Any combination of abnormal eye movements may be presented:

• Oculomotor nerve palsy is generally associated with downwards and outwards positioning of the ipsilateral eye. Because this cranial nerve also innervates the pupillary sphincter and levator palpebrae superioris, this form of OP is accompanied by mydriasis and ptosis.
• Isolated trochlear nerve palsy is related to preponderance of inferior oblique muscle function, resulting in upwards movements of the ipsilateral eye while gazing downwards and upon adduction.
• Functional impairment of the abducens nerve results in lateral rectus muscle paralysis and consequently disturbed outwards movements of the affected eye.
• Multiple nerve palsies give rise to more complex anomalies corresponding to the actions of maintained eye muscle function.

OP patients often claim visual impairment, mainly diplopia. The degree of diplopia is dependent on the current direction of gaze. Patients may "learn" to compensate for OP by adopting abnormal head positions. This condition is commonly referred to as ocular torticollis [8] [9].

• Pseudotumor

  We report a case of a 55-year-old female who had probable isolated neurosarcoidosis based on magnetic resonance imaging findings of relapsing pachymeningitis with an inflammatory process in the apex of the right orbit and pseudotumor inflammation of the [ncbi.nlm.nih.gov]

  Pediatric pseudotumor cerebri: Descriptive epidemiology. Can J Neurol Sci 1997;24:219-21. 5. Smith JL. Whence pseudotumor cerebri? J Clin Neuroophthalmol 1985;5:55-6. 6. Landan I, Policherla H, McLaurin J. [annalsofian.org]

  Orbital Pseudotumor This is an idiopathic, inflammatory orbital syndrome. The Tolosa-Hunt syndrome may be regarded as an extension of orbital pseudotumor through superior orbital fissure into cavernous sinus. [slideshare.net]

• Feeding Difficulties

  We report a 2-year-old boy who presented with congenital hypotonia, breathing and feeding difficulty, myopathic facies, proximal muscle weakness, ptosis, total external ophthalmoplegia and delayed motor developmental milestones. [ncbi.nlm.nih.gov]

• Strabismus

  In all cases, a rectus muscle snapped under minimal tension while held on a strabismus hook during strabismus surgery. [ncbi.nlm.nih.gov]

  Convert to ICD-10-CM : 378.72 converts approximately to: 2015/16 ICD-10-CM H50.89 Other specified strabismus Clinical Information A disorder characterized by slowly progressive paralysis of the external eye muscles A mitochondrial myopathy characterized [icd9data.com]

• Esotropia

  Ophthalmologic examination is significant for left esotropia and mild bilateral hypertropia. Extraocular movements are painless, with incomplete abduction of both eyes, worse on the left. [pedsinreview.aappublications.org]

  The clinical arguments are unconvincing, since mild VI nerve palsies may not create a primary position esotropia, and dissociated adduction nystagmus can be associated with VI nerve palsies (60) as the result of central adaptation to paresis or limitation [neuroophthalmology.ca]

  […] patient presented with vertical diplopia, which is commonly accompanied by compensatory contra lateral head tilt, while abducens (VI) nerve palsy was considered if the ophthalmologist indicated that the patient had binocular horizontal diplopia and esotropia [bmcophthalmol.biomedcentral.com]

• Myopathic Facies

  We report a 2-year-old boy who presented with congenital hypotonia, breathing and feeding difficulty, myopathic facies, proximal muscle weakness, ptosis, total external ophthalmoplegia and delayed motor developmental milestones. [ncbi.nlm.nih.gov]

• Dizziness

  He denies recent trauma, dizziness, weakness, headaches, nausea, vomiting, diarrhea, fever, and travel. The patient denies recent ingestion of alcohol, illicit drugs, medications, or toxins. [pedsinreview.aappublications.org]

  If you experience blurred vision, double vision, “floaters” in your vision, a sudden escalating headache, or dizziness, contact your doctor. Ophthalmoplegia is most often a symptom of another syndrome or disease. [healthline.com]

• Vertigo

  Vertigo and facial nerve palsy were associated in three cases and one case, respectively. [ci.nii.ac.jp]

  Notably, the absence of concomitant neurological signs, such as vertigo, ataxia, sensory symptoms, dysarthria, facial palsy, or pyramidal tract dysfunction, has been shown to be significantly correlated with a more rapid recovery [1, 5]. [webeye.ophth.uiowa.edu]

  To prevent permanent vestibuloauditory damage, symptoms of hearing loss, tinnitus, or vertigo require urgent referral to an otolaryngologist. Sometimes topical corticosteroids Keratitis may resolve with treatment of the underlying condition. [msdmanuals.com]

  Vertigo And Dizziness Program ( Saturday, May 11 19 07:17 am BST ) Osteoarthritis (OA) affects about 40 million people in the USA. OA of the knee is a leading cause of disability in the elderly. [pigglesbear.co.uk]

• Cognitive Impairment

  impairment Prolonged miniature endplate currents Lethal infantile mitochondrial myopathy Intermittent episodes of respiratory insufficiency due to muscle weakness Decreased size of nerve terminals Hand muscle atrophy Type 2 muscle fiber atrophy Lower [mendelian.co]

  Mental function is normal in most patients but some have cognitive impairments. Treatment Treatment Options: No specific treatment is available although physical therapy can be helpful. [disorders.eyes.arizona.edu]

  The additional physical characteristics and symptoms associated with KSS may include developmental delays; short stature (dwarfism); diminished muscle tone (hypotonia); hearing loss, eventually leading to deafness; cognitive impairment; progressive memory [rarediseases.org]

