Case ReportCase Report
A 70- year- old man with blurredA 70- year- old man with blurred
vision related to binocular diplop...
Patient profilePatient profile
Name: 李 O 定
Age: 70- year- old
Gender: male
Chart number: 15297789
Date of admission:
990512
Chief ComplaintChief Complaint
Blurred vision related to binocuclear
diplopia for one week.
Present IllnessPresent Illness
This 70-year-old man presented to our OPD
with the complaint of
binocular diplopia for abou...
Present IllnessPresent Illness
He had no
nausea, vomiting,
cough, fever,
limbs weakness, slurred speech,
body weight loss,...
Present IllnessPresent Illness
He went to OPH local clinics for help where
ophthalmologic examinations revealed no
signifi...
Present IllnessPresent Illness
Tracking back to his history,
he suffered from the same symptoms but diplopia was
preferenc...
Past HistoryPast History
Stroke Risk Factors:
Hypertension (+) with medical control for
more than 10 years.
DM Type 2 (+) ...
Previous hospitalizations:
Binocular diplopia related to left abduence
nerve palsy( 981029- 981102)
Personal history:
Alco...
Physical examinationPhysical examination
Vital signs: T: 36.5 , P: 78 /min , R: 22 /min BP: 144/83℃
mmHg
General appearanc...
Physical examinationPhysical examination
Chest & Heart:
Breathing sound: Bilateral clear without
retraction.
Heart sound: ...
Neurological examinationNeurological examination
Mental status: Consciousness: clear, GCS:
E4V5M6
Language: spontaneous sp...
Neurological examinationNeurological examination
CN-III, IV, VI.
Senile ptosis(R/L): (-) post operatively / (+)
EOM:
limit...
Limited to look laterally of right eye while looking toward
right side (-3 ~ -4)
Compensatory face turn in the right direc...
Limited to look laterally of left eye while looking toward left side (0 ~ -1)
Compensatory face turn in the left direction...
Neurological examinationNeurological examination
CN-VIII.
Hearing: normal
CN-IX , X.
Word articulation: normal
Swallowing:...
Neurological examinationNeurological examination
Muscle power: no limbs weakness
RUE distal grade 5 LUE distal grade 5
RUE...
Neurological examinationNeurological examination
Sensory:
Touch: normal
Coordination(Cerebellum):
Finger-Nose-Finger: R't-...
Differential Diagnosis- outlineDifferential Diagnosis- outline
Differential diagnosis of binocular diplopia
VINDICAT
Diffe...
Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia
Vascular
Cerebrovascular accident...
Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia
Neoplasm
Primary intracranial tum...
Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia
Demyelinating
Acute inflammatory ...
Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia
Congenital, Cranial nerve
Third c...
Differential Diagnosis of sixth nerve palsy- AnatomyDifferential Diagnosis of sixth nerve palsy- Anatomy
The abducens nucleus
• surrounded by the facial nerve fasciculus
• associated intimately with the medial longitudinal fasc...
The VI nerve exits the pons anteriorly, ascends along the clivus bone, crosses the petrous apex,
and descends below the pe...
Anatomy differential diagnosis of sixth nerve palsy-Anatomy differential diagnosis of sixth nerve palsy-
Nuclear lesions
N...
Anatomy differential diagnosis of sixth nerve palsy-Anatomy differential diagnosis of sixth nerve palsy-
Fasicular lesions...
Anatomy differential diagnosis of sixth nerve palsy-Anatomy differential diagnosis of sixth nerve palsy-
subarachnoid spac...
Anatomy differential diagnosis of sixth nerve palsy-Anatomy differential diagnosis of sixth nerve palsy-
subarachnoid spac...
Anatomy differential diagnosis of sixth nerve palsy-Anatomy differential diagnosis of sixth nerve palsy-
Petrous apex lesi...
Anatomy differential diagnosis of sixth nerve palsy-Anatomy differential diagnosis of sixth nerve palsy-
Cavernous sinus a...
