Table of Contents  
Year : 2022  |  Volume : 30  |  Issue : 3  |  Page : 116-118

Pars Plana Vitrectomy in a Patient with Severe Chronic Titubation

1 University of Uyo, Uyo, Akwa-Ibom State, Nigeria
2 Department of Ophthalmology, University College Hospital, University of Ibadan, Ibadan, Oyo, Nigeria
3 Dr. Agarwal’s Eye Hospital, Accra, Ghana
4 University of Calabar, Calabar, Cross River, Nigeria

Date of Submission19-Jun-2022
Date of Decision06-Sep-2022
Date of Acceptance12-Sep-2022
Date of Web Publication07-Nov-2022

Correspondence Address:
Dr. Emmanuel Olu Megbelayin
University of Uyo, Uyo, Akwa-Ibom State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_11_22

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Surgeries on head and neck structures can be very challenging in individuals with titubation from any cause. Head tremor or titubation is a classic feature of Parkinson’s disease (PD) and Parkinsonism due to depletion of dopaminergic neurons in the substantia nigra pars compacta. A literature search using keywords such as head tremor, titubation, PD, eye surgery was carried out in English in major databases archiving medical literature like Google Scholar, Hinari, Scopus, and PubMed. Pars plana vitrectomy (PPV) was successfully carried out in a patient with titubation. A simple head support could ameliorate head tremors to enable performance of eye surgeries.

Keywords: Head tremors, parkinson’s disease, titubation, vitrectomy

How to cite this article:
Megbelayin EO, Babalola YO, Seneadza A, Okonkwo SN. Pars Plana Vitrectomy in a Patient with Severe Chronic Titubation. Niger J Ophthalmol 2022;30:116-8

How to cite this URL:
Megbelayin EO, Babalola YO, Seneadza A, Okonkwo SN. Pars Plana Vitrectomy in a Patient with Severe Chronic Titubation. Niger J Ophthalmol [serial online] 2022 [cited 2023 Mar 22];30:116-8. Available from:

  Introduction Top

Head tremor or titubation is rhythmic non-stop nodding of the head with the forward and backward motions (oscillations) having equal amplitudes. Parkinson’s disease (PD) is the most popular cause of “shaking palsy” as it was called when first described by Dr. James Parkinson in 1817.[1],[2],[3],[4] It is a chronic, progressive neurodegenerative disease characterized by both motor and non-motor features. This disease has a significant clinical impact on patients, families, and caregivers through its progressive degenerative effects on mobility and muscle control.[5],[6] The term  Parkinsonism More Details is a symptom complex used to describe the motor features of PD, which include resting tremor, bradykinesia, and muscular rigidity. PD is the most common cause of parkinsonism, although a number of secondary causes also exist, including drugs.[7],[8]

Progressive degeneration of dopaminergic neurons in the substantia nigra pars compacta (SNpc), which project to the striatum (the nigrostriatal pathway), results in the loss of dopaminergic function in individuals with PD. The presence of nonmotor features supports the involvement of other neurotransmitters of the glutamatergic, cholinergic, serotonergic, and adrenergic systems, in addition to the neuromodulators adenosine and enkephalins.[9],[10],[11] The loss of dopamine in the striatum results in gamma aminobutyric acid (GABA) dysfunction, leading to inhibition of the thalamus. The end result is the decreased ability of the thalamus to activate the frontal cortex, resulting in the decreased motor activity characteristic of PD. Accordingly, restoring dopamine activity in the striatum with dopaminergic therapies mediates clinical improvement in the motor symptoms of PD.[12],[13],[14] This case report highlights a vitreoretinal procedure with good outcomes on a patient with head tremors.

