Diagnosis of Peripheral Ocular Motor Palsies and Strabismus

2015 ◽  
pp. 569-656 ◽  
Author(s):  
R. John Leigh ◽  
David S. Zee
Keyword(s):  
Nerve Palsy ◽  
Head Tilt ◽  
Abducens Nerve ◽  
Extraocular Muscles ◽  
Progressive External Ophthalmoplegia ◽  
Oculomotor Nerve Palsy ◽  
Tilt Test ◽  
Hering’S Law ◽  
Abnormal Head ◽  
Maddox Rod

This chapter reviews the physiologic basis for diplopia, including Sherington’s law of reciprocal innervation and Hering’s law of motor correspondence. Clinical testing is reviewed, including cover tests, red glass, Maddox rod, the Bielschowsky head-tilt test, and abnormal head postures. Clinical features (with illustrative video cases), etiology, and management of abducens nerve palsy, trochlear nerve palsy, oculomotor nerve palsy, and combined neuropathies are discussed, as well as Miller Fisher syndrome, amyotrophic lateral sclerosis, neuromyotonia, Brown’s syndrome and superior oblique myokymia. Disorders of the neuromuscular junction are examined, including systemic botulism, Lambert-Eaton myasthenic syndrome, and myasthenia gravis. Disorders affecting the extraocular muscles are reviewed, including chronic progressive external ophthalmoplegia, Duchenne dystrophy, myotonic dystrophy, oculopharyngeal dystrophy, congenital myopathies, Kearns-Sayre syndrome and mitochondrial myopathies. The chapter also discusses thyroid eye disease, acquired restrictive ophthalmopathies, and congenital cranial dysinnervation disorders (CCDD), Duane syndrome, horizontal gaze palsy with scloliosis, and congenital fibrosis of the extraocular muscles.

The Extraocular Muscles and Diplopia

2014 ◽  
pp. 124-161
Author(s):  
Shirley H. Wray ◽  
Shirley H. Wray
Keyword(s):  
Eye Movements ◽  
Nerve Palsy ◽  
Neuromuscular Junctions ◽  
Cranial Nerves ◽  
Abducens Nerve ◽  
Extraocular Muscles ◽  
Oblique Muscle ◽  
Oculomotor Nerve Palsy ◽  
Subjective Complaint ◽  
Oculomotor Nuclei

deals with action and innervation of the extraocular muscles. In their intact state, the extraocular muscles and the cranial nerves that innervate them are responsible for every movement of the eyes signaled by the cortex. Diplopia, or double vision, is the commonest subjective complaint associated with a lesion affecting the extraocular muscles, their neuromuscular junctions, the oculomotor nuclei or nerve, or pathways in the brainstem that maintain alignment of the eyes. The diplopia history focuses on distinguishing monocular from binocular diplopia and the diplopia examination pays attention to head position, ocular alignment, and the range of eye movements during monocular and binocular viewing as keys to diagnosis. Diplopia with full eye movements is fully discussed. Four illustrative cases are presented: episodic diplopia due to ocular myasthenia gravis; a case of esotropia (paresis of the lateral rectus with inward deviation of the eye) due to an abducens nerve palsy; a case of exotropia (paresis of the medial rectus with outward deviation of the eye) due to a fascicular oculomotor nerve palsy; and a case of hypertropia (vertical misalignment of the eyes due to paresis of the superior oblique muscle vs. skew deviation) caused by a post-traumatic trochlear nerve palsy.

scholarly journals Surgical Treatment of Cavernous Sinus Lesion in Patients with Nonfunctioning Pituitary Adenomas via the Endoscopic Endonasal Approach

2018 ◽  
Vol 79 (S 04) ◽  
pp. S311-S315 ◽  
Author(s):  
Kenzo Kosugi ◽  
Hiroyuki Ozawa ◽  
Kaoru Ogawa ◽  
Kazunari Yoshida ◽  
Masahiro Toda
Keyword(s):  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Nerve Palsy ◽  
Abducens Nerve ◽  
University Hospital ◽  
Oculomotor Nerve Palsy ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Nonfunctioning Pituitary Adenomas