More common –
vasculopathic (diabetes, hypertension, atherosclerosis),
traumatic,
idiopathic.
Less common –
increased intr...
VI nerve palsy with limitation of abduction:
Diabetic ophthalmoplegia
Thyroid eye disease
Myasthenia gravis
Orbital trauma...
5/12(Day1) Day2 Day3 Day4
Hospital course
CBC/DC,
Biochem
EKG
CXR
Brain MRI with
contrast
Biochem
Stool analysis
Urine ana...
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 carot...
Laboratory data and image- Brain MRI
No definite abnormal signal intensity lesion
in the brain including
supratentorial ce...
Laboratory data and image- Biochem
The patient was dischargedThe patient was discharged
with diagnosis of
Right sixth nerve palsy related to
Diabetic ophthal...
Discussion and take home messageDiscussion and take home message
Discussion
Neuro-ophthalmic manifestations of diabetes
Ta...
Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of
diabetesdiabetes
Accommodation
Pupil dysfunction
Opti...
Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of
diabetesdiabetes
Right peripheral facial nerve paresi...
Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of
diabetesdiabetes
IV nerve paresis affecting the right...
Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of
diabetesdiabetes
Left VI nerve paresis in an elderly ...
Discussion and take home messageDiscussion and take home message
Take home message
How to differentiate the OPH or Neuro s...
Thanks for your attention
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  1. 1. Case ReportCase Report A 70- year- old man with blurredA 70- year- old man with blurred vision related to binocular diplopiavision related to binocular diplopia PGY Yuh- Shin Chang Supervisor 楊浚銘醫師 990520
  2. 2. Patient profilePatient profile Name: 李 O 定 Age: 70- year- old Gender: male Chart number: 15297789 Date of admission: 990512
  3. 3. Chief ComplaintChief Complaint Blurred vision related to binocuclear diplopia for one week.
  4. 4. Present IllnessPresent 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.
  5. 5. Present IllnessPresent Illness He had no nausea, vomiting, cough, fever, limbs weakness, slurred speech, body weight loss, epistaxis, hearing impaired, trauma or other eye discomfort.
  6. 6. Present IllnessPresent 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.
  7. 7. Present IllnessPresent 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.
  8. 8. Past HistoryPast 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 (-)
  9. 9. 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
  10. 10. Physical examinationPhysical 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(-)
  11. 11. Physical examinationPhysical 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
  12. 12. Neurological examinationNeurological examination Mental status: Consciousness: clear, GCS: E4V5M6 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): (+) / (+)
  13. 13. Neurological examinationNeurological 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…..
  14. 14. Limited to look laterally of right eye while looking toward right side (-3 ~ -4) Compensatory face turn in the right direction….. (-3 ~ -4)
  15. 15. Limited to look laterally of left eye while looking toward left side (0 ~ -1) Compensatory face turn in the left direction….. 0 ~ -1
  16. 16. Neurological examinationNeurological examination CN-VIII. Hearing: normal CN-IX , X. Word articulation: normal Swallowing: normal CN-XII. Tongue protrusion: midline
  17. 17. Neurological examinationNeurological 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
  18. 18. Neurological examinationNeurological examination Sensory: Touch: normal Coordination(Cerebellum): Finger-Nose-Finger: R't- normal, L't- normal Gaits: normal
  19. 19. Differential Diagnosis- outlineDifferential Diagnosis- outline Differential diagnosis of binocular diplopia VINDICAT Differential diagnosis of sixth nerve palsy Anatomy differential diagnosis Etiology differential diagnosis
  20. 20. Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia Vascular Cerebrovascular accident Carotid-cavernous fistula or thrombosis Intracavernous carotid artery aneurysm Internal carotid artery dissection Infection Bacterial- Contiguous sinusitis, Mucocele (sphenoid sinus), PeriostitisAbcess Viral- Herpes zoster Fungal- Mucormycosis, Actinomycosis Spirochetal- Treponema pallidum MycobacterialMycobacterium tuberculosis Brain MRI, Clinical presentation CBC/DC, Infection source, Clinical presentation
