• No results found

Clinical Features of the Cranial Nerves Palsy Patients Attending at Neuro- Ophthalmology Department of a Tertiary Eye Care Hospital in Bangladesh

N/A
N/A
Protected

Academic year: 2021

Share "Clinical Features of the Cranial Nerves Palsy Patients Attending at Neuro- Ophthalmology Department of a Tertiary Eye Care Hospital in Bangladesh"

Copied!
7
0
0

Loading.... (view fulltext now)

Full text

(1)

Dr. Tanima Roy, DCO ABSTRACT

Objective: There is still limited information on the ophthalmic presentation of cranial nerve palsy. The objective of the current study is therefore to draw a clinical overview of the cranial nerve palsies attending at ophthalmology facilities.

Materials/Patients : A total of 113 patients were included in the study having different cranial nerve palsies, those were attended at Neuro-Ophthalmology Department of Chittagong Eye Infirmary & Training Complex (CEITC), Bangladesh from July 2012 to June 2013.

Methods: This is a cross sectional study. Detailed clinical information, clinical course, management and available supporting neuroimaging report were obtained from the study patients using a semi-structured questionnaire. Results: Among a total of 113 patients, 82 (72.46%) were male. The mean age of the patients was 53±15 years. The most (n=65, 57.52%) of the patients were aged 51 years and above. Diplopia was the most commonly found symptom followed by unilateral drooping of the upper eye lid. Diabetes Mellitus (DM) was found as the most commonly associated systemic disease (n=54, 47 .78 %), followed by systemic hypertension (n=17, 15%). Abducent nerve palsy was most commonly found (n=50, 44.24%), followed by oculomotor nerve palsy (n=36, 32%), facial nerve palsy (n=7, 6%) and fourth cranial nerve palsy (n=6, 5%). The remaining patients (n=14,10%) were presented with multiple cranial palsies with different diagnosis like neoplasm, Gradinigo syndrome, superior orbital syndrome, orbital apex syndrome, Weber syndrome, suspected and post cerebellopontine angle tumors, herpes zoster opthalmoplegia. Following the standard conservative management for cranial nerves palsies, 40(36%) and 43 (39%) patients were completely recovered within 3 months and 6 months, respectively. Diabetic retinopathy was also observed among 16 (15%) patients that were more common in sixth nerve palsy.

Mostly older patients aged more than 50 years were suffering from acute isolated third, fourth, sixth nerve palsy. The most common cause of such neuropathies was microvascular ischemia. In young patients, the causes of multiple cranial palsy were varied that should be carefully investigated further. Magnetic resonance imaging of brain (MRI) findings of hypertensive third nerve palsy indicates that neuroimaging has some role to find the causes other than microvascular ischemia.

Conclusion: The causes of the cranial nerve palsy are generally diverse. Isolated mono neuropathies are the common problems among patients with aged more than 50 years, systemic diseases, including DM and HTN. However, involvement of isolated or multiple cranial nerves, the age of the patient, signs of improvement, accompanying signs and symptoms in third, fourth, and sixth cranial nerve dysfunction provide important clues for diagnosis as well as for the better management of the cranial nerve palsy.

Clinical Features of the Cranial Nerves Palsy Patients Attending at

Neuro-Ophthalmology Department of a Tertiary Eye Care Hospital in Bangladesh

Introduction

Cranial nerve palsy in adults often manifests with ophthalmological features like acute diplopia, drooping of eyelid etc. There are various causes of isolated and multiple cranial nerve palsies such as vascular, traumatic, tumor, aneurysm etc. Ophthalmic findings of cranial nerve dysfunction frequently constitute an important fraction of the

clinical expression of central nervous system disorders. Hence, determination of the cause and treatment of a cranial nerve dysfunction is critical because failure to detect and diagnose an aneurysm can lead to rupture the aneurysm, or a failure to detect extraocular muscle (EOM) palsies can have severe consequences because EOM palsies can be the first sign of a brain tumor. Therefore, the current study aimed at investigating the cause and outcome of patients with different cranial nerve palsy in those who were attended at Neuro-ophthalmology Department of Chittagong Eye Infirmary & Training Complex (CEITC).

