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Eye movement Eye movement disorders disorders Professor Dr. Professor Dr. Ayman Youssef Ezeddin Ayman Youssef Ezeddin Eassa Eassa

Eye Movement Disorders

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Eye Movement Disorders

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Page 1: Eye Movement Disorders

Eye movement disordersEye movement disorders

Professor Dr.Professor Dr.

Ayman Youssef Ezeddin EassaAyman Youssef Ezeddin Eassa

Page 2: Eye Movement Disorders

Diplopia

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• Concomitant strabismus (ophthalmological) deviation is constant.

• Non concomitant strabismus (neurological) varies with gaze deviation (paralytic-restrictive)

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• Heterophoria: tendency for ocular misalignment

• Heterotropia: manifest under stress;– Fatigue– Bright sun– Alcohol– Anticonvulsants– Sedatives

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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

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Double vision

Present as: Overlapping images (ghosting) Frank diplopia Blurred vision

Physiologic diplopia

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Double vision• Image may be

– Tilted → oblique muscle– Vertical → lateral muscles– Horizontal → depressor & elevator muscles

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• Monocular diplopia: (double vision persists when closing one eye.)

– Refractory error– Psychogenic– Retinal– Cerebral cortex– Pinhole test solves the problem of diagnosis. **

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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

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Clinical assessment (cont.)

• Associated symptoms– Headache– Dizziness– Vertigo– Weakness (general)

• Medications received• Family history• Eye surgery

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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

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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

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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

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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

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Clinical assessment (cont.)• Pupils• Lids• Doll’s eyes• Bell’s phenomenon• Bruit• Edrophonium test• Forced ductions

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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

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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

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Abnormalities of optic nerve and retina

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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

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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

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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

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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

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Papilledema (cont.) • Malignant hypertension.• Diabetic papillopathy.• Anemia.• Hyperviscosity syndromes.• Pickwickian syndrome.• Hypotension.• Severe blood loss.• COPD ?±• Giant cell temporal arteritis.• Methanol poisoning.

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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

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