  Case history Top

A 56-year-old man presented with a 7-month history of sudden loss of vision in the left eye. There was no antecedent history of ocular trauma nor pain, redness, photophobia, photopsia, or floaters. He had no complaints in the right eye. He had been using spectacles for reading for 8 years prior to presentation and never had ocular surgery. He was a known diabetic and hypertensive of 5 years duration and regular on treatment. He gave a history of head tremors of 6 years duration for which he had sought medical attention in several hospitals. However, he had not been placed on medications and the head tremors had been progressively worsening. General examination revealed a grossly visible head tremor (front to back type). Systemic examination was essentially normal.

On ocular examination, the visual acuity was 6/6 in the right eye and light perception (PL) with accurate light projection in the left eye. Anterior segments were essentially normal in both eyes. The right fundus was normal with no diabetic retinopathy (DR) changes. There was no fundal view on the left eye due to dehemoglobinized non-clearing vitreous hemorrhage. Intraocular pressure by applanation tonometry was 18 and 20 mmHg in the right and left eyes respectively. Ocular B-scan revealed a left vitreous hemorrhage, an attached retina with the retino-choroidal-scleral complex within normal limits.

Based on the history and clinical findings, a diagnosis of left vitreous hemorrhage secondary to posterior vitreous detachment (PVD) was made. Other differential diagnoses of vitreous hemorrhage considered included retina vein occlusion with neovascularization, choroidal neovascular membrane with breakthrough hemorrhage, idiopathic polypoidal choroidal vasculopathy, and a ruptured retinal artery macroaneurysm. As our patient was a known diabetic, proliferative DR was also considered a less likely differential diagnosis because the fundus in the other eye was essentially normal. A fluorescein fundus angiography would have been useful in ruling out featureless DR but was not done due to unavailability.

The patient was scheduled for a pars plana vitrectomy (PPV) and possible endolaser if a retinal tear was found during the procedure. The workup for surgery among other routine tests, included a detailed drug history especially for dopamine that might interact with intraoperative medications like diazepam. An intravenous infusion line was established should it be needed intraoperatively.

Preoperatively, patient was prepared and draped in the conventional fashion as with every intraocular surgery. Ten per cent povidone iodine was used for cleaning the peri-ocular skin and eye lashes. Five per cent povidone was instilled on the ocular surface. Head stabilization was achieved with a U-shaped hand rest which accommodated the head. The extra space between the head and hand-rest was tightly packed with a sterile soft towel [Figure 1] and [Figure 2]). The U-shaped hand rest was made from a piece of foam covered with leather and it is routinely used for intraocular surgery. The packing with a sterile towel ensured there was no space for head movement.
Figure 1 U-shaped hand rest.

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Figure 2 Patient’s head placed in the U-shaped hand rest and packed with a towel to limit restriction of the head.

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Five milliliter of periocular xylocaine with adrenaline was given for peri-bulbar anesthesia in addition to 3 ml sub-tenons injection of xylocaine with adrenaline. Anxiety was noted as patient was irritable and apprehensive, so patient was given 5 mg of diazepam intravenously.

  Discussion Top

Ocular surgeries in patients with head tremors have been reported in patients with cataract. Deep brain stimulation, conscious sedation with propofol, and taping the patient’s head down are some of the methods previously used to stabilize the head during surgery.

Reports on vitrectomy in patients with head tremors are limited and despite an intensive literature search, the authors did not come across any scholarly article. Ocular surgeries in patients with severe head tremors always present as a unique challenge to the ophthalmic surgeon.[15],[16],[17] Ophthalmologists have had to rely on general anesthesia with the undesirable sequelae of retching, vomiting, and restlessness. These exertions sometimes cause wound dehiscence, prolapse of intraocular contents with risk of infection, and intraocular hemorrhage. Most tranquilizers, such as the phenothiazine group, are contraindicated because they accentuate the extrapyramidal reactions, and increase the tremor in Parkinson’s disease.[18]

In this index case, it was discovered that the use of a hand rest, towel pack, with adequate peribulbar and sub-tenons anesthesia using xylocaine with adrenaline and intravenous diazepam ensured patient was calm with subsequent considerable reduction of the head tremors throughout the duration of surgery.

