gobin-diplopia & fourth cranial nerve palsy
TRANSCRIPT
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DIPLOPIA & FOURTH CRANIAL NERVE PALSY
CARL V. GOBIN, MD AZ MONICA ANTWERPEN
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DIPLOPIA
• Anamnesis: – Persistent / intermittent – How long – Position double image – Direction of gaze – What distance
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DIPLOPIA
• Inspection: – Spastic closure of the eye – Head posture:
• Head tilt • Head turn • Chin up/ down
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Acquired IV nerve palsy
Origin: – Trauma of the skull:
• Fracture of the skull • Commotio contusion of the brain • Trauma of the orbit
– Microvascular accidents: • Diabetes • Hypertension
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Acquired unilateral IV n. palsy
• Vertical & torsional diplopia: – Depression > elevation
• Torticollis: – Head tilt towards the non-palsied side
• Hypertropia in laevo- OR dextroversion: – Adduction > abduction
• Excyclotropia • Positive Bielschowsky head tilt test:
– Hypertropia is maximal to the palsied side
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Acquired unilateral IV n. palsy • Vertical deviation is not large:
– Increase in adduction – Decrease in abduction – Increase in depression
• Horizontal deviation: – Superior oblique muscle is an abductor! – Small esotropia in downgaze
• Cyclotropia: – Superior oblique muscle is an incyclotortor! – Excyclotorsion due to inferior oblique overaction
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Acquired unilateral IV n. palsy
• Treatment: – Wait for spontaneous recovery – Prisms – Surgery: weakening procedures of the
inferior oblique muscle » Posterior myotomy » Anterotransposition » Disinsertion
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Acquired bilateral IV n. palsy • Frequently overlooked!
– Apparent unilateral trochlear palsy: • Paralysies à bascule (Hugonnier) • Postoperative ping pong effect
• Diplopia is often vaguely, indefinite
• Marked excyclotorsion (> 10°)
• V-pattern
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Acquired bilateral IV n. palsy
• Depression of the chin • Esotropia in depression : V-pattern • No limitation of eye movements • Hypertropia in laevo- AND dextroversion • Cyclotropia • Bilateral homonymous positive
Bielschowsky head tilt test
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Acquired bilateral IV n. palsy
• Treatment – Wait for spontaneous recovery – Prisms have little value due to incomitances – Surgery:
• Weakening both inferior oblique muscles • Combined with horizontal rectus surgery
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Case report: cranial trauma
• Bicycle accident • Diplopia
– Vertical /oblique – Depression > elevation – Right > left
• Head tilt • Fresnel doesn’t work
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Case report: cranial trauma
• Hess-Lancaster: small vertical deviation
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Case report: cranial trauma
• Motility : typical pattern • overaction left inferior oblique • Dextro- > laevoversion • Depression > elevation • Positive Bielschowsky head tilt test
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Case report: cranial trauma
• Treatment: surgery • Anterotransposition left inferior oblique • Posterior myotomy right inferior oblique • Central tenotomy both lateral recti
• Result: happy patient, no more diplopia
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Case report: microvascular accident
• 73 y. man : hypertension & diabetes • Diplopia
– Vertical / oblique – Dextro- > laevoversion
• Small head turn to the left • No previous treatment
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Case report: microvascular accident
• Hess-Lancaster: right hypertropia, V-pattern
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Case report: microvascular accident
• Motility pattern: typical • Right inferior oblique overaction • R/L in laevoversion & depression • Positive Bielschowsky head tilt test • V-exo pattern
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Case report: microvascular accident
• Treatment: fresnel prism worked
• Prism 3 diopter top at 45° before right eye
• Patient free of complaints
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AMICO 2012
• CASE REPORTS • Members of BSA • Assistants of all Belgian
universities • Your problem is our problem! • Contact Prof. Yuksel • [email protected]