Neuro Ophthalmology

Neuro-ophthalmology for Medical Student
Surat Tanprawate, MD, MSc(London), FRCP(T) Neurology Unit, Department of Medicine Chiang Mai University
Wednesday, October 31, 2012
The scope of Neuro-ophthalmology
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system
Eyelids Pupils
Oculomotor system
Disconjugate eyes: diplopia
Eyelids Pupils
Oculomotor system
Visual perception system Visual loss
Eyelids Pupils
Oculomotor system
Eyelids Pupils
Ptosis
Oculomotor system
Eyelids Pupils
Ptosis Anisocoria
Oculomotor pathway
Supranuclear(UMN)
FEF: horizontal conjugate gaze Diffuse frontal and occipital: vertical conjugate gaze
Nuclear (LMN) CN III, IV, VI Internuclear

PPRF, abducen interneuron, MLF (Horizontal gaze) riMLF, INC, PC (Vertical gaze)
Infranuclear(LMN)
Faciculus Cranial nerve NMJ muscle
Frontal eye elds
Right frontal lobe infarct
Frontal lobe lesion: no diplopia - Destructive FEF lesion:
eyes deviate to the lesion

- Excitatory lesion:
eyes deviate to contralateral to the lesion

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
Diplopia
Monocular diplopia Binocular diplopia
Repetitive images
Ghosting image
Misalignment of the eyes
- Cerebral polyopia - Non-organic
- Retinal disease - Refractive error
Nuclear control
Infranuclear control
Internuclear control
- CN III - CN IV - CN VI
- CN palsy - NMJ disorder - Muscle disorder
Horizontal diplopia - INO - PPRF Vertical diplopia - INC, riMLF
Key features

Nuclear and fascicular lesion
Brain stem sign: long tract sign, other CN involvement
Nerve lesion Neighborhood sign; other CN, other sign
Internuclear lesion specic 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
The action and nerve supply of the extraocular muscles is demonstrated.
Nuclear and nerve lesion
CN III
The oculomotor nerve (cranial nerve III)
CN IV
The course of the trochlear nerve in the pons
CN VI
facial nerve wraps around the nucleus of cranial nerve VI within the pons
A woman with acute diplopia for 2 weeks
Right LR palsy; No other neurological sign, MRI brain-normal
Right LR palsy; No other neurological sign, MRI brain-normal
Pure Right CN VI palsy

A 55 Y.O. with DM, HT presented with acute diplopia for 2 days
Left LR palsy
Left LR palsy
Dx. Left CN VI palsy from ischemic neuropathy
Bilateral LR could be pseudo sixth nerve palsy from IICP
Third nerve palsy
Multiple oculomotor nerve involvement
Cavernous sinus syndrome Superior orbital ssure syndrome
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
19
Superior orbital fissure syndrome
CN 3, 4, 6, V1
20
Superior orbital ssure 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
21
A patient with diplopia for 1 week with gait ataxia and areexia
2 weeks
2 months
2 weeks
2 months
in a patient with polyneuropathy, all CN can be involved causing total ophthalmoplegia

2 weeks
2 months
Dx. Miller Fisher syndrome

in a patient with polyneuropathy, all CN can be involved causing total ophthalmoplegia
Interneuclear lesion
Interneuclear ophthalmoplegia (INO): MLF lesion Bilateral INO : Bilateral MLF lesion One and a half syndrome: PPRF lesion + MLF lesion
Unilateral MLF lesion

internuclear ophthalmoplegia
Ipsilat. MR weakness Ipsilat. abducting saccade Contralat. adducting nystagmus Dissociated nystagmus
Interneuclear ophthalmoplegia (INO)
a. Normal primary position
b. Left impaired adduction on right gaze and horizontal nystagmus of the right eye
c. Normal left abduction on left gaze

d. Normal convergence
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
A man with sudden diplopia
WIBINO
One and a half syndrome

