4. HISTORY OF PRESENT ILLNESS
• The condition has started 5 weeks ago by sub acute onset
partially regressive course on treatment when the patient had
developed binocular diplopia which was vertical ( more
prominent on looking downward) improving with closure of
either eyes without fluctuation, diurnal variation, local eye
manifestations or apparent squint at that time.
5. HISTORY OF PRESENT ILLNESS
At that time, there was paresthesia in the right part of forehead at
beginning then extending to vertex within the following few days.
One week later, patient developed outward deviation of right eye
which progressed within ten days to develop dropping of right
upper eye lid which was partial associated with proptosis without
fluctuation, diurnal variation or local eye manifestations.
6. HISTORY OF PRESENT ILLNESS
One week later, patient developed right diminution of vision
associated with peri-orbital pain and color affection which
progressed till the patient only perceived light within around two
weeks.
7. HISTORY OF PRESENT ILLNESS
Through the history, the patient sought several ophthalmological
consultations and received topical treatments with no improvement
Then patient sought neurological consultation, she was admitted,
received 5 doses of pulse steroid with partial improvement of
dropping of right upper eye lid and forehead paresthesia and no
improvement as regard of the visual acuity but the patient noticed she
cannot move her right eye out-wards .
8. No symptoms suggestive other eye affection
No symptoms suggestive other cranial nerve affection
No symptoms suggestive motor , other sensory or cerebellar affection
No history of fever or headache suggested increased intracranial
pressure
No history of trauma , seizure or disturbed conscious level.
No history of chest or other systems affection
No history of oral , genital ulcers , joint affection or skin manifestation
9. • Born and live in Cairo
• Single
• menopause since ten years.
• No special habit of medical importance
•Social and menstrual history
10. PAST HISTORY
No history of blood transfusion
No history of trauma
No history of liver or kidney disease
No history of drug addiction .
11. • No history of similar condition
• Family history
12. FORMULATION
A 60 year female patient presented by subacute onset partial
regressive course of
Multiple cranial neuropathy ( right oculomotor , trochlear ,
abducens and ophthalmic division of trigeminal )and mild
proptosos with partial response on steroid
Right optic neuropathy with no improvement on steroid
14. • BP: 130/80
• Pulse: 84 beats/m, regular, average volume, equal on both sides.
• RR: 14 cycle/m.
• T: 37◦ C.
15. • Head and Neck: no characteristic facies, normal thyroid.
• Chest: fair air entry, no adventitious sounds.
• Heart: normal S1 & S2, no murmurs.
• Abdomen: Lax abdomen, not tender, no detectable ascites or supra
pubic dullness.
• Skin : no rash, plaques .
19. CRANIAL NERVES
• Olfactory: intact
• Optic:
VA: Rt: PL ; Lt: 6/9.
Color vision: intact on left eye
Visual field: NAD on left eye
Fundus examination: normal
20. CRANIAL NERVES
• Occulomotor, Trochlear, Abducent:
ocular motility :right partial 3rd , 6th and 4th cranial nerve palsy .
Pupil : Round regular bilateral. Right RAPD. Left RRR
Accommodation reflex : affected at right eye ( lag of right medial rectus )
No nystagmus.
21. CRANIAL NERVES
• Follow Up after pulse steroid :
ocular motility :
right Superior oblique , inferior oblique , superior , inferior rectus and
levator palpebrae marked improvement
Medial rectus show less improvement
Lateral rectus no improvement
22. CRANIAL NERVES
• Trigeminal :
Hypoesthesia involving right V1 which improved after pulse steroid
Sensory and motor NAD
Corneal reflex: intact
Jaw reflex: just elicited
• Facial Nerve:
No facial asymmetry
Glabellar reflex: normal
• Vestibulo-Cochlear:
Cochlear part: Intact
Vestibular part: intact .
23. CRANIAL NERVES
• Glossopharyngeal, Vagus:
Uvula: Centralized
Palatal movement: Intact on both side
Palatal& Pharyngeal Reflexes: present bilaterally
• Hypoglossal Nerve:
Tongue: no wasting, abnormal movements or fasciculation.
24. MOTOR SYSTEM
Upper limbs and Lower limbs:
Muscle state : no wasting or fasciculation
Power : full power
25. REFLEXES
Deep tendon reflexes:
• Normoreflexia of both knee and ankles
• Normal biceps, brachioradialis and triceps
• Superficial reflexes
Abdominal: preserved bilaterally upper, middle and lower
Plantar: Bilateral flexor plantar
30. LABORATORY TESTS
HGB 12
TLC 10
PLT 369
ESR 23
INR 1
LFT NAD
KFT NAD
VEP normal parameter on left
No response on right
OCT. Normal finding of right and left eyes
