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Show Periodic Unilateral Eyelid Retraction in a Pediatric Patient Nandini G. Gandhi, MD, Gina M. Rogers, MD, Randy H. Kardon, MD, PhD, Richard C. Allen, MD, PhD Abstract: A healthy 11-year-old girl presented with right upper eyelid retraction since birth. An evaluation including thyroid function studies and neuroimaging was negative, and the patient was scheduled for a right levator recession to address the eyelid malposition. Intraoperatively, after the induction of inhalational general anesthesia, the patient displayed cyclic right upper eyelid retraction. Occurring in intervals of exactly 48 seconds, these cycles involved a rapid elevation of the right eyelid from a position of half-closure to a retracted position just above the superior limbus. There was no change in pupil size or eye position during these cyclic spasms, and the contralateral eyelid was unaffected. The patient underwent an uncomplicated levator recession, which improved the upper eyelid retraction. Postoperative testing, including external motility video and infrared pupillometry, demonstrated no cyclic variation in eyelid position, eye position, or pupil size in the waking state. This is a unique case of unilateral eyelid retraction with periodic spasms under conditions of anesthesia without a preexisting oculomotor paresis; it represents an unusual variation on congenital eyelid retraction and clas-sically described cyclic oculomotor palsy. Journal of Neuro-Ophthalmology 2011;31:350-352 doi: 10.1097/WNO.0b013e31822db30b © 2011 by North American Neuro-Ophthalmology Society Congenital eyelid retraction in children has been reported in isolation and in association with disease processes, such as thyroid dysfunction, aberrant innervation of the third nerve, and levator fibrosis (1,2). Cyclic spasms associated with eyelid retraction have been reported almost exclusively in the setting of pre-existing oculomotor paresis and are thought to be the result of aberrant innervation (3-8). We present the case of a child with unilateral eyelid retraction and no pre-existing oculomotor paresis who demonstrated periodic spasms of eyelid retraction after the administration of inhalational anesthesia. We discuss the differential diag-nosis and appropriate workup for congenital eyelid retraction and propose possible mechanisms for this patient's unusual presentation. CASE REPORT A healthy 11-year-old girl presented for evaluation and management of right upper eyelid retraction since birth. The patient was the full-term product of an uncomplicated pregnancy and nontraumatic vaginal delivery. The family reported that the right upper eyelid had been retracted since birth, with no noticeable change in the position over time. They also noted that the patient's eyelids remained closed during sleep without abnormal movement of the eyelid while asleep. There was no history of ptosis, strabismus, or periocular/facial trauma, and she took no medications and had no known medication allergies. On initial examination, the patient had right upper eyelid retraction without proptosis (Fig. 1A). The palpebral fissure measured 11.5 mm on the right eye and 9 mm on the left eye. The margin reflex distance-1 measured 6 mm on the right eye and 3.5 mm on the left eye. Levator func-tion was normal on each side at 15 mm, and the patient demonstrated right lid lag on downgaze (Fig. 1B). The patient had full ductions and versions, and there was no variation in upper eyelid position, with changes in gaze position. The right lower eyelid elevated slightly on upgaze Department of Ophthalmology and Visual Sciences (NGG, GMR, RHK, RCA), University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Ophthalmology (NGG), Duke University Medical Center, Durham, North Carolina; Department of Veterans Affairs (RHK), Iowa City, Iowa; and Department of Otolaryngology- Head and Neck Surgery (RCA), University of Iowa Hospitals and Clinics, Iowa City, Iowa. Supported in part by an unrestricted grant from the Research to Prevent Blindness, New York, NY. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www. jneuro-ophthalmology.com). Address correspondence to Nandini G. Gandhi, MD, Duke Univer-sity Eye Center, DUMC 3802, Durham, NC 27710; E-mail: nandini. gandhi@gmail.com 350 Gandhi et al: J Neuro-Ophthalmol 2011; 31: 350-352 Clinical Observation Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. (Fig. 1C), and there was no change in eyelid position with jaw movement. Pupils were isocoric without variation in pupil size in different gaze positions. The anterior and pos-terior segment examination of both the eyes was normal, with the exception of mild superficial punctate epitheliop-athy of the right cornea. Thyroid function studies and MRI of the brain and orbits were normal. It was assumed that the eyelid retraction was idiopathic and isolated, and the decision was made to proceed with a right levator recession. After the induction of general anesthesia with inhaled sevoflurane and before the administration of local anesthetic, the patient displayed periodic spasms of right upper eyelid retraction (see Video, Supplemental Digital Content 1, http://links.lww.com/WNO/A23). Occurring in intervals of exactly 48 seconds, these cycles involved a rapid elevation of the right eyelid from a position of half-closure to a retracted position just above the superior limbus. The eyelid slowly drifted down to a position of half-closure after 8 seconds of full retraction. There were no fasciculations, changes in pupil size, or alterations in eye position during these spasms. The left eyelid was unaffected. The patient was observed for a total of 10 minutes, and these cycles occurred in exactly the same time interval. Of note, the patient had not re-ceived any other medications in the preceding 24 hours. Given that these spasms were not seen during wakefulness, the decision was made to proceed with surgery. At the 3.5-month postoperative visit, the right upper eyelid position had improved (Fig. 2). There were no cycles of eyelid retraction detected after prolonged observation in the clinic. Upon