7sem sq3

5,257 views
4,943 views

Published on

Published in: Health & Medicine
1 Comment
8 Likes
Statistics
Notes
  • Fantastic resources!
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
5,257
On SlideShare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
355
Comments
1
Likes
8
Embeds 0
No embeds

No notes for slide

7sem sq3

  1. 1. DR. MANALI HAZARIKA SINGH
  2. 3. Incomitant squints <ul><li>Variation in the amount of deviation in different directions of gaze. </li></ul>
  3. 4. Differences Incomitant squint Comitant squint 1. Age of onset Usually late Early childhood 2. Type of onset Sudden Gradual 3. Magnitude of squint Varies with eye position Same in all positions 4. Diplopia Present Absent 5. Headposture Abnormal Normal 6. Sensory adaptations * Rare Frequent 7. Past pointing/ false projection Present Absent 8. EOM Restricted Full 9.Secondary deviation More than primary Equal to primary
  4. 5. Incomitant strabismus <ul><li>Paralytic - Neurogenic, Myogenic, NMJ </li></ul><ul><li>Restrictive – Duane’s , Brown’s syndrome, Dysthyroid ophthalmopathy, Blow out fracture with incarceration of EOM. </li></ul>
  5. 6. Paralytic strabismus etiology <ul><li>I. Neurogenic lesions </li></ul><ul><li>1. Congenital hypoplasia or absence of nucleus: third and sixth cranial nerve palsies. </li></ul><ul><li>2. Inflammatory lesions: encephalitis,meningitis, neurosyphilis,peripheral neuritis (viral),infectious lesions of cavernous sinus and orbit. </li></ul><ul><li>3. Neoplastic lesions. </li></ul><ul><li>4. Vascular lesions:HTN , DM and atherosclerosis. </li></ul><ul><li>haemorrhage, thrombosis, embolism, aneurysms </li></ul><ul><li>or vascular occlusions. </li></ul>
  6. 7. Paralytic strabismus etiology <ul><li>5. Traumatic lesions: head injury </li></ul><ul><li>6. Toxic lesions:carbon monoxide poisoning, effects of diphtheria toxins (rarely),alcoholic and lead neuropathy. </li></ul><ul><li>7. Demyelinating lesions: multiple sclerosis </li></ul><ul><li>II. Myogenic lesions </li></ul><ul><li>1. Congenital lesions. These include absence, </li></ul><ul><li>hypoplasia, malinsertion, weakness and musculofacial anomalies. </li></ul><ul><li>2. Traumatic lesions. </li></ul>
  7. 8. Paralytic strabismus etiology <ul><li>3. Inflammatory lesions: Myositis (viral) , influenza, measles. </li></ul><ul><li>4. Myopathies:These include thyroid myopathy, carcinomatous myopathy, Progressive external ophthalmoplegia </li></ul><ul><li>III. Neuromuscular junction lesion </li></ul><ul><li>It includes myasthenia gravis. </li></ul>
  8. 9. Paralytic strabismus <ul><li>SYMPTOMS: </li></ul><ul><li>LIMITATION OF OCULAR MOVEMENTS </li></ul><ul><li>SUDDEN ONSET OCULAR DEVIATION </li></ul><ul><li>DIPLOPIA </li></ul><ul><li>CONFUSION </li></ul><ul><li>NAUSEA , VERTIGO </li></ul>
  9. 10. Diplopia
  10. 11. DIPLOPIA- A)Uncrossed diplopia with an esotropia.B)Crossed diplopia with an exotropia.
  11. 12. Paralytic strabismus <ul><li>SIGNS: </li></ul><ul><li>Limitation of movement in the field of action of the muscle </li></ul><ul><li>Difference in primary and secondary deviations </li></ul><ul><li>Compensatory HP </li></ul><ul><li>False projection </li></ul>
  12. 13. FALSE PROJECTION <ul><li>OBJECT IS PROJECTED TOO FAR IN THE DIRECTION OF ACTION OF THE PARALYSED MUSCLE. </li></ul><ul><li>DUE TO INCREASE OF SECONDARY DEVIATION , THE OBJECT IS PROJECTED ACCORDING TO THE NERVOUS ENERGY EXERTED </li></ul>
