Download - Neuro Ophthalmology
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Neuro-ophthalmologyfor
Medical StudentSurat Tanprawate, MD, MSc(London), FRCP(T)
Neurology Unit, Department of MedicineChiang Mai University
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
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Frontal eye fields
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Frontal lobe lesion: no diplopia- Destructive FEF lesion: • eyes deviate to the lesion
- Excitatory lesion: • eyes deviate to contralateral to the lesion
Right frontal lobe infarct
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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- PPRFVertical diplopia- INC, riMLF
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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
• 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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A woman with acute diplopia for 2 weeks
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A woman with acute diplopia for 2 weeks
Right LR palsy; No other neurological sign, MRI brain-normal
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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”Wednesday, October 31, 2012
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A 55 Y.O. with DM, HT presented with acute diplopia for 2 days
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A 55 Y.O. with DM, HT presented with acute diplopia for 2 days
Left LR palsy
Wednesday, October 31, 2012
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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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Third nerve palsy
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Multiple oculomotor nerve involvement
• Cavernous sinus syndrome
• Superior orbital fissure syndrome
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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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Superior orbital fissure syndrome
CN 3, 4, 6, V1Wednesday, October 31, 2012
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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
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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
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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 lesionInterneuclear ophthalmoplegia (INO): MLF lesionBilateral INO : Bilateral MLF lesionOne and a half syndrome: PPRF lesion + MLF lesion
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Unilateral MLF lesion• “ internuclear
ophthalmoplegia “• Ipsilat. MR weakness• Ipsilat. abducting
saccade• Contralat. adducting
nystagmus• Dissociated 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
WIBINOWednesday, October 31, 2012
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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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Infranuclear lesion ;
disease of ocular muscledisease of NMJ
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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 centers for ocular pursuit
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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
• 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”Wednesday, October 31, 2012
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case study: a boy with subacute dizziness
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Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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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
Wednesday, October 31, 2012
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Thank you for your kind attention
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The NeurologistCMU
Wednesday, October 31, 2012