Surgical management of neurogenic palsies 2 Flashcards
A patient comes to clinic with a complete R III nerve palsy
Describe what you see on CT and OM
Hypotropia and large exo deviation, ptosis and mydriasis
Complete- restriction in MR IO SR IR
Describe what ocular symptoms the patient with complete 3rd NP is likely to have?
Ptosis and mydriasis
Surgical options
Recess LR and resect MR
Tenotomy and tenectomy (weaken SO tendon)/ silicon expander
Oculomotor nerve
This nerve supplies the SR,IR,MR and IO. The only muscles not supplied are the LR and SO.
A patient present with superior division of III nerve palsy- levator palpebrae and SR muscle
Describe what you will see on cover test and OM
Esotropia and Hypertropia and ptosis
Describe what ocular symptoms the patient is likely to have with sup division 3rd NP
Ptosis and SR palsy, head tilt and head elevation
What are the surgical options for superior division 3rd NP
Knapp Procedure
Recess SO and resect SR
Ptosis surgery after strabismus surgery because the ptosis may pseudo
Trochlear nerve supplies which muscle and bilateral cases have what
This nerve supplies SO depressor.
There is excyclotorsion in bilateral SO palsy and you can diagnose bilateral IV palsy using a HESS chart
A patient present with a longstanding R IV nerve palsy
Describe what you will see on cover test and OM
In cover test there will be a R Hypertropia and Esotropia
On the ocular movements their will be SO minus, LIR overaction (bigger if unilateral), RIO overaction, LSR under action
Describe what ocular symptoms the patient with 4th NP is likely to have
Diplopia in downgaze/ laevodepresion
What are the surgical options?
R IO weakening myotomy or myectomy or recession combine IR recession of other eye
A patient present with a recent onset IV nerve palsy
How do you determine if it is unilateral or bilateral IV nerve palsy
This V pattern found tends to be quite large as this suggest the fourth nerve palsy is bilateral rather than unilateral. A masked bilateral fourth nerve palsy is when the palsy mimics a a unilateral palsy, typical the bilateral nature is only revealed after surgery. or unilateral a patient may have a chin down tilt whereas for bilateral they may have a chin down and not necessarily have a tilt.
What is the surgery for torsion
Torsion Harado Ito no torsion and if bilateral do SO tuck
Describe what you will see on the cover test and OM if it is bilateral IV nerve palsy
Large V Pattern, in primary position ET on CT and alternating hypertropia seen horizontally or with head tilt
Describe what ocular symptoms the patient is likely to have 4TH
Chin depression, V Pattern ET, Head tilt, alternating HT, Diplopia
What are the surgical options? 4TH
Depends on aetiology. Patients with traumatic or congenital fourth nerve palsies may be considered for patch, prism, or surgical treatment, especially if they are symptomatic in primary gaze.
What are the surgical options? Acquired 4TH
Patients with an acquired trochlear nerve palsy may respond to treatment of the underlying disease. Microvascular causes may spontaneously resolve over the course of weeks or months. When these palsies persist, they are typically responsive to prism treatment as they tend to cause comitant deviations.
A patient present with a VI nerve palsy
How do you determine if it is unilateral or bilateral VI nerve palsy?
Measure on lateral gaze also ask where they get diplopia, if only to right can be unilateral
How do you determine if the onset is recent?
Good case history
Describe what you will see on the cover test and OM in duanes retraction syndrome
Esotropia and restriction on lateral gaze, narrow palpebral fissures
Describe what ocular symptoms the patient is likely to have 6th
Head turn, diplopia, esotropia
What are the surgical options?
Is there still function in LR if none don’t operate on the muscle but if paresis can operate- can transpose using foster technique move SR to LR insertion increasing abducting affect of vertical muscles
Paresis V Paralysis
Paresis means that there is still limited movement and paralysis means that there is no movement at all
