Opthalmoplagia opthalmoparesis

Eye movement Motor coordination Motor pathway cerebellum basal ganglia vestibular system Paralysis nystagmus opthalmoparesis

eye movement(motor) pathway Supranuclear brainstem Internuclear Nuclear Craineal nerve NMJ muscle

Conjugate gaza palsy Horizontal: cortex &pontine Unilateral restriction of voluntary gaze to one side . Frontal damage: eye look to the lesion epilepsy: eye look away Pontine: abducent n or PPRF…impair look to site of lesion, look away ,towered hemiplasia

Vertical gaze palsy Up –gaze palsy:pretectal lesion with damage to post comissure Pretectal: parinaud syndrom: (paralysis of upward gaze,lid retraction,impaired converg,convergence retraction nystagmus,light near dissosiation) Causes: tumer,hydrocephalus 3rd v compress on PC, stroke of thalamic &midbrain ,MS,truma,wilson,syphlis ,TB,drug neuroliptic,barbiturate,tegretol)

Oculogyric crisis: Defention:episodic, spasmodic,conjugate ocular deviation,up wared &lateral. Accompanied with mental changes, may associate with dystonia or other dyskinesia Causes: encephalities lethargica, degenerative dis eg familial parkison, head truma,neurosyphlis,MS,ataxia telengictasia,drug:neuroleptic

Disconjucate eye movement

Internuclear pathology INO: Damage to the MLF between 3&6 nerve ,impair transmisstion of impulse to the ipsilateral medial rectus Impair ipsilateral adduction, abduction nystagmus No visual symptoms,other diplopia Nystagmus cause not clear but may adaptive

INO Causes: MS,brainstem infarct,truma,

The one and half syndrome Impaired congucate gaze to one side & impair adduction to the other side PPRF or abducent nucleus + MLF

Nuclear ,nerve control Double vision Brain stem contain the lower motor control of the eye movement 3rd supply all except: 4th SO, 6th LR

Nuclear (brain stem) Long tract signs Crossed phenomena Causes: Tumor,MS,stroke

cranial nerve pathology ocular neuropathy : Compressive :localization acoording to stations Non compressive: trauma, DM, vasculitis, demyelinating ( miller fisher syndrome), infection diphtheria

Ocular nerves pathway 3,4,6th nerve subarachnoid space cavernous sinus Superior orbital fissure orbit

At sub arachnoid Complete 3rd n palsy +_ other CN Causes: Posterior communicating aneurysm 3rd,superior cerebellur 4th nerve Tumor :meningeoma ,shwanoma Trauma Meningitis SAH Uncal herniation

At cavernous sinus Painful or painless if medially +_ 4,5,6 + Horner syndrome Causes: Cavernous sinus thrombosis Dural carotid cavernous sinus fistula Carotid aneurysm lateral painless Pituitary adenoma, apoplexy

At superior orbital fissure 3 +_,4,5.6 (no horner ,no maxillary nerve) Causes: Tolosa hunt syndrome

At the orbit Optic n visual loss, proptosis, swelling of lid ,chemosis Causes: Trauma ,tumor, cellulites

Imp note Many lesion extend from cavernous sinus to orbital apex and vice viscera Combined 3rd n & sympathetic denervation is pathognomonic for cavernous sinus lesion

neuromuscular Myasthenia graves (flactuation) botulism

muscle Hereditary :mitochondrial acquired trauma Thyroid inflammatory