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Block 11 Flashcards

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1
Q

What is a strabismus

A

Person cannot not align both eyes simultaneously under normal conditions. It can move in, out, up, or down
Can be constant or intermittent

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2
Q

What are the causes of strabismus

A

Congenital
Accommodative ET
Abnormal visual development
Neurological

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3
Q

What are the types of strabismus

A

CN palsy
Neurological diseases
Post. Fossa tumor
Increased ICP

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4
Q

LR
Primary
Secondary
Tertiary action

A

1: abduct
2: none
3: none

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5
Q

MR
Primary
Secondary
Tertiary

A

1: adduct
2: none
3: none

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6
Q

SR
Primary:
Secondary:
Tertiary:

A

1: elevate
2: intort
3: adduct

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7
Q

IO
Primary
Secondary
Teritary

A

1: extort
2: elevate
3: abduct

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8
Q

IR
Primary:
Secondary:
Tertiary:

A

1: depress
2: extort
3: adduct

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9
Q

SO
Primary:
Secondary:
Tertiary:

A

1: intort
2: depress
3: abduct

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10
Q

What are the symptoms of cranial nerve paralysis

A 
Double vision
Blurry vision
Decreased peripheral vision
HA
Dizziness
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11
Q

CN 3 innervates what…

A 
SR
MR
IR
IO
Superior palpebral 
EW nucleus
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12
Q

How does a CN 3 palsy appear

A

Down and out
Ptosis
Dilated pupil, no accommodation

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13
Q

What are the common causes of CN3 palsy in children

A

Congenital
Vascular
Tumor

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14
Q

What are the common causes of CN 3 palsy in adults

A

Demyelination disease
Vascular
Tumor
Diabetes

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15
Q

What are the common causes of CN 3 palsy in elderly

A

Vascular

Tumor

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16
Q

What are some causes of CN3 palsy

A 
Ischemic/vascular
Intracranial aneurysm
Neoplasm
Trauma
Migraine
Inflammatory 
Infectious
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17
Q

What test would you do on CN 3 palsy

A 
CH
External exam
VA
CT (exo, hypo) 
EOMs
Pupils
NPC
Accommodation testing
Hess-lancaster
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18
Q