Correspondence to : Dr. Tanima Roy

Assistant Surgeon

Chittagong Eye Infirmary and Training Complex Chittagong, Bangladesh E-mail : drtanimaroyeye@gmail.com September, 2013 Volume : 8 H O R IZ O N

(2)

Methods

This is a cross sectional study in which a total of 113 patients who attended at Neuro Ophthalmology clinic of CEITC betwen July 2012 to June 2013 with different cranial nerve palsy were enrolled. Detailed clinical information, clinical course, management and outcome were recorded. As clinically indicated available supporting neuroimaging report and laboratory test were obtained from the study patients using a semi-structured questionnaire.

Neurologically isolated palsy was defined as the absence of other signs and symptoms, with the exception of headache or periorbital pain, within 1 month of the onset of diplopia and during follow-up until enrollment. Congenital nerve palsy, Isolated optic nerve involvment, cranial nerve palsy due to myasthenia gravis or chronic progressive ophthalmoplegia, benign intracranial hypertension were excluded.

Details of the history including biographical details ( age, gender, address of patient), history of fever or any relevant history, sign and symptoms of cranial nerve palsy, time course of diplopia the presence of headache or pain, and a history of vasculopathic risk factors other than older age (i.e. diabetes mellitus, hypertension, hypercholesterolemia, stroke, myocardial infarction, peripheral neuropathy previously known or discovered at the time of diagnosis of the cranial mononeuropathy) presence of chronic complication of diabetes, medication history of subjects were recorded. The presence or absence of a history of neurologic disease, ocular motor palsy, or cancer or any other pertinent history was assessed by the examining neuro-ophthalmologist. Magnetic resonance imaging of the brain with and without gadolinium was advised as clinically indicated like multiple cranial nerve palsies, when younger patients without any relevant risk factors like recent viral illness, trauma, aged patient > 50 with vasculopathic risk factors but palsy was not resolving within 3 months, pupil involving 3rd nerve palsy, etc. Results of diagnostic testing (e.g, erythrocyte sedimentation rate, C reactive Protein, lipid profiles,blood sugar fasting and 2 hour after breakfast) were recorded. Hypercholesteromia or dyslipidemia at presentation was classified following European Atherosclerosis Society. According to this protocol, Cholesterol level >200 mg/dl, Triglyceride > 150 mg/dl, Low density lipoprotein >150 mg/dl were considered as Hypercholesteromia or dyslipidemia.1

A presumed micro vascular cause was assigned in those patients who has vascular risk factors, for whom the MRI scan and clinical testing did not reveal an alternative cause, other neurologic signs remained absent, and the ophthalmoparesis resolved spontaneously. All patients were followed until the resolution of diplopia or until a definitive diagnosis was established for their ocular motor palsy.Patients classified as idiopathic underwent MRI and, depending on clinical presentation, had negative supporting clinical test including Prostigmine results.

Diabetic Retinopathy was defined according to the International Clinical Diabetic Retinopathy Severity Scale adopted by American Academy of Ophthalmology(AAO) and the International council of Ophthalmology (ICO) under DRETT(Diabetic Retinopathy Education Treatment and Training) screening project at CEITC.

Results

Among a total of 113 patients, 82 (72.56%) were male and 31(27.43%) were female (figure 1). Most of the patients lived in rural area (n=73, 64.60%) and 40 number of patients (34.39%) came from urban area.

The mean age of the patients was 53±15 years. The most (n=65, 57.52%) of the patients were aged 50 years and above.

Table 1: Age distribution in study group

Figure 1 Common microvascular risk factors found in nerve palsies patients

Age group (in years) No. of the patient (%)

12 -30 19 (16.81) 31-40 10 (8.84) 41-50 19 (16.81) >51 65(57.52) Total 113 (100%) Diabetes Mallitus (DM) Systemic Hypertension (HTN) DM + HTN Hypercholesteromia Cerebrof Vascular diseases Cardiac diseases Chronic Kidney diseases (CKD) Peripheral neuropathy 60 50 40 30 20 10 0 H O R IZ O N

(3)

Diabetes Mellitus (DM) was found as the most commonly associated systemic disease (n=54, 47.78%), followed by systemic hypertension (n=17, 30%), DM and HTN both were found in 17 numbers of patients (15.04%), hypercholesterolemia associated with 30 patients(27.54%), History of Cardio vascular diseases, cardiac diseases, chronic kidney diseases, peripheral neuropathy were found in 7(6.19%), 3(2.65%), 2(1.16%), and 2(1.16%) patients, respectively.

