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Ophthalmology 2023 > Acute visual disturbance 3 - ocular motor palsies > Flashcards

Acute visual disturbance 3 - ocular motor palsies Flashcards

1
Q

muscle that moves the eye laterally

A

lateral rectus muscle

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2
Q

muscle that moves the eye medially

A

medial rectus muscle

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3
Q

muscle that moves the eye inferiorly

A

inferior rectus muscle

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4
Q

muscle that moves the eye superiorly

A

superior rectus muscle

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5
Q

what are the two oblique muscles called

A

superior oblique muscle
inferior oblique muscle

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6
Q

levator palpebrae superioris muscle

A

supplied by third cranial nerve
in a third nerve palsy, you get a ptosis because of this muscle

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7
Q

Hx of cranial nerve palsies

A

diplopia
anisocoria
ptosis
ophthalmoplegia
nystagmus
pain
systemic (headache, tinnitus, polyneuropathies)
variable vision (difficulty focussing)

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8
Q

acute onset is more likely to be stuff like

A

vascular, GCA, trauma, infection

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9
Q

subacute onset (weeks) is more likely to be stuff like

A

demyelination eg. MS

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10
Q

gradual onset (months to years) is more likely to be stuff like

A

compressive eg. slowly growing tumour

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11
Q

characterise the diplopia

A

horizontal, vertical, diagonal, torsional

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12
Q

vertical diplopia on downward gaze

A

4th nerve palsy

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13
Q

important things on PMHx

A

DM, HTN, lipids, thyroid, myasthenia gravis

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14
Q

element of ophthalmic examination

A

visual acuity
visual fields
pupil reflexes
opthalmoscopy
colour vision

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15
Q

testing eye movements

A

start off with distance target

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16
Q

acronym for remembering the elements of the ophthalmic exam

A

AFROC

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17
Q

third nerve palsy looks like

A

occulumotor nerve
down and out with ptosis
most common is vasculopathic/aneurysm

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18
Q

fourth nerve palsy looks like

A

trochlear nerve
nasal upshoot on contralateral gaze

19
Q

sixth nerve palsy looks like

A

unopposed medial nerve action
abducens nerve

20
Q

sixth nerve palsy looks like

A
21
Q

Sixth nerve palsy is when

A

the eye is turned inward because it affects the lateral rectus muscle so the eye can’t turn fully outward.

22
Q

abducens nerve palsy is

A

sixth nerve palsy

23
Q

aetiology of abducens nerve palsy

A

microvascular, trauma, raised ICP, idiopathic, GCA

24
Q

presentation of abducens nerve palsy

A

horizontal diplopia worse when looking at a distance and on ipsilateral gaze
esotropia also worse on distance and ipsilateral gaze
most common palsy

25
Q

Ddx of abducens nerve palsy

A

thyroid eye disease, orbital tumour, Duane syndrome

26
Q

management of abducens nerve palsy

A

MRI brain and orbits: patients <50years, polyneuropathy or systemic symptoms, history of cancer, no microvascular risk factors
FBC, BSL, ESR, CRP, lipids on older patients; other blood as indicated
manage vascular risk factors
driving advice, short term patching, prism lenses, botox injection or strabismus surgery

27
Q

prognosis of abducens nerve palsy

A

70% of microvascular cases recover in 6-12 weeks

28
Q

forth nerve palsy is more obvious on

A

ipsilateral head tilt

29
Q

a trochlear nerve palsy is

A

fourth nerve palsy

30
Q

aetiology of forth nerve palsy

A

microvascular, congenital, trauma, idiopathic

31
Q

presentation of forth nerve palsy

A

vertical diplopia and compensatory contralateral head tilt
diplopia worse on downsize and contralateral gaze
nasal upshoot (hypertropia on adduction) and ipsilateral head tilt
recent head trauma

32
Q

Ddx of trochlear/4th nerve palsy

A

myasthenia graves, thyroid eye disease, third nerve palsy

33
Q

management of trochlear/4th nerve palsy

A

CT or MRI: dorsal midbrain lesion/contusion/infarction
control of vascular risk factors in older patients
driving advice, short term patching, longer term prisms +/- surgery

34
Q

third nerve palsy is when the eye goes

A

down and out

35
Q

a blown pupil in third nerve palsy is suspicious for

A

aneurysm

36
Q

why is blown pupil indicative of an aneurysm in third nerve palsy

A

parasympathetic fibres travel on the outside of the third nerve
so when the third nerve travels near the posterior communicating artery, the outermost fibres (parasympathetic supply) are the first to be affected which causes the pupils to not be able to constrict (hence they get blown)

37
Q

oculomotor nerve palsy aetiology

A

microvascular, aneurysm, tumour, trauma, infiltrative, (e.g. leukaemia)
most cases without pupil involvement are ischaemic (HTN, DM etc)

38
Q

presentation of oculomotor nerve palsy

A

diplopia, ptosis, +/- pain, +/- pupil involvement (light and accomodation)
eye turned ‘down and out’
unable to adduct/infraduct/supraduct

39
Q

Ddx of oculomotor nerve palsy

A

myasthenia gravis, thyroid orbitopathy, GCA

40
Q

management of oculomotor nerve palsy

A

acute 3rd nerve palsy with fixed dilated pupil = emergency CTA or MRI/A
FBC, ESR, CRP for ?inflammatory causes (including GCA)
you may not need to image if there is no pupil involvement but you ned to see the patient everyday to ensure there is no new pupil involvement
medical management of vascular risk factors
driving advice, short term patching, longer term prism lenses +/- surgery

41
Q

prognosis of occulomotor nerve palsy

A

ischameic cases often resolve within 3 months

42
Q

diplopia and driving

A

people with diplopia are generally considered not fit to drive
for diplopia with an occluder, a three month non-driving period applies in order to reestalbish depth perception

43
Q

sudden loss of unilateral vision and driving

A

person shouldn’t be driving for an appropriate period (usually there months) to adapt to their new visual circumstance and re-etablish depth perception

44
Q

summary of eye muscles and their actions

A

Ophthalmology 2023 (18 decks)

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