What palsy is most common in children

A

CN 4

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19
Q

What muscles are innervated by CN 4

A

SO

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20
Q

How does a CN 4 palsy appear

A

Eye is up and in

Compensatory head tilt to the opposite side of palsy

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21
Q

What nerve has the longest intracranial pathway

A

CN 4

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22
Q

Why can a CN 4 palsy cause ipsilateral Horner’s syndrome

A

Because it runs near the sympathetic fibers

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23
Q

What is the Horner’s syndrome triad

A

Miosis
Ptosis
Anhidrosis

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24
Q

What are common causes of CN 4 palsys in children

A

Abnormal development of CN4/peripheral nerves

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25
What are the common causes of CN 4 palsy
``` #1 idiopathic #2 head trauma WITH loss of consciousness ```
26
What tests are performed for CN4 palsy
``` CH External exam CT EOMs Pupils Parks 3 step NPC Hess-Lancaster ```
27
What muscles are innervated by CN 6
LR
28
How does CN 6 palsy appear
Esotropia Compensatory head turn towards the affected eye
29
What nerve has the longest external course through the cranium
CN 6
30
What injury is CN 6 susceptible to
``` Injury Increase ICP Mastoid infection Skull fracture Tumors ```
31
What is the presentation of CN 6 palsy
Ipsilateral paresis of LR Convergent strabismus in temporal gaze Lateral diplopia Ipsilateral paresis of facial muscles
32
What palsy is most common in adults
CN 6
33
T/F the LR has 1 anterior ciliary muscle that innervates it
True
34
Why is the LR affected so much by ischemia
It has only one anterior ciliary muscle
35
What are some causes of CN 6 palsy
``` Trauma Aneurysm Ischemia Idiopathic Demyelination diseases Neoplasms Inflammation Meningitis ```
36
What tests are done in CN 6 palsy
``` CH External exam VA CT EOMs Hess-Lancaster ```
37
What is affected in Cavernous sinus palsy
CN 3, 4, V1, V2, 6, Horner's | NOT the optic nerve
38
What is the number one cause of cavernous sinus palsy
Neoplasms | Carotid cavernous fistula, aneurysm, fungal infxn, inflammation
39
What is affected in orbital apex syndrome
CN 3, 4, v1, 6, Horner's, Optic Nerve
40
What are the common causes of orbital apex syndrome
#1 neoplasms | Fungal, inflammation
41
MR palsy causes
Exo | N>D
42
IR palsy
Hyper/exo
43
SR palsy
Bilateral | V exo pattern
44
IO palsy
Eso
45
What is affected in double elevator palsy
SR and IO of the SAME eye
46
How does double elevator palsy present
No elevation in abduction or adduction Bells pheromones IS present
47
What is double depressor palsy (monocular depression deficiency)
IR and SO in the age eye are affected
48
How does double depressor syndrome appear
No depression in ab/adduction | Head is tilted down
49
What are causes of neurogenic palsys
``` Congenital Traumatic Inflammation Neoplastic Ischemic Toxic Demyelination diseases Idiopathic ```
50
Supranuclear palsy
Lesions above the oculomotor nerve nuclei
51
How does a supranuclear palsy appear
``` Gaze palsy Tonic gaze deviation Vergence anormality Saccadic/smooth pursuit disorders Nystagmus Ocular oscillations ```
52
What is internuclear palsy
Lesion of the medial longitudinal fasciculus
53
What are causes of internuclear palsy
MS in younger patients | Vascular in elderly
54
What is nuclear palsy
Unilateral CN3 with bilateral ptosis or SR underaction Palsy of IR, IO, or MR Browns syndrome Bilateral CN 3- sparred levator function
55
What is infranuclear palsy
CN 3, 4, 6
56
If CN 3 is affected in infranuclear palsy how does it appear
Central pupil sparing | Peripheral with pupil
57
In infranuclear if the pupil is spared what caused it?
Vascular
58
In infranuclear if the pupil is NOT spared what casued it?
Aneurysm
59
What are some management tests done for strabismus
CH CT, Hess-Lancaster, EOMs Differential diagnosis Additional tests (MRI, blood work)
60
What are the causes of strabismus
Aneurysm Neoplasms Ischemic
61
In ischemic causes how do they happen?
>40 yoa Sudden onset Resolves in 3 months Treat systemic factors
62
What is the first step in strabismus treatment
Glasses | Fresnel prism
63
What are som either treatements for strabismus besides glasses
Occlusion Botox Surgery
64
When is Botox commonly used
In CN 6 palsy
65
What are the side effects of Botox
``` Soreness at injection site Weakness in injected muscle Muscle soreness in whole body Difficulty swallowing Red rash ```
