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Causes and Prognosis in 4,278 Cases of Paralysis of the Oculomotor, Trochlear, and Abducens Cranial Nerves
Vol. 114, No. 6
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8V2 x 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Causes and Prognosis in 4,278 Cases of Paralysis of the Oculomotor, Trochlear, and Abducens Cranial Nerves EDITOR:
In the article, "Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves," by B. W. Richards, F. R. Jones, Jr., and B. R. Younge (Am. J. Ophthalmol. 113:489, May 1992), the authors provided data on 1,278 new patients who had oculomotor palsies, and compared their results with results in 3,000 earlier patients, published in the studies of Rucker1·2 and Rush and Younge.3 Using patient contact methods developed in the third study to identify false undetermined initial diagno ses and to discover patient recovery, they added useful conclusions concerning the de velopment and outlook of palsies, especially in patients younger than 50 years of age. I recently reviewed personal cumulative ex perience of 227 patients who had involvement of the trochlear and abducens cranial nerves, and who were seen in an ambulatory neuroophthalmologic private practice that consists mainly of older individuals. Among 119 patients who had trochlear cra nial nerve palsy, the average age was 61.5 years. Vascular causes, including stroke, hyper tension, and diabetes, accounted for 39 of the 119, the largest group in this series, and a number that exceeds the vascular as well as undetermined categories of Richards, Jones, and Younge. This unsurprising finding doubt less results from the greater number of older individuals in Florida, compared with Minne sota. (The average age in the recent Mayo Clin ic study was not given.)
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Correspondence
Of the patients in my review who had troch lear cranial nerve palsy, 77 had either a vascu lar cause or an undetermined cause for their palsies. Given the prognosis for recovery and the lack of dire underlying disease in these cases of trochlear cranial nerve palsy, the clini cians who treat older patient populations are clearly able to be reassuring, provided the di agnosis is secure. Similarly, among the 108 patients who had abducens cranial nerve palsy in my review, the average age was 57 years. Of these, 46 had microvascular causes only. This number sur passes all previous and current Mayo Clinic series, and I believe it to be the highest of any published number. Combined with the 30 pa tients with undetermined causes, more than two thirds of all patients over 55 years of age with abducens cranial nerve palsy will have a benign diagnosis and a good prognosis. Richards, Jones, and Younge confirm the high recovery rate among vascular and unde termined causes among all patients with ocu lomotor palsy, which was first reported in 1981. 3 Among those patients older than 55 years, temporizing is eminently practicable; cost-conscious physicians may carefully follow up their patients clinically, instead of initially obtaining expensive neuroimaging studies. JAMES A. RUSH, M.D.
Tampa, Florida
References 1. Rucker, C. W.: Paralysis of the third, fourth, and sixth cranial nerves. Am. J. Ophthalmol. 46:787, 1958. 2. : The causes of paralysis of the third, fourth, and sixth cranial nerves. Am. J. Ophthalmol. 61:1293, 1966. 3. Rush, J. A., and Younge, B. R.: Paralysis of cra nial nerves III, IV, and VI. Causes and prognosis in 1,000 cases. Arch. Ophthalmol. 99:76, 1981.
Reply EDITOR:
As Dr. Rush points out, the older age groups tend to have a more benign prognosis, which is emphasized in our study as well. The aver age age of our patients was 49 years, whereas in Dr. Rush's group the average age was mark-
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8V2 x 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Causes and Prognosis in 4,278 Cases of Paralysis of the Oculomotor, Trochlear, and Abducens Cranial Nerves EDITOR:
In the article, "Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves," by B. W. Richards, F. R. Jones, Jr., and B. R. Younge (Am. J. Ophthalmol. 113:489, May 1992), the authors provided data on 1,278 new patients who had oculomotor palsies, and compared their results with results in 3,000 earlier patients, published in the studies of Rucker1·2 and Rush and Younge.3 Using patient contact methods developed in the third study to identify false undetermined initial diagno ses and to discover patient recovery, they added useful conclusions concerning the de velopment and outlook of palsies, especially in patients younger than 50 years of age. I recently reviewed personal cumulative ex perience of 227 patients who had involvement of the trochlear and abducens cranial nerves, and who were seen in an ambulatory neuroophthalmologic private practice that consists mainly of older individuals. Among 119 patients who had trochlear cra nial nerve palsy, the average age was 61.5 years. Vascular causes, including stroke, hyper tension, and diabetes, accounted for 39 of the 119, the largest group in this series, and a number that exceeds the vascular as well as undetermined categories of Richards, Jones, and Younge. This unsurprising finding doubt less results from the greater number of older individuals in Florida, compared with Minne sota. (The average age in the recent Mayo Clin ic study was not given.)
777
Correspondence
Of the patients in my review who had troch lear cranial nerve palsy, 77 had either a vascu lar cause or an undetermined cause for their palsies. Given the prognosis for recovery and the lack of dire underlying disease in these cases of trochlear cranial nerve palsy, the clini cians who treat older patient populations are clearly able to be reassuring, provided the di agnosis is secure. Similarly, among the 108 patients who had abducens cranial nerve palsy in my review, the average age was 57 years. Of these, 46 had microvascular causes only. This number sur passes all previous and current Mayo Clinic series, and I believe it to be the highest of any published number. Combined with the 30 pa tients with undetermined causes, more than two thirds of all patients over 55 years of age with abducens cranial nerve palsy will have a benign diagnosis and a good prognosis. Richards, Jones, and Younge confirm the high recovery rate among vascular and unde termined causes among all patients with ocu lomotor palsy, which was first reported in 1981. 3 Among those patients older than 55 years, temporizing is eminently practicable; cost-conscious physicians may carefully follow up their patients clinically, instead of initially obtaining expensive neuroimaging studies. JAMES A. RUSH, M.D.
Tampa, Florida
References 1. Rucker, C. W.: Paralysis of the third, fourth, and sixth cranial nerves. Am. J. Ophthalmol. 46:787, 1958. 2. : The causes of paralysis of the third, fourth, and sixth cranial nerves. Am. J. Ophthalmol. 61:1293, 1966. 3. Rush, J. A., and Younge, B. R.: Paralysis of cra nial nerves III, IV, and VI. Causes and prognosis in 1,000 cases. Arch. Ophthalmol. 99:76, 1981.
Reply EDITOR:
As Dr. Rush points out, the older age groups tend to have a more benign prognosis, which is emphasized in our study as well. The aver age age of our patients was 49 years, whereas in Dr. Rush's group the average age was mark-