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Fall 2014 Neuro Ophthalmic Disease > Fall 2014: Lecture 5: Diplopia and CN Palsies LECTURE!!! > Flashcards

Fall 2014: Lecture 5: Diplopia and CN Palsies LECTURE!!! Flashcards

1
Q

Diplopia

  1. Monocular
    a. Ocular Problems
    b. What else?
A
  1. a. Corneal, Cataract, Refractive, Maculopathy

b. Cerebral

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2
Q

Diplopia

  1. Binocular
    a. The BIG one…

b. CNs? (3)
c. Supranuclear (4)
d. Neuro Muscular Junction (1)
e. What else?

A
  1. a. Strabismus
    b. 3,4,6
    c. INO, 1/2 Syndrome, Gaze Paresis, Skew Deviation
    d. Myasthenia Gravis
    e. EOMs
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3
Q

CASE HISTORY:

What should you ask? (First 4 are the TOP 4 QUESTIONS you SHOULD ASK!!!)

A
  1. Mono or Bino
  2. Direction
  3. Which Direction of Gaze is Worse
  4. Worse at DISTANCE of NEAR
    * Onset, Frequency, When does it occur, Ocular and/or Neuro symptoms, Medical Hx, Hx of Trauma and Ocular Sx’s, Do u observe a Head turn or tilt.
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4
Q

GOALS of CASE Hx

  1. The Examiner should decide 3 things. What are they?
A
  1. a. If Diplopia or misalignment is Neurologic, ocular, or childhood strabismus problem
    b. Which EOMs are involved
    c. Cause
    * Need to figure out what they mean by “DOUBLE” (True double or is it a GHOST IMAGE, SHADOW, HAZE, BLUR, or METAMORPHOPSIA)
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5
Q

Monocular Diplopia

  1. What are some causes?
    a. Should find out if it improves with what test?

b. Confirm by covering what?

A
  1. RE, Cataracts, Irregular Astigmatism, Corneal Scars, Tear Film Irregularities, ERMs, Iridotomy
    a. w/Pinhole
    b. an Eye
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6
Q

Treatment Options for Monocular Diplopia

  1. What should u do?
  2. What is the NUMBER 1 CAUSE of MONOCULAR DIPLOPIA?
A
  1. Treat Underlying Problem!
    a. Correct Refraction
    b. Rigid CLs
    c. Cataract Extraction
    * *EDUCATION is KEY!
  2. CATARACTS!!
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7
Q

Physical Examination

  1. External Examination
    a. What should you assess?
A
  1. a. Eye movements individually (DUCTIONS) and together (VERSIONS) as well as in all positions of Gaze.
    * Establish if Ocular misalignment is Comitant or Incomitant
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8
Q

Comitance

  1. Comitant: Define
    a. 3 Examples
  2. Noncomitant: Define
    a. Most Commonly due to what?
    b. Where is DEVIATION LARGEST?
    c. Deviation will VARY with what?
A
  1. Magnitude of Deviation is SAME in ALL DIRECTIONS of GAZE
    a. Decompensating Phoria
    b. Congenital Strabismus
    c. Less than 5 PD!!!
  2. a. a Muscle or Nerve Problem (Acquired)
    b. in the direction of action of the affected muscle
    c. Deviation varies w/the eye used for fixation
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9
Q

Tests for Comitancy

  1. What 2 tests?
A
  1. COVER TEST and MADDOX ROD!
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10
Q

Testing a Pt with Double Vision

  1. What tests should be done?
  2. What should be done in cases of unexplained diplopia?
  3. What else could be done if needed?
  4. What other tests?
A
  1. VAs, VFs, Color Vision, Pupils, EOMs, BP

Ocular Health Exam (special Attention to eyelids, orbits, and Optic Nerve)

  1. CN TESTING
  2. FORCED DUCTION TESTING
  3. NPC, Saccades (HORIZONTAL, THEN VERTICAL!!), Vergence Ranges, Stereopsis, Hirshberg/Krimsky, CT, Maddox Rod, Parks 3 Step (I think it helps tell us if it’s a 4 CN Palsy), Worth 4 Dot
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11
Q