Our patient was not on dopaminergic therapy, thus allowing the use of 5 ml of intravenous diazepam. The diazepam was administered only when patient complained of pain after peribulbar and sub-tenon xylocaine with adrenaline. The ocular pain was attributed to anxiety in our patient and diazepam was administered through pre-placed intravenous cannula. It is believed that physical restriction of the head by U-shaped hand rest padded with soft towel in patients with titubation was sufficient to limit head-shaking during vitrectomy procedures. Hence, intravenous diazepam may not be indicated if patient is not unduly anxious.

In conclusion, titubation should not be a barrier to PPV in patients with head tremors as the tremors can be limited by restriction and stabilization of the head as described above. The role of sufficient anesthesia and relief of anxiety cannot be over emphasized.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Schrag A, Horsfall L, Walters K. Pre-diagnostic presentations of Parkinson’s disease in primary care: a case-control study. Lancet Neurol 2015;1:57-64.  Back to cited text no. 1
Parkinson J. An essay on the shaking palsy. J Neuropsychiatry Clin Neurosci 2002;14:223-36.  Back to cited text no. 2
Jankovic J. Parkinson’s disease: clinical features and diagnosis. J Neurol Neurosurg Psychiatry 2008;79:368-76.  Back to cited text no. 3
John GB. Method for cataract extraction in Parkinsonism. JAMA 1965;191:347.  Back to cited text no. 4
Radhakrishnan DM, Goyal V. Parkinson’s disease: a review. Neurol India 2018;66:S26-35.  Back to cited text no. 5
Hornykiewicz O. The discovery of dopamine deficiency in the parkinsonian brain. J Neural Transm 2006;70:9-15.  Back to cited text no. 6
Schapira AHV. Recent developments in biomarkers in Parkinson’s disease. Curr Opin Neurol 2013;26:395-400.  Back to cited text no. 7
Singleton AB, Farer MJ, Bonifati V. The genetics of Parkinson’s disease: progress and therapeutic implications. Mov Disord 2013;28:14-23.  Back to cited text no. 8
Findley LJ. Epidemiology and genetics of essential tremor. Neurology 2000;54(suppl):S8-13.  Back to cited text no. 9
Dallapiazza RF, Lee DJ, De Vloo P, Philippe DV, Anton F, Hamani C. Outcomes from stereotactic surgery for essential tremor. Neurol Neurosurg Psychiatry 2019;90:474-82.  Back to cited text no. 10
Pramod VB, Kumaran S, Rashmee J, Radhika R. Anaesthetic management of a patient with Parkinsonism posted for cataract surgery: a case report. Int J Recent Trends Sci Tech 2013;9:233-4.  Back to cited text no. 11
Connolly B, Lang AE. Pharmacological treatment of Parkinson’s disease: a review. JAMA 2014;311:1670-83.  Back to cited text no. 12
Jankovic J, Poewe W. Therapies in Parkinson’s disease. Curr Opin Neurol 2012;25:433-47.  Back to cited text no. 13
Connolly B, Fox SH. Treatment of cognitive, psychiatric, and affective disorders associated with Parkinson’s disease. Neurotherapeutics 2014;11:78-91.  Back to cited text no. 14
Posaralli C, Prete ED, Roberto C, Nardi M, Figus M. Cataract surgery under topical anesthesia in a patient with Parkinson disease and deep brain stimulation: a report of feasibility. Eur J Ophthalmol 2014;25:34-8.  Back to cited text no. 15
Biousse V, Skibell BC, Watts RL. Ophthalmologic features of Parkinson’s disease. Neurology 2004;62:177-80.  Back to cited text no. 16
Archibald NK, Clarke MP, Mosimann UP, Burn D. The retina in Parkinsons disease. Brain 2015;132:1128-45.  Back to cited text no. 17
Nicholson G, Pereira AC, Hall GM. Parkinson’s disease and anaesthesia. Br J Anaesth 2002;89:904-16.  Back to cited text no. 18


  [Figure 1], [Figure 2]


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