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145 Cards in this Set
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- Back
___________: pupils of unequal size
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anisocoria
17% of normal pop have unequal pupil size 5% have greater than a 1 mm difference |
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To detect anisocoria, you must measure _____________
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pupils in BOTH BRIGHT and DIM illumination
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If Anisocoria is GREATER in bright light where is the problem?
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PARASYMPATHETICS --> problem with the iris constrictor
(larger eye is abnormal) |
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T/F If anisocoria is greater in bright light the problem must be sympathetic
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FALSE
parasympathetics |
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If Anisocoria is greater in dim light, it is a sign of what?
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SYMPTHETIC involvement --> problems with dilator (smaller eye is abnormal)
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Anisocoria in which one eye is LARGER in bright light and the other eye is LARGER in dim light is a sign of what?
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PARASYMPATHETIC and SYMPATHETIC INVOLVEMENT --> TONIC PUPIL SYNDROME
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What is Tonic pupil syndrome
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Anisocoria in which one eye is LARGER in bright light and the other eye is LARGER in dim light
may be a lesion at the cavernous sinus since both para and sympathetic fibers are present |
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Anisocoria which is equl in both bright and dim illumination is known ass
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Benign essential anisocoria-physiologica. Look at family album to se if its long standing
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Simple Central "See-Saw" anisocoria characteristics
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20% of normal population
anisocoria of the same amount of bright and dim, but may vanish in light--> switches from one eye to the other=see-saw |
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One of the most common causes of dilated pupils is what?
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iadvertent or purposeful inistillation of drops in the eye -->
scolopamine that is used for motion sikness could get on hands and touch eye leading to dilated pupil |
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How do you determine if pupils are pharmacologicaly dilated?
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in normal pt, the instillation of 1/8% pilocarpine shoudl NOT elicit a pupillary response.
HOWEVER, if there is a neurologica deficit, the 1/8% pilocarbine will cause CONSTRICTION after 30 minutes since the receptors respond to small concentrations of pilo if neuro problems exist. NORMAL pts with a pharmocological dilated pupil will NOT respond to 1/8% pilocarpine |
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T/F NORMAL pts with a pharmocological dilated pupil will NOT respond to 1/8% pilocarpine
|
T
only neurological deficit pts due --> causes constriction |
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A women notices that under bright light, OD pupil is larger than left, however at near, both pupils constrict, this is known as?
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Light near dissociation
|
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What are the 5 causes that lead to LIGHT NEAR DISSOCIATION
IMPORTANT |
1.Argyl-Roberts (sphyilis)
2.Doral Midbrain Syndrome 3 Amaurotic eye 4. Tonic pupils 5. Abberent regeneration A TADA |
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Typical size of Argyll-Robertson pupil:
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less than 2.5 mm
|
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OS greater than OD in dim
OD greater than OS in bright Diagnosis? |
Tonic pupil syndrome
one eye does not dilate or constrict well. HOWEVER:near constriction is NORMAL --> light near dossciation present miosiss does occur when pilocarpine is admiinstered |
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T/F Tonic pupil syndrome pts have light-near dissociation present
|
T
|
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4 common Tonic pupil immitators:
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1. posterior synechia
2. acute angle closure glaucoma 3. bitemporal sphincter palsy/temporal iris ischemia 4. Tadpole pupils (during headache, pupil is oval, otherwise, it is round) |
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a tonic pupil is ________ and is the ___ pupil in bright light and the ___ pupil in dim light
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mid-dilated
larger smaller also has light-near dissociation |
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Tadpole pupils are often seen due to what?
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secondary to migranes. pupil shoes unsual dilation and lasts only about 2 minutes during headaches, pupil looks like a tadpole
|
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3 cardinal signs of tonic pupil
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Sector paralysis
Stromal spread Stromal streaming |
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What is sector paralysis?
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a tonic pupil looks different because part of the pupil is curved and part is flattened. The FLAT region is due to sectors of the iris that are paralyized.
Each sector is innervated by a branch of othe short posterior ciliary nerve |
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What is stromal spread?
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the iris has roadial folds that reflects the tone between the sphincter and dilator muscles.
Loss of parasympathetic tons causes the stroma to disorganize and the laxity of the iris surface reflects the loss of tone. cardinal sign of tonic pupil |
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What is stromal streaming?
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to visualize, you must turn off the slit lap, tur the light on at 45 degrees and turn the light back on.
damage diris will stream towards the tight, functions part of the iris The stromal streamign will appear to move like a draw string ba. When light is on iris, the nomra part stream will tighten, but the bad part does not move at all. |
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Clinical features of tonic pupil
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flat edges of iris
vermiform iris movement (non-uniform constriction 260 degrees) poor reponse to light and near or light-near dissociation dilation lag followed prolonged near effort paradoxical pupil- anisocorica greater in light and dim |
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What causes tonic pupil?
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CILIARY ganglion is damaged
|
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2 possible causes of adies tonic pupil?
