Fourth Cranial Nerve Palsy Associated With Sildenafil Citrate
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Phosphodiesterase-5 inhibitors (PDE5i) have been developed for the treatment of coronary artery disease, but they are now widely used for the treatment of erectile dysfunction. Unfortunately, these drugs are also known to cause several ocular side effects. Among those symptoms that may be experienced, a nonarteritic anterior ischemic optic neuropathy (NAION) is the most common neuro-ophthalmological complication, and the prevalence is 0.09%–0.18% (1). To date, an occurrence of a fourth cranial nerve palsy has not been reported in the literature. The authors report a fourth cranial nerve palsy after sildenafil administration in a patient. A 50-year-old previously healthy man was referred to our clinic with a presumed diagnosis of a left fourth cranial nerve palsy. The patient developed an acute diplopia on his down gaze 20 days ago. He had a medical history of a right facial palsy that occurred 12 years ago and it recovered spontaneously, and there was no significant medical history such as diabetes mellitus, hypertension, hyperlipidemia, or cardiovascular disorder, excepting an erectile disorder. There was no significant surgical history or social history such as tobacco use. He denied any trauma history. The only medication that the patient was taking at that time was sildenafil. The day before the onset of the diplopia, he had taken sildenafil at 50 mg for erectile dysfunction. On review of the system, there were no other symptoms except that he experienced a flushing sensation and a headache right after the intake of sildenafil, which was noted as having been 1 day before the onset of the experience of diplopia, according to the patient's statement. On ocular examination, his visual acuity was noted as having been 20/20 in both eyes, and the measured intraocular pressure was normal range in both eyes. The distance and near deviation angles at that time were both orthotropia. A left hypertropia of 8 prism diopters (PDs) was measured in down gaze, and a 2 PD of left hypertropia was measured on dextroversion. The patient was orthophoric on other gazes. On the Bielschowsky head tilt test, the patient was orthophoric on a right head tilt and showed a 8 PD of the left hypertropia on a left head tilt. On the extraocular motility test, it was considered as notable for full ductions of his right eye, but 75% of the normal superior oblique muscle function was observed in the left eye. Both of the patient's pupils reacted normally to the direct light, and no disability in the afferent pupillary reaction was observed. The anterior segment examination showed normal findings, and the fundus examination revealed a healthy appearing optic nerve with 0.3 cup-to-disc ratio in both eyes, a mild excyclotorsion in the left eye, and otherwise unremarkable findings in both eyes of the retina. Upon review of a performed high-resolution pre- and post-contrast cranial nerve MRI with 3-dimensional sequences using a 3-T system (Magnetom Skyra; Siemens Healthineers, Erlangen, Germany) with a 32-channel phased-array head coil, this test revealed no abnormality in fourth cranial nerve pathway, and no abnormality was found on an MRA. Laboratory tests showed a hemoglobin level of 15.8 g/dL, white blood cell count of 5.32 × 103 μL (segmented neutrophil 58.8%, lymphocyte 36.3%, and monocyte 3.4%), and normal electrolytes. The erythrocyte sedimentation rate and C-reactive protein levels were noted also to be as normal. The fasting blood glucose level was noted as 96 mg/dL. Under this circumstance, the serological investigations revealed a positive result of antinuclear antibody, whereas the patient's anti-neutrophil cytoplasmic antibody showed a negative result. The anticardiolipin antibody, ganglioside antibody, thyroid antibody, and acetylcholine receptor antibody were all noted to have been within normal range. Other tests—liver, renal, and coagulation panel—were also noted as being normal. Although the antinuclear antibody showed positive findings, there were no symptoms representing rheumatic diseases such as dry eye, dry mouth, ulcer, and arthritis. Based on the above results, the patient was diagnosed as sildenafil-associated left fourth cranial nerve palsy. By preventing the cyclic guanosine monophosphates (cGMP) degradation, PDE5i enhance the vascular smooth muscle relaxation. In addition, since nitric oxide (NO) is required for cGMP to be produced, the PDE5i amplify the role of NO donors by interfering with cGMP degradation (2). Therefore, patients with cardiovascular disease who take nitrates should be cautious when taking sildenafil together because there may be serious side effects along with severe hypotension, and some of these side effects may even result in the death of the patient if left untreated (3). The incidence of cranial nerve palsy after the administration of sildenafil is very rare to occur in a patient, and only a few cases have been reported. Oculomotor nerve palsy (4) and the case of a combined oculomotor nerve palsy and abducens nerve palsy (5) have been reported in 1 case each. According to the previous case reports, preceded by headache, the diplopia appeared within 1 hour to 1 day after taking the medicine, whereby the condition shown to have improved within 3 months (4,5). In our case, the patient felt a headache immediately after taking sildenafil. The next day, diplopia caused by a fourth nerve palsy had developed. In all 3 cases, including our case, an acute cranial nerve palsy occurred within 1 day after taking sildenafil-based drugs, but the likelihood of temporal coincidence cannot be excluded as Donahue et al (4) mentioned. PDE5i also have been reported to increase the risk of NAION, which is caused by ischemia of the optic nerve head. It is known that PDE5 is widely expressed in the corpora cavernosa of penis, systemic arteries and veins, the pulmonary arteries, the myocardium, the skeletal muscles, and in the platelets, and the PDE5i can cause hypotension. Our case along with previously reported cases suggests that PDE5i can induce neurologic dysfunction probably related with systemic hypotension, even in patients without concomitant intake of nitrates (4). In conclusion, we report a case of fourth cranial nerve palsy a day after sildenafil administration. When treating patients with fourth nerve palsy, PDE5i may need to be scrutinized because the patients themselves may be reluctant to speak on these issues and PDE5i may be able to interact with underlying diseases or other drugs that it was taken.Keywords:
