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Binocular diplopia
1) Cranial nerves III, IV, and VI are involved in eye movement control. A lesion in these cranial nerves can cause abnormalities like ophthalmoplegia or diplopia. 2) Examination of eye movements includes testing in 9 cardinal positions as well as tests like cover-uncover, forced duction, and versions to localize the lesion. 3) Common causes of eye movement abnormalities include thyroid eye disease, orbital pseudotumor, orbital tumors, and cranial nerve palsies. Accurate diagnosis relies on clinical history and examination findings.
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Binocular diplopia
- 1. 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
- 5. Law of ocularmotor control • Sherrington’s law – Whenever an agonist m. receives an excitatory 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
- 6. Cranial n. • Originated from brainstem(Nucleus) • Short course within brainstem(fascicle) • Subarachroid space • Cavernous sinus and sup. Orbital fissure • Corresponding extraocular m.
- 8. Examination of eyemovement • Check in 9-cardinal posotion
- 9. forced duction test Paresis or Restriction ?
- 10. Bell phenomenon • Witheye closure, normal upward rotation of the eye • Perinaud syndrome – Limited upgaze, normal bell phenomenon – Supranuclear defect – Intact infranuclear function
- 11. • Saccades – Fast eye movement • Pursuit–following finger • Oculocephalic responses – Supranuclear • Vergence
- 12.
- 13. The cross-cover test Latent misalignment not revealed by the cover-uncover test
- 14.
- 15. Example: 3rd n.palsy, Lt.
- 16. • Red glasstest – Pt’s ability to report the location of two different colored light
- 18. • Maddox Rodtest Transparent red plastic cylinders. Produces straight line at 90 degree to the axis
- 22. • Hirshberg andKrimsky test – Fixation light is held 33cm – 1mm decentration= 7 degree of ocular deviation = 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
- 23. Diagnosis of binoculardiplopia
- 25. The lesion ofextraocular m. DDx Thyroid eye disease Inflammatory disorder Inflammatory orbital pseudotumor Wegener granulomatosis Sarcoidosis Crohn disease and Inflammatory bowel ds. Connetive tissue ds Tumors Lymphoma Metastatic tumors Rhabdomyosarcoma Infections Trichinosis Orbital venous congestion Carotid cavernous fistula Carotid cavernous thrombosis Infiltration Amyloidosis
- 26. Thyroid disease Clinical Px.Unilat. Or bilat. Proptosis Lid retraction with lid lag Ptosis Orbital congestion Restriction of EOM Visual loss d/t exposure, glaucoma, Compressive Optic neuropathy Dx. CT or MRI - Enlarged EOM TFT – usually, normal Autoantibodies Tx. Treat thyroid abnormality Lubricate cornea IOP control Position – Head elevation at night Ocular occlusion for diplopia Steroids, surgery, radiation, stop smoking
- 29. Myositis Clinical Pain over periorbital lesion Px. Periorbital sweling, proptosis, chemosis Diplopia, Restriction of EOM Ptosis, Lid retraction Enlargement & enhancement of structure Class Infectious – Trichinosis(parasitic infection), orbital cellulitis, abscess Non-infectious – pseudotumor(idiopathic inflammation of orbital contents) Infectious Non-infectious DDx. Systemic infectious condition WBC정상, fever(-), infection source(-) Tx. Broad spectrum antibiotics Steroid Tx. Surgical drainage
- 30. Pseudotumor • No infection,no underlying systemic disorder • Diagnosis – Suspected clinically – Healthy patient, presenting with unilat. & bilat. acute & subacute orbital syndrome – Diplopia :common – Pain – Visual loss: adjacent inflammation of the optic nerve
- 31. Thyroid ds vsPseudotumor
- 32. Orbital tumor • Lymphoidtumor • Metastases • Sx: acute & subacute severe orbital pain • Dx: orbital biopsy
- 33.
- 34. Trauma Fx. Orbit, med. wall& floor
- 35. Silent Sinus Syndrome •Chronic maxillary sinusitis->atrophy of the maxillary sinus -> Orbit wall deformation
- 36. Chronic progressive external ophthalmoplegia(CPEO) • Progressive limitation of EOM and ptosis • Diplopia with reading – Convergence insufficiency
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- 38.
- 39.
- 40. The lesion ofNeuromuscular Junction Ocular myasthenia and Myasthenia Gravis Intro Autoimmune disorder Postsynaptic acethylcholline receptors disorder Fatigbility Clinical Px. Unilat. Or bilat. Fluctuating ptosis Fluctuating binocular diplopia Worsen after exercise, tired, improved with rest(sleep test) Ptosis improves with ice appliance(ice test) Pupil : always normal all EOM or limited to one EOM Systemic Sx. : swallowing difficulty, resp. sx. Tx. Refer to neurologist Pyridostigmin(Mestinon) Corticosteroid Immuneosuppressants Thymectomy Sx. Tx. Of diplopia, ptosis: surgery->rarely necessary, stable pt.
- 41. fluctuating Ocular Myasthenia
- 42. The lesion ofCranial n.
- 43. 6th n. anatomy –Nucleus(med. Dorsal pontomedullary jc.)(->contralat. MLF- >subnucleus of 3rd n.) -> subarachnoid space->cavernous sinus(lat. of int. caroid a.)->sup. Orbital fissure, annulus of Zinn - >lat. Rectus m.
- 44. 6th n. Palsycommon cause
- 45.
- 46.
- 47. Conjugate Rt. Gazepalsy
- 49. Evaluatioin • Pt (>50yrs) – CBC, BC, CRP, ESR, glucose, lipid profile • Brain MRI, CTA, MRA – MRI : not always necessary persist after 3 month
- 50. 4th n. anatomy •Nucleus(periaqueductal gray matter)->Cross over (midbrain)- >subarachnoid space->Between cerebellar a. and post. cerebral a.- >cavernous sinus(above V1)->sup. orbital fissure, annulus of Zinn- >Sup. Oblique m.
- 51. 4th n. palsycommon cause
- 53.
- 55. Evaluatioin • Trauma? Nofurther Work up • Pt (>50 yrs) – CBC, BC, CRP, ESR, glucose, lipid • Brain MRI
- 56. 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)
- 58. Classification Pupil muscle Partial Not all muscle involved Complete Involvement Anisocoria All muscle involved Sparing isocoria
- 59. 3rd n. commoncause
- 67.
- 68. The lesion ofmultiple cranial n.
- 69. 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
- 71. Cavernous sinus syndrome •Combination of – Ophthalmoplegia (multiple cranial n. palsy) – Honer syn – Pain and V1 sensory loss
- 72. Lt. cavernous sinusmeningioma
- 73.
- 74. Miller Fisher syndrome Triad Ataxia Ophthalmoplegia Areflexia
- 75. The lesion ofInternuclear or supranuclear
- 77. Horizontal gaze paresis •Lesion of 6th n. nucleus – Loss of ipsilat. Voluntary and reflexive conjugate movement – Ipsilat. Facial weakness
- 78. Internuclear ophthalmoplegia • Lesionof MLF – Ipsilesional deficit of adduction – Nystagmus – Convergence may overcome adduction deficit
- 79. Convergence: normal
- 80. 1 and ½syndrome
- 81. Anatomy of conjugatevertical gaze
- 82. Conjugate Vertical eyemovement
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- 85.
- 86. Skew deviation andthe ocular tilt reaction(OTR) • Vertical misalignment • Acute brain stem dysfuction
- 89. 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 injery • Botulinum Toxin injection – Straighten for several weeks