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    下載 下載 Presentation Transcript

    • Case Report A 70- year- old man with blurred vision related to binocular diplopia PGY Yuh- Shin Chang Supervisor 楊浚銘醫師 990520
    • Patient profile
      • Name: 李 O 定
      • Age: 70- year- old
      • Gender: male
      • Chart number: 15297789
      • Date of admission:
        • 990512
    • Chief Complaint
      • Blurred vision related to binocuclear diplopia for one week.
    • Present Illness
      • This 70-year-old man presented to our OPD with the complaint of
        • binocular diplopia for about one week .
        • blurred vision related to diplopia of cars or persons while walking along the streets.
        • swelling sensation of both eyes and persistent binocular diplopia.
        • dizziness when he blinked his eyes while reliving when closing eyes.
    • Present Illness
      • He had no
        • nausea, vomiting,
        • cough, fever,
        • limbs weakness, slurred speech,
        • body weight loss,
        • epistaxis,
        • hearing impaired,
        • trauma or
        • other eye discomfort.
    • Present Illness
      • He went to OPH local clinics for help where
        • ophthalmologic examinations revealed no significant findings
        • except for
          • limited to look laterally of right eye while looking toward right side and
          • binocular diplopia especially looking toward right side .
      • The neurology further survey was suggested.
    • Present Illness
      • Tracking back to his history,
        • he suffered from the same symptoms but diplopia was preference when looking toward left side last year.
        • admitted to our ward under the impression of left abducence nerve palsy.
      • During last admission,
        • the brain MRI revealed no evidence of acute infarction .
        • No evidence of NPC was noted after ENT consulted .
      • Under the impression of binocular diplopia , he was admitted for further survey.
    • Past History
      • Stroke Risk Factors:
        • Hypertension (+) with medical control for more than 10 years.
        • DM Type 2 (+) diagnosed during last admission (981029- 981102) without OAA control or follow up .
      • Previous stroke:
        • Infarction (-) , ICH(-), TIA(-)
      • Heart disease (-)
      • Recent infection (-)
      • Previous hospitalizations:
        • Binocular diplopia related to left abduence nerve palsy ( 981029- 981102)
      • Personal history:
        • Alcohol (-), Betel nut (-), Cigarette (-)
      • Allergy History:
        • Food and drug allergy: denied
      • Family History:
        • not contributory
    • Physical examination
      • Vital signs: T: 36.5 ℃, P: 78 /min , R: 22 /min BP: 144/83 mmHg
      • General appearance: without ill looking
      • HEENT
        • Head: normocephalic
        • Ear: eardrum: intact , hearing: normal
        • Eyes : sclera: not icteric, conjunctiva: not pale
          • VA: 0.7 OU from near chart, IOP: 19/18 mmHg ,
          • Eyelid: Senile ptosis: (-) post operatively / (+), Proptosis (-),
          • Conj: no chemosis or vessels congestion.
        • Neck: supple, bruits (-), Burdzinski's sign(-)
    • Physical examination
      • Chest & Heart:
        • Breathing sound: Bilateral clear without retraction .
        • Heart sound: Regular heart beat, No murmur
      • Abdomen
        • Soft, not distended
        • Normoactive bowel Sound
      • Extremities
        • no pitting edema
    • Neurological examination
      • Mental status: Consciousness: clear, GCS: E 4 V 5 M 6
      • Language: spontaneous speech (+)
      • Cranial nerves:
      • CN-II.
        • Visual field: normal by confrontation test
        • Pupil size (R/L): 2.5 mm/2.5 mm, isocoric
        • Light reflex- direct and indirect
          • (R/L): (+) / (+)
    • Neurological examination
      • CN-III, IV, VI.
        • Senile ptosis(R/L): (-) post operatively / (+)
        • EOM :
          • limited to look laterally while looking toward right side (-3~ -4) OD
          • limited to look laterally while looking toward left side (0 ~ -1) OS
      • CN-V.
        • Sensory- (V1/V2/V3): R/L: ok / ok / ok
        • Motor- masseter m. (R/L) : ok / ok
      • CN-VII:
        • No facial palsy …..
      • Limited to look laterally of right eye while looking toward right side (-3 ~ -4)
      • Compensatory face turn in the right direction …..
      (-3 ~ -4)
      • Limited to look laterally of left eye while looking toward left side (0 ~ -1)
      • Compensatory face turn in the left direction …..
      0 ~ -1
    • Neurological examination
      • CN-VIII.
        • Hearing: normal
      • CN-IX , X.
        • Word articulation: normal
        • Swallowing: normal
      • CN-XII.
        • Tongue protrusion: midline
    • Neurological examination
      • Muscle power : no limbs weakness
        • RUE distal grade 5 LUE distal grade 5
        • RUE proximal grade 5 LUE proximal grade 5
        • RLE proximal grade 5 LLE proximal grade 5
        • RLE distal grade 5 LLE distal grade 5
      • DTR: no significant finding
        • (C5,6)--R‘t biceps ++ L’t biceps ++
        • (L3,4)--R't knee ++ L't knee ++
        • Plantar reponse(Babinski's sign)
          • R't: flexor, L't: flexor
    • Neurological examination
      • Sensory:
        • Touch: normal
      • Coordination(Cerebellum):
        • Finger-Nose-Finger: R't- normal, L't- normal
      • Gaits: normal
    • Differential Diagnosis- outline
      • Differential diagnosis of binocular diplopia
        • VINDICAT
      • Differential diagnosis of sixth nerve palsy
        • Anatomy differential diagnosis
        • Etiology differential diagnosis
    • Differential Diagnosis of binocular diplopia Brain MRI, Clinical presentation CBC/DC, Infection source, Clinical presentation Spirochetal- Treponema pallidum Mycobacterial Mycobacterium tuberculosis Fungal- Mucormycosis, Actinomycosis Viral- Herpes zoster Bacterial- Contiguous sinusitis, Mucocele (sphenoid sinus), PeriostitisAbcess I nfection Internal carotid artery dissection Intracavernous carotid artery aneurysm Carotid-cavernous fistula or thrombosis Cerebrovascular accident V ascular
    • Differential Diagnosis of binocular diplopia Brain MRI, Clinical presentation Clinical presentation Botulism Tick bite paralysis Myasthenia gravis N euromuscular junction Distant metastases: Lymphoma, Multiple myeloma, Carcinomatous metastases Local metastases : Nasopharyngeal tumour, Squamous cell carcinoma Primary cranial tumour : Chordoma, others Primary intracranial tumour : Pituitary adenoma, Meningioma, Craniopharyngioma, others N eoplasm
    • Differential Diagnosis of binocular diplopia Clinical presentation EOM, Clinical presentation Clinical presentation I nflammation Sarcoidosis, Wegener's granulomatosis, Eosinophilic granuloma Sixth nerve palsy Orbital myositis (Orbital pseudotumor ) Tolosa-Hunt syndrome Fourth cranial nerve palsy Third cranial nerve palsy  D iabetic ophthalmoplegia Recurrent demyelinating neuropathy (Ophthalmoplegic migraine) Acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome) D emyelinating
    • Differential Diagnosis of binocular diplopia EOM, Clinical presentation Brain MRI, Clinical presentation Thyroid function, Clinical T rauma T hyroid ophthalmopathy Wernicke's syndrome Alcoholism A lcohol   Sixth nerve palsy Fourth cranial nerve palsy Third cranial nerve palsy  C ongenital, Cranial nerve
    • Differential Diagnosis of sixth nerve palsy- Anatomy
      • The abducens nucleus
      • surrounded by the facial nerve fasciculus
      • associated intimately with the medial longitudinal fasciculus
      • traverse the paramedian pontine reticular formation and the corticospinal tract
    • The VI nerve exits the pons anteriorly, ascends along the clivus bone, crosses the petrous apex, and descends below the petroclinoid ligament to enter the cavernous sinus, where it runs between the lateral wall and the carotid artery 1. Nuclear lesions ….. 2. Fasicular lesions ….. 3. subarachnoid space ….. 4. Petrous apex lesions/fractures ….. 5. Cavernous sinus and superior orbital fissure lesions ….. …..
    • Anatomy differential diagnosis of sixth nerve palsy- Nuclear lesions
      • Nuclear lesions are mainly caused by infarction and tumour .
      • VI nerve
        • 60% cell bodies project directly to the lateral rectus muscle.
        • 40% project via the MLF, to the contralateral medial rectus and cause adduction of the contralateral eye.
      • Damage to the VI nerve nucleus produces an ipsilateral gaze palsy ……
    • Anatomy differential diagnosis of sixth nerve palsy- Fasicular lesions
      • Fasicular lesions are mainly a result of
        • infarction,
        • tumour or
        • demyelination .
      • This part of the nerve may be involved along with adjacent structures and
      • may produce a variety of signs/symptoms including
        • deafness (if VIII nerve involved) and
        • facial hemiplegia (if VII nerve involved) ……
    • Anatomy differential diagnosis of sixth nerve palsy- subarachnoid space
      • As the nerve ascends the subarachnoid space , it becomes vulnerable to various insults , including
        • compression from aneurysms,
        • meningeal infection,
        • inflammation (e.g. sarcoidosis) or
        • infiltration (e.g. lymphoma, leukaemia, carcinoma).
        • elevated intracranial pressure
    • Anatomy differential diagnosis of sixth nerve palsy- subarachnoid space
      • Patients with orbital inflammation have a VI nerve palsy in addition to
        • papilloedema
        • visual field changes ……
    • Anatomy differential diagnosis of sixth nerve palsy- Petrous apex lesions/fractures
      • The sixth nerve contact with the tip of the petrous part of the temporal bone.
        • petrous bone inflammation-
          • secondary to middle ear infections.
        • petrous bone fractures –
          • basal skull fractures following head trauma
      • may also involve cranial nerves V,VI, VII, and VIII ……
    • Anatomy differential diagnosis of sixth nerve palsy- Cavernous sinus and superior orbital fissure lesions
      • Cavernous sinus lesion are mainly a result of
        • carotid cavernous fistulas and
        • intracavernous aneurysms of the carotid artery
        • cavernous sinus thrombosis .
      • may also involve cranial nerves III, IV,VI, V 1 , and V 2 ……
      • More common –
        • vasculopathic (diabetes , hypertension, atherosclerosis),
        • traumatic,
        • idiopathic.
      • Less common –
        • increased intracranial pressure,
        • temporal arteritis,
        • cavernous sinus mass (menigioma, aneurysm, metastasis),
        • Multiple sclerosis,
        • sarcoidosis/vasculitis,
        • stroke (usually not isolated).
      Differential Diagnosis of sixth nerve palsy- Etiology for adults
      • VI nerve palsy with limitation of abduction:
        • Diabetic ophthalmoplegia
        • Thyroid eye disease
        • Myasthenia gravis
        • Orbital trauma
        • Break in fusion of a congenital esophoria
      Differential Diagnosis of sixth nerve palsy- Etiology for adults
    • 5/12( Day1 ) Day2 Day3 Day4 Hospital course CBC/DC, Biochem EKG CXR Brain MRI with contrast Biochem Stool analysis Urine analysis Dopscan Biochem Thyroid function Discharge Vitapoly Tab.(1# QD) Noopol(1200mg 1# QD) Broen-C Tab.(1# QID ) Accupril (10mg 1# QD) Doxaben (2mg 1# HS) Inderal(10mg 1# TID) Norvasc (5mg 1# QD) Erispan (0.25mg 1# TID) Imovane (7.5 mg 1# HS) Glucophage 500mg 1# TID) Mecobalamine(500mcg 1# BID) Euglucon (5 mg 1# QD) ENT was consulted: No evidence of NPC
      • Laboratory data and image- CBC/DC
      • Laboratory data and image- Biochem
      • Laboratory data and image- EKG
      • Laboratory data and image- CXR
      Back
      • Laboratory data and image- Biochem
      • Laboratory data and image- Urine analysis
      • Laboratory data and image- Stool analysis
      • Laboratory data and image- Dopascan
      • The findings reveal
        • Mild atherosclerotic change over bilateral CCA(s), bilateral carotid bifurcation(s), with no significant hemodynamic change.
        • Forward ophthalmic flow over both sides …..
      • Laboratory data and image- Brain MRI
      • No definite abnormal signal intensity lesion in the brain including
        • supratentorial cerebral hemisphere and
        • infratentorial cerebellum and
        • brain stem region.
      • No strong evidence of intracranial mass lesion ……
      • Laboratory data and image- Biochem
    • The patient was discharged
      • with diagnosis of
        • Right sixth nerve palsy related to
          • Diabetic ophthalmoplegia
        • Type 2 Diabetes mellitus
        • Hypertension
    • Discussion and take home message
      • Discussion
        • Neuro-ophthalmic manifestations of diabetes
      • Take home message
    • Neuro-ophthalmic manifestations of diabetes
      • Accommodation
      • Pupil dysfunction
      • Optic nerve
        • Non-arteritic AION
        • Optic nerve hypoplasia
      • Facial nerve (CN VII) palsy …..
      • Diabetic ophthalmoplegia
        • Ocularmotor (CN III) palsy
        • Trochlear nerve (CN IV) palsy
        • Abducens (CN VI) palsy
    • Neuro-ophthalmic manifestations of diabetes
        • Right peripheral facial nerve paresis, later diagnosed as Bell’s palsy.
    • Neuro-ophthalmic manifestations of diabetes
        • IV nerve paresis affecting the right eye following rupture of an intracranial aneurysm.
        • There is an underaction of the right superior oblique on gaze down and left .
        • Compensatory contralateral head tilt and chin-down position.
    • Neuro-ophthalmic manifestations of diabetes
        • Left VI nerve paresis in an elderly man; the left eye’s ability to abduct is very limited .
        • Compensatory face turn in the direction of the paralyzed muscle
    • Discussion and take home message
      • Take home message
        • How to differentiate the OPH or Neuro should be consulted when patient complained diplopia.
          • EOM limitation
          • Binocular diplopia without monocular diplopia
    • Thanks for your attention