Combined lesion : PPRF and MLF One and a half syndrome
Ipsilateral horizontal gaze palsy INO
Infranuclear lesion ;
disease of ocular muscle disease of NMJ
Total ophthalmopathy in CPEO patient
TRIO with Bilateral ptosis (MG)
Upper eyelid
Levator palpebral superioris(CN 3) Muller muscle (sympathetic) Frontalis muscle(CN 7)
Lower eyelid
Capsulopalpebral fascia (inferior rectus) Inferior tarsal muscle (sympathetic)
Ptosis
Non-neurogenic(mechanical) ptosis
Neurologic ptosis
Congenital ptosis
Uni-bilateral Partial-complete
Pupil involvement EOM impairment
Supranuclear lesion (cerebral ptosis) Contralateral cerebral hemisphere
LMN Neuropathic(N, fascicle, CN) NMJ Myopathic
Horners syndrome
Ptosis from Cranial nerve III lesion - complete or near complete ptosis - EOM involvement - Pupil dilatation
MG with enhancing ptosis
Ptosis due to NMJ lesion: sign of fatiguability

Nystagmus
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
Mechanism
Nystagmus may result from dysfunction
of the vestibular ending organ, vestibular nerve, brainstem, cerebellum, or cerebral centers for ocular pursuit
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)
In (A) a slow phase is followed by a slow phase while in (B)(D) a slow phase is followed by a fast phase
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 slow phase has increasing velocity exponential: central in origin (usual form of congenital nystagmus)
A woman with periodic vertigo occur when changing position
vestibular nystagmus
case study: a boy with subacute dizziness
Conclusion
Oculomotor system
Eyelids Pupils
Conclusion
Oculomotor system
Eyelids Pupils
Conclusion
Oculomotor system
Eyelids Pupils
Conclusion
Oculomotor system
Eyelids Pupils
Ptosis
Conclusion
Oculomotor system
Eyelids Pupils
Ptosis Anisocoria
Thank you for your kind attention

The Neurologist CMU

Neuro Ophthalmology

Transféré par

Informations du document

Description originale:

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Neuro Ophthalmology

Transféré par

Droits d'auteur :

Formats disponibles

Neuro-ophthalmology for Medical Student

Wednesday, October 31, 2012

The scope of Neuro-ophthalmology

Visual perception system

Wednesday, October 31, 2012

The scope of Neuro-ophthalmology

Disconjugate eyes: diplopia

Visual perception system

Wednesday, October 31, 2012

The scope of Neuro-ophthalmology

Disconjugate eyes: diplopia

Visual perception system Visual loss

Wednesday, October 31, 2012

The scope of Neuro-ophthalmology

Disconjugate eyes: diplopia

Visual perception system Visual loss

Wednesday, October 31, 2012

The scope of Neuro-ophthalmology

Disconjugate eyes: diplopia

Visual perception system Visual loss

Wednesday, October 31, 2012

Nuclear (LMN) CN III, IV, VI Internuclear

Wednesday, October 31, 2012

Frontal eye elds

Wednesday, October 31, 2012

Right frontal lobe infarct

Frontal lobe lesion: no diplopia - Destructive FEF lesion:

eyes deviate to the lesion

eyes deviate to contralateral to the lesion

Diplopia (double vision)

pic from wikipedia

Wednesday, October 31, 2012

Misalignment of the eyes

- Cerebral polyopia - Non-organic

- Retinal disease - Refractive error

- CN palsy - NMJ disorder - Muscle disorder

Horizontal diplopia - INO - PPRF Vertical diplopia - INC, riMLF

Wednesday, October 31, 2012

Nuclear and fascicular lesion

Brain stem sign: long tract sign, other CN involvement

Nerve lesion Neighborhood sign; other CN, other sign

The action and nerve supply of the extraocular muscles is demonstrated.

Wednesday, October 31, 2012

Nuclear and nerve lesion

Wednesday, October 31, 2012

The oculomotor nerve (cranial nerve III)

Wednesday, October 31, 2012

The course of the trochlear nerve in the pons

Wednesday, October 31, 2012

Wednesday, October 31, 2012

A woman with acute diplopia for 2 weeks

Wednesday, October 31, 2012

A woman with acute diplopia for 2 weeks

Right LR palsy; No other neurological sign, MRI brain-normal

Wednesday, October 31, 2012

A woman with acute diplopia for 2 weeks

Right LR palsy; No other neurological sign, MRI brain-normal

Pure Right CN VI palsy

A 55 Y.O. with DM, HT presented with acute diplopia for 2 days

Wednesday, October 31, 2012

A 55 Y.O. with DM, HT presented with acute diplopia for 2 days

A 55 Y.O. with DM, HT presented with acute diplopia for 2 days

Bilateral LR could be pseudo sixth nerve palsy from IICP