Study
Review All
Quiz!
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Cause of INO? |
Dz involving connection b/w III and IV nuclei, specifically the MLF |
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Most common etiology of unilat INO? Other causes? |
Ischemic-vascular (most common), neoplasm, trauma |
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Etiology of bilat INO? |
MS (most common in younger pts) |
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INO is seen mostly in (kids/adults/older), (males/females), and is (chronic/acute). |
older, males, acute |
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DDx of INO vs thyroid dz? |
Proptosis in thyroid dz |
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DDx of orbit dz vs INO? |
proptosis in orbit dz |
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In your pt you see an inability to adduct the RE with a nystagmus during abduction of the LE. Convergence is intact. Dx? Where is the lesion? |
Right Posterior INO affecting right MR, at the Pons "MLF" = "MR Looks Funny" Anterior INO = convergence is lost |
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T/F - RINO = RMLF lesion = RMR dysfxn. |
True |
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The CN VI nucleus sends signals to what two muscles for conjugate gaze? |
Ipsilateral LR (direct), contralateral MR (MLF connects CN VI nucleus to CN III nucleus) |
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What causes the nystagmus during INO? |
Incr innervation to weak MR results in excessive activity to contralateral LR. |
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Besides nystagmus and MR dysfxn, what other signs seen in INO? |
- Decr saccadic response of affected eye (glissade) |
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Anterior INO is located at what level of the brainstem? |
midbrain |
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Post INO located at what level of brainstem? |
Pons = Posterior |
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Anterior INOs are localized... |
between MLF and CN III nucleus |
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Posterior INOs are localized... |
between MLF and CN VI nucleus |
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Anterior INO is (infra/supra)nuclear? |
infra |
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Posterior INO is (infra/supra)nuclear. |
supra |
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Most INOs are (post/ant). |
post (2/3) ant = 1/3 |
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T/F - Bilat INOs tend to be acute. |
False - progressive |
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T/F - Bilat INOs in younger pts tend to be assoc w/ MS. |
True |
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T/F - If a Bilat INO is complete on both sides, it is most likely MS. |
False - Non-MS bilat INOs tend to be complete. |
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You see a pt with poor adduction in both right and left gaze with no abduction nystagmus. Dx? |
Bilat INO |
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What is WEBINO mostly assoc with? |
MS |
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You see a bilat INO with exotropia. You suspect... |
WEBINO Called "Wall-eyed" b/c as if pt is looking at both walls at each side. |
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Mortality of unilat INO 18 mos from Dx = __% |
42 |
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How do you Tx a pt with INO due to DM? |
Tx INO due to vascular etiology with prism; see improvement in 90 days. |
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A lesion that encompasses the MLF and PPRF on the same side at the level of the pons describes... |
One and a half syndrome |
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Etiology of 1.5 syndrome? |
infarction, MS |
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Your pt on forward gaze has an exo on the RE. On right gaze the RE can abduct but LE appears straight. On left gaze both eyes appear straight. Dx? |
left 1.5 syndrome Think of it this way - eye that appears straight in forward or R/L gaze is the side of the lesion |
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You see L-N dissoc of the pupils, inability to gaze upward with assoc nystagmus, and lid retraction on downgaze. Dx? |
DMS |
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What specific area of the midbrain is affected in DMS? |
Posterior commissure |
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T/F - It is possible to see a unilateral upward gaze dysfxn in DMS. |
False - post commissure lesion affects both eyes for upgaze |
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Where is the upward gaze center? How does it relate to DMS? |
RiMLF. The RiMLF from both sides pass thru the post commissure, which is damaged in DMS |
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Etiologies of DMS? |
Pinealoma, MS, infarction, syphyllis, AV malformations |
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What conjugate gaze syndrome involves Collier's sign? |
DMS - lid retraction on downgaze |
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Besides L-N dissoc, upward gaze paralysis, and Collier's sign, what other signs of ___ can be present? |
DMS; convergence spasm, decr downward saccades, papilledema, skew deviation |
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(horz/vert) divergence from acquired (supra/infra)nuclear or _____ disruption describes [this conjugate gaze syndrome]. |
vert, supra, vestibulo-ocular, skew deviation |
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Your patient's eyes appear to vertically diverge (and he also says he sees vertical diplopia), and you cannot isolate a single EOM that is causing it. You suspect... |
Skew deviation |
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Skew deviation suggests ____ or ____ disease. |
brainstem, cerebellar |
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T/F - Skew deviation typically presents with other neurologic dysfunction(s) |
True |
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T/F - Skew deviations are mostly noncomitant. |
False - 90% comitant |
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Your patient can change her hyper from left to right on different gaze positions. You suspect... |
noncomitant skew deviation |
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*What is the most common cause of spontaneous diplopia in middle-age and early senescent pts? |
Graves' |
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Eye involvement in Graves' dz can occur in pts with... |
- Hyperthyroidism |
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Pathophysiology of ocular involvement of Graves'? |
EOMs infiltrated with lymphocytic and plasmacytic material which incr volume of muscle; EOMs become fibrotic and shortened, thus pulls eye in corresponding direction of that muscle |
