Neuro-ophthalmology.pdf
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Transcript of Neuro-ophthalmology.pdf
![Page 1: Neuro-ophthalmology.pdf](https://reader034.fdocuments.us/reader034/viewer/2022042820/55cf9b45550346d033a56217/html5/thumbnails/1.jpg)
Clinical Neuro-Ophthalmology
Surat Tanprawate, MD, MSc(London), FRCP(T)!Neurology Unit, Department of Medicine!Chiang Mai University
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The scope of Neuro-Ophthalmology
• Oculomotor system!
• conjugate eye movement!
• Saccadic system !
• Pursuit system!
• Vergence system!
• Counter rolling system: VOR, Ocular fixation system
• Visual perception system!
!
• Eyelids!
• Pupils
Disconjugate eyes: diplopia
Visual loss
Ptosis
Anisocoria
Anisocoria
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Oculomotor pathway
• Supranuclear(UMN)!• FEF: horizontal conjugate gaze!• Diffuse frontal and occipital:
vertical conjugate gaze!• Nuclear (LMN)!
• Nerve III, IV, VI Nucleus!• Internuclear!
• PPRF, abducen interneuron, MLF (Horizontal gaze)!
• riMLF, INC, PC (Vertical gaze)!• Infranuclear(LMN)!
• Fasciculus!• Cranial nerve!• NMJ!• Muscle
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Frontal eye fields
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Frontal lobe lesion: no diplopia!- Destructive to FEF lesion: !
• eyes deviate to the lesion!- Destructive to Pontine lesion:!
• eyes deviate contralateral to the lesion!- Excitatory lesion: !
• eyes deviate contralateral to the lesion
Right frontal lobe infarct
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Case
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Dysconjugate eyes
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Diplopia (double vision)
• Diplopia is the simultaneous perception of the two images of a single object that may be displaced horizontally, vertically, diagonally!
• caused by impair EOMs functions
pic from wikipedia
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DiplopiaMonocular
diplopiaBinocular diplopia
Repetitive images
Ghosting image
- Cerebral polyopia!- Non-organic
- Retinal disease!- Refractive error
Misalignment of the eyes
Nuclear control
Internuclear control
Infranuclear control
- CN III!- CN IV!- CN VI
- CN palsy!- NMJ disorder!- Muscle disorder
Horizontal diplopia!- INO!- PPRF!Vertical diplopia!- INC, riMLF
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IIIIV
VI
Nuclear and Internuclear control
Vertical gaze internuclear control
Horizontal gaze internuclear control
Nuclear control: Nucleus III, IV, VI
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Infranuclear control
Fasciculus
Nerve
NMJ
Muscle
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Key featuresNuclear and fascicular lesion!
• Brain stem sign: long tract sign, other CN involvement!
Nerve lesion!
• Neighbourhood sign; other CN, other sign!
Internuclear lesion!
• Specific syndrome; Internuclear Ophthalmoplegia (INO), WEBINO, One and a half syndrome!
NMJ lesion!
• Fatiguability, not consistent with CN lesion, sign of myasthenia gravis!
Muscle lesion!
• Not consistent with CN lesion: not consistent with CN lesion, sign of myopathy
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The action and nerve supply of the extraocular muscles is demonstrated
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Nuclear and nerve lesion
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The oculomotor nerve (cranial nerve III)
CN III
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The course of the trochlear nerve in the pons
CN IV
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facial nerve wraps around the nucleus of cranial nerve VI within the pons
CN VI
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Isolated CN III palsy with sparing pupil
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Cause of oculomotor nerve palsy
• Common: vasculopathy (diabetes, atherosclerosis, aneurysm), tumor!
• Less common: inflammation, cavernous sinus thrombosis
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A woman with acute diplopia for 2 weeks
Right LR palsy; No other neurological sign, !MRI brain-normal
“Pure Right CN VI palsy”
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A 55 Y.O. with DM, HT presented with acute diplopia for 2 days
Left LR palsyDx. “Left CN VI palsy from ischemic neuropathy”
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Bilateral LR could be pseudo sixth nerve palsy from IICP
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Cause of CN VI palsy
• Most common: vasculopathy (diabetes, hypertension, atheroscleosis), trauma, idiopathic, IICP!
• Less common: giant cell arteritis, cavernous sinus lesion, multiple sclerosis, vasculitis, stoke
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Posterior communicating artery aneurysm causing CN III palsy
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Multiple nerve involvement
• Cavernous sinus syndrome!
• Superior orbital fissure syndrome
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!29
Cavernous sinus syndrome
• Association with !– other cranial nerve
involvement: 4, 5, 6 CN !– oculosympathetic paralysis!– Opthalmic branch of trigeminal
nerve!• Tend to be partial; alls
muscles innervated are not equally involved
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!30
Superior orbital fissure syndrome
CN 3, 4, 6, V1
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!31
Superior orbital fissure syndrome
• Involve CN 3, 4, 6 and V1 CN 5 distribution +/- oculosympathetic paresis without anhydrosis!
• May exopthalmos due to blockade of the opthalmic veins!
