OpthalmoplagiaOpthalmoplagiaopthalmoparesisopthalmoparesis

Eye movement Eye movement

MotorMotor coordinationcoordination Motor pathway cerebellum Motor pathway cerebellum basal gangliabasal ganglia vestibular systemvestibular system

Paralysis nystagmusParalysis nystagmus opthalmoparesis opthalmoparesis

eye movement(motor) pathway eye movement(motor) pathway

SupranuclearSupranuclear

brainstem Internuclearbrainstem Internuclear

NuclearNuclear

Craineal nerveCraineal nerve

NMJNMJ

musclemuscle

Conjugate gaza palsyConjugate gaza palsy

Horizontal: cortex &pontineHorizontal: cortex &pontine Unilateral restriction of voluntary gaze to Unilateral restriction of voluntary gaze to

one side .one side . Frontal damage: eye look to the lesion Frontal damage: eye look to the lesion epilepsy: eye look awayepilepsy: eye look away Pontine: abducent n or PPRF…impair look Pontine: abducent n or PPRF…impair look

to site of lesion, look away ,towered to site of lesion, look away ,towered hemiplasiahemiplasia

Vertical gaze palsyVertical gaze palsy

Up –gaze palsy:pretectal lesion with damage to Up –gaze palsy:pretectal lesion with damage to post comissurepost comissure

Pretectal: parinaud syndrom: (paralysis of upward Pretectal: parinaud syndrom: (paralysis of upward gaze,lid retraction,impaired converg,convergence gaze,lid retraction,impaired converg,convergence retraction nystagmus,light near dissosiation)retraction nystagmus,light near dissosiation)

Causes: Causes: tumer,hydrocephalus 3tumer,hydrocephalus 3rdrd v compress on PC, stroke v compress on PC, stroke of thalamic of thalamic &midbrain ,MS,truma,wilson,syphlis ,TB,drug &midbrain ,MS,truma,wilson,syphlis ,TB,drug neuroliptic,barbiturate,tegretol)neuroliptic,barbiturate,tegretol)

Oculogyric crisis:Oculogyric crisis:

DefentionDefention:episodic, spasmodic,conjugate :episodic, spasmodic,conjugate ocular deviation,up wared &lateral. ocular deviation,up wared &lateral. Accompanied with mental changes, may Accompanied with mental changes, may associate with dystonia or other dyskinesiaassociate with dystonia or other dyskinesia

CausesCauses: encephalities lethargica, : encephalities lethargica, degenerative dis eg familial parkison, head degenerative dis eg familial parkison, head truma,neurosyphlis,MS,ataxia truma,neurosyphlis,MS,ataxia telengictasia,drug:neuroleptictelengictasia,drug:neuroleptic

Disconjucate eye movementDisconjucate eye movement

Internuclear pathologyInternuclear pathology

INO:INO: Damage to the MLF between 3&6 Damage to the MLF between 3&6

nerve ,impair transmisstion of impulse to the nerve ,impair transmisstion of impulse to the ipsilateral medial rectusipsilateral medial rectus

Impair ipsilateral adduction, abduction Impair ipsilateral adduction, abduction nystagmusnystagmus

No visual symptoms,other diplopiaNo visual symptoms,other diplopia Nystagmus cause not clear but may Nystagmus cause not clear but may

adaptiveadaptive

INOINO

Causes: Causes: MS,brainstem infarct,truma, MS,brainstem infarct,truma,

The one and half syndromeThe one and half syndrome

Impaired congucate gaze to one side & Impaired congucate gaze to one side & impair adduction to the other sideimpair adduction to the other side

PPRF or abducent nucleus + MLFPPRF or abducent nucleus + MLF

Nuclear ,nerve control Nuclear ,nerve control

Double visionDouble vision Brain stem contain the lower motor control Brain stem contain the lower motor control

of the eye movementof the eye movement 33rdrd supply all except: supply all except: 44thth SO, 6 SO, 6th th LR LR

Nuclear (brain stem)Nuclear (brain stem)

Long tract signs Long tract signs Crossed phenomenaCrossed phenomena

Causes:Causes: Tumor,MS,strokeTumor,MS,stroke

cranial nerve pathologycranial nerve pathology

ocular neuropathy :ocular neuropathy : CompressiveCompressive :localization acoording to :localization acoording to

stationsstations Non compressiveNon compressive: trauma, DM, vasculitis, : trauma, DM, vasculitis,

demyelinating ( miller fisher syndrome), demyelinating ( miller fisher syndrome), infection diphtheria infection diphtheria

Ocular nerves pathwayOcular nerves pathway

3,4,63,4,6thth nerve nerve

subarachnoid spacesubarachnoid space

cavernous sinuscavernous sinus

Superior orbital fissureSuperior orbital fissure orbit orbit

At sub arachnoidAt sub arachnoid

Complete 3Complete 3rdrd n palsy +_ other CN n palsy +_ other CN Causes:Causes: Posterior communicating aneurysm 3Posterior communicating aneurysm 3rdrd,superior ,superior

cerebellur 4cerebellur 4thth nerve nerve Tumor :meningeoma ,shwanomaTumor :meningeoma ,shwanoma TraumaTrauma MeningitisMeningitis SAHSAH Uncal herniationUncal herniation

At cavernous sinusAt cavernous sinus

Painful or painless if medially +_ 4,5,6Painful or painless if medially +_ 4,5,6 + Horner syndrome+ Horner syndrome Causes:Causes: Cavernous sinus thrombosisCavernous sinus thrombosis Dural carotid cavernous sinus fistulaDural carotid cavernous sinus fistula Carotid aneurysm lateral painlessCarotid aneurysm lateral painless Pituitary adenoma, apoplexyPituitary adenoma, apoplexy

At superior orbital fissureAt superior orbital fissure

3 +_,4,5.6 (no horner ,no maxillary nerve)3 +_,4,5.6 (no horner ,no maxillary nerve) Causes:Causes: Tolosa hunt syndromeTolosa hunt syndrome

At the orbitAt the orbit

Optic n visual loss, proptosis, swelling of Optic n visual loss, proptosis, swelling of lid ,chemosislid ,chemosis

Causes:Causes: Trauma ,tumor, cellulitesTrauma ,tumor, cellulites

Imp noteImp note

Many lesion extend from cavernous sinus to Many lesion extend from cavernous sinus to orbital apex and vice visceraorbital apex and vice viscera

Combined 3Combined 3rdrd n & sympathetic denervation n & sympathetic denervation is pathognomonic for cavernous sinus lesionis pathognomonic for cavernous sinus lesion

neuromuscularneuromuscular

Myasthenia graves (flactuation)Myasthenia graves (flactuation) botulismbotulism

musclemuscle

Hereditary Hereditary :mitochondrial :mitochondrial acquiredacquired traumatrauma ThyroidThyroid inflammatoryinflammatory