Ophthalmology Update - Cleveland Clinic

i n v e s t i g a t i O n s
For more information, contact
Elias I. Traboulsi, M.D. at
traboue@ccf.org.
Case Study: Five-Month-Old Boy Presents with Incomitant Esotropia
Continued from page 25
into two categories: vascular and compressive. vascular
symptoms include subarachnoid hemorrhage, carotid-cavernous
fistula, epistaxis, subdural hematoma
and embolic or ischemic events. compressive symptoms
are caused by pressure of the aneurysm wall on
surrounding structures and depend on the initial
location, size and direction of growth.
Ophthalmically anterior and lateral extensions may
result in superior orbital fissure syndrome and cavernous
sinus syndrome, respectively. hahn et. al.
reported patients often complain of diplopia (89%),
retro-orbital pain (61%), headache (19%), blurred
vision (14%) and photophobia (4%). 8
common presenting signs include partial ophthalmoplegia
(77%), ptosis (51%), decreased visual acuity
(12%), complete ophthalmoplegia (16%), proptosis
(7%) and visual field defects (7%). isolated cranial
nerve palsies most frequently occur in the sixth nerve
(39%) because it is anatomically closest to the artery,
References
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dO, gray dt. pediatric third, fourth, and sixth
nerve palsies: a population-based study. am J
Ophthalmol 1999;127:388-92.
2. Kodsi sr, younge Br. acquired oculomotor,
trochlear, and abducent cranial nerve palsies
in pediatric patients. am J Ophthalmol
1992;114:568-74.
3. allison JW, davis pc, sato y, et al. intracranial
aneurysms in infants and children. pediatr
radiol 1998;28:223-9.
4. huang J, mcgirt mJ, gailloud p, tamargo rJ.
intracranial aneurysms in the pediatric population:
case series and literature review. surg
neurol 2005;63:424-32; discussion 432-3.
5. Barrow dl, alleyne c. natural history of giant
intracranial aneurysms and indications for
intervention. clin neurosurg 1995;42:214-44.
follow by the third nerve (11%). 8 Fourth-nerve palsy
has not been reported. the mechanisms of cranial
nerve palsies are believed to result from direct compression
or acute ischemia secondary to occlusion of
the cavernous sinus arterial branches supplying the
cranial nerves.
spontaneous improvement and complete resolution
are often noted. nguyen et al. reported a case of 60year-old
woman with recurrent episodes of isolated
sixth-nerve palsy as a result of iccaa. 9 mortality of
iccaa is low and spontaneous rupture is rare. surgical
intervention is reserved for complications of
vascular rupture, progressive ophthalmoplegia,
visual loss and radiographic evidence of enlargement
and extension into the subarachnoid space.
Our patient is being followed closely with frequent
neuroimaging. his right eye is being patched 2 hours
per day to avoid amblyopia.
6. linskey me, sekhar ln, hirsch W, Jr., yonas h,
horton Ja. aneurysms of the intracavernous
carotid artery: clinical presentation, radiographic
features, and pathogenesis. neurosurgery
1990;26:71-9.
7. linskey me, sekhar ln, hirsch Wl, Jr., yonas h,
horton Ja. aneurysms of the intracavernous
carotid artery: natural history and indications for
treatment. neurosurgery 1990;26:933-7; discussion
937-8.
8. hahn cd, nicolle da, lownie sp, drake cg. giant
cavernous carotid aneurysms: clinical presentation
in fifty-seven cases. J neuroophthalmol
2000;20:253-8.
9. nguyen dQ, perera l, Kyle g. recurrent isolated
sixth nerve palsy secondary to an intracavernous
carotid artery aneurysm. eye 2006.
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