Horner's syndrome(Bernard-Horner syndrome)

(oculosympathetic palsy)Horner's syndrome or Horner syndrome is a clinical syndrome caused by damage to the sympathetic nervous system.

History

• 1869- Johann Friedrich Horner the Swiss ophthalmologist who first described.

• Claude Bernard is also eponymised with the condition

Pathophysiology• The nervous system in the body does not consist of straight lines to and

from the brain. In respect to the eye, the sympathetic nerves travels from the brain down the spinal column to the chest area and back up.

• First neuron pathway, starts at the brain and travels down the spinal cord and into the chest.

• Second neuron pathway continues from the chest cavity, over the lungs and up the carotid artery in the neck.

• Third neuron pathway goes from the carotid artery and jugular vein through the middle ear and then into the eye.

• Upon entering the eye the nerve pathways split, one goes to the pupil and one goes to the muscles of the eyelid.

• Horner's syndrome may occur as a result of lesions found along the course of the nerve's route from the brain to the eye.

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Etiology• First Neuron Horner's Syndrome (Central lesions)

• (1)Ischemic posterioinferior cerebellar artery(Wallenberg 's syndrome)

• (2)Brain tumors

• Second Neuron Horner's Syndrome (Preganglionic lesions)

• (1) lung cancer ( (Pancoast tumor ) on apex of lung)

• (2) thoracic tumors

• (3) thyroid enlargement

•

(4) osteoarthritis of the neck

(5) neck trauma caused by injury

Third Neuron Horner's Syndrome (Postganglionic lesions) :-

Group I

(1) Cluster headache

(2) Middle ear infection

(3) Cervical rib traction on stellate ganglion

(4) skull fracture

(5 cavernous sinus tumor

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Group II

(1) involves facial sweating mechanism.

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Clinical features

• Ptosis (which is drooping of the upper eyelid from loss of sympathetic innervation to the superior tarsal muscle)

• miosis (constricted pupil)• anhidrosis (decreased sweating on the affected

side of the face)• dilation lag (slow response of the pupil to light)• Enophthalmos (the impression that the eye is

sunk in)

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• bloodshot conjunctiva• flushing of the face is on the affected side of the

face due to dilation of blood vessels under the skin.

• Heterochromia difference in eye color between the two eyes due to lack of sympathetic stimulation of the melanocytes in iris. (iris may be of a different color).

• Swelling of the lower eyelid

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DIAGNOSIS

• Cocaine drop test:-Cocaine cause dilated pupil.

• In Horners syndrome pupil fails to dilate – lack of norepinephrine

• Paredrine test:- helps to locate the lesion in 3rd neuronal pathway.Amphetamine causes –robust mydriasis. But in horner’s syndrome no effect.

• Dilation lag test

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Treatment

• Treatment depends on the location and cause of the lesion

• surgical removal of a tumor• tumor is malignant, radiation

and chemotherapy

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