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