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Ocular Palsy

Ocular Palsies


Presentation

  • An abducens palsy will present with impairment of lateral gaze of the affected eye.[sinaiem.org]
  • A 75-year-old woman presented with intermittent left-gaze-evoked binocular diplopia. She had an incomplete right third nerve palsy but became symptomatically diplopic and esotropic upon sustained left gaze.[jhu.pure.elsevier.com]
  • Of those patients with undiagnosed ischemic risk factors on presentation, 21% were found to have hypertension, 5.2% with diabetes, 53.8%, with cerebrovascular accident and 30.8% with hyperlipidemia.[iovs.arvojournals.org]
  • Unilateral third nerve palsy was present in 23 patients (26%), fourth nerve palsy in 14 patients (16%), and sixth nerve palsy in 52 patients (58%).[ncbi.nlm.nih.gov]
  • However, third nerve palsies can be "partial"; any individual sign or combination of signs may be present and, if present, may be complete or incomplete. Numerous patterns can therefore arise.[guwsmedical.info]
Upbeat Nystagmus
  • The most common pathological types of central nystagmus are downbeat nystagmus (DBN) and upbeat nystagmus (UBN). DBN is generally due to cerebellar dysfunction affecting the flocculus bilaterally (e.g., due to a neurodegenerative disease).[ncbi.nlm.nih.gov]
Downbeat Nystagmus
  • The most common pathological types of central nystagmus are downbeat nystagmus (DBN) and upbeat nystagmus (UBN). DBN is generally due to cerebellar dysfunction affecting the flocculus bilaterally (e.g., due to a neurodegenerative disease).[ncbi.nlm.nih.gov]
Rubral Tremor
  • Location/signs Etiologies Fascicle Demyelination; hemorrhage; infarction Ipsilateral cerebellar ataxia; (rare in childhood) contralateral rubral tremor; contralateral hemiparesis; vertical gaze palsy Subarachnoid space Meningitis; trauma or surgery; tumor[guwsmedical.info]

Workup

  • The clinician assesses all these variables along with the history and physical examination to decide on the appropriate workup for each patient.[guwsmedical.info]
  • Non-traumatic third nerve palsy cases must undergo a full workups with neuro-imaging. The usual clinical sign of a third nerve palsy is the outward and downward location of the involved eye. This may or may not be accompanied by lid drooping.[wrighteyecare.com]
  • A referral will then likely be made to a neurologist or neuro-ophthalmologist for evaluation and workup. Treatment Since most fourth nerve palsies are idiopathic, treatment is conservative given the high rate of spontaneous resolution.[encyclopedia.com]
  • Nevertheless, basic workup must be done.[eyewiki.aao.org]
  • Antibody—negative Toxoplasma PCR—negative Varicella Zoster PCR—negative Urine Studies Histoplasma Antigen Assay—negative Imaging Studies MRI brain with contrast, MRA head with contrast CT chest/abdomen/pelvis with contrast Transesophageal Ultrasound The workup[eyerounds.org]
Toxoplasma Gondii
  • gondii , abscess Other Wernicke encephalopathy Subarachnoid space Infection (basilar meningitis) Tuberculosis, cryptococcosis , ...[neurology.mhmedical.com]

Treatment

  • Treatments included the horizontal position along with analgesics, fluid therapy, and corticosteroids. The usefulness of blood patch remains controversial.[journals.lww.com]
  • What is included in treatment of nerve palsies or ocular nerve disorders? The treatment of eye movement problems depends on the underlying cause.[childrensnational.org]
  • Treatment After diagnosis and treatment of the underlying disorder, observation of any recovery of oculomotor nerve function is necessary before surgical intervention.[guwsmedical.info]
  • Treatment was provided for each case including prisms, occlusion, typoscope, scanning exercises, and refraction. CONCLUSIONS: OMCNP account for 18% of eye movement abnormalities in this stroke sub-population.[ncbi.nlm.nih.gov]
  • Treatment options exist for a few disorders: miglustat for NP-C and aminopyridines for DBN and UBN. It is therefore particularly important to identify treatable cases with these conditions.[ncbi.nlm.nih.gov]