Hirshberg/Krimsky

  1. Which eye do u put the Prism over?
A
  1. Over the FIXATING EYE
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12
Q

Park’s 3-Step

  1. Step 1: What do you look for?
  2. Step 2: What are you looking for?
  3. Step 3: What kind of deviation are you looking for?
A
  1. Which eye has the HYPER DEVIATION? (Rt eye or Lt Eye?)
  2. Is DEVIATION GREATER on Rt GAZE or Lt GAZE?
  3. Is DEVIATION LARGER on RIGHT HEAD TILT or LT HEAD TILT?
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13
Q

Park’s 3-Step

  1. Which muscles are affected in a Pt w/a LEFT HYPERTROPIA, GREATER in RIGHT GAZE, and Greater on Left Head Tilt?
A
  1. If Left HYPER: Then it’s SO and IR. (Then you pick the OPPOSITE PAIR in the other EYE!)
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14
Q

Forced Duction Test

  1. Performed to determine what?
    a. POSITIVE TEST = ?
    b. Negative = ?
A
  1. If Restriction of Eye Movement is due to a Neurological Disorder or a mechanical Restriction
    a. NO MOVEMENT = MUSCLE RESTRICTION (ORBITAL MASS)
    b. MOVEMENT = NERVE PALSY
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15
Q

Treatment

  1. If Ischemic?
  2. Occlusion (4)
  3. Prism (2)
A
  1. Treat Systemic Risk Factors
  2. Eye Patch (Deprivation)

Bangerter Foil (Graded Occlusion…look at actual foil, doesn’t occlude 100% (can simulate a 20/25-20/400 occlusion)

Spot Patch (Scotch tape over the center of the lens. Still allows input, but disrupts enough signal to stop the double vision)

Tape

  1. Fresnel, Ground in Prism
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16
Q

Horizontal Diplopia Major Causes

  1. Name them (7)
A
  1. CI
  2. DI
  3. Decompensated Strabismus
  4. CN 6 Palsy
  5. CN 3 Palsy
  6. INO
  7. MG
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17
Q

Vertical Diplopia Major Causes

  1. Name them (4)
A
  1. CN 4 Palsy
  2. Thyroid-Associated Ophthalmopathy
  3. MG
  4. Skew Deviation
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18
Q

Horizontal Diplopia: CI

  1. What is it?
  2. Test results?
  3. Symptoms?
  4. Primary CI
  5. Secondary CI
A
  1. Eyes cant come inward.
  2. Eso greater at NEAR than distance, RECEDED NPC and BO RANGES
  3. Horizontal, INTERMITTENT DIPLOPIA at NEAR, HAs, Eyestrain, difficulty w/Near Work
  4. No abnormalities on Neuro-ophthalmic Exam
  5. Some other detectable Abnormality (Parkinson’s, Dorsal Midbrain Syndrome, Partial 3rd Nerve Palsy)
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19
Q

Horizontal Diplopia: DI

  1. Kind of disorder?
  2. Signs?
  3. Symptoms?
  4. Gradual Onset..Test?
A
  1. Acquired that causes COMITANT ESODEVIATION!!!
  2. Greater ESO at DISTANCE than at NEAR. Usually BENIGN
  3. Asthenopia, Motion Sickness, HAs, Photophobia, DIPLOPIA at DISTANCE!
  4. Imaging (MRI w/Contrast…Skull BASE TUMOR causing Partial 6th nerve palsy)
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20
Q

Horizontal Diplopia: Decompensating Phoria

  1. What happens when Fusion breaks Down?
  2. Type of DIPLOPIA SEEN?
  3. Pt may give Hx of DOING WHAT?
  4. Pt may have what type of Eso or Exo tropia?
A
  1. Latent Strabismus becomes a MANIFEST TROPIA and pt sees Diplopic
  2. At first, it’s Intermittent Horizontal Diplopia
  3. Intermittently Closing one eye to see clearly
  4. Comitant. May be able to “straighten” Eye w/Effort
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21
Q