  21. 21. Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia Neoplasm Primary intracranial tumour: Pituitary adenoma, Meningioma, Craniopharyngioma, others Primary cranial tumour: Chordoma, others Local metastases: Nasopharyngeal tumour, Squamous cell carcinoma Distant metastases: Lymphoma, Multiple myeloma, Carcinomatous metastases Neuromuscular junction Myasthenia gravis Tick bite paralysis Botulism Brain MRI, Clinical presentation Clinical presentation
  22. 22. Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia Demyelinating Acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome) Recurrent demyelinating neuropathy (Ophthalmoplegic migraine) Diabetic ophthalmoplegia Third cranial nerve palsy Fourth cranial nerve palsy Sixth nerve palsy Inflammation Sarcoidosis, Wegener's granulomatosis, Eosinophilic granuloma Orbital myositis (Orbital pseudotumor ) Tolosa-Hunt syndrome Clinical presentation EOM, Clinical presentation Clinical presentation
  23. 23. Differential Diagnosis of binocular diplopiaDifferential Diagnosis of binocular diplopia Congenital, Cranial nerve Third cranial nerve palsy Fourth cranial nerve palsy Sixth nerve palsy Alcohol Alcoholism Wernicke's syndrome Trauma Thyroid ophthalmopathy EOM, Clinical presentation Brain MRI, Clinical presentation Thyroid function, Clinical
  24. 24. Differential Diagnosis of sixth nerve palsy- AnatomyDifferential Diagnosis of sixth nerve palsy- Anatomy
  25. 25. 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
  26. 26. 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 uclear lesions 2. Fasicular lesions….. 3. subarachnoid space….. 4. Petrous apex lesions/fractures….. 5. Cavernous sinus and superior orbital fissure lesions….. …..
  27. 27. Anatomy differential diagnosis of sixth nerve palsy-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 ……
  28. 28. Anatomy differential diagnosis of sixth nerve 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)……
  29. 29. Anatomy differential diagnosis of sixth nerve palsy-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
  30. 30. Anatomy differential diagnosis of sixth nerve palsy-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……
  31. 31. Anatomy differential diagnosis of sixth nerve palsy-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……
  32. 32. Anatomy differential diagnosis of sixth nerve palsy-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, V1, and V2 ……
  33. 33. 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-Differential Diagnosis of sixth nerve palsy- Etiology for adultsEtiology for adults
  34. 34. 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-Differential Diagnosis of sixth nerve palsy- Etiology for adultsEtiology for adults
  35. 35. 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
  36. 36. Laboratory data and image- CBC/DC
  37. 37. Laboratory data and image- Biochem
  38. 38. Laboratory data and image- EKG
  39. 39. Laboratory data and image- CXR Back
  40. 40. Laboratory data and image- Biochem
  41. 41. Laboratory data and image- Urine analysis
  42. 42. Laboratory data and image- Stool analysis
  43. 43. 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…..
  44. 44. 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……
  45. 45. Laboratory data and image- Biochem
  46. 46. The patient was dischargedThe patient was discharged with diagnosis of Right sixth nerve palsy related to Diabetic ophthalmoplegia Type 2 Diabetes mellitus Hypertension
  47. 47. Discussion and take home messageDiscussion and take home message Discussion Neuro-ophthalmic manifestations of diabetes Take home message
  48. 48. Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of diabetesdiabetes 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
  49. 49. Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of diabetesdiabetes Right peripheral facial nerve paresis, later diagnosed as Bell’s palsy.
  50. 50. Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of diabetesdiabetes 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.
  51. 51. Neuro-ophthalmic manifestations ofNeuro-ophthalmic manifestations of diabetesdiabetes 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
  52. 52. Discussion and take home messageDiscussion 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
  53. 53. Thanks for your attention

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