Cardinal features of superior oblique myokymia: An infrared oculography study

Recommended Reading

Question: What are the cardinal features of superior oblique myokymia?
Answer: There are 6 cardinal features of eye movement abnormality in superior oblique myokymia including:
1) involuntary intorsion and torsional oscillations;
2) episodic events lasting seconds;
3) worsening with infraduction and abduction positions that require activation of the superior oblique, and improvement with supraduction and adduction positions where the superior oblique is not activated;
4) overshooting of saccades on infraduction;
5) extorsion and diminished oscillations that were unmasked upon removal of a visual target, consistent with underlying weakness; and
6) improvement with membrane stabilizers used to treat neuropathic conditions. These features localized the lesion to the trochlear nerve, fascicle, or nucleus but not to the superior oblique muscle or neuromuscular junction.

https://www.youtube.com/watch?v=EXpBXrva77U

Trial of Tocilizumab in Giant-Cell Arteritis

BACKGROUND
Giant-cell arteritis commonly relapses when glucocorticoids are tapered, and the prolonged use of glucocorticoids is associated with side effects. The effect of the interleukin-6 receptor alpha inhibitor tocilizumab on the rates of relapse during glucocorticoid tapering was studied in patients with giant-cell arteritis.

METHODS
In this 1-year trial, we randomly assigned 251 patients, in a 2:1:1:1 ratio, to receive subcutaneous tocilizumab (at a dose of 162 mg) weekly or every other week, combined with a 26-week prednisone taper, or placebo combined with a prednisone taper over a period of either 26 weeks or 52 weeks. The primary outcome was the rate of sustained glucocorticoid-free remission at week 52 in each tocilizumab group as compared with the rate in the placebo group that underwent the 26-week prednisone taper. The key secondary outcome was the rate of remission in each tocilizumab group as compared with the placebo group that underwent the 52-week prednisone taper. Dosing of prednisone and safety were also assessed.

RESULTS
Sustained remission at week 52 occurred in 56% of the patients treated with tocilizumab weekly and in 53% of those treated with tocilizumab every other week, as compared with 14% of those in the placebo group that underwent the 26-week prednisone taper and 18% of those in the placebo group that underwent the 52-week prednisone taper (P<0.001 for the comparisons of either active treatment with placebo). The cumulative median prednisone dose over the 52-week period was 1862 mg in each tocilizumab group, as compared with 3296 mg in the placebo group that underwent the 26-week taper (P<0.001 for both comparisons) and 3818 mg in the placebo group that underwent the 52-week taper (P<0.001 for both comparisons). Serious adverse events occurred in 15% of the patients in the group that received tocilizumab weekly, 14% of those in the group that received tocilizumab every other week, 22% of those in the placebo group that underwent the 26-week taper, and 25% of those in the placebo group that underwent the 52-week taper. Anterior ischemic optic neuropathy developed in one patient in the group that received tocilizumab every other week.

CONCLUSIONS
Tocilizumab, received weekly or every other week, combined with a 26-week prednisone taper was superior to either 26-week or 52-week prednisone tapering plus placebo with regard to sustained glucocorticoid-free remission in patients with giant-cell arteritis. Longer follow-up is necessary to determine the durability of remission and safety of tocilizumab. (Funded by F. Hoffmann–La Roche; ClinicalTrials.gov number, NCT01791153.)

Full article available at 
http://sfx.stanford.edu/local?sid=Entrez:PubMed&id=pmid:28745999
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Neuro-ophthalmology Recommended Reading – Seesaw Nystagmus – with video

www.nejm.org
Recommended by Yaping Joyce Liao, M.D., Ph.D.

A 52-year-old man presented to the emergency department with a 1-year history of headache and reduced visual acuity. Physical examination showed seesaw nystagmus; a …

http://www.nejm.org/doi/full/10.1056/NEJMicm1613244#t=article