The Clinical Analysis Of 86 Patients With Ophthalmoplegia

Ophthalmoplegia is a group of common clinical symptoms, including ptosis, eye movement disorder, diplopia and pupillary abnormality. Diseases of the nerve center, fiber links, the nerves, neuromuscular junction or the muscles can cause these symptoms. So the lesions can be located in the brain hemisphere, brain stem, bases of skull, cavernous sinus, superior orbital fissure, orbit or any other parts of the brain. Ophthalmoplegia can be caused by diverse nervous system diseases, including stroke, brain tumor, aneurysm, myasthenia gravis, cavernous sinus thrombosis, inflammatory disease and so on. It can also be caused by many metabolic or autoimmune diseases, such as diabetes or thyroid dysfunction. Although each of these diseases presents special clinical features, when the patients come for treatment with ophthalmoplegia as the initial symptom, in particular lacking of clear signs, it is difficult for the doctors to make correct diagnosis in a short time, but to consult a large number of auxiliary inspections to identify the disease.So these patients can easily be misdiagnosed or missed. Although there is some literature at home and abroad which is related to the causes of ophthalmoplegia, it is mostly restricted to a particular subject area, and the results from it are also variable. Now it has not reached a consensus on how to make correct diagnosis as soon as possible and how to evaluate the prognosis in advance. The aim of this study is to analyze the causes, clinical features and prognoses of ophthalmoplegia, and try to find an easy way to make the diagnosis as early as possible. Methods:Our research was a retrospective study. The data came from the patients in the First Hospital of Jilin University from January 1999 to March 2009, who had ophthalmoplegia as the main initial symptom without paralysis of limbs. The total number was 86 cases. The study excluded supranuclear ophthalmoplegia, Adie syndrome, trauma, congenital diseases such as congenital paralytic strabismus, orbital space occupying lesions. The study also excluded the patients who lost consciousness or did not have clear diagnoses and complete information. With the general collection of the data which included gender, age, past history, predisposing cause, onset form of the disease, involvement of the nerves and muscles, accompanied symptoms and signs, results of the auxiliary inspection, we analyzed the relationship between cause, age and involvement of the nerves and muscles. We also evaluated the prognosis of the patients, analyzed the clinical features of the diseases, and tried to find an easy way to make the diagnosis as early as possible.Results:In all the patients, diabetic ophthalmoplegia, aneurysm, inflammatory diseases were the three main causes of ophthalmoplegia. 25 cases of diabetic ophthalmoplegia were often seen in the patients who were over 50 years old. In these patients, 13 of them had unilateral abducent nerve involved, 8 of them had unilateral oculomotor nerve involved, 4 of them had combined ocular motor nerves involved. In all these patients, only 2 cases involved pupillary sphincter(16.67%). Aneurysm was also a main cause of ophthalmoplegia (25 cases). In most of these patients, the age of them were from 40 to 59 years old. 24 patients had unilateral oculomotor nerve involved, all of whom had pupillary sphincter involved (100%).1 patient had unilateral abducent nerve involved.Inflammatory diseases which caused ophthalmoplegia were 22 cases.They were often seen in the patients who were under 60 years old.In these patients, 11 cases of Tolosa-Hunt Syndrome(THS) often involved unilateral combined ocular motor nerves(5 cases), followed by unilateral abducent (3 cases) or oculomotor(2 cases) nerve paralysis.There was also 1 patient who had bilateral combined ocular motor nerves involved.All the 6 cases of Guillain-Barre syndrome(GBS) had bilateral combined ocular motor nerves involved.3 cases of nonspecific inflammatory diseases in this study all involved unilateral ocular motor nerves.In 78 patients with ophthalmoplegia which were caused by nerves involvement, 48.72%of them had oculomotor nerve involved, especially unilateral oculomotor nerve involvement. In patients who were over 50 years old and had unilateral oculomotor nerve involved, the three main causes of ophthalmoplegia were aneurysm (13 cases), diabetic ophthalmop- legia(8 cases) and tumor(2 cases), while in patients who were under 50 years old, the common reasons were aneurysm(11 cases) and THS(2 cases). 25.64%of the 78 patients had unilateral abducent nerve involved.In patients who were over 50 years old and had unilateral abducent nerve involved, the most common cause was diabetic ophthalmoplegia (12 cases), while in patients who were under 50 years old, the most common reason was inflammatory disease(4 cases). The proportion of the patients who had combined ocular motor nerves involved was also 25.64%,and most of them had bilateral combined ocular motor nerves involvement. These patients were almost under 60 years old. The most common reason of their ophthalmoplegia were inflammatory diseases, which included GBS (5 cases), THS(1case),cerebrospinal meningitis (1 case) and brainstem encephalitis (1 case).There were also 7 patients whose ophthalmoplegia were caused by myasthenia gravis. In these patients, 3 cases had unilateral lesions, and 4 cases had bilateral lesions. Levator was mostly affected(85.71%). One patient whose ophthalmoplegia was caused by thyroid associated opthalmopathy (TAO) presented inferior rectus involvement.71 cases of all the patients came for treatment within 30 days, as soon as they found ophthalmoplegia. According to the recovery of ophthalmoplegia after treatment, 4 cases were cured(5.63%), 43 cases were improved(60.56%), 24 cases were invalid(33.80%).In the three main reasons,the ophthalmoplegia caused by inflammatory disease had a higher rate of improvement(95.45 % ).The following ones were diabetic ophthalmoplegia(56.52%) and the symptoms caused by aneurysm (45.00%).Conclusions:Diabetic ophthalmoplegia, aneurysm, inflammatory diseases are common causes of ophthalmoplegia.Diabetic ophthalmoplegia often has unilateral abducent nerve involved,followed by unilateral oculomotor nerve involved.It rarely involves pupillary sphincter.Aneurysm often has unilateral oculomotor nerve involved. And it often involves pupillary sphincter.In these inflammatory diseases, THS often has unilateral combined ocular motor nerves involved, followed by unilateral oculomotor or abducent nerve involved;GBS has bilateral combined ocular motor nerves involved; nonspecific inflammatory disease often involves unilateral ocular motor nerves. MG often involves levator. TAO can involve inferior rectus.In this study, most of the oculomotor nerves were unilateral involved.In patients who were over 50 years old and had unilateral oculomotor nerve involved, the three main causes of ophthalmoplegia were aneurysm, diabetic ophthalmoplegia and tumor, while in patients who were under 50 years old, the common reasons were aneurysm and THS. And all the abducent nerves were unilateral involved. In patients who were over 50 years old and had unilateral abducent nerve involved, the most common cause was diabetic ophthalmoplegia, while in patients who were under 50 years old, the most common reason was inflammatory disease. Most of the combined ocular motor nerves involvements were bilateral.The patients who had bilateral combined ocular motor nerves involvement were almost under 60 years old. The most common reason of their ophthalmoplegia was inflammatory disease.The reasons of ophthalmoplegia are variable, each of them has special clinical features. Making correct diagnosis needs taking many factors into consideration, which include age, past history, involvement of the nerves and muscles, accompanied symptoms and signs, results of the auxiliary inspection and so on. The symptoms of ophthalmoplegia can be improved in many patients if they accept early treatment according to the causes. In the three main reasons of ophthalmoplegia, the ones caused by inflammatory diseases had a higher rate of improvement.