Progressive External Ophthalmoplegia

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Identifier 926-3
Title Progressive External Ophthalmoplegia
Ocular Movements Bilateral Ptosis; Facial Weakness; Complete External Ophthalmoplegia; Normal Pupils; Absent Convergence
Creator Shirley H. Wray, M.D., Ph.D., FRCP, Professor of Neurology Harvard Medical School, Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Contributor Primary Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Subject Bilateral Ptosis; Facial Weakness; Complete External Ophthalmoplegia; Normal Pupils; Bilateral Progressive External Ophthalmoplegia (PEO); Mitochondrial Myopathy
Supplementary Materials PowerPoint Presentations: Progressive External Ophthalmoplegia: http://library.med.utah.edu/NOVEL/Wray/PPT/Progressive_External_Ophthalmoplegia.ppt Shirley H. Wray, M.D., Ph.D., FRCP, Harvard Medical School Mitochondrial Myopathy: http://library.med.utah.edu/NOVEL/Wray/PPT/Mitochondrial_Myopathy_guest_lecture.ppt Shirley H. Wray, M.D., Ph.D., FRCP, Harvard Medical School
Presenting Symptom Difficulty in moving her eyes. Droopy eyelids
History The patient is a retired physician, age 70, who recalls having eye muscle exercises as a child way back in 1924. Years later, she noted difficulty in focusing her eyes on horizontal gaze to the right and left which preceded the onset of bilateral ptosis. She presented in 1985, at age 65, with marked limitation of eye movements in all directions and she found that she needed to turn her head in order to look to either side. At this time she had ptosis of the left lid. By 1987, at age 66, external ophthalmoplegia had progressed and she had only a few degrees of eye movement in all directions. Progressive bilateral ptosis was treated by ptosis surgery at this time. Also at age 66 a cardiac evaluation revealed an incomplete right bundle branch block. At this time, a deltoid muscle biopsy showed ragged red fibers with trichrome stains. Diagnosis: Mitochondrial Myopathy. A sural nerve biopsy revealed a chronic axonal and demyelinating peripheral neuropathy. In 1991, at age 70, a repeat muscle biopsy confirmed the diagnosis of a mitochondrial myopathy with mtDNA deletions. Therapy: Co-enzyme Q10. In Nov. 1991, at age 70, she noted instability of her gait "walking as if drunk" with relentless progression over the next 10 months. The patient was lost to follow-up in 1991. The term mitochondrial cytopathy has been used to emphasize multisystem involvement in progressive external ophthalmoplegia (PEO). This patient had the constellation of: Progressive External Ophthalmoplegia Facial Weakness Right Bundle Branch Block Chronic Axonal and Demyelinating Peripheral Neuropathy Ataxia
Clinical This 70 year old physician with Progressive External Ophthalmoplegia (PEO) has advanced multisystem disease due to a large mtDNA deletion. Muscle involvement is diagnostic. The myopathic signs illustrated are: 1. Partial bilateral ptosis post ptosis surgery 2. Weakness of the orbicularis oculi muscle with impaired eye closure and inability to bury her eyelashes fully 3. A complete external ophthalmoplegia with absent convergence. 4. Weakness of the lower face impairing the ability to grip the lips tightly together. 5. Marked weakness of flexion of the head against moderate resistance. 6. A history of instability of gait and ataxia
Neuroimaging Neuroimaging studies were not done in this case. MR of the Brain in Mitochondrial Myopathy published in 1995 illustrates MR images in KSS and PEO (14). The figures included: A 61-year old woman (patient 1) with KSS, moderately severe truncal and appendicular ataxia, and a documented mtDNA deletion. A. T1-weighted sagittal image demonstrates severe cerebellar vermian atrophy (arrow) A 23-year old man (patient 2) with KSS, cognitive impairment, ataxia and an mtDNA deletion. A. T2 weighted image demonstrates regions of hyperintense signal (arrows) in the subcortical white matter. The periventricular regions were spared. B. T2-weighted image shows foci of hyperintense signal (arrows) in the dorsal midbrain. A 37-year old woman (patient 8) with CPEO manifested by external ophthalmoplegia, ataxia, and sensorineural hearing loss. A. Long-repetition-time/short-echo-time (proton density) axial image. In the frontal lobes, abnormal hyperintense signal predominates in the subcortical white matter (arrows), whereas in the posterior temporal and parietal lobes the abnormal signal extended from the subcortical regions to the ventricular surface (curved arrows). B. T2-weighted axial MR image demonstrates bilateral hyperintense signal abnormalities in the globus pallidus (arrows). Hyperintense white matter abnormalities and ventricular dilatation are also present. C. T1-weighted sagittal image demonstrates cerebral cortical and cerebellar vermian atrophy (arrow) and thinning of the corpus callosum. Other PEO patients are reported show predominantly white matter damage that correlated with spongiform degeneration of the brain verified by autopsy examinations.