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EOM involvement prevalence in Graves'? |
IR = 60-70% "IMS" = "I MuscleS" |
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Your Graves' dz pt shows up with a right hypo (and restricted upgaze). You suspect what muscle is involved? |
IR since Graves' shortens the muscle thus pulls the eye down. |
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T/F - Graves' dz with ocular involvement is assoc w/ IOP increase in restricted field of gaze. |
True - 6mmHg or more |
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Pathophysiology of ocular myasthenia? |
Acquired autoimmunity; destroyed ACh receptors at NMJ (70-89% decr in receptors), thus weakness of with repetitive/sustained activity |
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Avg lifespan of ACh in normals? In myasthenia? |
7-11 days normal |
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T/F - Ocular Myasthenia is assoc w/ thymus hypoplasia. |
False - hyper |
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What autoimmune dz mentioned is related to thymus problems? |
ocular myasthenia (thymus hyperplasia, thymoma, dysthyroid dz) |
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Thymoma in myasthenia is more likely in younger, middle, or older aged pts? |
Older |
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T/F - About half of myasthenia pts will show eye signs initially. |
True (40-50%) |
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T/F - Most ocular myasthenia pts will develop generalized dz within 2-3 yrs. |
True (50-94%) |
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What are the most common symptoms of ocular myasthenia? Most commonly affected muscle? |
Ptosis and diplopia (90%) |
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T/F - There is often pupil involvement in ocular myasthenia. |
False - little or none |
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T/F - MG onsets in women earlier than men |
True |
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Why did Dr. S have a picture of Hugh Hefner and some playboy bunnies??? |
MG occurs in young women (under 40) and older men (over 40)! |
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R INO |
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What is the most common CN palsy? |
VI (Abducens) Remember "ATOM" mnemonic - Abducens, Trochlear, Oculomotor, Mixed |
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What is the Tensilon test used for? |
For DDx MG vs neural cause of palsy - if the pt is able to recover after tensilon, then reason is MG |
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What is Peek Sign? |
incomplete eye closure assoc w/ MG |
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What is Cogan's Lid Twitch Sign? |
For MG - have pt look down then up. Lid twitch on upgaze is positive |
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What is the icepack test? What is its sensitivity? |
For MG pts - place ice on eye for 2 mins; ptosis should disappear. Works by decr activity of cholinesterase in NMJ. 90% sensitivity |
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How do you admin the Tensilon test? |
Inject edrophonium chloride into the arm or hand vein of the MG pt; re-eval deviation 3-4 mins post-injection. |
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T/F - Tensilon test works better for ptosis vs ophthalmoparesis. |
True |
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Sensitivity of Tensilon test? Specificity? |
Sens = 86% |
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Sensitivity of Acetylcholine Receptor Antibody Titer? Specificity? |
Sens = 64% |
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What is a ptosis crutch? |
For ocular myasthenia pts - holds up ptosis with wire behind glasses |
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What drug mentioned is used to Tx ocular myasthenia? Dose? How does it work? |
Pyridostigmine (Mestinon) 60mg TID - an anticholinesterase agent |
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Mestinon has a __ min onset, duration __ hrs. |
30 min, 4 hrs |
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T/F - Mestinon works better for diplopia vs ptosis. |
False - just like tensilon, better for ptosis |
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ADEs of Mestinon? |
GI upset, colitis |
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Your pt's eyes looks like they "freeze" during EOM testing - there is limited motility in all directions. There is also bilateral ptosis, but the pupils are normal. Dx? |
CPEO |
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T/F - CPEO is worse later in the day. |
False - no diurnal variation (vs ocular myasthenia) |
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T/F - CPEO can be associated with limb and/or facial muscle weakness. |
True |
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T/F - Kearns-Sayre syndrome onsets after age 20. |
False - before 20 yrs old |
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What is the Kearns-Sayre syndrome triad? What other signs? |
Triad =Pigmentary retinopathy, Progressive ophthalmoplegia, Heart block Also incr CSF protein, short stature, delayed sexual maturity |
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T/F - CPEO is progressive and asymmetrical. |
False - it is progressive but symmetrical |
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Tx Kearns-Sayre syndrome? |
No known Tx, just Tx exposure keratopathy |
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Initial Sx of PSP? |
Loss of balance, falls |
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What disease involves supranuclear ophthalmoplegia with nuchal rigidity? |
PSP - also has loss of balance, behavioral changes |
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Areas of brain affected in PSP? |
Basal ganglia, brainstem, frontal lobe, cerebellum, spinal cord |
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Eye signs of PSP? |
Loss of vertical sacc, vert gaze, horz eye movement, bell's phenomenon; square wave jerks |
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T/F - PSP involves loss of vertical saccades |
True |
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Your patient has no vertical saccades, no vertical gaze, and an inability to do horz eye movements. You also see square wave jerks and no Bell's phenomenon. Dx? |
PSP |
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DMS is aka... |
Parinaud's |
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A pinealoma can cause this conjugate gaze syndrome |
DMS (Parinaud's) |
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T/F - 1.5 syndrome can be caused by neoplasm. |
False (the slides did not mention neoplasms as a cause, just infarctions, MS) |