EOMs Actions

  1. SR
    a. Primary
    b. Secondary
    c. Tertiary
  2. IR
  3. LR
  4. MR
  5. SO
  6. IO
A
  1. a. Elevate
    b. Intort
    c. Adduct
  2. a. Depress
    b. Extort
    c. Adduct
  3. a. Abduct
  4. a. Adduct
  5. a. Intort
    b. Depress
    c. Abduct
  6. a. Extort
    b. Elevate
    c. Abduct
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22
Q

Etiologies of Palsies: Most common Identifiable Causes

  1. CN3
  2. CN 4
  3. CN 6
  4. Multiple (Any combo of 3rd, 4th, and 6th)
A
  1. Vascular
  2. Head Trauma
  3. Neoplasm
  4. Neoplasm
    * All of them…Most common Group is UNDETERMINED
    * Except of the Multiple…Most common is same as Most common identifiable cause.
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23
Q

CN 3 Palsy

  1. Where does it start?
  2. CN 3 Travels DOWN and thru what?
  3. While traveling down, it will pass what arteries?
    a. Why is this so important?
    b. If u have an Aneurysm and it compresses on CN3, what will u see?
  4. After traveling thru the Cavernous Sinus it gets to what next?
  5. What happens here?
  6. What does the CILIARY GANGLION CONTROL?
  7. With CN 3, which Fibers cross and innervate muscles CONTRALATERALLY?
    a. and Ipsilaterally?
A
  1. Midbrain
  2. Thru the CAVERNOUS SINUS
  3. Post. Cerebral Artery, Post. Communicating Artery, and the ICA.
    a. Because the Pupillary fibers will lie along side these arteries!
    b. a DILATED PUPIL
  4. The Superior Orbital Fissure
  5. It branches into a SUPERIOR DIVISION (Controls SR and LEVATOR) and an INFERIOR DIVISION (MR, IR, IO)
  6. Sphincter and Accommodation
  7. SR
    a. IO, IR, MR, and P… (reason y Pt can have a Bilateral Ptosis)
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24
Q

3rd Nerve Palsy Classficiations

  1. Complete
    a. What muscles affected?
    b. Where does the EYE SIT?
    c. Ptosis?
    d. Diplopia?
  2. Partial
    a. Muscles affected?
    b. Ptosis?
    c. Diplopia?
A
  1. a. ALL innervated by CN 3
    b. “Down and Out”
    c. YES
    d. Usually don’t notice it due to I/L PTOSIS
  2. a. 1 or more CN3 muscles affected (Mild to severe)
    b. Yes and No (Mild to severe)
    c. Can cause HORIZONTAL, VERTICAL, and/or OBLIQUE DIPLOPIA
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25
Q

3rd Nerve Palsy Classficiations

  1. Pupil Sparing
    a. How do pupils react to light?
  2. Pupil involved
    a. LARGER PUPIL on what side of the PALSY?
    b. Reaction to Light?
A
  1. a. Symmetric pupils and react BRISKLY to light
  2. a. on the same SIDE of the PALSY
    b. POORLY REACTIVE to light.
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26
Q

Etiology of CN 3 Palsies

  1. Most Life Threatening?
  2. Best Px
  3. Most common cause in adults
  4. Most common acquired cause in kids?
  5. Most likely pupil sparing?
A
  1. Aneurysm
  2. Ischemic
  3. Ischemic/Vascular
  4. Traumatic
  5. Ischemic/Vascular
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27
Q

Etiologies of CN 3

Name them

A
  1. Ischemic/Vascular
  2. Compressive (Aneurysm, Neoplasm)
  3. Traumatic
  4. Inflammatory (MS)
  5. Infectious (Meningitis)
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28
Q

Nuclear 3rd Nerve Palsy

  1. Common?
  2. Ipsilateral Palsy?
  3. Contralateral?
  4. Levators involved?
  5. Causes? (3)
A
  1. RARE
  2. MR, IR, IO
  3. SR
  4. Yes… Bilateral Ptosis
  5. MS, Stroke, Tumor
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29
Q