Table 2: Patient distribution of different cranial nerve palsies between < 50yrs and 50 and above age groups

Microvascular causes were the most common causes of sixth nerve palsy (n=35, 70%) which were frequently found in older age group (n=31, 88.57%). Four patients (8%) had a reliable history of a preceding viral illness. Ten patients (20%) were diagnosed as idiopathic. History of trauma was also noticed by one patient (2%). All patients were recovered.

*Others: It includes multiple cranial nerve palsies , neurologically non isolated cranial nerve palsies.

Table 4: Causes of isolated third nerve palsies in two age groups

*Microvascular causes include DM, HTN, Hypercholesterolemia, H/0 CVD

*Microvascular causes includes DM, HTN, Hypercholesterolemia, H/0 CVD

Table 3: Causes of isolated sixth nerve palsies between two age groups

Abducent nerve palsy (6th CN) was most commonly found (n=50, 44.24%), followed by oculomotor nerve (3rd Cranial nerve) (n=36, 32%), facial nerve palsy (n=7, 6.13%) and fourth cranial nerve palsy (n=6, 5%). Among the patients of 50 years and older group, 35 (70%) had sixth cranial nerve palsy, 23(63.3%) had third cranial nerve palsy,3 (2.6%) had fourth nerve palsy,3 (2.6%) had

facial nerve palsy. In third nerve palsy, microvascular ischemia also

was the most common causes (n=28,77.7%).Pupil involved in 13(47.4%) cases. MRI finding of pupil involved cases were ischemic change in both cerebral hemisphere (4 cases) multiple ischaemic cerebral infarction (1 cases) mild cerebral and cerebellar atrophies MRA finding of all these cases were within normal limit. MRI finding of pupil sparing four hypertensive cases were acute brain stem stroke, subtle old infarct in the left basal ganglia, infarction in thalamus, MRA showed vertebral artery hypoplasia in one case. One patient gave history of taking Sildenafil before complete palsy developed; all other clinical examination and test were normal except lacunar infarction in right parietal white matter and resolved within 6th month. One patient had partial third nerve palsy complaining progressive diplopia.

Causes <50 years Total (%)

Isolated sixth nerve palsy 15 35 50 (44.24) Isolated third nerve palsy 13 23 36 (31.85) Isolated fourth nerve palsy 3 3 6 (5.30) Isolated seventh nerve palsy 4 3 7 (6.13)

Others* 8 6 14 (12.38%)

Total 43(38.05) 70(61.94) 113 (100)

50 years and above

Micro vascular causes* 4(11.4) 31(88.6) 35(70)

H/O viral illness 4 0 4(8)

Trauma 1 0 1(2)

Idiopathic 6 4 10 (20)

Total 15(30) 35(70) 50 (100)

Isolated sixed cranial

nerve palsy <50 years (%) 50 years (%) Total (%)

Isolated 3rdnerve

palsy nerve palsy < 50 years 50 years Total (%)

Pupil involving

Micro vascular causes* 3 10 13 (47.4) Pupil Sparing 2 13 15 (53.6) Pupil involving Trauma 1 0 Pupil Sparing 2(11.1) 1 0 Pupil involving Idiopathic 3 0 Pupil Sparing 4(5.55) 1 0 Partial 3rd N involvement Neoplasm 1 0 1(0.88) Drugs (?) 1 0 1(0.88) Total 13(36.2) 23(63.8) 36 (100) September, 2013 Volume : 8 H O R IZ O N

(4)

MRI finding showed hydrocephalus due to third ventricle obstructing mass and he was referred to neurosurgeon.

Among six patients with fourth nerve palsy, four (66.6%) had vasculopathic risk factors which were resolved. One patient had a history of trauma and resolved after three month. In one patient there was mild improvement of diplopia after six months and the patient was diagnosed as idiopathic and advised to use spectacles.

Table 6: Causes of Isolated Seventh nerve palsy

There were seven patient with facial palsy three (42.85%) have micro vascular risk factor and four (42.85%) were idiopathic.

Table 7: Diabetic retinopathy (DR) and cranial nerve palsies

PDR: proliferative diabetic retinopathy. NPDR: Non proliferative diabetic retinopathy. CSME: Clinically significant macular oedema*Other complications include peripheral neuropathy

Diabetic retinopathy was found in 35 patients of cranial nerve palsy. Nine patients (56.25%) with six cranial nerve palsy had diabetic retinopathy; six (37.5%) patients with third cranial nerve palsy had retinopathy. Non proliferative diabetic retinopathy (NPDR) found in one patient with facial nerve palsy.

