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Understanding eye movement 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 stationary object on retina during brief movement Optokinetic: hold the image steady on retina during sustained head movement
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Binocular diplopia

Nov 22, 2014

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Ji Young Lee

 
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Page 1: 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

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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

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Cranial n.

• Originated from brainstem(Nucleus)• Short course within brainstem(fascicle)• Subarachroid space• Cavernous sinus and sup. Orbital fis-

sure• Corresponding extraocular m.

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Examination of eye move-ment

• Check in 9-cardinal posotion

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forced duction test

Paresis or Restriction ?

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Bell phenomenon

• With eye closure, normal upward rota-tion of the eye

• Perinaud syndrome– Limited upgaze, normal bell phenomenon– Supranuclear defect – Intact infranuclear function

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• Saccades– Fast eye movement

• Pursuit–following finger

• Oculocephalic responses– Supranuclear

• Vergence

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Cover-uncover test

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The cross-cover testLatent misalignment not revealed by the cover-uncover test

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right abduction deficit

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Example: 3rd n. palsy, Lt.

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• Red glass test – Pt’s ability to report the location of two differ-

ent colored light

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• Maddox Rod test Transparent red plastic cylinders. Produces straight line at 90 degree to the axis

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• 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

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Diagnosis of binocular diplopia

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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

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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

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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.

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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

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Thyroid ds vs Pseudotumor

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Orbital tumor

• Lymphoid tumor• Metastases

• Sx: acute & suba-cute severe orbital pain

• Dx: orbital biopsy

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ProptosisOrbita mass

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Trauma

Fx. Orbit, med. wall& floor

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Silent Sinus Syndrome

• Chronic maxillary sinusitis->atrophy of the maxillary sinus -> Orbit wall deformation

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Chronic progressive external oph-thalmoplegia(CPEO)

• Progressive limitation of EOM and ptosis• Diplopia with reading – Convergence insufficiency

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Diffuse limitation

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Myotonic Dystrophy

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Congenital brown syndrome

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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.

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Ocular Myasthenia fluctuating

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The lesion of Cranial n.

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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.

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6th n. Palsy common cause

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Lt. mi-crovascular 6th n. palsy

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exopho-ria

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Conjugate Rt. Gaze palsy

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Evaluatioin

• Pt (>50 yrs)– CBC, BC, CRP, ESR, glucose, lipid profile

• Brain MRI, CTA, MRA–MRI : not always necessary

persist after 3 month

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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.

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4th n. palsy common cause

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Head tilting

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Evaluatioin

• Trauma? No further Work up• Pt (>50 yrs)– CBC, BC, CRP, ESR, glucose, lipid

• Brain MRI

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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)

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Classification

Pupil muscle

Partial Not all muscle involved

Com-plete

Involvement

All muscle involved

Anisocoria

Sparing isocoria

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3rd n. common cause

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Evaluation

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The lesion of multiple cranial n.

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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

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Cavernous sinus syndrome

• Combination of– Ophthalmoplegia (multiple cranial n. palsy)– Honer syn– Pain and V1 sensory loss

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Lt. cavernous sinus menin-gioma

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Cavernous sinus aneurysm

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Miller Fisher syndrome

Triad

Ataxia

Ophthalmoplegia

Areflexia

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The lesion of Internuclear or supranuclear

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Horizontal gaze paresis

• Lesion of 6th n. nucleus– Loss of ipsilat. Voluntary and reflexive conju-

gate movement– Ipsilat. Facial weakness

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Internuclear ophthalmople-gia

• Lesion of MLF– Ipsilesional deficit of adduction– Nystagmus– Convergence may overcome adduction deficit

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Conver-gence:normal

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1 and ½ syndrome

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Anatomy of conjugate vertical gaze

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Conjugate Vertical eye movement

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Post. com-missure

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Down gaze paresis

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Skew deviation and the ocular tilt reaction(OTR)

• Vertical misalignment • Acute brain stem dysfuction

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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