Fascicular 3rd Nerve Palsies

  1. Often Associated w/”Crossed” Neurologic Signs
    a. Benedikt’s Syndrome
    b. Weber’s Syndrome
    c. Claude Syndrome
A
  1. a. Lesion in RED NUCLEUS. (3rd nerve palsy w/a CONTRALATERAL ARM or LEG TREMOR)
    b. Near CEREBRAL PEDUNCLE (3rd nerve palsy w/CONTRALATERAL ARM or LEG WEAKNESS)
    c. 3rd nerve Palsy w/CONTRALATERAL TREMOR and ATAXIA!!!
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30
Q

Compressive 3rd Nerve Palsy! (KNOW THIS INFO!!)

  1. Aneurysm
    a. MOST COMMONLY where?
    b. Acute/Late Onset?
    c. % Pupil Involved?
    d. Pain?
    e. Emergency?
    f. Dilate?
  2. Neoplasm
    a. Fast/Slow progressing?
    b. Primary tumors of Oculomotor Nerve?
    c. Tumors Adjacent to Nerve?
A
  1. a. at Junction of IC and Pos Communicating ARTERY!!!!
    b. ACUTE
    c. 86%
    d. Yes…Persisting SEVERE PAIN
    e. YES!
    f. NO! Want doctor to see what is going on.
  2. a. Slow
    b. Neurinomas and SCHWANNOMAS
    c. PITUITARY and Sphenoid Wing Meningioma
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31
Q

CN 3 Palsy Management

  1. What do u do?
A
  1. URGENT REFERRAL for imaging (MRI + MRA or CTA)
32
Q

Ischemic

  1. CN Palsies due to Ischemia result from what?
A
  1. Insufficiency of SMALL BVs that supply the fibers in the nerve trunk.
33
Q

Characteristics of Ischemic Palsies

  1. Age?
  2. Medical Hx?
  3. Timecourse?
  4. Examination?
  5. Px?
A
  1. > 40
  2. HTN, Diabetes, Atherosclerosis, Smoking!
  3. Sudden onset
  4. Complete palsy w/Ptosis, Normal Pupil, No other CN involvement, No other neurologic signs or symptoms
  5. Resolves w/in 3 Months
34
Q

3rd Nerve Palsies in Kids

  1. About 1/2 are what?
  2. Acquired causes?
    a. Most common?
A
  1. Congenital
  2. Trauma, Inflammatory, Neoplasm, Ophthalmoplegic Migraine
    a. TRAUMA
35
Q

CN 4 Palsy

  1. CN Pathway.
A

Crosses over Temporum to the Cavernous Sinus –> then to the Sup. Orbital Fissure (Travels over it) –> to the SO.

36
Q

CN 4 Palsy

  1. Nerve Crosses just after leaving what brain?
  2. What could happen if a Lesion damages the 4th nerve nucleus?
A
  1. the Midbrain to INNERVATE the CONTRALATERAL SO!!! (so lesion —> in CONTRALATERAL PALSY)
  2. Can damage descending Sympathetic Fibers –> Ipsilateral Preganglionic Horner’s Syndrome and a CONTRALATERAL SO Palsy!
37
Q

Etiologies of CN 4 Palsy

  1. 3 MOST COMMON?
  2. 3 Rare?
A
  1. Congenital, Ischemic, and Traumatic

2. Aneurysm, Neoplasm, Inflammatory

38
Q

Congenital CN 4 Palsy

  1. When can it present?
    a. Proposed etiologies?
  2. Facial Asymmetry?
  3. Progression of deviation?
  4. Other CN involvement or neurological signs?
  5. Main thing to do!?
  6. Vergence Ranges?
  7. Tx?
A
  1. Childhood or Decompensate later in life
    a. Hypoplasia of 4th nerve nucleus; Birth trauma; Anomalies of SO Muscle
  2. Mild
  3. NO
  4. NO
  5. Look at old pics!
  6. LARGE = CONGENITAL!!
  7. Vertical Prism!!
39
Q