questioning, the family denied any changes in eyelid position during wakefulness or during sleep. The patient was videotaped with the eyelid position observed in primary position and in downgaze for 5 minutes each: no cyclic variation of eyelid position was detected. Infrared pupillometry performed for 5 minutes likewise demon-strated no cycles of miosis or mydriasis of either eye. Ocular motility was once again confirmed as being normal. DISCUSSION We were unable to find other reports of unilateral eyelid retraction with periodic spasms without a pre-existing oculomotor paresis under conditions of inhalational general anesthesia. This case represents an unusual variation on isolated pediatric upper eyelid retraction and classically described oculomotor palsy with cyclic spasms. Upper eyelid retraction in children has been reported in isolation and in association with systemic and local disease processes (1,2,9-13). The diagnosis of primary, isolated congenital eyelid retraction can be made only when sys-temic conditions and neurological injury have been ex-cluded. In a review of 16 pediatric patients with unilateral and bilateral eyelid retraction, Stout and Borchert (1) found that the most common causes were hyperthyroidism (either acquired or congenital), aberrant innervation, and local tis-sue changes (orbital lesions or fibrosis of the levator com-plex). Abnormally dense extensions of the lateral and medial horn of the levator at the level of the Whitnall ligament have been documented in cases of isolated congenital eyelid retraction (2). Posttraumatic upper eyelid retraction second-ary to adhesions between the levator complex and other orbital structures has also been reported (10). FIG. 1. A. In primary position, the patient demonstrated 2.5 mm of right upper eyelid retraction and is orthophoric. B. In downward gaze, there is right lid lag. C. In upward gaze, there is an elevation of the right lower eyelid. FIG. 2. Postoperative appearance at 3.5 months shows no evidence of right eyelid retraction. Gandhi et al: J Neuro-Ophthalmol 2011; 31: 350-352 351 Clinical Observation Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Oculomotor palsy with cyclic spasms is a rare condition first described in 1884 by Rampoldi (8) as "oculo-palpebral imbalance" in a healthy 4-year-old girl. In their review of the literature through 1975, Loewenfeld and Thompson (6) identified only 54 cases; Miller and Lee (7) identified an additional 31 cases between 1975 and 2003. The majority are characterized by the presence of an oculomotor palsy with regular cyclic spasms of varying degrees of eyelid re-traction, adduction of the globe, and/or pupillary mydriasis (3-8,14). Loewenfeld and Thompson (6) calculated the av-erage time of each cycle is 73.6 seconds (with a range of 20 seconds to 3.5 minutes), with the paretic phase being con-sistently longer than the spastic phase in nearly all cases. The exact mechanism of cyclic oculomotor palsy is unknown. Most theories invoke the principle of aberrant innervation following an initial insult to the oculomotor nerve, but the question of whether the process is primarily supranuclear or infranuclear remains controversial (3,6,14,15). Our case combines features of isolated eyelid retraction and cyclic oculomotor palsy but is distinct from all previously reported cases. First, in spite of the idiosyncratic cyclic spasms of eyelid retraction, our patient had no evidence or history of pre-existing oculomotor paresis. Second, our patient's eyelid was affected in isolation without involvement of the extraocular muscles or pupillary muscles. Finally, the cycles were only present during inhalational general anesthe-sia and were not observed during wakefulness or sleep. The mechanism for our patient's clinical findings is un-clear. If we assume a neurological basis, both peripheral and central factors may be involved. The unilaterality of the eyelid spasms speaks to peripheral nerve involvement, whereas the rhythmic cycles that were unmasked with gen-eral anesthesia suggest disinhibition of central control. It is possible that the patient had an injury in utero or in the perinatal period that affected some fibers of the superior division of the third nerve. The patient's eyelid retraction suggests sustained overaction of injured axons that have re-innervated the levator muscle, and the presence of normal levator function is consistent with a population of unin-jured, neurons capable of transmitting normal physiologic impulses (6). The periodic nature of our patient's eyelid retraction may be due to development of abnormal supranuclear con-nections. These connections might transmit impulses that overcome levator inhibitors (6,16). Levator inhibition is unnecessary while awake but is required during general anesthesia. Alternatively, it is possible that this phenomenon is a pharmacologic effect of inhaled sevoflurane. Sevoflurane has been implicated in causing localized or generalized tonic- clonic movements at the end of induction (17-19). These signs are often accompanied by burst suppression on electro-encephalography, indicating altered cortical activity as a pos-sible cause for the seizure-like movements (18). Possibly, our patient's eyelid retraction was due to myopathic changes in the levator, making it susceptible to the effects of sevoflurane. However, we were unable to find any reports of periodic muscle spasms with the inhalational anesthetics in conditions of generalized myopathy. Infants and children presenting with unilateral eyelid retraction without an obvious ocular syndrome warrant a careful history and workup to identify an underlying cause. Thyroid function studies should be performed to rule out congenital or acquired thyroid disease. Imaging of the brain and orbits should be performed with special attention to the entire course of the third nerve to rule out a mass lesion, evidence of trauma, or other structural abnormali-ties. The possibility of cyclic eyelid retraction should be considered, especially in those patients with evidence of a pre-existing oculomotor palsy. 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