Pathology A skeletal muscle biopsy is diagnostic in mitochondrial myopathy due to a mtDNA deletion. In mitochondrial myopathy defective oxidative phosphorylation results in mitochondrial proliferation in Type 1 and 2A muscle fibers. Fibers with the most severe biochemical defects may degenerate and adjacent fibers with less severe or no defects may appear normal. The combination of a patchy moth-eaten appearance in individual muscle fibers along with mitochondrial proliferation gives rise to the ragged-red fiber seen on modified Gomori trichrome staining. NADH staining shows abnormal subsarcolemmal mitochondria in the muscle fibers. The electron microscopic sections of skeletal muscle show abnormal mitochondria.
Etiology Mutations in mtDNA are maternally inherited in a graded fashion. A single mtDNA mutation can lead to dramatically different clinical phenotypes, creating a very large spectrum of expressivity. For example, the A3243G mutation associated with mitrochondrial encephalomyopathy, lactic academia, stroke-like episodes (MELAS) can also cause cardiomyopathy, diabetes and deafness, or external ophthalmoplegia. Deletions of mtDNA in skeletal muscle, ranging in size from 3.8 to 9.1 kilobases, were found in an identical location on muscle biopsy in five of eleven personal cases (3 KSS, 8 PEO). The deletion encompasses structural genes for the mitochondrial respiratory chain and is associated with impaired mitochondrial function. The variable involvement of multiple organs, (e.g. heart, brain and retina in PEO and KSS) may be attributable to a mixed population of mutant and normal genomes in varying amounts in different tissues. Both muscle and brain are also involved in patients with mitochondrial encephalomyopathy, namely, the MELAS syndrome which is characterized by mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes; and MERRF, characterized by myoclonic epilepsy associated with ragged-red fibers. In MELAS, dysfunction of the central nervous system dominates the clinical picture. While there is considerable overlap of symptoms and signs between PEO, KSS, MELAS, and MERRF, there is general agreement that cases of mitochondrial myopathy, PEO and KSS, with or without clinical involvement of the brain, should be considered separately. The term mitochondrial encephalomyopathy or cytopathy has been applied to the multisystem diseases involving brain, skeletal muscle, and other organs. These disorders and the clinical phenotypes of mtDNA disease span the spectrum of all known oxidative phosphorylation disorders and include PEO., deafness, cardiomyopathy, MELAS and MERRF.
Disease/Diagnosis Progressive External Ophthalmoplegia; Mitochondrial Cytopathy.
Treatment Co-enzyme Q (ubiquinone) deficiency is present in KSS and PEO and treatment strategies are based on supplying electron transport chain cofactors and substraits, and antioxidants in an attempt to protect against mtDNA free-radical damage. Co-enzyme Q10 (ubiquinone) 4 mg-kg/day has the largest literature-supported efficacy in mitochondrial disease.
