Today we discussed an approach to ptosis, diplopia and dysconjugate gaze. A few points:
An approach to diplopia: A useful first step is to break down between monocular (i.e. present with 1 eye closed) and binocular (far more common). If binocular, run through the potential causes anatomically from the central to peripheral.
Monocular: Consider ophthalmological causes
Binocular:
If changes through the day, consider myasthenia gravis
If thyroid disease present, consider Graves ophthalmopathy
If facial trauma, consider orbital fracture (most likey to cause inferior oblique palsy because of orbital floor fracture) other orbital diseases (e.g. tumor, infiltration, etc)
Once neurological:
1) Cerebral hemisphheres- gaze palsy/preference from frontal lesion (e.g. stroke), progressive supranuclear palsy (vertical then horizontal palsy with dementia, parkinsonism)
2) Brainstem- III, IV, or VI nuclei, internuclear ophthalmoplegia (can't adduct eye)- ipsilateral median longitudinal fasciculus (MLF)- leaves convergence intact. Brainstem causes include ischemic stroke, tumor, bleed, infection, demyelination
3) Nerves exiting the brainstem- compression (tumor, aneurysm), infarction or inflammation(e.g. DM2, vasculitis). REMEMBER WERNICKE'S! (thiamine deficiency), Miller-Fisher variant of Guillan-Barre (would have areflexia, ataxia),
4) Meninges- meningitis, neurosarcoid, leptomeningeal spread of cancer
5) Cavernous sinus thrombosis- III, IV, V1, V2, VI pass through; often associated with facial infections
6) NMJ- myasthenia as above
In someone with diplopia, how do you figure out which eye is the problem (if it's not obvious)?
A couple of pearls:
1) If someone complains of diplopia on looking in one diagonal direction, it is either the same-sided and oriented rectus muscle or the other-sided oppositely-oriented oblique muscle (e.g. diplopia on looking up and right, it is either R superior rectus or L inferior oblique. Diplopia on looking down and L is either L inferior rectus or R superior oblique)
2) If you cover up an eye when the patient is having diplopia, the eye that, when covered, takes away the most peripheral image is the problem
Ptosis:
Some considerations:
CN III palsy- should have ocular movement abnormalities, may have pupillary involvement (would be mydriasis from loss of parasympathetics)
Horner's syndrome- miosis (from loss of sympathetics), anhydrosis
Neuromuscular junction disorders- myasthenia gravis, botulism
Links:
1) Cerebral hemisphheres- gaze palsy/preference from frontal lesion (e.g. stroke), progressive supranuclear palsy (vertical then horizontal palsy with dementia, parkinsonism)
2) Brainstem- III, IV, or VI nuclei, internuclear ophthalmoplegia (can't adduct eye)- ipsilateral median longitudinal fasciculus (MLF)- leaves convergence intact. Brainstem causes include ischemic stroke, tumor, bleed, infection, demyelination
3) Nerves exiting the brainstem- compression (tumor, aneurysm), infarction or inflammation(e.g. DM2, vasculitis). REMEMBER WERNICKE'S! (thiamine deficiency), Miller-Fisher variant of Guillan-Barre (would have areflexia, ataxia),
4) Meninges- meningitis, neurosarcoid, leptomeningeal spread of cancer
5) Cavernous sinus thrombosis- III, IV, V1, V2, VI pass through; often associated with facial infections
6) NMJ- myasthenia as above
In someone with diplopia, how do you figure out which eye is the problem (if it's not obvious)?
A couple of pearls:
1) If someone complains of diplopia on looking in one diagonal direction, it is either the same-sided and oriented rectus muscle or the other-sided oppositely-oriented oblique muscle (e.g. diplopia on looking up and right, it is either R superior rectus or L inferior oblique. Diplopia on looking down and L is either L inferior rectus or R superior oblique)
2) If you cover up an eye when the patient is having diplopia, the eye that, when covered, takes away the most peripheral image is the problem
Ptosis:
Some considerations:
CN III palsy- should have ocular movement abnormalities, may have pupillary involvement (would be mydriasis from loss of parasympathetics)
Horner's syndrome- miosis (from loss of sympathetics), anhydrosis
Neuromuscular junction disorders- myasthenia gravis, botulism
Links:
Click here for a review from Neurology on evaluation of diplopia (need subscription to get)
Click here for a review of the link between migraine and stroke (a controversial, hot topic)
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