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Gaze palsy

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Gaze palsy

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Gaze palsy

  1. 1. Gaze Palsy Presenter- Dr Shubhangini J Moderator-Dr Monica Samant
  2. 2. Ocular Motor system- Nuclear SupranuclearInfranuclear Inter nuclear
  3. 3. Supranuclear control of ocular motility- Versions- Same direction Vergence- Opposite direction Supranuclear control
  4. 4. Eye Movements- Eye Movements Version Saccades Smooth Pursuit Optokinetic Vestibulo- ocular Vergence Divergence Convergence
  5. 5. Saccadic System-
  6. 6. Cells in PPRF Burst Cell-sends pulse step to move the eye Pause Cell- inhibits firing of burst cell allowing burst cell to initiate saccade Tonic Cell – maintain the eye position
  7. 7. Smooth Pursuit System
  8. 8. Vestibulocerebellar system-  Important input of gaze system  Modulate eye movements  Stabilize eye against the gravitatinal & accelerational force  Maintaining clear vision
  9. 9. Cerebellum-  Eye movements  Fixation accuracy  Suppress the vestibulo-ocular reflex  Controls smoothness of pursuit movements  Accuracy of saccades
  10. 10. Lesion of Supranuclear oculomotor pathways -  Based on anatomical location-  Lesions of internuclear system  Immediate premotor structure in the brain  PPRF  Posterior commisure  Rostral mesencephalon  Cerebral hemisphere  Descending pathway from cerebral hemisphere  Superior colliculus  Thalamus
  11. 11. Clinical Examination  Asymptomatic for gaze palsy  Blurring of vision  Diplopia
  12. 12. Pre-requisite-  Observe position of eye in primary gaze  Ductions  Versions & vergence  Pursuit  Saccades
  13. 13. Oculocephalic maneuvers-  Dolls eye reflex  Tilt the head 30 degree forward & fixate a distant target  Rotate the head in direction opposite to gaze palsy  Direct projection from vestibular system to ocular motor nuclei  Prenuclear,nuclear infranuclear reflex does not overcome  Lesion in cerebral cortex overcome by VOR
  14. 14. Vestibular ocular reflex -  Tilt the head by 60 degree & irrigate external auditary meatus with cool/warm water  In normal subject/supranuclear gaze palsy eye deviate towards the irrigated side- nystagmus with fast phase to opposite side  Fast phase towards the stimulated eye when warm water is used
  15. 15. Supranuclear eye movement disorder- Gaze palsy Horizontal Vertical
  16. 16. Vertical gaze palsy-  Midbrain lesion  B/L cerebral hemisphere dysfunction  Parkinsons disease  Progressive supranuclear palsy  lipidosis
  17. 17. Parinaud syndrome-  Dorsal midbrain syndrome  Lesion of posterior commisure & MRF  Cause- compression by mass in pineal region  Dilatation of third ventricle  Midbrain infarction  multiple sclerosis  AV malfomation  Poor to absent upgaze  Convergence retraction nystagmus in upgaze  Colliers sign  Setting sun sign
  18. 18. Parinaud syndrome-  EMG shows co-contraction of occulomotor innervated muscles- retraction of globe  Neuroimaging scan  Surgical treatment causes resolution of ocular findings
  19. 19. Progressive supranuclear palsy- Lesion of mesencephalic structure-  Steele-Richardson-Olszewski syndrome  Onset –after 40 years  Disorder of basal ganglia  Marked rigidity –trunk & neck  Little tremor  Difficulty with vertical eye movements down > up  Progresses to horizontal gaze disorder  End stage – global ophthalmoplegia
  20. 20. Progressive supranuclear palsy-  Vertical direction more severely affected initially  Voluntary saccades affected first, convergence, and smooth pursuit later  Slowing of saccade velocity  Supranuclear movements primarily affected (vestibulo- ocular reflex spared)  Square wave jerks  Gait abnormalities  Nuchal rigidity
  21. 21. Progressive supranuclear palsy-  Eyelid abnormalities:  upper eyelid retraction  reduced blink rate  apraxia of eyelid opening  blepharospasm  Postural instability with falls (often backwards)  Cervical and axial dystonia
  22. 22. Progressive supranuclear palsy-  Wilson’s disease  Huntington diseas  Kernicterous
  23. 23. Parkinsons disease-  Lesion of descending pathway from cerebral hemisphere  Upgaze palsy affecting saccades followed by pursuit  Cogwheel pursuit
  24. 24. Lipidosis-  Lipid storage disease variant of niemann picks disease  Vertical saccades  Intact vertical oculocephalic maneuvers  Progressive dementia in late childhood  Choreoathetosis  hepatosplenomegaly
  25. 25. Whipples disease-  Involvement of CNS – supranuclear gaze palsy  Initially vertical  Progressive dementia  Hypersomnia  Ataxia  Uveitis
  26. 26. Monoocular elevation paresis-  No ocular deviation in primary gaze  Inability to elevate one eye  Prenuclear congenital unilateral midbrain lesion  Oculocephalic maneuver is normal  Lesion in pretectum  Connection of riMLF to the occulomotor nuclei  Forced duction & tensilon test are negative
  27. 27. Monoocular elevation paresis-
  28. 28. Skew deviation-  Skew deviation is a vertical divergence  “prenuclear” lesion of the vertical vestibulo-ocular pathways in the brainstem or cerebellum.  Comitant, associated with cyclotorsion of one or both eyes.  Noncomitant it can mimic a partial third or fourth cranial nerve palsy
  29. 29. Skew deviation-  Occur most commonly with vascular lesions of the pons or lateral medulla (Wallenberg's syndrome)  lesions of the midbrain or upper pons  Alternating skew deviation, the hypertropia changes with the direction of gaze. The adducting eye usually is hypotropic,mimick superior oblique overaction.
  30. 30. Skew deviation-
  31. 31. Ocular tilt reaction-  cyclotorsion of both eyes, and paradoxical head tilt, all to the same side – that of the lower eye  A tonic (sustained) ocular tilt reaction occurs with lesions of the ipsilateral utricle, vestibular nerve or nuclei, or a lesion in the region of the contralateral interstitial nucleus of Cajal and medial thalamus  A phasic (paroxysmal) ocular tilt reaction occurs with lesions of the ipsilateral interstitial nucleus of Cajal and may respond to baclofen. 
  32. 32. Horizontal gaze palsy-  More common  Vary from  Gaze evoked nystagmus  Dysmetria of movements  Total inability to move the eye  Commonly occur in CVA patients
  33. 33. Internuclear ophthalmoplegia-  Lesion in MLF  Between the abducens nucleus and C/L medial rectus subnucleus of the oculomotor nerve  Impairs adducting saccades of the ipsilateral eye, which become either slow or absent  Dysmetria  Disconjugate nystagmus.
  34. 34. Internuclear ophthalmoplegia-  If INO is bilateral  abduction saccades also may be slow  Upward beating and torsional nystagmus  Other clinical features  skew deviation  defective vertical smooth pursuit  impairment of the vertical VOR  impaired ability to suppress or cancel the vertical VOR.
  35. 35. Internuclear ophthalmoplegia-  Occur with a variety of disorders of brainstem  Vascular  Demyelinating  Metastatic  Must be differentiated from the pseudo-INO of myasthenia or a long-standing exotropia.
  36. 36. One & half syndrome-  Damage to the caudal pons  Ipsilateral MLF and either the ipsilateral PPRF or the abducens nucleus  It results in an ipsilateral gaze palsy with an ipsilateral INO  Intact horizontal movement is abduction of the contralateral eye
  37. 37. One & half syndrome-  If the facial nerve nucleus or fasciculus is involved, oculopalatal myoclonus may develop  Most common causes  multiple sclerosis and  brainstem stroke  followed by metastatic  primary brainstem tumors  Ocular myasthenia may cause a pseudo-one-and-a- half syndrome
  38. 38. Ocular motor apraxia-  Loss of or severely diminished volitional saccades  Retention of the fast phases of vestibular nystagmus • Difficult horizontal saccades • Head thrust towards desired direction Congenital • Balint syndrome • Both Horizontal & Vertical • Simutagnosia/optic ataxia Acquired
  39. 39. Convergence paralysis-  Midbrain lesions ,dorsal midbrain syndrome.  Cerebellar degeneration, Parkinson's disease, and progressive supranuclear palsy, are associated with poor convergence.  Lack of pupillary constriction on attempted convergence may differentiate psychogenic convergence paralysis from organic disease.
  40. 40. Divergence paralysis-  Uncrossed horizontal diplopia  Intermittent or constant esotropia  Abduction is full.  Break in fusion later in life  Treated easily with base-out prisms for the distance correction  Divergence paralysis is a controversial entity, difficult to differentiate from divergence insufficiency and bilateral sixth cranial nerve palsies.
  41. 41. Functional gaze palsies-  Horizontal gaze palsy – miosis during attempted gaze  Saccades-VOR should be stimulated (oculocephalic maneuvers,calorics,chair rotation ), OKN test  Pursuit
  42. 42. THANK YOU

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