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OD2 Semester 1 - Applied Clinical Training > Fusion: 1-3 Horner's - Week 12 > Flashcards

Fusion: 1-3 Horner's - Week 12 Flashcards

1
Q

What are the relevant parts of this patient’s presentation? (4)

A

49 yr old woman
collecting new reading glasses
ache in neck and left arm for past week
left lid droopy (ptosis)

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2
Q

Define unilateral ptosis

A

palpebral fissure symmetry of >/= 1mm, affecting upper eyelid

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3
Q

What can unilateral ptosis result from? (3)

A

dysfunction of upper-eyelid muscles alongside injury
inflammation or lesions of the lids or orbit
eye surgery

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4
Q

What 2 muscles are involved in the raising of the upper eyelid? What is each muscle innervated by?

A

Levator palpebrae superioris (CN3 innervation)

Superior tarsal muscle (sympathetic innervation)

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5
Q

What are the 2 common forms of ptosis

A

acquired and congenital

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6
Q

What are the common causes of ptosis? (5)

A 
age-related
trauma, mechanical
myogenic
neuromuscular 
neurogenic
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7
Q

Name 2 myogenic causes of ptosis

A

Chronic Progressive External Ophthalmoplegia (CPEO)

Oculopharyngeal Muscular Dystrophy

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8
Q

Name 1 neuromuscular cause of ptosis

A

Myasthenia Gravis

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9
Q

Name 2 neurogenic causes of ptosis

A

CNIII palsy

Horner’s syndrome

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10
Q

What changes occur to the levator muscle with age-related ptosis? (3)

A

loss of muscle tone
inability to hold upper lid in proper position
disinsertion of the aponeurosis

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11
Q

What is ‘aponeurosis’? Explain what it is (1) and its function. (4) What is it important for? (2)

A

An aponeurosis is a type of connective tissue found throughout the body.

Aponeuroses provide an attachment point for muscles to connect to bone, and can also envelope muscles and organs, bind muscles together, and bind muscles to other tissues. They are important for muscle movement and posture.

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12
Q

What are the risk-factors for age-related ptosis? (4)

A

chronic CL wear
rubbing of eyes (conjunctivitis)
systemic health conditions
cataracts surgery

(also age as well obviously!)

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13
Q

What condition is a common cause of blepharitis?

A

trauma-related ptosis

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14
Q

Name the 5 sub-categories of trauma-related ptosis

A

traumatic myogenic - (laceration of levator)
traumatic aponeurotic - (when eyelid vigorously pulled)
mechanical - (scar tissue)
neurogenic - (neurotoxins, head/neck injury, FBs)
mixed-mechanism

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15
Q

What tests can you use to diagnose CPEO? (3)

A

comprehensive physical exam
goldmann perimetry: (map range of EOM movement)
muscle biopsy

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16
Q

Describe the ptosis seen in CPEO. Can it be unilateral? (3)

A

Ptosis asymmetrical. Can be unilateral. Limited ocular motility

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17
Q

What tests can you use to diagnose OPMD? (oculopharyngeal muscular dystrophy)

A

Positive family history: 2 or more generations
Presence of ptosis + dysphagia: (inability do drink 80ml cold water in 8 seconds)
PCR testing for PABPN1 mutation

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18
Q

What are the ptosis related features for OPMD? (4)

A

slowly progressive bilateral ptosis
EOM weakness
dysphagia
proximal limb weakness

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19
Q

What tests can you use to diagnose Myasthenia Gravis? (3) (also giving very brief explanations)

A

Edrophonium (tensilon) test: inhibit acetylcholinesterase
Ice test: useful for ptosis. ice on lid (2-5 min) - transient improvement in ptosis
Serum anti-ACh receptor/muscle-specifi kinase antibody titre

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20
Q

Describe the general features of Ocular Myasthenia Gravis (3)

A

Ptosis most common sign: unilateral or bilateral
Weakness of EOM: incomitant strabismus
Most progress to general Myasthenia Gravis

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21
Q

Can general myasthenia gravis involve neck fatigue?

A

yes. Also can have jaw fatigue

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22
Q

How does bell’s palsy (facial nerve palsy) affect the face?

A

weakness/paralysis of all muscles on one side of the face

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23
Q

How fast is the onset of bell’s palsy

A

sudden onset

24
Q

How does 3rd nerve palsy arise?

A

lesion/damage to the oculomotor nerve (3rd nerve)

25
Q

What proportion of 3rd nerve palsy sufferers have ptosis on first presentation?

A

86%

26
Q

Describe the clinical features of 3rd nerve palsy (3)

A

Dilated pupil with sluggish reaction
Affected eye positioned down and out (limited adduction, infraduction, supraduction)
Manifestations depend on affected area of CNIII track

27
Q

How does Horner’s Syndrome arise? Is it an afferent or efferent defect?

A

disruption of sympathetic innervation to the eye (is an efferent defect)

28
Q

In regards to the patient’s left lid ptosis: what should you consider in history taking? (5)

A 
Onset
Does it vary in severity
Has px had ocular surgery
Any trauma
Any history of amblyopia
29
Q

How can we rule out or diagnose or distinguish if 3rd nerve palsy or Horner’s Syndrome as the cause of ptosis? (i.e. what test can we use?)

A

Pupil testing

incidentally: the patient here has horner’s syndrome

30
Q

What key feature should we look for to identify Horner’s Syndrome when testing pupils?

