Vol. 117, No. 6

Letters to The Journal

811

(Guillain-Morraret triangle). 1 Transneuronal
degeneration of the inferior olivary nucleus
resulting from interruption of the dentatoru­
bro-olivary tract is the proposed mechanism of
inferior olivary disease. 3 An interval of ten to 11
months between primary brainstem lesion and
Department of Ophthalmology, Anheuser-Busch Eye
onset of palatal myoclonus is typical, with a
Institute, Saint Louis University Health Sciences
Center. Supported in part by an unrestricted grant
reported range of less than one month to 49
from Research to Prevent Blindness, Inc., New York,
months. 4
New York.
There have been 17 reported cases of magnet­
Inquiries to Sophia M. Chung, M.D., Anheuser-Busch
ic resonance imaging documentation of inferior
Eye Institute, 1755 S. Grand Blvd., St. Louis, MO 63104. olivary hypertrophy, nine of which also had
the clinical diagnosis of palatal myoclonus. 2
Palatal myoclonus, an involuntary, continu­
The patients were described in neurologic,
ous, rhythmic movement disorder of the soft
neuroradiologic, and radiologie literature. 2 We
palate, may be associated with simultaneous
treated a patient with oculopalatal myoclonus
jerky, nystagmoid movements of the oculomo­
and inferior olivary hypertrophy demonstrated
tor system. 1 This constellation of findings is
with magnetic resonance imaging.
referred to as oculopalatal myoclonus. Move­
ments of the tongue, facial muscles, pharynx,
We examined a 65-year-old man who had a
larynx, and diaphragm may also occur.
one-month history of "jumping eyes," drool­
ing, and difficulty with speaking and swallow­
Palatal myoclonus, and its variants, is almost
ing. He had had a brainstem stroke four months
always associated with hypertrophie degenera­
previously. He was found comatose, and on
tion of the inferior olivary nucleus. 2 The re­
awakening complained of bilateral blindness.
verse, however, need not occur. This lesion is
T 2 -weighted magnetic resonance imaging, done
thought to be a late complication of cerebellar
soon after the patient's stroke, demonstrated
or brainstem disease, such as stroke or hemor­
hyperintense lesions in the ventral and dorsal
rhage, involving the dentatorubro-olivary tract

Magnetic Resonance Imaging
Findings in Oculopalatal Myoclonus
Guy G. Massry, M.D.,
and Sophia M. Chung, M.D.

Fig. 1 (Massry and Chung). Left, T2-weighted axial magnetic resonance imaging at the level of the pons
demonstrates hyperintense lesions ventrally and dorsal y, consistent with a hemorrhagic infarct. Right, Sagittal
view depicts rostral and caudal extension of the dorsal lesion.

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June, 1994

AMERICAN JOURNAL OF OPHTHALMOLOGY

curs a l m o s t exclusively w i t h olivary h y p e r t r o p h i c d e g e n e r a t i o n , m a g n e t i c r e s o n a n c e im­
a g i n g p r o v i d e s a n excellent adjunct
for
d i a g n o s i s . T h u s , familiarization w i t h the m a g ­
netic r e s o n a n c e i m a g i n g findings will p r o v e
helpful to the o p h t h a l m o l o g i s t w h o may en­
c o u n t e r this d i s o r d e r .