Table 8: Causes of multiple cranial nerve palsies in two different age groups

IOID- Idiopathic orbital inflammatory disease: PCA: posterior cerebral artery, CS: cavernous sinus.

Multiple cranial nerve palsies and neurologically non isolated features were present in14 patients (12.38%). One patient with partial 3rd nerve palsy had positive prostigmine test treated with tablet pyrostigmine for 2 weeks, thereafter, he developed 6th nerve palsy. On Magnetic resonance imaging (MRI), he had temporal lobe tumor invading the CS (astrocytoma). Gradinigo syndrome was diagnosed in one patient with sixth nerve palsy, numbness and pain in right side of face, ear and MRI revealed acute mastoiditis. Two patients came with external ophthalmoplegia with fifth nerve (1st division) involvement but had no proptosis, one patient MRI showed lateral rectus swelling and other had sphenoidal sinus mucocele, both were diagnosed as Superior orbital syndrome (SOS) ,treated with oral prednisolone and resolved completely. There were two patients who were diagnosed with orbital apex syndrome on the basis of external ophthalmoplegia (one had partial palsy of 3rd,4th,6th,nerve ,both had no proptosis), fifth nerve (1st division) involvement and optic nerve involvement. Both were treated with intravenous steroid followed by oral steroid and gradually tapered.

Table 5: Causes of Isolated fourth nerve palsy

Microvascular causes 1 3 4 (66.6%) Idiopathic 1 0 1 (16.6%) Trauma 1 0 1 (16.6%) Total 3 (50%) 3 (50%) 6 (100%) Micro vascular 0 3 3(42.85) Idiopathic 4 0 4 (57.14) Total 4 (57.14) 3 (42.85) 7 (100)

<50 years 50 years Total (%) Isolated fourth nerve palsy

<50 years 50 years Total (%) Isolated seventh nerve palsy

PDR +CSME (s/p laser PRP, focal) 2 3 0 5 1 11(31.4) NPDR+CSME (s/p focal laser) 1 2 1 5 1 10 (28.6) NPDR mild to moderate 6 1 0 7 0 14 (40.0) Total 9 (25.7) 6(17.1) 1(2.9) 17(48.6) 2(5.7) 35 (100) 6th Nerve palsy 3rd Nerve palsy 7th Nerve palsy 4th Nerve palsy Other Compli cations* Total (%)

Causes 50yrs 50yrs Total

6th+3rd (partial) CN palsy Temporal lobe tumor invading

the CS (astrocytoma) 1 0 1 Rt Horizontal gaze palsy Fourth ventricle obstructing

tumor(ependymoma) 1 0 1 Lt 6th+ 3rd (partial) CN palsy Idiopathic 1 0 1 Rt 6th+5th+8th CN palsy Suspected CP angle tumor 0 1 1 Rt Gradinigo syndrome Acute mastoiditis 1 0 1 Rt 6th+ 7th CN palsy Microvascular causes 0 1 1 Weber syndrome

( rt 3rd+lt hemiparesis) Rt Infarction in territories supplied

by PCA, and parietal lobe also 0 1 1 Superior orbital syndrome(SOS) IOID 1 1 2

Orbital Apex syndrome IOID 1 1 2

Herpes zoster opththalmoplegia herpes zoster 0 1 1

Status post CP angle tumor - 1 0 1

6th n palsy+

resolved optic neuritis Under evaluation 1 0 1

Total 8 6 14 H O R IZ O N

(5)

Herpes zoster ophthalmoplegia resolved with short course of oral steroid. One young hypertensive patient with acute psychotic disorder was first treated as a case of retrobulbar neuritis and improved, but after one month, the patient developed sixth nerve palsy again and advised for MRI of brain and then, the patient was missed out for any further follow up. 7

Discussion

Our study was cross sectional study conducted in a specialized tertiary eye care hospital for a year. Thus, this study was aimed to investigate the involvement of eye in cranial nerve palsies. More than half of our total studied patients with cranial nerves palsies were older aged 50 years and above. The most common cause of such acute ocular mononeuropathy in older age is micro vascular ischemia of the peripheral portion of the nerve2,3. In our study, micro vascular ischemia was mostly (61.94%) the cause of third, sixth, fourth, seventh nerve palsy among the patients aged 50 years and above, which is comparable to other study6,7.Moreover, these finding signifies that older age might be an important risk factor for the ophthalmological manifestation of cranial nerve palsies.