  13. 14. Stages- SPREAD OF COMITANCE <ul><li>Paresis of the particular muscle (LSO) </li></ul><ul><li>Overaction of antagonist of same eye (LIO) </li></ul><ul><li>Overaction of contralateral yoke muscle(RIR) </li></ul><ul><li>Secondary inhibitional palsy of antagonist of the yoke muscle (RSR) </li></ul>
  14. 15. Pathological sequelae of the right lateral rectus muscle paralysis.
  15. 16. Clinical types of ocular palsies <ul><li>Isolated muscle paralysis </li></ul><ul><li>LR and superior oblique are the most common muscles to be paralysed singly, as they have separate nerve supply. </li></ul><ul><li>Isolated paralysis of the remaining four muscles is less common, except in congenital lesions. </li></ul>
  16. 17. Clinical types of ocular palsies <ul><li>2. 3 rd nerve paralysis </li></ul><ul><li>Ptosis </li></ul><ul><li>Eyeball is down, out and slightly intorted </li></ul><ul><li>Ocular movements are restricted in all the directions except outward. </li></ul><ul><li>Pupil is fixed and dilated </li></ul><ul><li>Accommodation is lost </li></ul><ul><li>Crossed diplopia is elicited on raising the eyelid. </li></ul>
  17. 18. Clinical types of ocular palsies <ul><li>3. Double elevator palsy. </li></ul><ul><li>congenital </li></ul><ul><li>caused by third nerve nuclear lesion. </li></ul><ul><li>characterised by paresis of the superior rectus and the inferior oblique muscle of the involved eye. </li></ul>
  18. 19. Clinical types of ocular palsies <ul><li>4. Total ophthalmoplegia </li></ul><ul><li>extraocular muscles including LPS and intraocular muscles, </li></ul><ul><li>viz., sphincter pupillae, and ciliary muscle </li></ul><ul><li>are paralysed </li></ul><ul><li>third, fourth and sixth cranial nerves. orbital apex syndrome and cavernous sinus thrmb </li></ul>
  19. 20. Clinical types of ocular palsies <ul><li>5. External ophthalmoplegia . In this condition, all </li></ul><ul><li>extraocular muscles are paralysed, sparing the intraocular muscles. </li></ul><ul><li>It results from lesions at the level of motor nuclei sparing the Edinger-Westphal </li></ul><ul><li>nucleus </li></ul>
  20. 21. Investigations <ul><li>Diplopia charting </li></ul><ul><li>Hess charting </li></ul><ul><li>Forced duction test </li></ul><ul><li>Force generation test </li></ul>
  21. 22. DIPLOPIA CHARTING <ul><li>AREAS OF SINGLE VN AND DIPLOPIA </li></ul><ul><li>DIST. BETWN THE TWO IMAGES IN AREAS OF DIPLOPIA </li></ul><ul><li>WHETHER THE IMAGES ARE AT THE SAME LEVEL OR NOT </li></ul><ul><li>WHETHER THE DIPLOPIA IS HOMONYMOUS OR CROSSED </li></ul>
  22. 23. Diplopia chart of a patient with right lateral rectus palsy.
  23. 24. HESS SCREEN <ul><li>DIFF. PARETIC FROM </li></ul><ul><li>RESTRICTIVE </li></ul><ul><li>RECENT ONSET </li></ul><ul><li>PARESIS FROM </li></ul><ul><li>LONG STANDING </li></ul>
  24. 25. Hess chart
  25. 26. Forced duction test
  26. 27. Investigations to find out the cause of paralysis <ul><li>orbital ultrasonography, </li></ul><ul><li>orbital and skull computerised tomography scanning and </li></ul><ul><li>neurological investigations. </li></ul>
  27. 28. TREATMENT <ul><li>TREAT THE CAUSE </li></ul><ul><li>WAIT N WATCH – 6MTHS – B COMPLEX , SYSTEMIC STEROIDS </li></ul><ul><li>TREAT DIPLOPIA- OCCLUDER ON THE AFFECTED EYE WITH INTERMITTENT USE OF BOTH EYES TO AVOID SUPPRESSION AMBLYOPIA </li></ul><ul><li>SURGERY- STRENGTHENING OF THE PARALYSED MUSCLE - RESECTION; WEAKENING OF THE OVERACTING MUSCLE - RECESSION. </li></ul>