Prognosis

  • Richards BW, Jones FR Jr, Younge BR: Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol 1992;113:489-496.[karger.com]
  • Prognosis for resolution of ischemic ocular motor cranial nerve palsy is excellent.[iovs.arvojournals.org]
  • Prognosis Two recent series have found fair to poor visual and sensori-motor outcome in oculomotor nerve palsy/paralysis of children with comparable mix of congenital, traumatic, and neoplastic cases.339,440 The best ophthalmologic outcome with measurable[guwsmedical.info]
  • Prognosis is good. Many people get better over 3 to 6 months. However, some people have permanent eye muscle weakness.[medlineplus.gov]
  • Prognosis The prognosis for trochlear nerve palsies is dependent upon the underlying cause. Most cases of idiopathic or microvascular nerve palsies resolve within a several weeks to six-month time period without treatment.[encyclopedia.com]

Etiology

  • Ocular motor nerve palsy: A clinical and etiological study.[ijo.in]
  • RESULTS: An etiological diagnosis was made in 74% of cases during a mean time of 17 23 months from symptom onset. Myasthenia gravis was the most common diagnosis (n 60, 45.5%).[ncbi.nlm.nih.gov]
  • Etiology of Infranuclear Third Nerve Palsy.[guwsmedical.info]
  • Results: An etiological diagnosis was made in 74% of cases during a mean time of 17 23 months from symptom onset. Myasthenia gravis was the most common diagnosis (n 60, 45.5%).[karger.com]
  • Etiology Bell's Palsy Encompassing around 51% of cases of facial nerve palsy, Bell's palsy is a unilateral, acute onset ( Infection Severe bacterial infections including otitis media, otitis externa and mastoiditis can cause facial nerve palsy due to[webeye.ophth.uiowa.edu]

Epidemiology

  • Seah; Ischemic Ocular MotorNnerve Cranial Nerve Palsy in Singapore - A 22-month Epidemiology Review. Invest. Ophthalmol. Vis. Sci. 2007;48(13):950.[iovs.arvojournals.org]
  • Researchers explored the epidemiology and surgical outcomes of facial nerve palsy using the Rochester Epidemiology Project (REP) database, under the direction of Elizabeth A. Bradley, MD, oculoplastic and orbital surgeon at the Mayo Clinic.[healio.com]
  • ., Hou, P.K. (1999) Epidemiologic study of ocular refraction among schoolchildren in Taiwan in 1995.[scindeks.ceon.rs]
  • A epidemiologic survey and clinical analysis of strabismus in children. J Korean Ophthalmol Soc. 1981;22:847–53. Google Scholar Boyaci A, Akal A, Tutoglu A, Kandemir H, Koca I, Boyraz I, Celen E, Ozkan U.[bmcophthalmol.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology

  • In some cases, the precise site of the lesion is clear, whereas in others, the location of the lesion is speculative. [1] Pathophysiology To understand the pathophysiology of the oculomotor nerve palsy it is essential to know its track.[eyewiki.aao.org]

Prevention

  • Ointment can be placed on the eye at bedtime to prevent corneal exposure. Preservative-free preparations are preferred when used chronically to decrease the incidence of allergy or toxicity.[webeye.ophth.uiowa.edu]
  • Non-surgical treatments: patching in visually immature children to prevent amblyopia occlusion or prisms to relieve diplopia in visually mature individual (especially during the observation period) botulinum toxin injection of the antagonist muscle(s)[www2.medicine.mcgill.ca]
  • The hope is that preventing secondary contracture of the medial rectus muscle will increase the chances of recovery without strabismus surgery.[wrighteyecare.com]
  • To further clarify, classically a posterior communicating artery aneurysm will cause compression of the entire third nerve and so prevent ANY nerve signal conduction thus affecting the somatic system and also the autonomic.[en.wikipedia.org]
  • This leads to severe horizontal double vision (side to side), usually bad enough to require patching of one eye to prevent the double vision.[richmondeye.com]

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