Ocular neuromyotonia (ONM) is a rare but distinctive clinical entity characterized by involuntary episodic contraction of one or more muscles supplied by the ocular motor nerves. A retrospective review was conducted on all patients with ONM seen by the neuroophthalmology service in the past 20 years. Ten patients were identified with ONM; six affecting vertical muscles (superior oblique; inferior rectus; superior rectus) and four affecting lateral rectus muscles. Case 1 has been reported previously. Most episodes occurred every 10-40 min, lasted a few seconds to several minutes, and were repeated throughout the day. Only two patients had previously undergone cranial radiation. Two had thyroid eye disease. One patient presented with superior oblique myokymia and subsequently developed ONM. Membrane stabilizing medications were prescribed in 7 of the 10 patients with varied success. ONM episodes ceased after extraocular muscle surgery in one patient with thyroid eye disease.
There has been much discussion and controversy over the management of blowout fractures of the orbit. At various times, recommendations have included operating on all orbital floor fractures and operating on none of them. As our understanding of blowout fractures and their sequelae has evolved over time, so too has understanding of when and whom would benefit from surgery. In the past, the focus has often been on early versus late repair. The focus should really be on understanding the mechanisms of diplopia and enophthalmos in orbital floor fractures, the best way to evaluate a patient, and, finally, the best method of restoring maximal function and appearance. We present herein a historical perspective on the management of orbital floor fractures and our current recommendations for the indications and timing of surgical repair.The term "blowout fracture" was coined by Smith and Regan in their well-known article in 1957. 1 Smith and Regan proposed what is known as the hydraulic theory for blowout fractures. Trauma results in an increase in intraorbital pressure, leading to a fracture in the weakest part of the orbitthe floor (Fig. 1). Fujino and Makino proposed the transmission theory, whereby a force applied to the inferior orbital rim results in rim deformity but not fracture. 2 This force is transmitted to the weaker orbital floor, which then fractures. In either case, the resulting orbital floor fracture can lead to volume expansion of the orbit, causing enophthalmos, extraocular muscle restriction, and diplopia.Over the years there has been much discussion and debate in practice and in the literature about the appropriate indications for and timing of orbital floor fracture repair. Opinions have ranged from recommending surgery on every blowout fracture to a more conservative approach of observation. In this article, we review and analyze the extensive literature on this topic. Based on the literature discussion, and our own experience, we then propose current recommendations for the indication and timing of orbital floor fracture repair. We also outline what we have found to be useful adjuncts in the clinical evaluation and surgical management of these patients.
HISTORICAL PERSPECTIVEThe consequences of orbital blowout fracture were described by Lang in 1889, when he theorized Downloaded by: University of Florida. Copyrighted material.
The Hess screen test was designed by Walter Rudolf Hess in 1908 with subsequent modifications.(1, 2) Hess was a famous neurophysiologist who was awarded the Nobel Prize in 1949 for his research into the functional organization of the vegetative nervous system.(3, 4) The original test used a black screen on which was marked a square-meter tangent scale. The tangent nature of the coordinate lines converts equidistant points, seen in a virtual sphere like a perimeter, into a two-dimensional chart. The test relies on color dissociation using red/green complementary filters. This maximizes the ocular deviation. A red target is illuminated or projected at the juncture where each tangent line crosses. A green light is projected by the patient and each plot is recorded. The test is repeated for the opposite eye resulting in a chart showing an inner and outer range of ocular rotation for each eye.
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