Objective The main purpose of this article is to assess the effectiveness and safety of surgery via the endoscopic endonasal approach (EEA) for cavernous sinus (CS) lesion in patients with nonfunctioning pituitary adenomas (NFPA). Design Retrospective study. Setting Keio University Hospital. Participants Thirty patients who underwent CS surgery via the EEA between 2009 and 2017 for Knosp grade 4 NFPA with pre- and postoperative magnetic resonance imaging available for volumetric analysis. Main Outcome Measures Clinical presentation, extent of resection, and surgical complications. Results Gross total and near total resection of CS tumors was achieved in 12/30 (40%) cases of Knosp grade 4 NFPA. The average resection rate of CS lesions in these 30 patients was 73.5%; 77.3% in primary cases and 70.1% in recurrent cases that did not vary significantly. Preoperative visual disturbance and oculomotor nerve palsy improved in 12/19 (63.1%) and ⅗ (60%) cases, respectively. Complications associated with CS via the EEA were postoperative cerebrospinal leakage (1/30, 3.3%), meningitis (1/30, 3.3%), and transient cranial nerve palsy (2/30, 6.7%). These complications except a case of mild transient abducens nerve palsy occurred in recurrent cases with subdural lesions. Conclusions Although the optimal management of CS lesions in NFPA is controversial, debulking via the EEA is an effective and safe option that improves neurological symptoms and enables effective adjuvant radiotherapy. Recurrent cases with subdural invasion are technically challenging, even using the EEA, and special care is required to avoid complications.

scholarly journals Tolosa-Hunt Syndrome: A Case Report

2021 ◽  
Vol 59 (238) ◽  
Author(s):  
Siddhanta K.C. ◽  
Shreeyanta K.C. ◽  
Prajjwal Kunwar ◽  
Krishna Dhungana
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Steroid Therapy ◽  
Nerve Palsy ◽  
Rectus Muscle ◽  
Abducens Nerve ◽  
Oculomotor Nerve Palsy ◽  
Unknown Etiology ◽  
Resonance Imaging ◽  
Hunt Syndrome

Tolosa-Hunt Syndrome is a rare disease characterized by painful ophthalmoplegia affecting third, fourth, and/or sixth cranial nerve caused by non-specific inflammation in the cavernous sinus or superior orbital fissure of unknown etiology. We presented a 67-year-old female with Tolosa-Hunt Syndrome. She had a right-sided headache and periorbital pain with double vision. Examination showed right-sided ptosis, right-sided trochlear and abducens nerve palsy, and partial right-sided oculomotor nerve palsy with hypoesthesia in the area of the ophthalmic division of the trigeminal nerve. Magnetic resonance imaging of head and orbit showed altered signal intensity changes in the optic nerve and lateral rectus muscle. After steroid therapy, pain and ptosis were significantly improved in 72 hours. Tolosa-Hunt Syndrome is a diagnosis of exclusion, with clinical presentation, normal investigations, magnetic resonance imaging findings, and response to steroid therapy crucial in making the diagnosis.

Pituitary Apoplexy Presenting as Isolated Oculomotor Nerve Palsy

2007 ◽  
Vol 41 (4) ◽  
pp. 246
Author(s):  
Moon Seok Yang ◽  
Won Ho Cho ◽  
Seung Heon Cha
Keyword(s):  
Nerve Palsy ◽  
Pituitary Apoplexy ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy

Left suboccipital supracerebellar transtentorial approach for resection of tectal cavernous malformation

2019 ◽  
Vol 1 (2) ◽  
pp. V19
Author(s):  
Hussam Abou-Al-Shaar ◽  
Timothy G. White ◽  
Ivo Peto ◽  
Amir R. Dehdashti
Keyword(s):  
Nerve Palsy ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy ◽  
Entry Zone ◽  
Third Nerve Palsy ◽  
History Of ◽  
Tectal Plate ◽  
The Right ◽  
Transtentorial Approach ◽  
Third Nerve

A 64-year-old man with a midbrain cavernoma and prior bleeding presented with a 1-week history of diplopia, partial left oculomotor nerve palsy, and worsening dysmetria and right-sided weakness. MRI revealed a hemorrhagic left tectal plate and midbrain cavernoma. A left suboccipital supracerebellar transtentorial approach in the sitting position was performed for resection of his lesion utilizing the lateral mesencephalic sulcus safe entry zone. Postoperatively, he developed a partial right oculomotor nerve palsy; imaging depicted complete resection of the cavernoma. He recovered from the right third nerve palsy, weakness, and dysmetria, with significant improvement of his partial left third nerve palsy.The video can be found here: https://youtu.be/ofj8zFWNUGU.

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