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
Wednesday, October 31, 2012
The scope of Neuro-ophthalmology
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system
Eyelids Pupils
Wednesday, October 31, 2012
The scope of Neuro-ophthalmology
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system Visual loss
Eyelids Pupils
Wednesday, October 31, 2012
The scope of Neuro-ophthalmology
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system Visual loss
Eyelids Pupils
Ptosis
Wednesday, October 31, 2012
The scope of Neuro-ophthalmology
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system Visual loss
Eyelids Pupils
Ptosis Anisocoria
Wednesday, October 31, 2012
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 elds
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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
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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
Wednesday, October 31, 2012
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
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Key features
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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.
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Nuclear and nerve lesion
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CN III
The oculomotor nerve (cranial nerve III)
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CN IV
The course of the trochlear nerve in the pons
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CN VI
facial nerve wraps around the nucleus of cranial nerve VI within the pons
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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
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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
Left LR palsy
Wednesday, October 31, 2012
A 55 Y.O. with DM, HT presented with acute diplopia for 2 days
Left LR palsy
Dx. 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 ssure 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, V1
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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
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A patient with diplopia for 1 week with gait ataxia and areexia
2 weeks
2 months
Wednesday, October 31, 2012
A patient with diplopia for 1 week with gait ataxia and areexia
2 weeks
2 months
in a patient with polyneuropathy, all CN can be involved causing total ophthalmoplegia
Wednesday, October 31, 2012
A patient with diplopia for 1 week with gait ataxia and areexia
2 weeks
2 months
Dx. Miller Fisher syndrome
in a patient with polyneuropathy, all CN can be involved causing total ophthalmoplegia
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Interneuclear lesion
Interneuclear ophthalmoplegia (INO): MLF lesion Bilateral INO : Bilateral MLF lesion One 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)
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
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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
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A man with sudden diplopia
WIBINO
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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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Wednesday, October 31, 2012
Infranuclear lesion ;
disease of ocular muscle disease 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
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
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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
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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
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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
Wednesday, October 31, 2012
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
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case study: a boy with subacute dizziness
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Conclusion
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system
Eyelids Pupils
Wednesday, October 31, 2012
Conclusion
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system
Eyelids Pupils
Wednesday, October 31, 2012
Conclusion
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system Visual loss
Eyelids Pupils
Wednesday, October 31, 2012
Conclusion
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system Visual loss
Eyelids Pupils
Ptosis
Wednesday, October 31, 2012
Conclusion
Oculomotor system
Disconjugate eyes: diplopia
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Visual perception system Visual loss
Eyelids Pupils
Ptosis Anisocoria
Wednesday, October 31, 2012
Thank you for your kind attention
Wednesday, October 31, 2012
The Neurologist CMU
Wednesday, October 31, 2012
