Oculomotor Disorders Flashcards

1
Q

Clinical presentation of CNIII palsy?

3

A
  1. Sudden onset of binocular horizontal, vertical, or oblique diplopia
  2. Ptosis or a droopy eyelid
  3. 25% are idiopathic
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2
Q

What is a major complication of congenital CNIII palsy?

A

amblyopia

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3
Q

Why might pt with congenital CNIII palsy not complain of double vision?

A

because they have suppressed vision in the affected eye

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4
Q

What would you find on the eye exam for CNIII palsy?

A
  1. partial or complete ptosis
  2. dilated, and poorly or nonreactive pupil
  3. Deficits in adduction, elevation and depression (EOMs)
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5
Q

What is considered a complete impairment of CN III?

2

A
  1. Impairment in the majority of the functions in the muscles of the eye that are controlled by cranial nerve III
  2. ptosis
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6
Q

Complete III nerve palsies are associated most commonly with what kind of eye movement?
2

A

large-angle exotropia and hypotropia (down and out) and Ptosis.

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7
Q

How can we rule out if compressive lesion is affecting CNIII?

A

It will almost always involve the pupil

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8
Q

Ischemic palsy is different from a tumor how?

A

Will usually not involved the pupil

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9
Q

If complete impairment of CNIII with pupil affected what do we do?

A

tumor= MRI

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10
Q

If complete impairment without affected pupil what do we do?

A

watch for 3 months

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11
Q

If incomplete impairment of CNIII what do we do?

A

MRI

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12
Q

Hallmark of Complete CN 3 Palsy??

A

Ptosis with down and out movement

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13
Q

What else should be in the diff with CN3 symtpoms?

4

A
  1. Vasculopathic
    - HTN
    - Diabetes
  2. Tumor
  3. Congenital
  4. Aneurysm
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14
Q

What is our goal in treating CNIII palsy?

A

goal is to maximize visual function, including ocular alignment

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15
Q

Why is CN IV so prone to injury from blunt head trauma or compression (ICP, brain tumors, swelling)?

A

Its long course coming from the back of the head

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16
Q

Clinical presentation of CN IV?

3

A
  1. vertical diplopia/ tortional diplopia
  2. objects in primary position or in downward gaze will be double
  3. PATIENT MAY TILT HEAD TO SIDE TO BE ABLE TO SEE BETTER
17
Q

If a patient is experiencing CNIV palsy which side will their head be tilting?

A

head tilting to the side opposite the paralyzed muscle

18
Q

Where will the eye be pointing in cranial nerve IV palsy?

A

nasal upshoot

ability to rotate downward is weak because of superior oblique muslce

19
Q

IN CNIV palsy where is deviation the greatest?

A

when gaze is directed toward the weak muscle = greater hypertropia

20
Q

Hallmark signs of CN4 palsy?

2

A

head tilt and nasal upshoot

21
Q

What else should be in the differential for CN IV palsy?

4

A
Acquired  (40%)
1. Vasculopathic (13%)
-HTN
-Diabetes
2. Tumor (10%) (2.8%)
3. Trauma (54%)
Congenital  (60%)
22
Q

If imaging is normal in a suspected CNIV nerve palsy what should the next step be?

A

Lumbar puncture may be warranted in patients who have normal imaging studies but are suspected of having subarachnoid space lesions.

23
Q

What disease often affects the 6th cranial nerve?

A

diabetes

24
Q

Clinical presentation of CNVI palsy?

A

horizontal diplopia that worsens with gaze with gaze laterally
-strabismus present right away with gaze to lateral side but could later present in straight forward gaze

25
Q

Where will the affected eye be deviated in CNVI palsy?

A

primary position is esotropia (crossed eyed/buried eye)

26
Q

Hall mark sign of CN VI palsy?

A

buried eye?

27
Q

In all cranial palsies where is the eye’s primary position/deviation?

A

Away from the movement of the eye

moves eye downward then eye will stay up

28
Q

In all cranial nerve palsies where is the deviation the worst?

A

When the gaze is toward the injured muscle

29
Q

What else should be in the Diff for CNVI?

3 plus some subcategories

A
  1. Vasculopathic
    - -HTN
    - -Diabetes
  2. Tumor
  3. Elevated cranial pressure
    - -Temporal arteritis
    - -Pseudotumor cerebri
30
Q

If it persists for more beyond 6-12 months what do we do?

In what cases should imaging be done immediately?

A

Neuroimaging to exclude neoplasm

focal signs or papilledema are present

31
Q

What are some treatments that could be used for CNVI palsy?

4

A
  1. alternate patching,
  2. prism therapy,
  3. strabismus surgery, and
  4. botulinum toxin.
32
Q

Hallmarks for each palsy?

A

“Down and out” = CN 3 Palsy
“Nasal upshoot” = CN 4 Palsy
“Cross eyed” = CN 6 Palsy