Traumatic CN 4 Palsy

  1. Uni or Bi?
  2. What should you do?
  3. Px?
  4. Management?
A
  1. EITHER
  2. ORDER neuroimaging
  3. Partial or Complete Resolution
  4. Treat residual diplopia w/PRISM!!
40
Q

Ischemic CN 4 Palsy

  1. Age?
  2. MHx
  3. Timecourse?
  4. Examination?
  5. Px?
  6. Tx?
A
  1. > 40
  2. HTN, Diabetes, Atherosclerosis, Smoking
  3. Sudden onset of DIPLOPIA (w/TORSION…so rotated images) and No progression
  4. 4th nerve palsy, Normal FUSIONAL RANGES, no other CN Involvement or neurologic signs or symptoms
  5. Resolve w/in 3 MONTHS
  6. Manage Systemic Risk Factors
    * CN4 PALSY: Want to do PARK’s 3 STEP!!!
41
Q

CN 6 Palsy: Pathway

  1. Where does it start?
  2. Nucleus at top: Deals with what?
    a. Biggest thing with these neurons?
    b. Travels down thru what?
  3. After Passing thru the Posterior FOSSA, what does it do?
    a. Why is this so important to know?
  4. Then it travels thru the Cavernous Sinus to the Sup. Orbital Fissure to what?

5, What can be affected with this palsy?

A
  1. PONS
  2. Primary Motor Neurons and Interneurons
    a. Cross CONTRALATERALLY at the MLF
    b. Thru the Subarachnoid Space
  3. It Bends over the PETROUS APEX of the TEMPORAL BONE
    a. If something causes increased Intracranial pressure, damage occurs here!!! (MOST IMPORTANT THING to REMEMBER!!)
  4. To Lateral Rectus!
  5. LR and MR (CN3)…because the nerves travel near the MLF….
42
Q

NUCLEAR CN 6 Palsy

  1. What kind of palsy is it?
    a. What does this mean?
  2. I/C Facial Weakness?
A
  1. Ipsilateral Horizontal Gaze Palsy
    a. Neither eye can look in the direction of the lesion
  2. Ipsilateral Facial Weakness
43
Q

Fascicular CN 6 Palsy

  1. Often Associated w/”Crossed” Neurologic Signs
    a. Raymond Syndrome
    b. Millard-Gubler Syndrome
    c. Foville’s Syndrome
A
  1. a. CN 6 palsy w/CONTRALATERAL HEMIPARESIS
    b. CN 6 and 7 PALSIES w/CONTRALATERAL HEMIPARESIS
    c. IPSILATERAL CN 5-8 Palsies and HORNER’s Syndrome can occur and Contralateral HORIZONTAL GAZE PALSY and Hemiparesis and Hemisensory Loss!
44
Q

Etiology of CN 6 Palsy

  1. Most common?
  2. What else?
A
  1. Neoplasm

2. Taumatic, Ischemic, Elevated ICP, Aneurysm, Inflammatory, Meningitis

45
Q

CN 6 Palsy

  1. It’s especially vulnerable as it climbs over the PETROUS APEX of the TEMPORAL BONE (4 main causes)
A
  1. a. Elevated ICP
    b. Mastoid Infection
    c. Skull Fracture
    d. Tumors
46
Q

Characteristics of Isolated CN 6 Palsy

  1. Age
  2. MHx
  3. Timecourse
  4. Examination
  5. Px
  6. Tx
A
  1. > 40
  2. HTN, Diabetes
  3. Sudden Onset
  4. ESOTROPIA in PRIMARY Position, UNILATERAL Restriction of ABDUCTION w/SLOW ABDUCTING SACCADES
  5. Resolve w/in 3 months
  6. Manage systemic (>55…GCA considered…ESR+CRP)
47
Q

Multiple CN Palsy: Cavernous Sinus

  1. Could be a combo of what?
  2. Causes
    a. #1?
    b. What else?
A

CNs 3-5(V1 and V2), 6, or Horner’s Syndrome

  • Normal Optic Nerve Function
    2. a. NEOPLASMS
    b. Carotid Cavernous Fistula, Aneurysm, Fungal Infection, Inflammation, Tolosa-Hunt
48
Q

Multiple CN Palsy: Orbital Apex Syndrome

  1. Any Combo of what CNs?
  2. CAUSES
    a. #1?
    b. What else?
A
  1. CN 3,4,5(V1), 6, or Horner’s Syndrome
    * ALSO OPTIC NERVE DYSFUNCTION!!
  2. a. NEOPLASMS!
    b. Fungal Infection; Inflammation
49
Q

GCA

  1. Always consider in Pts >55 presenting with what?
  2. Symptoms
  3. Check what?
A
  1. Constant or Intermittent Diplopia
  2. HA, Weight Loss, Jaw Claudication, Myalgia, Scalp Tenderness, Neck Pain, Fatigue
  3. ESR, CRP, CBC; and Temporal Artery Bx
50
Q

TIA

  1. CC w/this?
A
  1. Intermittent Diplopia….so think about this as a DDx.

Decreased BF –> Transient Diplopia that can last for a few mins (always less than 24 hrs!)

Symptoms: Vertigo, Facial numbness, Hand or leg weakness/Numbness, Dysarthria

51
Q

W/U for CN Palsies

  1. MRI
  2. MRA
  3. Over 50 w/Symptoms of GCA
  4. Additional Lab tests based on Pt Hx?
A
  1. Compressive Lesion
  2. Aneurysm
  3. ESR, CRP, TABx
  4. CBC, FTA-Ab, ESR, CRP, RPR, Glucose Intolerance Test
52
Q

Tx for CN Palsy

  1. What r they?
A
  1. Ischemic –> Treat systemic Risk factors
  2. Occlusion (Eye Patch, Clip-on occluder, Tape)
  3. Prism (Fresnel, Ground in Prism)
  4. Sx or Botox Injections!
53
Q

Muscle Disorders: Duane Retraction Syndrome

  1. Congenital Defect of innervation to what muscle?
  2. Anomalous innervation of what muscle by what CN?
  3. Characteristics (3)
  4. Other Findings (3)
A
  1. LR, by CN 6
  2. LR, by CN 3
  3. a. Limited ABDUCTION (or ADDUCTION)
    b. Retraction of the Globe on ADDUCTION
    c. Narrowing of palpebral fissure on ADDUCTION.
  4. a. Head Turn
    b. Convergence Deficiency
    c. Upshoots or Downshoots on Adduction
54
Q

Muscle Disorders: Duane Retraction Syndrome

  1. Huber’s Classification
    a. Type 1
    b. Type 2
    c. Type 3
A
  1. a. Limited AbDuction
    b. Limited ADDUCTION
    c. Limited AbDUCTION and ADDUCTION
55
Q

Muscle Disorders:

  1. Weakness (2)
  2. Restriction
    a. Muscle Entrapment (2)
    b. Enlarged Extraocular Muscles (2)
    c. What else? (1)
A
  1. Myopathy
    a. CPEO
    b. Myotonic Dystrophy
  2. a. i. Orbital Wall Fracture
    ii. Brown Syndrome

b. i. Thyroid Eye Disease
ii. Inflammation (Orbital Pseudotumor)

c. Orbital Tumor

56
Q

CPEO (Chronic Progressive External Ophthalmoplegia)

  1. What do you see?
A
  1. Progressive Limitation of Eye Movements
    a. Ptosis: Usually BILATERAL and SYMMETRIC
    b. Eyes remain straight in PRIMARY GAZE
    c. Orbicularis Weakness (Histology of “Ragged Red Fibers)
57
Q

CPEO (Chronic Progressive External Ophthalmoplegia)