• Slurred Speech

  Internal medicine; a work for the practicing physician on diagnosis and treatment, with a complete Desk index (1920) (14598349227).jpg 1 690 1 048; 157 KB Riproduci file multimediale Ophthalmoplegia-and-Slurred-Speech-in-an-Intravenous-Drug-User-pmed- [commons.wikimedia.org]

  Description of Case A 35-year-old unemployed man presented to Accident and Emergency with a three-day history of progressive diplopia and a one-day history of slurred speech. [journals.plos.org]

• Abnormal Reflex

  reflex ) 構音障害 ( dysarthria ) 先天性外眼筋線維症 ( congenital fibrosis of the extraocular muscle ) 複視 ( diplopia ) ガングリオシド ( ganglioside ) 磁気共鳴画像法 ( magnetic resonance imaging ) 慢性進行性外眼筋麻痺 ( chronic progressive external ophthalmoplegia ) ミトコンドリアDNA ( mitochondrial [lsd-project.jp]

OP is diagnosed clinically and has to be associated with an underlying disorder. Demographic parameters, symptom onset and disease progression, the presence of unilateral or bilateral complaints and concomitant pathologies should be considered when establishing a list of differential diagnoses. With regards to cranial nerve palsies, extensive knowledge regarding the course of cranial nerves coordinating eye muscle contractions is required to deduce the site of injury from clinical symptoms [1]. Brain imaging may be indicated to visualize lesions of the central nervous system and in this context, magnetic resonance imaging is generally the most sensitive technique. However, computed tomography is usually preferred for an evaluation of orbital tissues [10]. Images obtained by means of computed tomography may, for instance, depict spindle-shaped, enlarged extraocular muscles, as is characteristic of Graves disease. Other entities may be associated with abnormally thin, atrophic ocular musculature. Laboratory analyses of blood samples are usually carried out to assess the patient's general condition and to reveal the underlying pathology. Cerebrospinal fluid specimens may be obtained for similar reasons.

• Hypercapnia

  Equipment and dive profile analysis led to the conclusion of hypercapnia and arterial gas embolism as the probable causes of the diver's symptoms. This is a unique case of isolated bilateral ophthalmoplegia presenting in a diving injury. [ncbi.nlm.nih.gov]

Ophthalmoplegia (OP) generally refers to the presence of eye movement alterations that are caused by paralysis of the extraocular musculature. Because cranial nerve palsies account for considerable shares of OP cases [1], extraocular muscles shall be enumerated according to their respective innervation:

• The oculomotor nerve (III) accounts for the coordination of superior and inferior rectus muscles, medial rectus muscles, and inferior oblique muscles.
• The trochlear nerve (IV) is required for superior oblique muscle function.
• The lateral rectus muscles are innervated by the abducens nerve (VI).

In the broader sense, OP may also describe clinical symptoms arising from internal muscle paralysis. In detail, pupillary sphincter and dilator and/or the ciliary muscle may be affected. These muscles mediate narrowing and widening of the pupil, a means of adaptation to light intensity, and changes of lens shape, thus adapting the eye to short range focus. The pupillary sphincter and ciliary muscle are innervated by the oculomotor nerve.

Cranial nerve palsies may be caused by space-occupying lesions such as a cerebral aneurysm or brain tumors or may be triggered by an increased intracranial pressure, inflammation [2], infection or stroke. Intrinsic muscle dysfunction is less common but may be observed in cases of multiple sclerosis [3], myasthenia gravis, and diabetes mellitus [4], among others. These are systemic disorders not usually restricted to ocular muscles. Congenital OP may indicate developmental defects [5] or hereditary disorders such as congenital muscle dystrophy [6]. Additionally, mutations of mitochondrial DNA are commonly associated with myopathy, including but not limited to OP [7].

1. Stalcup ST, Tuan AS, Hesselink JR. Intracranial causes of ophthalmoplegia: the visual reflex pathways. Radiographics. 2013;33(5):E153-169.
2. Zurawski J, Akhondi H. Tolosa-Hunt syndrome-a rare cause of headache and ophthalmoplegia. Lancet. 2013;382(9895):912.
3. Hassen GW, Bhardwaj N. Images in clinical medicine. Bilateral internuclear ophthalmoplegia in multiple sclerosis. N Engl J Med. 2013;368(3):e3.
4. Greco D, Gambina F, Maggio F. Ophthalmoplegia in diabetes mellitus: a retrospective study. Acta Diabetol. 2009;46(1):23-26.
5. Krasny A, Lutz S, Gramsch C, Diepenbruck S, Schlamann M. Accessory eye muscle in a young boy with external ophthalmoplegia. Clin Anat. 2011;24(8):948-949.
6. Voit T, Parano E, Straub V, et al. Congenital muscular dystrophy with adducted thumbs, ptosis, external ophthalmoplegia, mental retardation and cerebellar hypoplasia: a novel form of CMD. Neuromuscul Disord. 2002;12(7-8):623-630.
7. McClelland C, Manousakis G, Lee MS. Progressive External Ophthalmoplegia. Curr Neurol Neurosci Rep. 2016;16(6):53.
8. Mitchell PR. Ocular torticollis. Trans Am Ophthalmol Soc. 1999; 97:697-769.
9. Boricean ID, Barar A. Understanding ocular torticollis in children. Oftalmologia. 2011;55(1):10-26.
10. LeBedis CA, Sakai O. Nontraumatic orbital conditions: diagnosis with CT and MR imaging in the emergent setting. Radiographics. 2008;28(6):1741-1753.