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Eye Movement Disorders
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Eye movement disordersEye movement disorders
Professor Dr.Professor Dr.
Ayman Youssef Ezeddin EassaAyman Youssef Ezeddin Eassa
Diplopia
• Concomitant strabismus (ophthalmological) deviation is constant.
• Non concomitant strabismus (neurological) varies with gaze deviation (paralytic-restrictive)
• Heterophoria: tendency for ocular misalignment
• Heterotropia: manifest under stress;– Fatigue– Bright sun– Alcohol– Anticonvulsants– Sedatives
Double vision
• Onset is always abrupt.• Cover one eye relieves the problem.• May be intermittent.• Solved by or compensated by head position
as:– Congenital superior oblique palsy– Ocular myasthenia– Thyroid ophthalmopathy
Double vision
Present as: Overlapping images (ghosting) Frank diplopia Blurred vision
Physiologic diplopia
Double vision• Image may be
– Tilted → oblique muscle– Vertical → lateral muscles– Horizontal → depressor & elevator muscles
• Monocular diplopia: (double vision persists when closing one eye.)
– Refractory error– Psychogenic– Retinal– Cerebral cortex– Pinhole test solves the problem of diagnosis. **
Clinical assessment• Cover one eye →• Daily variation (morning and evening).• Affected by fatigue• Images separated
– Vertically– Horizontally– Or oblique
• Distance between images constant despite the gaze direction or vary.
• Worse for near or distance.• Do eye lids drop• Influenced by head posture.• The progression course
Clinical assessment (cont.)
• Associated symptoms– Headache– Dizziness– Vertigo– Weakness (general)
• Medications received• Family history• Eye surgery
Clinical assessment (cont.)
• Lateral rectus– Worse at distance & looking to the side of weak
muscle.
• Superior oblique– Worse on downward to side opposite weak muscle– Difficult reading, watching TV in bed, going downstairs
• Medial rectus– Worse for near than far & to contralateral side more
Clinical assessment (cont.)• General inspection
– Ptosis (MG)– Ptosis + dilated pupil → occulomotor nerve palsy– Lid lag → thyroid– Lid retraction →
• 3rd nerve• Dorsal midbrain lesion• Hypokalemic periodic paralysis• Chronic steroid use
– Proptosis• Orbital lesion• Inflammatory (periorbital swelling, conjunctival injection)• Psseudotumor• Lymphoma• Dural sinus
Clinical assessment (cont.)• Head posture → to compensate• Sensory visual function
– Acuity– Color vision– Confrontation– Field of vision
• Stability of fixation– Stability of gaze holding mechanism المريض ينظر
التلقائية العين حركة يالحظ ثم محدد لهدف
Clinical assessment (cont.)• Versions (pursuit, saccades & ocular muscle
over reaction)• Convergence
باتجاه – متحرك هدف متابعة المريض من يطلب ) الناتجة ) العينين حركة متابعة و الطبيب اصبع األنف
ذلك عن
• Ductionsالواحدة – العين حركة يتابع ثم عين اغالق يطلب
• Ocular alignment & muscle balance– Should neutralize the head tilt
Clinical assessment (cont.)• Pupils• Lids• Doll’s eyes• Bell’s phenomenon• Bruit• Edrophonium test• Forced ductions
Causes• Encephalopathy HIV• Basilar meningitis or neoplastic infiltrates• Botulism• Brain stem lesions (stroke, encephalitis)• Carotid cavernous fistula• Cavernous sinus thrombosis• Fisher syndrome• Intoxications• MS• myasthenia
Causes (cont.)• Leigh’s disease (subacute necrotizing encephalopathy)• Orbital pseudotumor• Paraneoplastic encephalopathy• Associated with polyradiculopathy• Psychogenic• Tolosa-Hunt syndrome• Trauma• Wernicke’s encephalopathy• Myopathies: mitochondrial, fiber type disproportion• Vitamin E deficiency• Supra-para nuclear gaze palsy
Abnormalities of optic nerve and retina
Swollen optic disc
• True• Pseudo
– Clear peripapillary nerve fibers– No spontaneous venous pulsations (SVP)– Presence of hemorrhages– Hereditary optic disc drusen white people more
(more axonal degeneration)– Retinitis pigmentosa
Unilateral optic nerve (disc) edema
• Optic neuritis (papillitis if swollen disc occur)• Anterior ischemic optic neuropathy• Orbital comprssion lesions• Central retinal vein occlusion• Leukemia infiltrates• Neuropathy delayed radiation effect• Leber’s hereditary optic neuropathy
Differentiation of early papilledema and pseudo one
PapilledemaPseudopapilledemaDisc colorHyperemicPink yellowishMarginsIndistinct at superior
& inferior poles, later entire
Irregular blurred
Disc elevation & vessels
MinimalSVP (-)
Center of disc most elevated ± SVP
Nerve fiber layerDull May obscur blood
vessels
No edema
hemorrhagesSplinterRetinal, subretinal
Papilledema
= optic disc swelling secondary to ↑ ICP.• Acutely central visual acuity is generally normal.• Enlargement of the physiological blind spot,
concentric constriction and inferior visual fields loss.
• 4 stages for papilledema:– Early– Acute– Chronic– atrophic
Papilledema (cont.) • Malignant hypertension.• Diabetic papillopathy.• Anemia.• Hyperviscosity syndromes.• Pickwickian syndrome.• Hypotension.• Severe blood loss.• COPD ?±• Giant cell temporal arteritis.• Methanol poisoning.
Optic neuropathy with normally appearing optic disc = retrobulbar optic neuritis
Unilateral• Optic neuritis• Compressive lesion (visual
loss)examination: ? Normal (=field defects in fellow eye → compressive)
• Giant celll arteritis• Other vasculitides• Post stroke, severe blood
loss
Bilateral• Nutritional• Tobacco-alcohol• Vitamin B12 deficiencies• Folate deficiency• Toxic heavy metal• Drug related
– Chloramphenicol– Isoniazide– Chloroprpamide
• Bilateral compressive• Bilateral retrobulbar