  1. Type of Dz?
  2. Clinical Findings are evident by what decade of life?
  3. Multiple Systemic Manifestations?
A
  1. MITOCHONDRIAL Dz (Progressive over years)
  2. 2nd Decade
  3. Cardiomyopathy
58
Q

Kearns-Sayre Syndrome

  1. What’s the Triad?
  2. Onset prior to what?
  3. What Protein level is elevated?
  4. What brain dysfunction is seen?
A
  1. a. CPEO
    b. Pigmentary Retinopathy
    c. Cardiac Conduction Defect
  2. BEFORE 20!!
  3. Cerebellar Dysfunction
59
Q

Myotonic Dystrophy

  1. Myotonia: DEFINE
    a. Most common ADULT ONSET what?
    b. Genetic?
    c. Symptoms are worsened by what?
A
  1. Slow relaxation of the muscles after voluntary contraction.
    a. Muscular Dystrophy
    b. AD
    c. Excitement, cold, fatigue. *Early Detection: Shake hands (Poor release)
60
Q

Myotonic Dystrophy (2)

  1. What kind of ptosis do u see?
  2. Cataract type?
  3. Distinctive Facial Features?
  4. What Cardiac Defects?
A
  1. Bilateral Ptosis w/Progressive Ophthalmoplegia
  2. Christmas Tree Cataract
  3. Frontal Balding, Facial Weakness, Long Face, Temporal Wasting, “Hatchet Face”
  4. Cardiac Conduction Defects
61
Q

Muscle Entrapment

  1. Orbital “Blowout” fractures are COMMON after what?
  2. Herniation of Orbital Contents into what?
  3. Muscle Entrapment should be Differentiated from what?
A
  1. after Severe Facial Trauma
  2. into the sinuses can cause entrapment of an eye muscle resulting in limited ocular motility
  3. from nerve palsies. (Forced Duction Testing (Restriction v. Paresis))
62
Q

Brown Syndrome

  1. Limitation of Elevation in what Eye movement?
    a. This is due to RESTRICTED movement of what MUSCLE?
    b. What test should be done?
    c. Usually what?
A
  1. in ADDUCTION
    a. of the SO Tendon thru the TROCHLEA
    b. Forced Duction Test
    c. Congenital, but acquired cases can occur
63
Q

Thyroid Eye Dz

  1. Most common cause of what?
  2. Issues?
A
  1. of Proptosis
  2. a. Restricted Eye Movements
    b. Lid Retraction
    c. Lid Lag in Down Gaze
    d. Orbital Congestion
64
Q

Thyroid Eye Dz

  1. Visual Complications?
  2. Most common cause of what?
  3. Signs?
A

Compressive Optic Neuropathy

Diplopia (When Pt tries looking UP or OUT!)

MOST COMMON CAUSE of RESTRICTIVE STRABISMUS

  1. a. Exposure Keratopathy
    b. Increased IOP
    c. Kocher’s Sign
    * Spasmatic Retraction of upper lid on fixation
65
Q

Thyroid Eye Dz

  1. Treatments (6)
A
  1. a. Thyroid Tx
    b. Lubrication for Cornea
    c. Prism for Diplopia
    d. Oral or IV ROIDS
    e. Radiation therapy of the ORBITS
    f. Surgery: Orbital Decompression
66
Q

Orbital Decompression

  1. What is it?
A
  1. Used in Cases of Sight-Threatening
    * Start w/removal of walls (Usually Orbital Floor and medial wall)
    * DOUBLE VISION is EXPECTED as a SIDE EFFECT! (Most Pts need Eye muscle Sx after this)
67
Q

MG: Ocular Signs

  1. “Great Mimicker” of what?
  2. Ocular Motility will do what?
  3. When are Symptoms worse?
  4. Pupil Involvement?
  5. Ptosis worsened by what?
  6. Cogan’s Lid Twitch: Define
A
  1. of DIPLOPIA (may be variable, during the day and from 1 day to the next)
  2. vary from visit to visit
  3. at end of the day or when fatigued
  4. NONE!
  5. by sustained up gaze
  6. Pt saccades from downgaze to upgaze…brief overelevation of UPPER EYELID!!
68
Q

