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• Pursuit system
• Vergence system
Repetitive Ghosting
images image Misalignment of
the eyes
Muscle Fasciculus
Nerve
NMJ
Ophthalmotrope (Ruete, 1857)
bjo.bmj.com/content/93/5.cover-expansion
Nuclear and Internuclear control
III
IV
VI
Nuclear control:
Nucleus III, IV, VI
Horizontal gaze Vertical gaze
internuclear control internuclear control
Steps to exam patient with
diplopia
1. Monocular vs Binocular diplopia
3. Other finding
a.eye lids
b.pupils
Nerve lesion
Internuclear lesion
NMJ lesion
Muscle lesion
• Part
• nuclear complex->fasciculus->basilar-
>intracavernous->intraorbital
• pupillomotor fibres
Stroke syndrome of CN III
palsy
1. Weber’s syndrome
2. Benedikt’s syndrome
3. Nothnagel’s syndrome
4. Claude’s syndrome
Weber’s
syndrome
• Contralateral
hemiparesis
• Ipsilateral CN III
palsy
• +/- contralateral
parkinsonism,
http://www.cram.com
corticobulbar palsy
• Ipsilateral CN III
palsy
• Contralateral
extrapyramidal sign
Upward
Neutral position
Right gaze Left gaze
Downward
Oculomotor nuclear
complex lesion
A woman with diplopia for 1 month
Tuberculoma at midbrain
Key finding of nuclear
complex CN III lesion
• +/- ptosis
• “Left-Right-Left” • “Right-Left-Right”
• 20% Ischemic
• 10% Aneurysm
• 40% Traumatic
1. Foville syndrome
2. Millard-Gubler syndrome
Millard-Gubler syndrome (ventral pontine syndrome)
2. Corticospinal tr (contralat
hemiparesis)
“Cross hemiplegia”
Foville’s syndrome (inferior medial pontine syndrome)
29
Superior orbital fissure
syndrome
CN 3, 4, 6, V1
30
Superior orbital fissure syndrome
• Involve CN 3, 4, 6 and V1 CN 5
distribution +/- oculosympathetic
paresis without anhydrosis
• May exopthalmos due to
blockade of the opthalmic veins
• Blindness due to extension of
the pathologic process to
involve the optic canal
31
Interneuclear
lesion
Horizontal
Interneuclear ophthalmoplegia (INO): MLF lesion
Bilateral INO : Bilateral MLF lesion
One and a half syndrome: PPRF lesion + MLF lesion
Unilateral MLF lesion
• “ internuclear
ophthalmoplegia “
• Ipsilateral MR weakness ipsilateral side
• Contralat. abducting nystagmus
Interneuclear ophthalmoplegia (INO)
WIBINO
One and a half syndrome
• Combined lesion :
PPRF and MLF
• “ One and a half
syndrome “
– Ipsilateral horizontal gaze
palsy
– INO
Bilateral PPRF lesion
• Clinical syndrome
• ischemia/hemorrhage
• obstructive hydrocephalus
• infection
• tumour
Syndrome of
ophthalmoparesis
• Miller-Fisher syndrome
• Wernicke encephalopathy
A patient with diplopia for 1 week with gait
ataxia and areflexia
2 weeks 2 months
Dx. Miller Fisher syndrome
in a patient with polyneuropathy, all CN can be involved
causing total ophthalmoplegia
Wernicke’s encephalopathy
• Triad
• ophthalmoparesis/nystagmus
• acute confusion
• ataxia
A pancreatic cancer patient with NG tube feed
for 3 months
She develop confusion with ataxia and dizziness
Victor M, et al. The Wernicke-Korsakoff Syndrome and Related Neurologic Disorders Due to
Alcoholism and Malnutrition. 2nd ed. 1989.
Treatment regime
• Thiamine IV is recommended
• IV route
disease of NMJ
disease of ocular muscle
Neuromuscular Junction
Features of NMJ
disorder
• Ophthalmoplegia is not consistent with
nerve distribution
• Fatigue
• Fluctuating course
• with other muscle weakness esp. ptosis,
proximal muscle weakness
A patient with diplopia and ptosis
Eyelid and ptosis
• Upper eyelid
–Levator palpebral
superioris(CN 3)
–Muller
muscle(sympathetic)
–Frontalis muscle(CN 7)
• Lower eyelid
–Capsulopalpebral
fascia(inferior rectus)
–Inferior tarsal
muscle(sympathetic)
Ptosis
Non-neurogenic(mechanical)
ptosis
Neurologic ptosis
Congenital ptosis
- EOM involvement
- Pupil dilatation
MG with enhancing ptosis
• miosis
• anophthalmos
• anhidrosis
Afferent visual pathway
and visual loss
Visual loss
• Assessment
• Visual acuity
• Pupillary reflex
• Visual field
• Fundus
Visual loss
Non-neurological
Diplopia causes
-refractive error
Neurologic causes -corneal problem
-cataract
-glaucoma
-retinal and choroidal
disease
Symp: ptosis,
anhydrosis Visual
Parasymp: ptosis. system
EOM
• Jerk nystagmus: