Double trouble

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Clinical Approach to Diplopia and oculomotor nerve palsy.

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  • Double trouble

    1. 1. Double Trouble
    2. 2. Case 1 <ul><li>55 year old with 3 day history of double vision. </li></ul><ul><li>Similar episode of diplopia about 10 years ago. </li></ul><ul><li>Diabetes for 15 years. </li></ul><ul><li>No meds or allergies </li></ul>
    3. 3. Case 1
    4. 4. Case 1 <ul><li>Diagnosis ? </li></ul><ul><li>Investigations? </li></ul>
    5. 5. 75 YR Man WITH DIPLOPIA <ul><li>Sudden onset 4/8/03 </li></ul><ul><li>Optometrist found nothing </li></ul><ul><li>Same day headache, nausea, vomiting </li></ul><ul><li>In ER lid began to droop </li></ul>
    6. 6. Hospital Course <ul><li>MRI, MRA negative </li></ul><ul><li>CT, CTA negative </li></ul><ul><li>Discharged after 8 days </li></ul><ul><li>Headache persisted </li></ul><ul><li>Referred to WEH </li></ul>
    7. 7. PMH <ul><li>Diabetic </li></ul><ul><li>Atrial tachycardia </li></ul><ul><li>Hypercholesterolemia </li></ul><ul><li>Acephalgic migraines </li></ul><ul><li>Glaucoma suspect </li></ul>
    8. 8. PAST OCULAR HISTORY <ul><li>1992-episode of “tight” feeling around both eyes followed by 20 second episode of vertical diplopia </li></ul><ul><li>Similar episode 1 month before where he felt like eyes were “crossing” </li></ul><ul><li>MRI normal </li></ul>
    9. 9. Medications <ul><li>Lipitor </li></ul><ul><li>Prevacid </li></ul><ul><li>Clarinex </li></ul>
    10. 10. Examination <ul><li>OD OS </li></ul><ul><li>VA 20/25 20/30 </li></ul><ul><li>Color 8/8 8/8 </li></ul><ul><li>VF FTFC FTFC </li></ul><ul><li>Motility </li></ul><ul><li>Pupils </li></ul><ul><li>Fundus WNL WNL </li></ul>
    11. 18. NEXT STEP(S)?
    12. 21. 78 YEAR OLD WOMAN <ul><li>PROGRESSIVELY DROOPING RUL, BINOCULAR DIPLOPIA, AND BLURRY VISION OD FOR 2-3 WEEKS. </li></ul><ul><li>SYMPTOMS DO NOT VARY DURING DAY. </li></ul><ul><li>NO EYE PAIN, HEADACHE, OR TRAUMA. </li></ul>
    13. 22. MEDICAL HISTORY <ul><li>BREAST CANCER S/P LUMPECTOMY, CHEMO AND XRT 10 YEARS AGO. </li></ul><ul><li>HYPERTENSION. </li></ul><ul><li>DEPRESSION. </li></ul>
    14. 23. EXAMINATION AS SHOWN MOTILITY 15/15 15/15 COLOR WNL WNL FUNDUS FULL FULL CVF 5 -> 3 7 -> 6 PUPILS 20/40 20/60 VISION OS OD
    15. 27. MRI: T2-WEIGHTED
    16. 28. MRI: T1-WEIGHTED WITH GADOLINIUM
    17. 29. HOSPITAL COURSE <ul><li>NEUROSURGICAL CONSULTATION -> STEREOTACTIC BIOPSY. </li></ul><ul><li>FROZEN SECTION: GLIOBLASTOMA MULTIFORME, GRADE IV. </li></ul><ul><li>RIGHT ANTERIOR TEMPORAL LOBE RESECTED. </li></ul>
    18. 31. R L
    19. 32. Aberrant Regeneration of the Third Nerve <ul><li>Congenital, trauma, tumors, aneurysm, migraine. </li></ul><ul><li>Ischemia is exceptionally rare cause. </li></ul><ul><li>Globe retraction in upgaze , miosis on adduction (pseudo light-near dissociation). </li></ul><ul><li>MRI/MRA in all patients with non-traumatic cases of third nerve palsy or presumed “ischemic” third nerve palsy. </li></ul>
    20. 33. Evaluation of Isolated TNP Complete Partial Pupil involved ? No Ischemic risk factors ? Yes Observe MRI/MRA (or CTA) Yes Pupil involved ? Yes No Re-evaluate after 1 week involved spared Observe if ischemic risk factors, otherwise consider Imaging, LP Modified from clinical pathways in neuro-ophthalmology , AG Lee
    21. 34. PUPIL SPARING REPORTED IN 8-15% OF III-PALSY DUE TO ANEURYSMS PUPIL SPARING CN III PALSY 10 YEARS OLD MRI / MRA 20 YEARS OLD MRI / MRA, ? A-GRAM 40 YEARS OLD MRI / MRA, ? A-GRAM 60 YEARS OLD B/P, FBS, ?ESR, FOLLOW DAILY
    22. 35. Different scenario <ul><li>50 year old with history of intermittent “double vision” for 8 months. </li></ul><ul><li>No headache, no vision loss. </li></ul>
    23. 36. Different scenario <ul><li>VA 20/20 OU. </li></ul><ul><li>IOP 13mm/Hg OU. </li></ul><ul><li>Normal color plates. </li></ul><ul><li>Hertel Exo OD 17 OS 18 Base 100. </li></ul>
    24. 37. Different scenario Pseudo Von-Graffe’s sign Lid retraction in adduction
    25. 38. MRA WILL PICK UP 95% OF ANEURYSMS > 3mm MRA CONVENTIONAL A-GRAM
    26. 39. MRA
    27. 40. CTA or MRA ? 5-6 mm aneurysms can be missed Aneurysm detection Evaluation of Neck vessels Flexibility of display Contrast Patients with implanted metal Scanning time Superior Problematic Superior Not necessary in 3D TOF and 2D TOF Iodinated contrast Contraindicated Can be used Longer Short MRA CTA
    28. 41. Case <ul><li>A 73 year old lady referred by a neurosurgeon. </li></ul><ul><li>History of “double vision” for 3 months (horizontal and binocular) , worse when she looks to the left. </li></ul><ul><li>Has seen a neurologist , who ordered an MRI  showed “intracranial meningiomas” of the falx, and left hemisphere. </li></ul>
    29. 42. Motility
    30. 43. Case <ul><li>Does not see double when she wakes up AM for an hour. </li></ul><ul><li>Patient reported that she is getting “tired” real quickly and unable to do “any work in the house”. Feels her legs and arms are “heavy”. </li></ul>
    31. 44. Video Fatigability
    32. 45. Case 23 Orbicularis weakness OD >OS
    33. 46. Always remember ! <ul><li>Ocular myasthyenia gravis. </li></ul>
    34. 47. Imaging for isolated Non-traumatic TNP <ul><li>Children < 10 years : MRI/MRA regardless of pupil status. </li></ul><ul><li>10-50 year old with pupillary sparing and no vascular risk factors: MRI/MRA  if normal  medical evaluation and observe. </li></ul><ul><li>If aberrant regeneration: MRI/MRA with contrast. </li></ul><ul><li>With pupillary involvement  if MRI/MRA is normal  Cerebral angiography. </li></ul>

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