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ANATOMY
The midbrain represent the uppermost portion of the brainstem,
containing numerous important nuclei and white matter tract, most of
which are involved in motor control, as well as auditory and visual
pathways.5
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(A).
(B).
house inhibitory burst neurons for vertical and torsional saccades. The
INC projects to vertical motorneurons in the oculomotor and trochlear
subnuclei on the contralateral side of the brainstem via posterior
commissure. The INC also contains neurons that project to motor neurons
of the neck and trunck muscles, and appears to coordinate combines eyehead movements in torsional and vertical planes.7
Saccades
Smooth pursuit
Vestibulo-ocular reflex
Bells phenomenon
Disturbances of downward eye movements:
Downward gaze preference (setting sun sign)
2.
Downbeating nystagmus
Downward saccades and smooth pursuit may be
impaired, but vestibular movements are relatively
preserved
Disturbances of vergence eye movements:
Convergence-retraction nystagmus (Koeber-SalusElschnig syndrome)
3.
Paralysis of convergence
Spasm of convergence
Paeralysis if divergence
A or V pattern exotropia
Pseudo-abducens palsy
4.
5.
6.
7.
Skew deviation
2.
3.
4.
5.
Drug-induced
Barbiturates, carbamazepine, neuroleptic agents
Degenerative
6.
7.
Extraocular
examination
motility
examination
of
both
eyes
Patients was able to read all of ischihara color plates with each eye.
Contrast examination was 1,25% for both eyes. Amsler grid testing
revealed no scotoma or metamorphopsia on both eyes.
This patient showed evidence of dorsal midbrain syndrome. The
ocular examination showed vertical gaze palsy with limitation and
convergence of upward eye movement, Setting Sun sign at rest, Lid
retraction, and light-near dissociation.
The clinical diagnosis for this patient was dorsal midbrain syndrome,
bilateral immature senile cataract, and hypertension. The patient was
planned to do MRI examination and consult to internal department for the
underlying disease.
CONCLUSION
Patients with eye movement disorder should undergo proper work up
in order to search for the underlyying mechanism. An understanding the
functions and relationships between these different midbrain structures
allows better correlation between regions of pathologic involvement and
patient symptomatology.
REFERENCE
1.
2.
3.
Leigh RJ, Zee DS. The Neurology of Eye Movements. Fourth edition.
Chapter 1: A Survey of Eye Movements: Characteristics and
Teleology. Oxford; 2006. p. 3-19
4.
Leigh RJ, Zee DS. The Neurology of Eye Movements. Fourth edition.
Chapter 12: Diagnosis of Central Disorders of Ocular Motility. Oxford;
2006. p. 599-718
5.
6.
7.
Leigh RJ, Zee DS. The Neurology of Eye Movements. Fourth edition.
Chapter 6: Synthesis of the Command for Conjugate Eye
Movements. Oxford; 2006. p. 261-314
8.