Abducens nerve
Oculomotor nerve palsy
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Ophthalmoplegia due to spheniod sinus aspergillosis is rare. We report two cases of sphenoid sinus aspergillosis with diplopia. A diabetic patient presented with complete oculomotor nerve palsy and showed more rapid progression, severe symptoms, and delayed and incomplete recovery from the neurologic deficits. The other patient presented with trochlear nerve palsy and showed slower progression milder symptoms, and more rapid recovery. We suggest that immediate imaging should be performed to diagnose the cause of diplopia in patients with atypical unilateral persistent facial pain with diplopia especially in patients with diabetes mellitus.
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The results of the conservative approach in the management of patients with orbital blow-out fractures were studied at the Orbital Centre, Amsterdam. In 54 out of 111 patients with a pure blow-out fracture, high resolution CT was performed. In these 54 patients with diplopia, clinical examination together with the analysis of direct multiplanar high resolution CT revealed four cases of impaired motility. These were oedema, oculomotor nerve palsy, enophthalmos and adhesions around the lower eye muscles and the orbital floor. Patients were immediately instructed to exercise eye movements thoroughly. If diplopia did not resolve, further management was decided on. In all patients with edema or oculomotor nerve palsy, diplopia resolved spontaneously. Surgery was necessary to reduce diplopia in the enophthalmos and adhesion groups. This study shows that eye movement exercises together with a 'wait and see' approach diminish the number of operations by 50% in patients with pure blow-out fractures. It also circumvents the iatrogenic adhesions between eye muscles and orbital floor, which are difficult to treat.
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A 70-year-old Korean female with diplopia and left ptosis due to oculomotor nerve palsy presented to the hospital. The patient was treated with electroacupuncture, sweet bee venom pharmacopuncture, and moxibustion. She also received acupuncture and herbal medicines Siryeng-tang and Boikyangwi-tang. The change in length (mm) from the medial canthus to the lateral iris was measured to evaluate limitation of eye movement, and Numeric Rating Scale (NRS) for diplopia. Limitation of eye movement and diplopia was used to determine diplopia. The limitation of eye movement and diplopia were improved after the administration of the Korean medicines. Korean medicine may be effective in treating limitation of eye movement and diplopia due to oculomotor nerve palsy. Keywords: oculomotor nerve palsy, sweet bee venom, electroacupuncture, moxibustion, Korean medicine
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Abstract: Maxillary nerve block is widely used for treating trigeminal neuralgia. Common complications of the procedure include bleeding and sensory abnormalities, but ophthalmic complications have been rarely reported. A 60-year-old woman underwent maxillary nerve block for refractory trigeminal neuralgia. Ten minutes after the procedure had ended, the patient reported double vision when she tried to turn the left eye outward. After examination, the patient was presumed to have diplopia due to the abducens nerve block. However, the symptom disappeared approximately 30 minutes later without any treatment. Thus, to prevent diplopia, the dose of local anesthetics should be reduced. Moreover, negative blood aspiration should be confirmed during the injection. To the best of our knowledge, this is the first case to report diplopia after maxillary nerve block without neurolysis through the lateral infrazygomatic approach. Keywords: diplopia, nerve block, trigeminal neuralgia
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Trigeminal Nerve
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Abstract We report a case of a 47-year-old patient recently diagnosed with left abducens nerve palsy, who was admitted in our clinic with diplopia. The cranio-facial CT scan revealed left sphenoid fungal rhinosinusitis and the patient underwent endoscopic surgery with complete removal of the fungal material. The immediate postoperative evolution of the patient was favourable, with partial improvement of diplopia. The first month follow-up visit revealed the recurrence of the diplopia, so the patient performed an MRI scan of the brain that showed a cavernous sinus meningioma. The patient was referred to a neurosurgeon who choose a “wait-and-see” strategy instead of surgery. The paper presents the limits of computed tomography versus magnetic resonance imaging in the radiologic diagnosis of intracranial tumors.
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Sixth nerve palsy
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