eye movement disorders
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Eye Movement DisordersTRANSCRIPT
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Eye movement disordersEye movement disorders
Professor Dr.Professor Dr.
Ayman Youssef Ezeddin EassaAyman Youssef Ezeddin Eassa
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Diplopia
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• Concomitant strabismus (ophthalmological) deviation is constant.
• Non concomitant strabismus (neurological) varies with gaze deviation (paralytic-restrictive)
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• Heterophoria: tendency for ocular misalignment
• Heterotropia: manifest under stress;– Fatigue– Bright sun– Alcohol– Anticonvulsants– Sedatives
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Double vision
• Onset is always abrupt.• Cover one eye relieves the problem.• May be intermittent.• Solved by or compensated by head position
as:– Congenital superior oblique palsy– Ocular myasthenia– Thyroid ophthalmopathy
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Double vision
Present as: Overlapping images (ghosting) Frank diplopia Blurred vision
Physiologic diplopia
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Double vision• Image may be
– Tilted → oblique muscle– Vertical → lateral muscles– Horizontal → depressor & elevator muscles
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• Monocular diplopia: (double vision persists when closing one eye.)
– Refractory error– Psychogenic– Retinal– Cerebral cortex– Pinhole test solves the problem of diagnosis. **
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Clinical assessment• Cover one eye →• Daily variation (morning and evening).• Affected by fatigue• Images separated
– Vertically– Horizontally– Or oblique
• Distance between images constant despite the gaze direction or vary.
• Worse for near or distance.• Do eye lids drop• Influenced by head posture.• The progression course
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Clinical assessment (cont.)
• Associated symptoms– Headache– Dizziness– Vertigo– Weakness (general)
• Medications received• Family history• Eye surgery
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Clinical assessment (cont.)
• Lateral rectus– Worse at distance & looking to the side of weak
muscle.
• Superior oblique– Worse on downward to side opposite weak muscle– Difficult reading, watching TV in bed, going downstairs
• Medial rectus– Worse for near than far & to contralateral side more
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Clinical assessment (cont.)• General inspection
– Ptosis (MG)– Ptosis + dilated pupil → occulomotor nerve palsy– Lid lag → thyroid– Lid retraction →
• 3rd nerve• Dorsal midbrain lesion• Hypokalemic periodic paralysis• Chronic steroid use
– Proptosis• Orbital lesion• Inflammatory (periorbital swelling, conjunctival injection)• Psseudotumor• Lymphoma• Dural sinus
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Clinical assessment (cont.)• Head posture → to compensate• Sensory visual function
– Acuity– Color vision– Confrontation– Field of vision
• Stability of fixation– Stability of gaze holding mechanism المريض ينظر
التلقائية العين حركة يالحظ ثم محدد لهدف
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Clinical assessment (cont.)• Versions (pursuit, saccades & ocular muscle
over reaction)• Convergence
باتجاه – متحرك هدف متابعة المريض من يطلب ) الناتجة ) العينين حركة متابعة و الطبيب اصبع األنف
ذلك عن
• Ductionsالواحدة – العين حركة يتابع ثم عين اغالق يطلب
• Ocular alignment & muscle balance– Should neutralize the head tilt
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Clinical assessment (cont.)• Pupils• Lids• Doll’s eyes• Bell’s phenomenon• Bruit• Edrophonium test• Forced ductions
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Causes• Encephalopathy HIV• Basilar meningitis or neoplastic infiltrates• Botulism• Brain stem lesions (stroke, encephalitis)• Carotid cavernous fistula• Cavernous sinus thrombosis• Fisher syndrome• Intoxications• MS• myasthenia
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Causes (cont.)• Leigh’s disease (subacute necrotizing encephalopathy)• Orbital pseudotumor• Paraneoplastic encephalopathy• Associated with polyradiculopathy• Psychogenic• Tolosa-Hunt syndrome• Trauma• Wernicke’s encephalopathy• Myopathies: mitochondrial, fiber type disproportion• Vitamin E deficiency• Supra-para nuclear gaze palsy
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Abnormalities of optic nerve and retina
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Swollen optic disc
• True• Pseudo
– Clear peripapillary nerve fibers– No spontaneous venous pulsations (SVP)– Presence of hemorrhages– Hereditary optic disc drusen white people more
(more axonal degeneration)– Retinitis pigmentosa
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Unilateral optic nerve (disc) edema
• Optic neuritis (papillitis if swollen disc occur)• Anterior ischemic optic neuropathy• Orbital comprssion lesions• Central retinal vein occlusion• Leukemia infiltrates• Neuropathy delayed radiation effect• Leber’s hereditary optic neuropathy
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Differentiation of early papilledema and pseudo one
PapilledemaPseudopapilledemaDisc colorHyperemicPink yellowishMarginsIndistinct at superior
& inferior poles, later entire
Irregular blurred
Disc elevation & vessels
MinimalSVP (-)
Center of disc most elevated ± SVP
Nerve fiber layerDull May obscur blood
vessels
No edema
hemorrhagesSplinterRetinal, subretinal
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Papilledema
= optic disc swelling secondary to ↑ ICP.• Acutely central visual acuity is generally normal.• Enlargement of the physiological blind spot,
concentric constriction and inferior visual fields loss.
• 4 stages for papilledema:– Early– Acute– Chronic– atrophic
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Papilledema (cont.) • Malignant hypertension.• Diabetic papillopathy.• Anemia.• Hyperviscosity syndromes.• Pickwickian syndrome.• Hypotension.• Severe blood loss.• COPD ?±• Giant cell temporal arteritis.• Methanol poisoning.
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Optic neuropathy with normally appearing optic disc = retrobulbar optic neuritis
Unilateral• Optic neuritis• Compressive lesion (visual
loss)examination: ? Normal (=field defects in fellow eye → compressive)
• Giant celll arteritis• Other vasculitides• Post stroke, severe blood
loss
Bilateral• Nutritional• Tobacco-alcohol• Vitamin B12 deficiencies• Folate deficiency• Toxic heavy metal• Drug related
– Chloramphenicol– Isoniazide– Chloroprpamide
• Bilateral compressive• Bilateral retrobulbar
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