Download - Binocular diplopia
Understanding eye move-ment
• Cranial n.– III(oculomotor n.), IV(trochlear n.) VI(abducens
n.)
• Steady on retina– Fixation: hold image of stationary object on
fovea– Vestibulo-ocular reflex: hold image of sta-
tionary object on retina during brief movement– Optokinetic: hold the image steady on retina
during sustained head movement
Law of ocular motor control
• Sherrington’s law– Whenever an agonist m. receives an excita-
tory signals to contract, inhibitory signal in sent to antagonist m.
• Hering’s law– During conjugate the eye movement, yoke m.
pair(same direction) receive equal innervation
Cranial n.
• Originated from brainstem(Nucleus)• Short course within brainstem(fascicle)• Subarachroid space• Cavernous sinus and sup. Orbital fis-
sure• Corresponding extraocular m.
Examination of eye move-ment
• Check in 9-cardinal posotion
forced duction test
Paresis or Restriction ?
Bell phenomenon
• With eye closure, normal upward rota-tion of the eye
• Perinaud syndrome– Limited upgaze, normal bell phenomenon– Supranuclear defect – Intact infranuclear function
• Saccades– Fast eye movement
• Pursuit–following finger
• Oculocephalic responses– Supranuclear
• Vergence
Cover-uncover test
The cross-cover testLatent misalignment not revealed by the cover-uncover test
right abduction deficit
Example: 3rd n. palsy, Lt.
• Red glass test – Pt’s ability to report the location of two differ-
ent colored light
• Maddox Rod test Transparent red plastic cylinders. Produces straight line at 90 degree to the axis
• Hirshberg and Krimsky test– Fixation light is held 33cm– 1mm decentration= 7 degree of ocular devia-
tion = 14 PD
– Edge of pupil : 15 degree, 30 PD– Middle of iris : 30 degree– Edge of iris : 45 degree
– Prism in front of fixating eye
Diagnosis of binocular diplopia
The lesion of extraocular m.
DDxThyroid eye disease
Inflammatory disorder Inflammatory orbital pseudotumorWegener granulomatosisSarcoidosisCrohn disease and Inflammatory bowel ds.Connetive tissue ds
Tumors LymphomaMetastatic tumorsRhabdomyosarcoma
Infections Trichinosis
Orbital venous conges-tion
Carotid cavernous fistulaCarotid cavernous thrombosis
Infiltration Amyloidosis
Thyroid disease
Clinical Px.
Unilat. Or bilat. ProptosisLid retraction with lid lagPtosisOrbital congestionRestriction of EOMVisual loss d/t exposure, glaucoma, Compressive Optic neuropathy
Dx. CT or MRI - Enlarged EOMTFT – usually, normalAutoantibodies
Tx. Treat thyroid abnormalityLubricate corneaIOP controlPosition – Head elevation at nightOcular occlusion for diplopiaSteroids, surgery, radiation, stop smoking
Myositis
Clini-cal Px.
Pain over periorbital lesionPeriorbital sweling, proptosis, chemosisDiplopia, Restriction of EOMPtosis, Lid retractionEnlargement & enhancement of structure
Class Infectious – Trichinosis(parasitic infection), orbital cellulitis, abscessNon-infectious – pseudotumor(idiopathic inflammation of or-bital contents)
Infectious Non-infectious
DDx. Systemic infectious condition WBC정상 , fever(-), infection source(-)
Tx. Broad spectrum antibioticsSurgical drainage
Steroid Tx.
Pseudotumor
• No infection, no underlying systemic dis-order
• Diagnosis– Suspected clinically– Healthy patient, presenting with unilat. & bilat.