66
What is a mechanical restriction
EOM is tethered or a systemic disease reduces the elasticity of one or more muscles Incomitant nonparetic deviations
67
What are some common characteristics of mechanical restrictions
Gross limitation of ocular movement in one or more gazes Small deviation of ortho in primary Normal binoularity vision aided by compensatory head movement Positive forced duction testing
68
What tests are done for mechanical restrictions
``` Alternate CT Maddox rod (prism over affected eye) ``` Both eyes: Hirschberg/Krimsky
69
What is Duanes syndrome characterized by
Limitations in ABDuction, ADDuction, or both
70
Type 1 Duanes
Limited ABDuction
71
Type 2 duanes
Limited ADDuction
72
Type 3 duanes
Limited ABDuction and ADDuction
73
T/F a patient with limited abduction in the absence of a significant strabismus in primary position should be considered Duane’s syndrome until otherwise proven
True
74
What are some characteristics of Duanes
``` Congenital Unilateral No strab in primary Enopthalmos in primary A/V pattern ```
75
What is the most common onset of Duanes
Sporadic during infancy
76
What causes Duanes syndrome
Fibrotic LR MR that is inserted too far posteriorly Anomalous innervation
77
How is binocularity in Duanes Syndrome patients
High level Compensatory head posture toward affected eye Amblyopia and diplopia are rare
78
How is motility in Duanes syndrome
Up/downshoot of affected eye during adduction Mimics overaction of IO and/or SO Surgery will not help overshoot
79
What is the differential diagnosis of Duanes
LR palsy - absence of retraction with adduction - esotropic angle larger in CN6P - rarely have vertical anomalous movements
80
What are the treatments for Duanes
Surgery if significant strab in primary, help head posture, improve binocular field of vision Prism to alleviate head posture
81
What is Browns syndrome
Restricted elevation on adduction
82
What are the characteristics of Browns
Unilateral OD>OS Females Constant can be intermittent
83
What is the cause of BRowns
Sue to thickening of the SO tendon Cannot move through throchlea effectively Congenital Acquired (trauma) May improve with time
84
How is motility in Browns
Restricted elevation or absence of elevation in adduction Positive forced duction Minimal or no vertical deviation in primary V pattern Audible click Head posture: chin elevated pointed towards posterior shoulder Mild down shoot of affected eye No overactin of ipsilateral SO Widening of palpebral fissure in adduction
85
How is binocularity in Browns
High level of bingo vision in primary Ortho in primary Rare amblyopia Rare diplopia
86
What is the differential for Browns
IO paresis Hypotropia in primary Head tilt to affected side/head Turn and elevation A pattern Can do parks 3 step
87
How do you treat Browns
Most do not need treatment Primary: surgery Secondary: prism (BU or yoked) vision therapy to improve elevation in adduction (no successful)
88
What is MG
An autoimmune NM disorder of voluntary striated muscle
89
Who is most often affected by MG
``` Females Females under 40 Men over 60 Neonatal or congenital Onset can follow stress ```
90
What is the etiology do MG
Antibodies released and block and destroy ACh receptors There are less receptors so less nerve signals so muscle weakness Thymus gland could be involved (immune repsonse via T cells) larger thymus is MG patients
91
What is the halllmark of MG
Muscle weakness that worsens after periods of activity and improves after periods of rest
92
What are the 2 types of MG
Generalized (whole body) | Ocular (eyes)
93
Generalized MG signs and symptoms
Weakness of arm and leg Muscles Difficulty with speech, chewing, swallowing, and breathing
94
What are the signs and symptoms of ocular MG
Ptosis (most common) (palsy of lev.,unilateral, progressive) Diplopia Nystagmus moments Saccadic abnormalities
95
MG causes issue with what muscles
``` Skeletal muscle Orbicularis oculi Masseter (cant open jaw) Sternocleidomastoid (head droop) Tongue (poor gag repsonse) Diaphragm (death) ```
96
What is MG crisis
When muscels are too weak to control breathing
97
What are teh most common associations of MG
Thymomas Thymus hyperplasia Thyroid disease Autoimmune (rheumatoid factor)
98
What do you use to diagnose ocular MG
Old photos EOMs>fatigue - Ptosis with prolonged up gaze or rapid opening and closing of eye - Conan’s lid twitch (down gaze, the upper lid will twitch as patient looks up) Ice test (2-5 minutes, ptosis will get improve) (cold makes the ACh breaks down much slower, there will be more ACH available)
