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Show journal of Neuro- Ophthalmolo^ y 16( 3): 231- 232, 1996. © 1996 Lippincott- Raven Publishers, Philadelphia Letters to the Editor To the Editor: In their paper entitled " Simultaneous, multiple cranial neuropathies in patients with diabetes mel-litus," Eshbaugh et al. ( 1) state that " only nine previous cases of this entity have been previously described" ( to their knowledge). For the sake of accuracy, I would point out that Collier ( 2) stated in 1930 that he had seen diabetic patients with simultaneous paralyses of the third and fourth cranial nerves on one side. He also discussed in detail a 64- year- old woman with glycosuria who developed simultaneous right third and fourth nerve palsies that spontaneously resolved. Six months later, she developed an acute left retrobulbar optic neuropathy associated with incomplete left third and fourth nerve pareses. Ocular motility recovered, but vision did not. This was 6 years before Jordan ( 3) reported his case, which Eshbaugh et al. suggest was the first example of this phenomenon in the literature. Walsh and Hoyt ( 4) described a case of multiple simultaneous cranial neuropathies in 1969, and we described two cases in 1981 ( 5). Our cases were perhaps significant for two reasons. First, both patients had substantial retro-orbital or frontal pain associated with the ophthal-moparesis, thus simulating a " Tolosa Hunt syndrome"; neither improved with systemic corticosteroids. Second, there was pathologic confirmation of the ischemic nature of the associated optic neuropathy in one patient. We suspect that there are other cases of both unilateral and bilateral simultaneous cranial neuropathies in diabetics floating around in the literature as well and that the condition is not particularly uncommon. Neil R. Miller, M. D. Douglas A. Jabs, M. D. W. Richard Green, M. D. Johns Hopkins Wilmer Eye Institute Baltimore, Maryland REFERENCES 1. Eshbaugh CG, Siatkowski RM, Smith JL, Kline LB. Simultaneous, multiple cranial neuropathies in diabetes mellitus. / Neuw- Ophthahtol 1995; 15: 219- 24. 2. Collier J. Paralysis of the oculomotor nerve- trunks in diabetes. Proc R Six Med 1930; 23: 627- 30. 3. Jordan WR. Neuritis manifestations in diabetes mellitus. Arch Intern Med 1936; 57: 307- 58. 4. Walsh FB, Hoyt WF. Clinical neuw- ophthalniology, 3rd ed. vol 1. Baltimore: Williams and Wilkins, 1969; 1109- 20. 5. Jabs DA, Miller NR, Green WR. Isehaemic optic neuropathy with painful ophthalmoplegia in diabetes mellitus. Br } Ophthalmol 1981; 65: 673- 8. Author's Response To the Editor: We appreciate the comments of Miller et al, and regret that we failed to include in our paper the other cases mentioned. Since the acceptance of our manuscript, we have seen two additional patients with this entity, and concur that " diabetic cranial polyneuropathy" may be more common than previously reported. R. Michael Siatkowski, M. D. J. Lawton Smith, M. D. Bascom Palmer Eye Institute Miami, Florida To the Editor: I read with interest the article by Ehrenpreis and Biedlingmaier entitled " Isolated third- nerve palsy associated with frontal sinus mucocele" ( 1). I have had experience with a case that causes me to question whether the patient presented in print actually had a third- nerve palsy. This patient was a 72- year- old woman who was sent to me 3 months after the diagnosis of an ischemic left third- nerve palsy that had failed to improve. On presentation, the patient had 3 mm of ptosis and diminished elevation in both abduction and adduction. Symptomatic diplopia was present. Palpation of the orbit revealed a nontender fluctuant mass in the superior nasal orbit. There was no axial proptosis. Computed tomography scanning of the orbits and sinuses showed a solid mass extending from the frontal sinus into the superior nasal orbit with direct apposition to the globe. Magnetic resonance imaging scanning confirmed its cystic nature. These scans were quite similar to Figs. 3 and 4 of the referenced article. 232 232 LETTERS TO THE EDITOR i A diagnosis of frontal sinus mucocele with orbital invasion was made, and the mass was resected through the frontal sinus via a coronal scalp flap approach. The wall of the cyst was carefully peeled from the superior orbit through the frontal sinus. Visual inspection showed the orbital periosteum to be still intact. The sinus was then packed with adipose tissue. Two weeks later the patient was greatly improved, as her diplopia, limited elevation, and ptosis had resolved. This course of recovery is consistent with mechanical decompression of the superior nasal orbit. The trochlea may also have been made dysfunctional by the mass effect, leading to a secondary Brown's syndrome, which was also relieved by the surgical procedure. It appears that the same is the case for Drs. Ehrenpreis and Biedlingmaier's patient. The notion that their patient suffered a true " third- nerve palsy" from this mucocele should be brought into question. Richard H. Legge, M. D. Department of Ophthalmology and Division of Neurology University of Nebraska Medical Center Omaha, Nebraska Acknowledgement: I thank Dr. Jeffrey Reynolds for otolaryngological consultation. REFERENCE 1. Ehrenpreis SJ, Biedlingmaier JF. Isolated third- nerve palsy associated with frontal sinus mucocele. / Neuro- Ophthalmol 1995; 15: 105- 8. J Neuro- Ophthalmol, Vol. 16, No. 3, 1996 |