  28. 29. Restrictive strabismus <ul><li>Duane’s retraction syndrome </li></ul><ul><li>Superior oblique sheath syndrome (Brown syndrome) </li></ul><ul><li>Blow-out fractures – incarceration of muscle </li></ul><ul><li>Strabismus fixus, </li></ul><ul><li>Dysthyroid ophthalmopathy </li></ul>
  29. 30. Duane’s retraction syndrome (DRS) <ul><li>On attempted adduction there is retraction of globe : co-contraction of both MR and LR (narrowing of palpebral fissure) </li></ul><ul><li>On attempted abduction, the palpebral fissure opens </li></ul>
  30. 31. DUANE’S <ul><li>FAILURE OF INNERVATION OF LR BY 6 TH N  3 rd N. </li></ul><ul><li>Type I  LIMITED ABDUCTION, NORMAL ADDUCTION, PRIMARY POSITION- N </li></ul><ul><li>Type II  LIMITED ADDUCTION , NORMAL ABDUCTION </li></ul><ul><li>Type III  LIMITED ADDUC AND ABDUC </li></ul>
  31. 32. Brown syndrome <ul><li>Superior oblique sheath syndrome </li></ul><ul><li>A tight superior oblique sheath: congenital or acquired </li></ul><ul><li>Restriction of elevation in adduction </li></ul><ul><li>Positive forced duction test </li></ul>
  32. 33. Strabismus fixus <ul><li>Bilateral fixation in convergent position due to fibrous tightening of the medial recti </li></ul><ul><li>The cornea was completely hidden in the right eye and only 2 mm of the superotemporal cornea was detectable in the left eye </li></ul>
  33. 34. BLOW OUT FRACTURE
  34. 35. SYNKINESES <ul><li>Involuntary movement of muscles or limbs accompanying a voluntary movement. </li></ul>
  35. 37. Nystagmus <ul><li>DEFN: Regular , rhythmic, to and fro involuntary oscillatory movements of the eyes. </li></ul><ul><li>ETIO: Disturbance of factors responsible for maintaining normal ocular posture-sensory visual pathway, vestibular apparatus,semicircular canals,midbrain, cerebellum </li></ul>
  36. 38. Features of nystagmus <ul><li>Pendular/Jerk </li></ul><ul><li>Rotatory/Horizontal/ Vertical </li></ul><ul><li>Rapid/slow </li></ul><ul><li>Latent/Manifest </li></ul>
  37. 39. TYPES OF NYSTAGMUS <ul><li>1.PHYSIOLOGICAL NYSTAGMUS </li></ul><ul><li>A) OPTOKINETIC NYSTAGMUS </li></ul><ul><li>B) END POINT NYSTAGMUS </li></ul><ul><li>C) VESTIBULAR NYSTAGMUS </li></ul>
  38. 40. 2. Pathological <ul><li>Sensory deprivation </li></ul><ul><ul><li>Horizontal and pendular </li></ul></ul><ul><ul><li>Central vision impairment in <2yr age * </li></ul></ul><ul><li>Motor imbalance /neurologic diseases </li></ul><ul><ul><li>Congenital nystagmus / manifest nystagmus </li></ul></ul><ul><ul><li>Latent nystagmus (congenital esotropia) </li></ul></ul><ul><ul><li>Vestibular nystagmus </li></ul></ul><ul><ul><li>Upbeat nystagmus </li></ul></ul><ul><ul><li>Downbeat nystagmus </li></ul></ul><ul><ul><li>See saw nystagmus of Maddox </li></ul></ul><ul><ul><li>Convergence- retraction nystagmus </li></ul></ul><ul><ul><li>Periodic alternating nystagmus </li></ul></ul><ul><ul><li>Gaze evoked nystagmus </li></ul></ul><ul><ul><li>Miner’s nystagmus </li></ul></ul>
  39. 41. THANK YOU
  40. 42. Alphabet patterns : A-V <ul><li>V pattern: difference in deviation in the upgaze and downgaze of >15 prism dioptres </li></ul><ul><li>A pattern: difference in deviation in the upgaze and downgaze of >10 PD </li></ul>
  41. 44. CAUSES <ul><li>IOOA </li></ul><ul><li>SO UNDERACTION </li></ul><ul><li>SR UNDERACTION </li></ul><ul><li>BROWN SYNDROME </li></ul><ul><li>CRANIOFACIAL ANOMALIES </li></ul>
  42. 45. A PATTERN <ul><li>CAUSES </li></ul><ul><li>SOOA </li></ul><ul><li>IO UNDERACTION </li></ul><ul><li>IR UNDERACTION </li></ul>

×