A

anisocoria

31
Q

Define anisocoria

A

inequality in the size of the pupils of >/= 0.6mm

32
Q

Name the potential causes of anisocoria (4)

A

physiological
pharmacological exposure
direct damage to iris muscles
interruption to the sympathetic/parasympathetic pathway

33
Q

Describe the parasympathetic pathway of iris innervation (4)

A

Pre-gang: EW-nucleus via 3rd nerve – cil. gang.

Post-gang: Short cil. nerve — sphincter

34
Q

Describe the sympathetic pathway of iris innervation (5)

A

Pre-gang: exits T1 — sup cerv. gang.

Post-gang: follow carotid artery – long cil. nerve – dilator

35
Q

In Horner’s syndrome, when would we expect to see greater anisocoria? Why?

A

Since it’s a sympathetic problem. Expect to see greater anisocoria in dim

36
Q

Name 3 parasympathetic-issue causes of anisocoria. When would anisocoria be greater in these conditions?

A

3rd nerve palsy
Adie’s tonic pupil
Parinaud’s syndrome

Would expect anisocoria greater in the light in these conditions

37
Q

Is it a problem if Horner’s is accompanied with pain?

A

YES! DANGER!

38
Q

How can you localise the lesion in horner’s syndrome?

A

Pharmacological tests combined with imaging techniques (MRI)

39
Q

What are the 3 classical signs of Horner’s Syndrome?

A

Miosis
Ptosis
Facial anhydrosis

40
Q

How might lesion to the sympathetic innervation of the iris occur? (4)

A

May arise from:

  • carotid artery dissection, tumour development in certain areas like the neck
  • lesion in midbrain, brain stem, upper spinal cord, neck, eye orbit
  • inflammation or growths affecting lymph nodes of neck
  • surgery or trauma to the neck or upper spinal cord

(note: horner’s can also be idiopathic, occurring for no apparent reason)

41
Q

Describe the process of the 1st neuron in the 3 neuron arc of sympathetic eye innervation (2)

A

Hypothalamus pass down through the midbrain and pons

Terminate at spinal level C8-T2

42
Q

Describe the process of the 2nd neuron in the 3 neuron arc of sympathetic eye innervation (2)

A

Pre-gang fibres exit spinal cord at T1 and enter cervical symp. chain
Ascend symp. chain –> sup. cerv. gang.

43
Q

Describe the process of the 3rd neuron in the 3 neuron arc of sympathetic eye innervation (3)

A

sup. cerv. gang. –> cavernous sinus
enter orbit through sup. orbital fissure
iris dilator muscle and eyelids and sweat glands on face

44
Q

Which is more dangerous: Pre-ganglionic or Post-ganglionic Horner’s syndrome?

A

Post-ganglionic is more dangerous = serious pathology with high incidence of malignancy)

(pre-ganglionic = benign causes)

45
Q

What symptoms are associated with a 1st order neuron lesion in horner’s? (5)

A 
ataxia
vertigo
nystagmus
hemisensory loss
dysarthria + dysphagia
46
Q

What symptoms are associated with a 2nd order neuron lesion in horner’s? (3)

A

prior trauma
facial, neck, shoulder, or arm pain
previous thoracic or neck surgery

WAIT A MINUTE: DID SOMEBODY SAY ARM PAIN!?!?!?? The patient ALSO had ARM PAIN!!!

47
Q

What symptoms are associated with a 3rd order neuron lesion in horner’s? (2)

A

distribution of 1st and 2nd trigeminal nerve numbness

diplopia from 6th nerve palsy

48
Q

What pharmacological agent is considered the gold standard for testing for horner’s?

A

cocaine drops. If horner’s, affected eye doesn’t dilate even with the drops

49
Q

What is the physiological basis behind cocaine eye drops?

A

cocaine blocks the reuptake of NAD, allowing NAD to accumulate in the synaptic cleft

(in pre-ganglionic horner’s: little-no NAD is released in the first place meaning blocking reuptake doesn’t change anything)

(in post-ganglionic horner’s: cocaine has no effect here as well as the presynaptic terminal is not functional)

50
Q

What is an alternative to cocaine drops that can be used to confirm horner’s? What effect does it have?

A

Apraclonadine (causes reversal of anisocoria where the affected pupil actually dilates and normal pupil stays same size)

51
Q

What is the physiological basis behind aproclonidine?

A

is and alpha-2 agonist that acts on the presynaptic terminal and decreases NAD production

52
Q

Why does horner’s react to aproclonidine so well?

A

In horner’s there is an upregulation of postsynaptic alpha-1 receptors – resulting in supersensitivity to apraclonidine for dilation in both pre- and post-ganglionic horner’s (so horner’s pupil dilates)

53
Q

What drop can we use to differentiate between a lesion affecting 1st or 2nd order neuron from a lesion affecting the 3rd? (in horner’s)

A

Hydroxyamphetamine

3rd order horner’s pupils won’t dilate as well, whereas normal/1st/2nd order dilate

54
Q

When is the hydroxyamphetamine test considered positive for post-ganglionic horner’s?

A

when the anisocoria increases by at least 1mm

55
Q

What is the physiological basis behind hydroxyamphetamine?

A

it releases stored NAD from the presynaptic vesicles

OD2 Semester 1 - Applied Clinical Training (47 decks)

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