References

Fig. 2 (Massry and Chung). T 2 -weighted axial mag­
netic resonance imaging shows increased signal in­
tensity of the inferior olivary nucleus.
p o n s , consistent w i t h a h e m o r r h a g i c infarct.
The dorsal lesion e x t e n d e d rostrally to the m i d b r a i n a n d caudally to the m e d u l l a (Fig. 1). The
p a t i e n t recovered his vision in two w e e k s a n d
was d o i n g well u n t i l he d e v e l o p e d the follow­
ing s y m p t o m s .
O n e x a m i n a t i o n , his b e s t - c o r r e c t e d visual
acuity was 2 0 / 6 0 in b o t h eyes at d i s t a n c e a n d
2 0 / 3 0 in b o t h eyes at n e a r . External e x a m ­
ination d e m o n s t r a t e d i n v o l u n t a r y , r h y t h m i c
m o v e m e n t s of the face a n d p a l a t e , w h i l e extraocular motility disclosed s y n c h r o n o u s vertical
n y s t a g m u s w i t h a rotary c o m p o n e n t . T h e r e
were m o d e r a t e cataractous c h a n g e s in b o t h
eyes evident on slit-lamp e x a m i n a t i o n . Results
of the p u p i l l a r y a n d f u n d u s e x a m i n a t i o n , a n d
G o l d m a n n visual fields w e r e w i t h i n n o r m a l
limits. A r e p e a t m a g n e t i c r e s o n a n c e i m a g i n g
disclosed r e s o l u t i o n of the h e m o r r h a g e b u t in­
creased signal i n t e n s i t y of the inferior olivary
n u c l e u s (Fig. 2).
The p a t h o l o g i c features found in olivary hy­
pertrophie degeneration include enlargement
a n d v a c u o l a t i o n of n e u r o n s , gliosis, a n d d e m y e lination. 2 These c h a n g e s lead to a n i n c r e a s e in
mobile water p r o t o n s a n d may b e r e s p o n s i b l e
for the h i g h signal s e e n on m a g n e t i c r e s o n a n c e
imaging. 5 Because o c u l o p a l a t a l m y o c l o n u s oc­

1. Nakada, T., and Kwee, I. L.: Oculopalatal myoc­
lonus. Brain 109:431, 1986.
2. Uchino, A., Hasuo, K., Uchida, K., Matsumoto,
S., Tsukamoto, Y., Ohno, M., and Masuda, K.: Oli­
vary degeneration after cerebellar or brain stem
haemorrhage. MRI. Neuroradiology 35:335, 1993.
3. Sperling, M. R., and Herrmann, C , Jr.: Syn­
drome of palatal myoclonus and progressive ataxia.
Two cases with magnetic resonance imaging. Neurol­
ogy 35:1212, 1985.
4. Miller, N. R.: Walsh and Hoyt's Clinical NeuroOphthalmology, vol. 2, ed. 4. Baltimore, Williams
and Wilkins, 1988, pp. 920-921.
5. Revel, M. P., Mann, M., Brugieres, P., Poirier, J.,
and Gaston, A.: MR appearance of hypertrophie
olivary degeneration after contralateral cerebellar
hemorrhage. AJNR 12:71, 1991.

Horner's Syndrome After
Tonsillectomy
C h a r l e s G. S h i s s i a s , B . A . ,
a n d K a r l C. G o l n i k , M . D .
Department of Ophthalmology, Storm Eye Institute,
Medical University of South Carolina. Supported in
part by an unrestricted grant from Research to Pre­
vent Blindness, Inc., New York, New York.
Inquiries to Karl C. Golnik, M.D., Department of Oph­
thalmology, Medical University of South Carolina, 171
Ashley Ave., Charleston, SC 29425.
A 9-year-old boy, w i t h a h i s t o r y of c h r o n i c
s i n u s c o n g e s t i o n a n d a n e p i s o d e of otitis m e d i a ,
u n d e r w e n t tonsillectomy a n d a d e n o i d e c t o m y
for t r e a t m e n t of c h r o n i c tonsillitis. The p r o c e ­
d u r e was p e r f o r m e d u n d e r g e n e r a l e n d o t r a c h e al a n e s t h e s i a w i t h o u t difficulty or i n t r a o p e r a ­
tive c o m p l i c a t i o n . Each p a l a t i n e tonsil w a s
g r a s p e d at the s u p e r i o r p o l e , d i s s e c t e d b l u n t l y
d o w n to the b a s e , a n d t h e n t r a n s e c t e d w i t h a
tonsillar s n a r e in t h e u s u a l fashion. Bleeding
w a s c o n t r o l l e d b y figure-of-eight, 2-0 c h r o m i c
catgut s u t u r e s at the s u p e r i o r a n d inferior p o l e s
of each fossa, a n d w i t h m i n i m a l e l e c t r o c a u t e r y .