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Show ORIGINAL CONTRIBUTION Pontine Gaze Deviation and Face Turn Relieved by Eye Muscle Surgery Peykan Turkgiioglu, MD, Orhan Aydemir, MD, Cem Oztiirkmen, MD and Hanefi Yildinm, MD Abstract: A 34-year-old woman developed a bi-lateral horizontal gaze palsy, left gaze deviation, and right face turn consequent to a pontine hemorrhage. A bilateral horizontal recession and resection of extraocular muscles in both eyes (Parks procedure) eliminated the gaze deviation and face turn. This is the first reported case in which this procedure was used to correct a face turn in a patient with bilateral horizontal gaze palsy but without ocular misalignment. (/ Neuro-Ophthalmol 2008;28:104-106) Bilateral lesions of the pons caused by hemorrhage, neoplasm, or dysimmune syndromes may result in horizontal gaze palsy with preservation of vertical gaze (1-3). Asymmetric damage to the pathways mediating horizontal gaze might result in asymmetric horizontal gaze deficits, a gaze deviation, and/or a partial sixth nerve palsy, which could lead to an adaptational face turn. We report a patient with bilateral horizontal gaze palsy, a leftward gaze deviation, and a rightward face turn in whom the gaze deviation and face turn were eliminated by extraocular muscle surgery. no associated ocular misalignment or nystagmus (Fig. 1). Convergence and vertical eye movements were unaffected. There was a 15° face turn to the right to place the eyes in a straight ahead position for viewing (Fig. 2). The eyes were deviated 30 prism diopters to the left with the face aiming forward. The oculocephalic maneuver and horizontal caloric stimulation produced no eye movement, indicating that vestibulo-ocular responses were absent. Steropsis was 2000 arc/second on the fly test in the right face turn position. There was no other ocular pathologic condition including pupillary reactions. Brain MRI revealed a chronic pontine hematoma at the lower dorsal part of the pons but was otherwise normal (Fig. 3). We performed a 5 mm recession of the right medial rectus and an 8 mm resection of the right lateral rectus, together with a 6 mm resection of the left medial rectus and a 7 mm recession of the left lateral rectus (Parks procedure) to correct the face turn. At the time of surgery, forced duction testing revealed restricted adduction of the left eye and restricted abduction of the right eye, suggesting contractures of the left lateral and right medial recti. On the first postoperative day, there was no face turn, and the eyes were aligned. No face turn or ocular misalignment was noted during a 9-month follow-up period (Fig. 4). CASE REPORT A 34-year-old woman complained of right face turn and inability to look right and left for 4 years after a spontaneous pontine hemorrhage due to an isolated pontine cavernoma that had been surgically drained. There were no other medical problems. Best-corrected visual acuity was 20/20 in both eyes. Ocular motility examination revealed bilateral horizontal gaze palsy (no abduction and adduction in either eye) with Departments of Ophthalmology (PT,OA) and Neuroradiology (HY), Firat University School of Medicine, Elazig, Turkey; and Department of Ophthalmology (CO), Sani Konukoglu Hospital, Gaziantep, Turkey. Address correspondence to Peykan Tiirkcoglu, MD, Assistant Professor of Ophthalmology Firat University School of Medicine, Department of Ophthalmology, Elazig, Turkey; E-mail: peykan74@ yahoo.com DISCUSSION Abnormal head position develops to maintain binocularity, expand the binocular visual field and obtain the best possible visual acuity. Abnormal head position also dampens nystagmus with a null point and maintains best possible visual acuity. Kestenbaum (4) recommended 5 mm recession of the yoke muscles responsible for the slow phase of nystagmus and 5 mm resection of their antagonists for the treatment of patients who had nystagmus with a null point. However, the Kestenbaum procedure resulted in ocular misalignment in extreme horizontal gaze positions. To avoid this problem, Parks (5) modified the Kestenbaum procedure by performing unequal amounts of resection and recession of the rectus muscles in the two eyes to account for differences in the actions of these muscles. 104 J Neuro-Ophthalmol, Vol. 28, No. 2, 2008 Pontine Gaze Deviation J Neuro-Ophthalmol, Vol. 28, No. 2, 2008 FIG. 1. At presentation, there is left gaze deviation, absent horizontal gaze, and preserved vertical gaze. Coats et al (6) reported four patients who developed a face turn due to unilateral pontine damage causing unilateral gaze palsies. The patients were unable to look to the same side as the lesion but unlike our patient, their patients developed a face turn toward the side of the lesion to eliminate diplopia (6). Our patient also differs from those of Coats et al (6) in that the lesion involved both sides of the pons such that the patient had bilateral horizontal gaze palsy. We presume, however, that the right pontine damage was slightly greater than the left pontine damage because there was a leftward gaze deviation when the face aimed forward. In the patients described by Coats et al (6), the extraocular muscle surgery was designed to relieve esotropia (6). They weakened the medial rectus muscle of the eye ipsilateral to the gaze palsy (the esotropic eye) and strengthened the ipsilateral lateral rectus either by tendon transfer or by a Jensen procedure to provide some abduction capacity. In the contralateral eye, they recessed the lateral rectus muscle without touching the medial rectus muscle (which had limited function). In our patient, there was no esotropia and neither eye had any movement to either side, so we performed an operation as dictated by Parks. It successfully relieved the abnormal face turn by rotating both eyes an equal amount in the direction of the face turn. FIG. 2. At presentation, there is a 15° right face turn. FIG. 3. T2 sagittal MRI demonstrates a chronic hematoma in the caudal dorsal pons. 105 J Neuro-Ophthalmol, Vol. 28, No. 2, 2008 Tiirkcuoglu et al REFERENCES Koehler PJ, Wattendorff AR, Goor C, et al. Bilateral horizontal gaze paralysis due to pontine hemorrhage: a case report. Clin Neurol Neurosurg 1986;88:121-5. Pierrot-Deseilligny C, Goasguen J, Chain F, et al. Pontine metastasis with dissociated bilateral horizontal gaze paralysis. J Neurol Neuro-surg Psychiatry 1984;47:159-64. Muni RH, Wennberg R, Mikulis DJ, et al. Bilateral horizontal gaze palsy in presumed paraneoplastic brainstem encephalitis associated with a benign ovarian teratoma. J Neuroophthalmol 2004;24:114-8. Kestenbaum A. New operation for nystagmus [In French]. Bull Soc Ophtalmol Fr 1953;6:599-602. Parks MM. Symposium: Nystagmus: congenital nystagmus surgery. Am Orthopt J 1973;23:35-9. Coats DK, Avilla CW, Lee AG, et al. Etiology and surgical management of horizontal pontine gaze palsy with ipsilateral esotropia. J AAPOS 1998;2:293-7. FIG. 4. Nine months after the Parks procedure, the eyes are aligned, and there is no face turn. 106 © 2008 Lippincott Williams & Wilkins |