99
What is the clinical pearl of MG
Presence of an inconsistent deviation along with ptosis and restricted ocular motility
100
What are some further tests that can be done in MG
Electromyography Sleep test Systemic antiAChase agents (tension and neostigmine test) Pysical/Neuro exam Blood test MRI/CT scan Pulmonary function
101
How can you treat culver MG
Occlusion** Prism (not successful) Strabismus/ptosis surgery (not common) Spontaneous remission occurs in 30% of cases
102
What is teh systemic treatment for MG
``` AntiAChase agents Immunosuppressive drugs Thymectomy Plasmapheresis (severe) IV immunoglobulin (severe) ``` No cure, treat signs and symptoms
103
What is Graves Disease
Autoimmune disorder that results from overproduction of thyroid hormone Hyperthyroidism
104
What are teh 2 types of Graves
Graves dermopathy | Graves Ophthalmopathy
105
What are the signs and symptoms of Graves
``` Enlargement of thyroid Weight loss He’s sensitivity Change in menstruation Fatigue Thick red skin Tachycardia Budging eye ** ED ```
106
What is Graves ophthalmopathy
Autoimmune inflammation of orbital tissue and muscles Most common cause of spontaneous diplopia in middle aged people
107
What is teh histology of Graves Ophthalmopathy
Enlargement of EOMs Reduced elasticity and motility Affected EOMs produces an incomitant deviation
108
What are the characteristics of Graves Ophthalmopathy
Bilateral Females Younger than 40 Inherited
109
What are the risk factors for Graves Ophthalmopathy
Stress Pregnancy Autoimmune Smoking
110
What are common signs of Graves Ophthalmopathy
``` Periorbital congestion Pro ptosis Lid lag Exophthalmos Optic neuropathy Impaired ocular motility ``` Dry gritty sensation, photophobia, tearing, double vision, pressure behind eyes, vison loss
111
How is motility affected in Graves Ophthalmopathy
``` Positive forced duction IR most commonly affected LR is least affected (IR>MR>SR>LR) In severe cases eye is tethered down There will be a restriction in upgaze and hypotropia of affected eye ```
112
What is Graves ophthalmopathy often mistaken for
SR paresis
113
What is eye alignment in Graves
Diplopia worse in the morning Restriction of elevation and abduction (hypotropia) Could also have ET, XT, cyclotorsion)
114
How do you diagnose Graves Ophthalmopathy
Tonometry (increased in up gaze) Hertel exophthalmometer Slit lamp (keratopathy) Optic nerve eval (optic neuropathy) CT of orbits, thyroid fxn tests (T3/T4/TSH)
115
What is the prognosis for Graves Ophthalmopathy
Spontaneous improvement Deviation may persist even with control Improvement in motility can occur with decreased orbital edema
116
What are the treatment options for Graves Ophthalmoscopy
Prism (Fresnel) Surgery (in significant ocular deviations/restrictions) Artificial tears Cold compress for eyelid edema Smoking cessation
117
What is the systemic treatment for Graves ophthalmopathy
Radioactive iodine therapy Corticosteroids Anti-thyroid drugs Thyroidectomy These will not always improve ocular symptoms) Ocular signs may worsen for 3-6 months)
118
Versions
Conjugate movements of both eyes
119
Ductions
One eye
120
How do you record versions
SAFE
121
How do you record ductions
Record as a percent of normal
122
What is uncrossed diplopia
ESO | Light hits nasal retina
123
What is uncrossed diplopia
EXO Light hits temporal retina Crosses the VA of the fixating eye
124
Maddox Rod | Red Light through white dot
Ortho
125
Maddox Rod | Red Line to the right
Eso | Uncrossed diplopia
126
Maddox Rod | Red line to the left
Exo | Crossed diplopia
127
Maddox Rod | Red line below
R hyper
128
Maddox Rod | Red line above
L hyper
129
What is fibrosis syndrome
Tissues of EOMs are abnormal | Replaced with fibrotic tissue
130
What are some presentations of fibrosis syndrome
Severely restricted eye movements Ptosis Can elevation
131
How many muscles are affected in fibrosis syndrome
All muscles or just 1
132
What is the most common muscle affected by fibrosis syndrome? How does it appear
IR | Hypodeviation 20-30 degrees below horizontal
133
What is the onset of fibrosis syndrome
Congenital (Autosomal dominant) Acquired (sporadic) Stable, non-progressive
134
How is bino in fibrosis syndrome
Poor
135
What can occur in fibrosis syndrome
``` Poor versions and ductions Ptosis Amblyopia Assymmetrical Cosmesis Reduced stereopsis ```
136
What are the treatments for fibrosis syndrome
Amblyopia therapy Manage ptosis Manage abnormal head movement Difficult to treat with surgery

Motility (5 decks)

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