito. Most common in the tropical countries. Neurological manifestations are not commonly seen in dengue, it can present as encephalitis, encephalopathy, neuromuscular disorders and neuro-ocular disorders. Cranial mononeuropathy is a very exceptional manifestation. A 48-year-old Indian male was diagnosed with dengue, complicated with isolated unilateral sixth cranial nerve palsy. The patient was managed conservatively. Patient made a fast and full ocular recovery following treatment with methyl prednisolone. Hence, dengue can present with a cranial nerve palsy and the recovery process can be hasten with the use of corticosteroids.

Paediatric rhombencephalitis presenting with bradycardia: a good recovery despite cardiac involvement

Rhombencephalitis is a rare condition, often caused by infection, commonly presenting with myoclonic jerks, ataxia and cranial nerve palsy. Typically, it has a high morbidity and mortality, with worse prognosis associated with cardiopulmonary involvement. Herein, we present the case of a 10-year-old boy, presenting with headache, vomiting, symptomatic bradycardia and rapidly progressing ophthalmoplegia from a sixth nerve palsy, without additional brainstem symptoms. Previously, pericarditis, myocarditis and heart failure have been associated with rhombencephalitis, but not bradycardia. The cause of his rhombencephalitis was presumed viral, but despite extensive screening, the virus responsible was never isolated. Following treatment with intravenous antibiotics and antivirals in a high dependency unit, he recovered well with no neurological deficit on discharge and marked radiological improvement on MRI 4 weeks later. Although rare, rhombencephalitis should be considered in a child presenting with neurological symptoms, particularly alongside a cranial nerve palsy, developing over a rapid time course.

Isolated Oculomotor Cranial Nerve Palsy as Unusual Presentation of Primary High-Grade Burkitt’s Cell Lymphoma in HIV Patient: Case Report and Literature Review

Burkitt lymphoma (BL) is a highly aggressive B-cell neoplasm that is well known to be associated with HIV. The presentation usually reflects the underline immunodeficiency state (like opportunistic infections and chronic diarrhea, and enlarged lymph nodes). The most common causes for 3rd cranial nerve palsy are intracranial aneurysm, ischemia, trauma, and migraine. But for our case, it turned out to be associated with underline HIV and BL, which is an unusual cause. Here, we present a 43-year-old gentleman with no past medical history presented to the emergency department with 4 days history of drooping of left eyelid and headache and binocular diplopia with no other neurological features. CT abdomen showed lymph node enlargement. Lymph node biopsy showed the characteristic of Burkitt’s cell lymphoma. He was started on chemotherapy, but unfortunately, he died. We’re enlightening this case of an isolated oculomotor nerve palsy to diagnose lethal pathology like disseminated BL.

A rare case of rickettsial fever with isolated third cranial nerve palsy causing hemophagocytic lymphohistiocytosis

Rickettsial infections are being increasingly diagnosed in the Indian subcontinent with the advent of affordable and sensitive diagnostic techniques. Rickettsial infections are sometimes complicated by the development of secondary hemophagocytic lymphohistiocytosis (HLH) which is life-threatening unless identified early and treated. Here, we describe a case of rickettsial fever in a 41-year-old male who presented with fever, skin rash, and neurological obtundation, complicated by both third cranial nerve palsy and HLH. The patient showed a good recovery in sensorium with intravenous doxycycline and dexamethasone, although the oculomotor nerve palsy persisted for about two months after discharge. This case highlights the need to initiate treatment for rickettsial fever and HLH on clinical grounds before waiting for confirmation by laboratory tests.