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Ophthalmoplegia

Ophthalmoparesis

Ophthalmoplegia refers to abnormal eye movements and possibly disturbed adaptation and accommodation resulting from paralysis of the extraocular muscles involved in these processes. Ophthalmoplegia may indicate cranial nerve palsy, but may also be related to a variety of other diseases.


Presentation

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]
Lymphadenopathy
  • The illness is usually characterized by fever, rash, and lymphadenopathy, but severe cases progress to pulmonary and neurological involvement.[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]
  • 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]
Hyporeflexia
  • It is characterized by early onset of symptoms, mild proximal muscle weakness, hyporeflexia or areflexia, normal serum creatine kinase (CK) levels and myopathic electromyography finding, uniform type 1 fibers, and nonprogression.[ncbi.nlm.nih.gov]
  • The patient will subsequently start to develop partial external ophthalmoplegia and mild gait ataxia with hyporeflexia.[elsevier.es]
  • Type 2 muscle fiber atrophy Lower limb muscle weakness Limb muscle weakness Pectus carinatum Scoliosis Respiratory failure EMG: decremental response of compound muscle action potential to repetitive nerve stimulation Respiratory insufficiency Goiter Hyporeflexia[mendelian.co]
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]

Workup

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]
Brain Edema
  • Reversible focal brain edema in a patient with MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes) syndrome. J Epilepsy 1996; 9:79-82 [Google Scholar] 10. Clark JM, Marks MP, Adalsteinsson E, et al.[ajronline.org]

Treatment

  • Treatment [ edit ] Treatment and prognosis depend on the underlying condition. For example, in thiamine deficiency, treatment would be the immediate administration of vitamin B1. See also [ edit ] Paresis References [ edit ] External links [ edit ][en.wikipedia.org]
  • We review the causes of ophtalmoparesis and the treatment with RTX in GPA.[ncbi.nlm.nih.gov]
  • Treatment Treatment Options: No effective treatment is known.[disorders.eyes.arizona.edu]

Prognosis

  • Treatment [ edit ] Treatment and prognosis depend on the underlying condition. For example, in thiamine deficiency, treatment would be the immediate administration of vitamin B1. See also [ edit ] Paresis References [ edit ] External links [ edit ][en.wikipedia.org]
  • The patient also had upper and lower respiratory tract involvement and kidney manifestations with good prognosis. We review the causes of ophtalmoparesis and the treatment with RTX in GPA.[ncbi.nlm.nih.gov]
  • Prognosis & Life Expectancy of Ophthalmoplegia Patients with isolated ophthalmoplegia will have a normal life expectancy with a good overall prognosis. The prognosis of ophthalmoplegia also depends on the underlying cause of this condition.[epainassist.com]
  • Treatment and prognosis (whether the disorder abates or eventually resolves) depends on the cause of impaired horizontal eye movements.[msdmanuals.com]
  • For symptomatic diplopia, treatment options include fogging one glasses lens, patching one eye, a Fresnel prism or ground-in prism glasses, or strabismus surgery. [13] Prognosis Little is documented regarding the prognosis of reverse INO, due to it's[eyewiki.aao.org]

Etiology

  • Our case demonstrates the importance of considering isolated neurosarcoidosis as a potential underlying etiology of painful ophthalmoplegia, even without systemic manifestation of the disease.[ncbi.nlm.nih.gov]
  • Highly variable and depend on the etiology, but the lesion will be affecting the medial midbrain or pons of the brainstem 3,5,8. Treatment and prognosis Highly variable and depend on the etiology 2. Promoted articles (advertising)[radiopaedia.org]
  • In older people, stroke is a more common etiology.[eyewiki.aao.org]
  • At age 3 days she suffered left-sided posterior intracerebral and subdural hemorrhages of unknown etiology.[journals.lww.com]

Epidemiology

  • April 2014 Volume 55, Issue 13 Free ARVO Annual Meeting Abstract April 2014 A national epidemiological study of chronic progressive external ophthalmoplegia in the United Kingdom - molecular genetic features and neurological burden Author Affiliations[iovs.arvojournals.org]
  • Clinical and epidemiologic features of Guillain-Barré syndrome. J Infect Dis Dec. 1997; 176 Suppl 2:92-8. Burina A, Sinanović O, Smajlović D, Vidović M. Bilateral oculomotor nerve palsy in Guillain-Barre syndrome. Med Arh. 2008; 62(2):119-20. Lo YL.[journals.sbmu.ac.ir]
  • Descriptive epidemiology in Rochester, Minn, 1976 to 1990. Arch Neurol 1993;50:78-80. 3. Radhakrishnan K, Thacker AK, Bohlaga NH, Maloo JC, Gerryo SE. Epidemiology of idiopathic intracranial hypertension: A prospective and case - control study.[annalsofian.org]
  • Statistical analysis The strengthening reporting of observational study in epidemiology (STROBE) guidelines was used to design and report this study.[bmcophthalmol.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Lutz first described a case of INO of abduction in 1923. [2] Although his hypothesis that supranuclear fibers in the pons divide to innervate the ipsilateral medial rectus and the contralateral lateral rectus is now known to be untrue,[eyewiki.aao.org]
  • John Leigh for discussions regarding the pathophysiologic mechanism for the ophthalmoplegia. Disclosures None. Footnotes Correspondence to Dr Matthew J.[stroke.ahajournals.org]
  • In this article, potential pathophysiological mechanisms are discussed.[ncbi.nlm.nih.gov]
  • Internuclear ophthalmoplegia: pathophysiology and diagnosis. Bailliéres Clin Neurol. 1992 Aug;1(2):455-70. 3. Liu, GT, et al. Neuro-Ophthalmology Diagnosis and Management. W.B. Saunders Company; 2001. 4. Keane, JR.[reviewofoptometry.com]

Prevention

  • We also review the related literature and highlight the mechanism and preventive measures.[ncbi.nlm.nih.gov]
  • One example is the proptosis (bulging eyes) caused by Grave’s disease, which can also prevent normal eye movement. Rarely, ophthalmoplegia can also be brought on by a deficiency in vitamin B-1, also known as thiamine.[eyehealthweb.com]
  • Prevention There is no way to prevent ophthalmoplegia. Resources ORGANIZATIONS American Academy of Neurology. 1080 Montreal Ave., St. Paul, MN 55116. (612) 695-1940. 〈 〉.[encyclopedia.com]
  • Prevention There is no way to prevent ophthalmoplegia. Resources Organizations American Academy of Neurology. 1080 Montreal Ave., St. Paul, MN 55116. (612) 695-1940. .[medical-dictionary.thefreedictionary.com]

Summary

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].

References

Article

  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.

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Last updated: 2019-07-11 21:54