In our study, Diabetes mellitus (47.78%), systemic hypertension (30%), hyperlipidemia (27.49%), cerebrovascular accident (6.19%) were also found as a commonly observed risk factors. A Population-based case-control study conducted by Sanjay Patel et al revealed that diabetes mellitus is more strongly associated with sixth nerve palsy rather than hypertension8. This study confirms the widely accepted concept that diabetes is an independent risk factor for sixth nerve palsy than hypertension (61% vs.11.7%). However, we found HTN and DM to be similarly associated with third nerve palsy.

In our study, sixth nerve palsy was common in both younger and older age group which is in line with the study conducted by Richards B. W. et al and also consistent with most of the previous conducted studies2,9.

Retrospective analyses of large data series suggested that follow-up without immediate neuroimaging in patients with suspected micro vascular ischemia may reduce the economic burden to the patients. On MRI of pupil involving cases, ischemic change and cerebral infarction in both cerebral hemispheres were most frequent findings. Acute brain stem strokes, infraction in basal ganglia, infraction in thalamus were found in hypertensive pupil sparing cases. Prompt initiation of antiplatelet therapy or anticoagulation for brain stem infarction and immediate evaluation and control of blood pressure in hypertensive brain stem hemorrhage cases are required for better prognosis. This also indicates the importance of MRI for initial evaluation of patients with acute isolated ocular Table 10: Diabetes Mellitus (DM) and Systemic

hypertension (HTN)with different cranial nerve palsy

Most of the isolated cranial nerve palsies were resolved within 3 months (35.4%) and 6 months (38.05%)respectively. However, it took more than 6 month in 5 cases (4.42%).Systemic steroid was given as conservative management and improved. Neoplasm cases were referred to specialized neurosurgery facility, and neurologically non isolated cases like weber syndrome were sent to specialized neuro Medicine care facility for further management. Surgical correction of squint was advised in two cases, lagophthalmos correction was needed in post removal of CP angle tumor. One patient was managed by spectacle with prism.

Only DM was present in 37 (52.85%) patients with cranial nerve palsies. Of these, sixth nerve palsy was present in more than 60% (n=21) patients, followed by oculomotor palsies (27.7%, n=10)).

Table 9: Outcomes of cranial nerve palsies Outcome No. of the patient (%) Palsy resolved within 3 month 40 (35.4) Palsy resolved within 6 month 43 (38.05) Needs more than 6 months 5 (4.42) Conservative management 6 (5.53) Referred to other subspecialties (Neurosurgery, ENT) 6 (5.30) Surgical correction of palsies 3 (2.65)

Lost for follow up 10 (8.84)

Total 113 (100)

Risk factors 6th CN 3rd CN 7th CN 4th CN Others Total

Only DM 21 10 1 3 2 37 (52.85) DM+HTN 10 6 0 0 1 17 (24.29) HTN 4 10 1 0 1 16 (22.86) Total 35 26 2 3 4 70 (100%) September, 2013 Volume : 8 H O R IZ O N

(6)

cranial nerve palsy even in the population aged more than 50 years10. Elderly patient, DM, Hyperlipidemia, HTN, smoking are the common risk factors for any cerebrovascular or cardiovascular disease. Therefore, life style modifications, use of statin, control of DM and HTN decreases the risk or further cerebrovascular or cardiovascular accident as well as their ophthalmological consequences.

In our study, we could not identify any cause in 16.81 % cases in spite of doing MRI and supporting laboratory test. Our idiopathic cases were less in compared to the study done by Sanjay V. Patel et al where they found 26% idiopathic cases out of total 137 cases of sixth nerve palsy cases and this proportion was higher in comparision to study conducted by George B. Peters et al where they found 13% idiopathic cases, because they did anti-nuclear antibody titers, angiotensin converting enzyme levels, and cerebrospinal fluid analysis for demyelinating diseases in all cases 6, 11. We tried to find out the reasons in idiopathic cases by specific laboratory investigations based on our provisional diagnosis, nonetheless, we could not find out the reasons for the idiopathic cases. This can be considered as a limitation of our study.