MG: Testing

  1. What are they?
A
  1. Ice Pack Test
  2. Tensilon Test (Edrophonium)
  3. Blood test for Ach Receptor Antibodies
  4. Repetitive nerve stimulation test
69
Q

Control of Horizontal Eye Movement

  1. What Nucleus is the HORIZONTAL GAZE CONTROL CENTER?
    a. Interneurons connect from here to what?
    b. Activation of Rt. CN6 nucleus will do what?
  2. What is RESPONSIBLE for HORIZONTAL SACCADES?
A
  1. CN 6 Nucleus
    a. to the CONTRALATERAL CN3 Nucleus via the MLF!
    b. Move the Right eye to the right via LR and Left eye to right via MR
  2. PPRF!!
70
Q

INO

  1. Signs?
    a. Ipsilateral what?
    b. Contalateral what?
    c. Convergence affected?
    d. INO Named for side of LIMITED what?
  2. Symptoms? (3)
A
  1. a. Ipsilateral ADDUCTION DEFICIT
    b. Contralateral Abducting Nystagmus
    c. may or may not be affected
    d. of Limited Adduction
  2. a. Blurred Vision w/Eccentric Gaze
    b. Horizontal Diplopia
    c. Oscillopsia
71
Q

INO: Patho

  1. Disruption of what?
    a. Axons of CN6 nucleus CROSS MIDLINE and ASCEND MLF to what?

b. NYSTAGMUS in ABDUCTING EYE is SEEN. Why?

A
  1. of MLF in the PONS
    a. to MR SUBNUCLEUS

b. due to an attempt to increase innervation to the WEAK ADDUCTING EYE

72
Q

INO: Most Common Causes

  1. most common? (2)
  2. Px?
A
  1. Brainstem Infarction (stroke)
    MS (demyelinating Dz)
  2. May improve spontaneously over weeks.
73
Q

Bilateral INO

  1. Impaired what?
  2. Nystagmus where?
A
  1. Adduction in both Eyes.
  2. In both eyes when ABDUCTING
    * Wall-eyed Bilateral INO (WEBINO): Severe BINO
    * Vertical, Gaze-Evoke Nystagmus
74
Q

One and a Half Syndrome

  1. What is it?
    a. Lesion of what?
  2. What do u see with a RIGHT1 1/2 Syndrome?
A
  1. INO + Ipsilateral Conjugate Gaze Palsy
    a. Of MLF and CN6 NUCLEUS!
  2. Both eyes CANT look to the right, and there is Impaired ADDUCTION of the RT Eye with Abducting Nystagmus in the Left Eye
75
Q

Skew Deviation

  1. What is it?
  2. Cause
  3. Symptoms
A
  1. Vertical or Oblique Misalignment of the Eyes due to a BRAINSTEM LESION!
  2. usually from ACUTE BRAINSTEM LESIONS (Stroke, tumor, infection, MS)
  3. Binocular Vertical Diplopia w/maybe a Torsional Component. and Other Associated Symptoms include (Vertigo, arm/leg numbness or weakness)
76
Q

Ocular Tilt Reaction

  1. What is it?
  2. Cause?
A
  1. a. Skew Deviation
    b. Ocular Torsion (Both eyes tilted TOWARD the HYPO EYE)

c. Head Tilt (towards the HYPOEYE)
2. Lesion of Pontomedullary Junction or Paramedian Thalamic-Mesencephalic Region

77
Q

Dorsal Midbrain Syndrome

  1. What is it?
  2. Cause?
A
  1. Supranuclear Ophthalmoplegia (Some eye movements are affected more severely than others)
    * Supranuclear Upgaze Palsy
    * Abnormal Convergence (Convergence Retraction Nystagmus)
    * Eyelid Retraction, Abnormal Pupils, Horizontal Diplopia
  2. Pineal Region Tumors, Stroke or MS

Fall 2014 Neuro Ophthalmic Disease (14 decks)

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