Surgical management of neurogenic palsies 2

Question 1

A patient comes to clinic with a complete R III nerve palsy
Describe what you see on CT and OM

Answer 1

Hypotropia and large exo deviation, ptosis and mydriasis
Complete- restriction in MR IO SR IR

Question 2

Describe what ocular symptoms the patient with complete 3rd NP is likely to have?

Answer 2

Ptosis and mydriasis

Question 3

Surgical options

Answer 3

Recess LR and resect MR
Tenotomy and tenectomy (weaken SO tendon)/ silicon expander

Question 4

Oculomotor nerve

Answer 4

This nerve supplies the SR,IR,MR and IO. The only muscles not supplied are the LR and SO.

Question 5

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

Answer 5

Esotropia and Hypertropia and ptosis

Question 6

Describe what ocular symptoms the patient is likely to have with sup division 3rd NP

Answer 6

Ptosis and SR palsy, head tilt and head elevation

Question 7

What are the surgical options for superior division 3rd NP

Answer 7

Knapp Procedure
Recess SO and resect SR
Ptosis surgery after strabismus surgery because the ptosis may pseudo

Question 8

Trochlear nerve supplies which muscle and bilateral cases have what

Answer 8

This nerve supplies SO depressor.

There is excyclotorsion in bilateral SO palsy and you can diagnose bilateral IV palsy using a HESS chart

Question 9

A patient present with a longstanding R IV nerve palsy
Describe what you will see on cover test and OM

Answer 9

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

Question 10

Describe what ocular symptoms the patient with 4th NP is likely to have

Answer 10

Diplopia in downgaze/ laevodepresion

Question 11

What are the surgical options?

Answer 11

R IO weakening myotomy or myectomy or recession combine IR recession of other eye

Question 12

A patient present with a recent onset IV nerve palsy

How do you determine if it is unilateral or bilateral IV nerve palsy

Answer 12

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.

Question 12

What is the surgery for torsion

Answer 12

Torsion Harado Ito no torsion and if bilateral do SO tuck

Question 13

Describe what you will see on the cover test and OM if it is bilateral IV nerve palsy

Answer 13

Large V Pattern, in primary position ET on CT and alternating hypertropia seen horizontally or with head tilt

Question 14

Describe what ocular symptoms the patient is likely to have 4TH

Answer 14

Chin depression, V Pattern ET, Head tilt, alternating HT, Diplopia

Question 15

What are the surgical options? 4TH

Answer 15

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.

Question 16

What are the surgical options? Acquired 4TH

Answer 16

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.

Question 17

A patient present with a VI nerve palsy
How do you determine if it is unilateral or bilateral VI nerve palsy?

Answer 17

Measure on lateral gaze also ask where they get diplopia, if only to right can be unilateral

Question 18

How do you determine if the onset is recent?

Answer 18

Good case history

Question 19

Describe what you will see on the cover test and OM in duanes retraction syndrome

Answer 19

Esotropia and restriction on lateral gaze, narrow palpebral fissures

Question 20

Describe what ocular symptoms the patient is likely to have 6th

Answer 20

Head turn, diplopia, esotropia

Question 21

What are the surgical options?

Answer 21

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

Question 22

Paresis V Paralysis

Answer 22

Paresis means that there is still limited movement and paralysis means that there is no movement at all