Three out of four patients with cranial nerve palsies due to trauma were resolved. Only one such case needed surgical correction. Previous study reported that prognosis of traumatic palsies was poor, but it differed in our patients. However, number of such cases (n=4) in our study were not enough to comment any concluding remarks. Sixth nerve palsy can also be developed after viral illness. All viral cases in our study were resolved. Kyoko Watanabe et al studied the characteristics of cranial nerve palsy in diabetic patients, in which they found nine out of 19 patients had facial palsy, however, we found only 4 patients with facial palsy who had microvascular risk factors12.

In the largest referral-based series conducted by Richards et al, 21% of sixth nerve palsies were associated with neoplasm. Sixth nerve palsies associated with intracranial mass lesions ( mostly cavernous sinus) were found frequently with other cranial nerve palsies2.

In our study 4.42% cases were associated with neoplasm. Sixth nerve palsy associated with other cranial nerve palsy in 4 cases in which neoplasm was found. Our current study was comparable with the study done by Sanjay V. Patel et al where

they found only 4% cases were associated with neoplasm among 137 new cases of sixth nerve palsy over a 15-year period6. However, the duration of our study was only one year, thus our study findings may be too preliminary for drawing any conclusion regarding this. Further prospective study for a longer duration is therefore required.

There was a striking difference between associations of neurologically isolated and non–neurologically isolated cases; the former group was predominantly associated with vascular (DM and HTN) or undetermined disorders, whereas the latter group was largely associated with more serious medical and neurologic disorders7. These facts were also established in our study.Multiple cranial nerve palsies and neurologically non isolated features were found in 14 patients (2.48%). Idiopathic orbital inflammatory disease were found in 4 cases, neoplasm found in 3 patients; Gradinigo syndrome and Weber syndrome were also found in one case each.

Domenico Greco et al demonstrated that the coexistence of diabetic retinopathy and cardiovascular risk factors was slightly higher in their studied patients with sixth nerve palsy13. Similarly, in our current study, diabetic retinopathy was more associated with sixth nerve palsy (57.46%) than third nerve palsy (37.5%). There is no specific treatment of nerve palsy-induced diplopia in diabetic patients yet. The management is therefore is only strong reassurance to the patient for recovery. Maintaining optimal glycemic control as well as minimizing the other high risk factors for ischemia, including hypertension and hyperlipidemia may accomplish the recovery. We advised vitamin- B12 (injectable followed by oral), oral vitamin B1,B2. Vitamin B12 is supposed to be good for diabetics for several reasons. Recent research has shown that vitamin B12 may help to mitigate some of the most common complications associated with long-term diabetes, including diabetic retinopathy and diabetic neuropathy. Some diabetic medications, including metformin, may also cause vitamin B12 deficiency. Vitamin-B supplementation may therefore have some added benefit for the patients with DM14-17.

The causes of the cranial nerve palsy are generally diverse. Extra ocular movement disturbances can be also an important initial manifestation of a brain disease. Isolated mono neuropathies are the

H O R IZ O N

(7)

common problems among patients with aged more than 50 years, systemic diseases, including DM and HTN. Sixth nerve was most frequently affected in diagnosed cases of our study. However, involvement of isolated or multiple cranial nerves, the age of the patient, signs of improvement, accompanying signs and symptoms in third, fourth, and sixth cranial nerve dysfunction provide important clues for diagnosis as well as for the better management of the cranial nerve palsy.

References

1. Stanley Davidson in the Davidson’s Principles and Practice of Medicine 21st Edition, eds-Nicki R. Colledge,Stuart H. Ralston, Brian R. Walker, (Churchill Livingstone Elsevier) 2011;1131-1236

2.Richards BW, Jones FR, Younge BR. Causes and prognosis in 4,278cases of paralysis of the oculomotor, trochlear, and abducens cranialnerves. Am J Ophthalmol 1992;113:489–96. 3.Asbury AK, Aldredge H, Hershberg R, Fisher CM. Oculomotor palsy in diabetes mellitus: a clinicopathological study. Brain 1970;93:555– 66

4.Jacobson DM, McCanna TD, Layde PM. Risk factors for ischemic ocular motor palsies. Arch Ophthalmol 1994;112:961-6

5. Sanders SK, Kawasaki A, Purvin VA. Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol 2002; 134:81-4

6. Patel SV, Mutyala S, Leske DA, et al. Incidence, associations, and evaluation of sixth nerve palsy using a population-based method. Ophthalmology 2004;111: 369-75 7. Berlit P. Isolated and combined paresis of cranial nerves III, IV, and VI. A retrospective study of 412 patients. J NeurolSci1991; 103:10–15

