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