• Blindness due to extension of the pathologic process to involve the optic canal
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A patient with diplopia for 1 week with gait ataxia and areflexia
2 weeks 2 months
in a patient with polyneuropathy, all CN can be involved causing total ophthalmoplegia
Dx. Miller Fisher syndrome
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Interneuclear lesion
Interneuclear ophthalmoplegia (INO): MLF lesion!Bilateral INO : Bilateral MLF lesion!One and a half syndrome: PPRF lesion + MLF lesion
Horizontal
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Unilateral MLF lesion• “ internuclear
ophthalmoplegia “!• Ipsilateral MR weakness
ipsilateral side!• Contralat. abducting
nystagmus
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Interneuclear ophthalmoplegia (INO)
c. Normal left abduction on left gaze
d. Normal convergence
a. Normal primary position
b. Left impaired adduction on right gaze and horizontal nystagmus of the right eye
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Bilateral MLF lesion
• Bilateral MLF lesion!–Bilateral adducting weakness!–Bilateral abducting nystagmus!–Impaired vertical vestibular and pursuit !–Impaired vertical gaze holding!–Gaze evoked nystagmus!
• Wall eyed bilateral INO : WEBINO!–exotropia
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A man with sudden diplopia
WIBINO
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One and a half syndrome• Combined lesion :
PPRF and MLF!• “ One and a half
syndrome “!–Ipsilateral horizontal gaze
palsy!–INO
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Bilateral PPRF lesion
• Bilateral horizontal gaze failure!
• Sparing vertical gaze!
• Sparing pupil!
• May combine with other brain stem sign
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A woman with diplopia and facial palsy
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Interneuclear lesion
Upward and downward gaze failureVertical
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Vertical gaze control
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Cause of internuclear lesion
• Common: demyelination (multiple sclerosis), brainstem infarction!
• Less common: tumor, infection
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Infranuclear lesion ; !
disease of NMJ !disease of ocular muscle
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Neuromuscular Junction
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Features of NMJ disorder
• Ophthalmoplegia is not consistent with nerve distribution!
• Fatigue!
• Fluctuating course!
• with other muscle weakness esp. ptosis, proximal muscle weakness
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A patient with diplopia and ptosis
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Total ophthalmopathy in CPEO patient
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TRIO with Bilateral ptosis (MG)
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• Upper eyelid – Levator palpebral
superioris(CN 3) – Muller
muscle(sympathetic) – Frontalis muscle(CN 7)
• Lower eyelid – Capsulopalpebral
fascia(inferior rectus) – Inferior tarsal
muscle(sympathetic)
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Ptosis
Neurologic ptosis
Non-neurogenic(mechanical) ptosis
!•Uni-bilateral •Partial-complete
!•Pupil involvement •EOM impairment
!Supranuclear lesion(cerebral ptosis) •Contralateral cerebral hemisphere
LMN •Neuropathic(N, fascicle, CN) •NMJ •Myopathic
Congenital ptosis
Horner’s syndrome
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Ptosis from Cranial nerve III lesion!
- complete or near complete ptosis!
- EOM involvement!
- Pupil dilatation
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MG with enhancing ptosis
Ptosis due to NMJ lesion: sign of fatiguability
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Nystagmus
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Nystagmus• Ancient Greek (nustagmos (Ancient
Greek, "nodding, be sleepy")!
• Involuntary biphasic rhythmic ocular oscillation in which one or both phase are slow!
• The slow phase is responsible for the initiation and generation of the nystagmus, whereas the fast (saccadic) phase i a corrective movement bringing the fovea back on target!
• Type: jerk (direction to fast phase) ; pendular nystagmus
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Mechanism
• Nystagmus may result from dysfunction of the vestibular ending organ, vestibular nerve, brainstem, cerebellum, or cerebral centre for ocular pursuit
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Peripheral vs Central nystagmus
• Severe vertigo
• Minute to Day to weeks duration
• Hearing loss, tinnitus associated
• Usually horizontal with torsion
• Very rarely purely vertical or torsional
• Commonly peripheral vestibular organ dysfunction: labyrynthitis, meniere’s disease
• None or mild vertigo
• Often chronic
• May be purely vertical or torsional
• Visual fixation usually has no effect
• Downbeat, upbeat, torsional
• Etiologies commonly vascular, demyelination, pharmacologic, toxic
Peripheral nystagmus Central nystagmus
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In (A) a slow phase is followed by a slow phase while in (B)–(D) a slow phase is followed by a fast phase
A schematic illustration of nystagmus waveforms
(A) pendular nystagmus
(B) an accelerating velocity exponential slow phase jerk nystagmus (CN)
(C) a decelerating exponential slow phase jerk nystagmus (MLN)
(D) a linear or constant velocity slow phase jerk nystagmus (MLN)
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Mechanism• Pendular nystagmus: is central (brainstem/
cerebellum)!
• Jerk nystagmus: !
• linear (constant velocity) slow phase: peripheral vestibular dysfunction!
• slow phase has decreasing velocity exponential: brainstem neural integrator, cerebellar!
• slow phase has increasing velocity exponential: central in origin (usual form of congenital nystagmus)
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A woman with periodic vertigo occur when changing position
“vestibular nystagmus”
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Case study: a boy with subacute dizziness
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Conclusion
• Oculomotor system!
• conjugate eye movement!
• Saccadic system !
• Pursuit system!
• Vergence system!
• Counter rolling system: VOR, Ocular fixation system
• Visual perception system!
!
• Eyelids!
• Pupils
Disconjugate eyes: diplopia
Visual loss
Ptosis
Anisocoria
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The Neurologist CMU
The Neurologist CMU
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Thank you for your kind attention