acute & subacute orbital syndrome– Diplopia :common– Pain – Visual loss: adjacent inflammation of the optic
nerve
Thyroid ds vs Pseudotumor
Orbital tumor
• Lymphoid tumor• Metastases
• Sx: acute & suba-cute severe orbital pain
• Dx: orbital biopsy
ProptosisOrbita mass
Trauma
Fx. Orbit, med. wall& floor
Silent Sinus Syndrome
• Chronic maxillary sinusitis->atrophy of the maxillary sinus -> Orbit wall deformation
Chronic progressive external oph-thalmoplegia(CPEO)
• Progressive limitation of EOM and ptosis• Diplopia with reading – Convergence insufficiency
Diffuse limitation
Myotonic Dystrophy
Congenital brown syndrome
The lesion of Neuromuscular Junc-tion
Ocular myasthenia and Myasthenia Gravis
Intro Autoimmune disorderPostsynaptic acethylcholline receptors disorderFatigbility
Clinical Px. Unilat. Or bilat. Fluctuating ptosisFluctuating binocular diplopiaWorsen after exercise, tired, improved with rest(sleep test)Ptosis improves with ice appliance(ice test)Pupil : always normalall EOM or limited to one EOMSystemic Sx. : swallowing difficulty, resp. sx.
Tx. Refer to neurologistPyridostigmin(Mestinon)CorticosteroidImmuneosuppressantsThymectomySx. Tx. Of diplopia, ptosis: surgery->rarely necessary, stable pt.
Ocular Myasthenia fluctuating
The lesion of Cranial n.
6th n. anatomy
– Nucleus(med. Dorsal pontomedullary jc.)(->contralat. MLF->subnucleus of 3rd n.) -> subarachnoid space->cav-ernous sinus(lat. of int. caroid a.)->sup. Orbital fissure, annulus of Zinn ->lat. Rectus m.
6th n. Palsy common cause
Lt. mi-crovascular 6th n. palsy
exopho-ria
Conjugate Rt. Gaze palsy
Evaluatioin
• Pt (>50 yrs)– CBC, BC, CRP, ESR, glucose, lipid profile
• Brain MRI, CTA, MRA–MRI : not always necessary
persist after 3 month
4th n. anatomy
• Nucleus(periaqueductal gray matter)->Cross over (mid-brain)->subarachnoid space->Between cerebellar a. and post. cerebral a.->cavernous sinus(above V1)->sup. orbital fissure, annulus of Zinn->Sup. Oblique m.
4th n. palsy common cause
Head tilting
Evaluatioin
• Trauma? No further Work up• Pt (>50 yrs)– CBC, BC, CRP, ESR, glucose, lipid
• Brain MRI
3rd n. anatomy
• Complex of subnuclei(dorsal of midbrain) –>subarachnoid space->sup. Cerebral a. and post. Cerebral a.-> cavernous sinus->sup. orbital fissure, annulus of zinn->sup. division(levator, SR), inf. Division(parasym,MR,IR,IO)
Classification
Pupil muscle
Partial Not all muscle involved
Com-plete
Involvement
All muscle involved
Anisocoria
Sparing isocoria
3rd n. common cause
Evaluation
The lesion of multiple cranial n.
Orbital apex syndrome
• Combination of– Ophthalmoplegia (multiple cranial n. palsy)– Honer syn– Pain and V1 sensory loss– Visual loss
• Classic cause – Neoplasm, infection• Biopsy, CT, MRI
Cavernous sinus syndrome
• Combination of– Ophthalmoplegia (multiple cranial n. palsy)– Honer syn– Pain and V1 sensory loss
Lt. cavernous sinus menin-gioma
Cavernous sinus aneurysm
Miller Fisher syndrome
Triad
Ataxia
Ophthalmoplegia
Areflexia
The lesion of Internuclear or supranuclear
Horizontal gaze paresis
• Lesion of 6th n. nucleus– Loss of ipsilat. Voluntary and reflexive conju-
gate movement– Ipsilat. Facial weakness
Internuclear ophthalmople-gia
• Lesion of MLF– Ipsilesional deficit of adduction– Nystagmus– Convergence may overcome adduction deficit
Conver-gence:normal
1 and ½ syndrome
Anatomy of conjugate vertical gaze
Conjugate Vertical eye movement
Post. com-missure
Down gaze paresis
Skew deviation and the ocular tilt reaction(OTR)
• Vertical misalignment • Acute brain stem dysfuction
Treatment of diplopia
• Patching
• Prism– Usually less than 20 or 30 PD and relatively stable
state
• Strabismus surgery– Recommended to wait at least 6 month after in-
jery
• Botulinum Toxin injection– Straighten for several weeks