Journal of Ophthalmology & Clinical Research Category: Clinical Type: Case Report
Papilloedema in a Patient with Cervical Dystony - A Case Report
*Corresponding Author:Anatilevich Igor Makarov
Research Center Of Neurology, Moscow, Russian Federation
Received Date: Nov 03, 2017 Accepted Date: Feb 26, 2018 Published Date: Mar 12, 2018
There are several forms of the torticollis depending on the position of the head;
Laterocollis: The head bends to the side and the patient touches his ear with his shoulder
Retrocollis: Backward deflection, head thrown
Antecollis: Chin lowered down
Torticollis: Turn of the head, chin in contact with the shoulder
It was found that the most frequent manifestations of cervical dystonia are muscle pains, as well as various emotional disorders of the personality, psychological problems and social limitations. A high prevalence of anxiety and depressive disorders is known in these patients.
The main method of conservative treatment at present is the use of botulinum toxin preparations, which are injected into intense hypertrophied muscles to block neuromuscular transmission. Injections should be repeated at intervals of 3 to 5 months. In recent years, a more effective method of high-frequency pulsed electrostimulation of structures of the extrapyramidal system of the brain by stereotactic operative access has been used .
• Ptosis of upper eyelid, strabismus, and different width of pupils were absent
• Friendly eye movements were without abnormalities
• Visual acuity was 20/20 without correction
• Intraocular pressure was 12/11 mmHg by pneumotonometry
Ophthalmoscopy and Optical Coherent Tomography (OCT) of the optic disc (Figure 1 & 2): optic nerve disc was pale pink, borders in the nasal, upper and lower regions were blurred. Disc promised anteriorly, stranded above the level of the retina in these areas. The disc diameter was slightly enlarged in the nasal area. The changes were more pronounced on the right eye. The caliber of blood vessels was increased, the fullness of the veins, the ratio of the artery/vein was 1/2, the tortuosity was moderate, the course of the vessels was normal. The macular area and the retina on both eyes were without features, druses and pathological foci.
The OCT conclusion
It is known that one of the diagnostic sign of the increased intracranial pressure is edema of the optic nerve disc. The edema is caused by anatomic features of the subarachnoid cavity which stretches to the eye back pole [5,6].
At the same time, the patients with the cervical dystonia have tight and hypertrophied muscles of the neck which are so spastically strained that they arguably strangulate the veins blocking the blood outflow through them. As it was told above, outflow of the blood from the brain is carried out on the jugular veins. The jugular veins pass lateral sides of the neck. Perhaps, at that kind of cervical dystonia when the head is inclined sideways, that is at the laterocollis, the neck muscles spastically strained and strangulate the jugular veins, so as to block the blood outflow. In this regard, there is a local hypervolemia of the blood in dural venous sinuses of the brain. It is not excluded; the rising pressure leads to decrease of the blood pressure gradient between dural sinuses and cerebrospinal fluid in cover villuses of the subarachnoid cavity. Depression of the cerebrospinal fluid absorption in the villuses may be lead to increasing the intracranial pressure. Such intracranial hypertension is not as strongly evident as at total block of cerebrospinal fluid outflow pathways by a tumor or aneurysm. But nevertheless its long existence can lead to papilledema finally.
Shah VA, et al.,  describe neurological picture of the intracranial hypertension after unilateral neck dissection. Kurschel, S et al.,  report about a clinical case of existence of papilledema at the 13-year-old boy with torticollis, classifying it as secondary form of the idiopathic intracranial hypertension. Also, the clinical case-report of the papilledema with Arnold Chianti malformation type I was reported . Popiela M, et al.,  describe the bilateral papilledema at the patient with Camurati-Engelmann diseases, specifying about the edema reason following of the jugular veins strangulation.
Long term duration papilledema leads to block of axoplasmatic liquid current in nerve fibers. This can lead to neurodegeneration of nerve cells that was found by decreasing RNFL thickness in OCT investigation at the young man. This decreasing is not so strongly as optic nerve disc atrophy in expressed intracranial pressure.
In this study it is clear that the RNFL thickness decreasing comes not at once, and after several years from debut of laterocollis. This neurodegeneration is not strongly evident as it is about moderate rising of intracranial pressure owing to disturbance the venous outflow of the blood from the brain. In the studies Smith KA, et al.,  it is established that at 82% of patients with the idiopathic intracranial hypertension had visual improvement and decreased RNFL thickness and indicators improved after stenting of dural venous sinus.
Obviously general nature of papilledema at laterocollis with the same changes at some astronauts at long duration space flight missions. These changes are described in literature as space-flight associated neuro-ocular syndrome . One of the reasons of the syndrome also consists in the venous blood outflow disturbance on the jugular veins from the brain in the microgravity space flight [13,14]. Long observation over patients with similar pathogenesis of papilledema can bring more data for studying the influence of microgravity on the optic nerve.
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Citation: Makarov AI (2018) Papilloedema in a Patient with Cervical Dystony - A Case Report. J Ophthalmic Clin Res 5: 40.
Copyright: © 2018 Anatilevich Igor Makarov, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.