References 1) DiMauro S, Bonilla E. Zeviani M, Nakagawa M, DeVivo DC. Mitochondrial myopathies. Ann Neurol 1985; 17:521-538. 2) Evans OB, Parker CC, Haas, RH, Naidu S, Moser HW, Bock, HGO. Clinical and Laboratory Features of Mitrochondrial Encephalomyopathy Syndromes. In Inborn Errors of Metabolism of the Nervous System. In Neurology in Clinical Practice, 3rd Ed. Vol II. Butterworth Henemann 2000;68:1595-1662. 3) Gallastegui J, Hariman RJ, Handler B, Lev M, Bharati S. Cardiac involvement in the Kearns-Sayre syndrome. Am J Cardiol 1987 Aug 1:60(4): 385-8. http://www.ncbi.nlm.nih.gov/pubmed/3618501 4) Holt IJ, Harding, AE, Morgan-Hughes JA. Deletions of muscle mitochondrial DNA in patients with mitochondrial myopathies. Nature 1988;331:717-719. http://www.ncbi.nlm.nih.gov/pubmed/2830540 5) Holt IJ, Harding AE, Cooper JM, Schapira AH, Toscano A, Clark JB, Morgan-Hughes JA. Mitochondrial myopathies: clinical and biochemical features of 30 patients with major deletions of muscle mitochondrial DNA. Ann Neurol. 1989 Dec;26(6):699-708. http://www.ncbi.nlm.nih.gov/pubmed/2604380 6) Kearns TP, Sayre GP, Retinitis pigmentosa, external ophthalmoplegia and complete heart block: unusual syndrome with histologic study in one of two cases. AMA Arch Ophthalmol. 1958 Aug:60(2):280-9. http://www.ncbi.nlm.nih.gov/pubmed/13558799 7) Kosmorsky G, Johns DR. Neuro-ophthalmologic manifestations of mitochondrial DNA disorders: chronic progressive external ophthalmoplegia, Kearns-Sayre syndrome, and Leber's hereditary optic neuropathy. Neurol Clin. 1991 Feb;9(1):147-61. Review. http://www.ncbi.nlm.nih.gov/pubmed/2011107 8) Mitsumoto H, Aprille JR, Wray SH, Nemni R, Bradley WG. Progressive External Ophthalmoplegia (PEO): clinical, morphologic and biochemical studies. Neurology. 1983 Apr:33(4):452-61. http://www.ncbi.nlm.nih.gov/pubmed/6300733 9) Moraes CT, DiMauro S, Zevani M et al Mitochondrial DNA deletions in progressive external ophthalmoplegia and Kearns-Sayre Syndrome. N Eng J Med. 1989;320:1293-1299. http://www.ncbi.nlm.nih.gov/pubmed/2541333 10) Naviauz RK. Mitochondrial DNA Disorders. Eur J Pediatr. 2000;159 (Suppl 3):S219-226. Review. http://www.ncbi.nlm.nih.gov/pubmed/11216904 11) Van Goethem G, Martin JJ, Van Broeckhoven C. Progressive external ophthalmoplegia characterized by multiple deletions of mitochondrial DNA: unraveling the pathogenesis of human mitochondrial DNA instability and the initiation of a genetic classification. Neuromolecular Med. 2003;3(3):129-46. Review. http://www.ncbi.nlm.nih.gov/pubmed/12835509 12) Wallace DC, Singh G, Lott MT, Hodge JA, Schurr TG, Lezza AM, Elsas LJ II, Nikoskelainen EK. Mitochondrial DNA mutation associated with Leber's hereditary optic neuropathy. Science 1988; 242:1427-1430. http://www.ncbi.nlm.nih.gov/pubmed/3201231 13) Wallace DC Mitochondrial genetics: a paradigm for aging and degenerative diseases? Science. 1992 May 1;256(5057):628-32. http://www.ncbi.nlm.nih.gov/pubmed/1533953 14) Wray SH, Provenzale JM, Johns DR, Thulborn KR. MR of the brain in mitochondrial myopathy. AJNR Am J Neuroradiol. 1995 May;16(5):1167-73. http://www.ncbi.nlm.nih.gov/pubmed/7639148 15) Zeviani M, Moraes CT, DiMauro S, Nakase H, Bonilla E, Schon EA, Rowland LP. Deletions of mitochondrial DNA in Kearns-Sayre syndrome. Neurology 1988; 38:1339-1346. http://www.ncbi.nlm.nih.gov/pubmed/3412580
Relation is Part of 906-2, 926-2, 945-3, 946-1
Contributor Secondary Ray Balhorn, Video Compressionist; Steve Smith, Videographer
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 1991
Type Image/MovingImage
Format video/mp4
Source 3/4"""" Umatic master videotape
Rights Management Copyright 2002. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Language eng
ARK ark:/87278/s63f7m75
Setname ehsl_novel_shw
Date Created 2005-08-22
Date Modified 2017-11-22
ID 188568
Reference URL https://collections.lib.utah.edu/ark:/87278/s63f7m75
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