8. Sanjay V. Patel, Jonathan M. Holmes, David O. Hodge, James P. Burke. Diabetes and Hypertension in Isolated Sixth Nerve Palsy: A Population-Based Study. American Academy of Ophthalmology 2005; 112:760–763

9. Madhura A. Tamhankar, Valerie Biousse, Gui-Shuang Ying, Sashank Prasad, Prem S. Subramanian, Michael S. Lee,

Eric Eggenberger, Heather E. Moss, Stacy Pineles, Jeffrey Bennett, Benjamin Osborne, Nicholas J. Volpe, Grant T. Liu, Beau B. Bruce, Nancy J. Newman, Steven L. Galetta, Laura J. Balcer .Isolated Third, Fourth, and Sixth Cranial Nerve Palsies from Presumed Microvascular versus Other Causes

A Prospective Study. Ophthalmology 2013

(10.1016/j.ophtha.2013.04.009)

10. Chou KL, Galetta SL, Liu GT, Volpe NJ, Bennett JL, Asbury AK, Balcer L J. Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. Journal of the Neurological Sciences 2004; 219: 35-39

11. George B. Peters III, Sophie J. Bakri, Gregory B. Krohel. Cause and Prognosis of Non traumatic Sixth Nerve Palsies in Young Adults. American Academy of Ophthalmology 2002; 109:1925–1928

12. Kyoko Watanabe, RyokoHagura, Yasuo Akanuma, Toshiaki Takasu, Hiroshi Kajinuma, NobusadaKuzuya, Minoru Irie. Characteristics of cranial nerve palsies in diabetic patients.Diabetes Research and Clinical Practice1990;10: 19-27

13.Domenico Greco, Francesco Gambina ,Filippo Maggio, Ophthalmoplegia in diabetes mellitus: A retrospective study. Acta Diabetol 2009; 46:23–26

14. National Institutes of Health Office of Dietary Supplements: "Vitamin B12"; 2010

15. Brazionis L, Rowley K Sr, Itsiopoulos C, Harper CA, O'Dea K.Homocysteine and diabetic retinopathy. Diabetes Care 2008; 31:50-6

16.Sun Y, Lai MS, Lu CJ.Effectiveness of Vitamin B12 on Diabetic Neuropathy -- Systematic Review of Clinical

Controlled Trials HYPERLINK "http://www.

ncbi.nlm.nih.gov/pubmed/?term=Acta+Neurolgica+Taiwa nica%3B+%22Effectiveness+of+Vitamin+B12+on+Diabetic+ N e u r o p a t h y + - - + S y s t e m a t i c + R e v i e w + of+Clinical+Controlled+Trials%22" \o "Acta neurologica Taiwanica." Acta Neurol Taiwan. 2005;14(2):48-54

17. Amy Campbell, Metformin and Risk for Vitamin B12 Deficiency. www.diabetesselfmanagement.com; December 4 2006.Availablefrom:http://www.diabetesselfmanagement.com /Blog/AmyCampbell/metformin_and_risk_for_vitamin_b1 2_deficiency/% September, 2013 Volume : 8 H O R IZ O N

References

Related documents

analysis where the variable of perceived ease of use is also correlated with behavioural intention to use. 3) The Third Hypotheses (H3): can be supported by the

Very early on in formulating his conception of calculi, Wittgenstein was acutely aware of difficulties in determining the number of measurement scales to be used

John Hutcheson from the Forest Research Institute has described the insects of pohutukawa, as follows: &#34;There is a large community of insects associated with this

It has been shown that in patients with acute asthma, serum levels of hs-CRP were increased compared with healthy controls, and no significant correlations were found between

Garrett’s ranking technique to identify problems and constraints of farmers in marketing of their produce revealed that in case of wheat and paddy the most important

A Gaussian shaping amplifier module is used to read out the “tail pulse” signals such as from PMTs, charge sensitive preamplifiers and other similar detection

As for the Wenchuan earthquake, anomalous phenomena have been studied, such as the decrease of Signal to Noise Ratio (SNR) recorded by DEMETER from 4 VLF transmit- ters at ground

This postulation is particularly intrigued by concentrate the asymptotic behavior of stochastic differential equations with state– free commotion.. Such equations