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ciliary ganglion damage OR
aberrant regenration of CB fibers to iris sphincter so that pupil constriction when pt tries to accomodaqqte |
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____ is the origion of the parasypathetic pupillomoter fiber pathway
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edinger westphal nucelus
only 3% of the fibers from the Edinger Westphal nuclus are bound for the sphincter muscle |
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only __% of the fibers from the Edinger Westphal nuclus are bound for the sphincter muscle
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3
|
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________% of the edinger westphal fibers are used for accomodative function
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90%
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Why is there near-light dissociation?
|
there are 30x more fibers at the EW nuceus for accomodation than for dilation. Thus damage to the ciliar ganglion ther will be a smaller portion of accomodatve fibers and therefore, accomodation will be intact. However, damage to the few fibers constriction fiber will have a much larger effect
|
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T/F Quinine can cause tonic pupil
|
T
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____ tonic pupil is infetion in the orbit
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local
due to chicken pox of the eye, retrobulbar masses, ocular surgery (PRP), oribtal tumor |
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Neuropathic causes of tonic pupii include:
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DIABETES is the most common cause of light/near dissociation; can lead to bilateral tonic pupils
Syphilis Sarcoids Lyme If you can rule out all these causes --> Adie's tonic |
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_________is the most common cause of light/near dissociation; can lead to bilateral tonic pupils
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DIABETES
|
|
idiopathic cause of toinc pupil is know nas
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Adies
20% are asymptomatic 90% have unilateral presentation Fellow eye involvement is common at 4% per year |
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T/F Adies tonic pupil is commonly bilateral
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FALSE
90% are unilateral! |
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T/F Adies Tonic pupil affects women more than wen
|
T
2.6:1 |
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What affects does Tonic pupil have on corneal?
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DIMINISHED corneal sensitivity
sensory fibers from the cornea travel through the ciliary ganglion but do not synapse lesions of the ciliary ganglion not only affect sympathetic and parasymathetic motor fibers, ut aso sensory fibers form the cornea |
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What affect does Tonic pupil have on deep tendon reflexes?
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Decreased deep tendon reflexes- demmonstrated by the absense of a leg movement we knee is tapped.
|
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managmenet of adies tonic?
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leave it alone
-can cycloplege both eyes to relieve discomfort of accomodation |
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If pt has a CN III palsy and the pupil is involved 86% of the time its due to ___________
If pt has a CN III palsy and has spared pupils 77% are due to ______ |
aneurysm
vasculopathic |
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A complete CN III palsy is what?
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inability to move eye in or up
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A complete CN III palysy and a dilated pupil is the result of ________-
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aneurysm
|
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A complete CN III palsy with a spared pupil is usually the result of
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diabetes
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An incomplete CN III palsy with a dilated pupil is usually the result of _____
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ANEURYSM
|
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If you your pt has an incomplete CN III palsy and a spared pupil what is the cause?
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CANT TELL --> it may just mean that the pupil has not become involved
|
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An ACUTE onset CN III palsy with puil involvement is an EMERGENCY. What is the cause?
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aneursym t the junction of the posteiror communicating and internal carotid arteries
20% die in first 48 hours of subarachnoid hemorrhage. |
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Dorsal Midbrain Syndrome etiology
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compression of dorsal, rostra midbrain in region of posterior commissure
tumor CSF obstruction Inflammatory Infection |
|
Signs of DMS
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1.tectal pupils=mid-dilated, don't react well to light but will react to near
2. upgaze pareis= dorsal midbrain contains the upgaze center, patient may present with their chin because of downgaze paresis. 3.Retraction nystagmus- pt tries to look up but eyes go in or out instead of up 4. Eyelid retraction (Collier's sign)- eyes cannot look up but lids rise normally pt tries to |
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Clinical features of DMS
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bilatera myddriasis
pupils fixed to light preserved near response suprnuclear paresis of upgaze- comes from the brain lid retraction defective convergence accomodative paresis possible CN4 palsy |
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Possible cause of DMS?
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pineal gland tumor just posterior to dorsal midbrain.
MUST DO neuroimagin (MRI and MRV) |
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A blow out pupil is known as
|
Hutchinson Pupil
when intracranial pressure suddenly increases, the brain can shift downward cuasing the uncus of the parahippocampal gyrus to compress the teraclinoid ligament, wich in turn compresses CN III. This causes pupil to be FIXED and DILATED |
|
Can Uncal Syndrome be bilateral?
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NO
will see unilateral fxed dilated pupil!! uncus of temporal lobe wil lbe compressing third nerve. |
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Pupil size:
> BRIGHT = ________________ > DIM = _____________________ > BRIGHT, < DIM = ________________ |
PARASYMPATHETIC
OCULOSYMPATHETIC BOTH, TONIC |
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Pharmacologic Testing for Adie’s Tonic Pupil:
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Weak (1/8 or 1/10) pilocarpine
Miosis owing to “denervation supersensitivity” Acquired phenomenon |
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LOCAL TONIC PUPIL causes:
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VARICELLA
RETROBULBAR ORBITAL TUMOR ORBITAL SURGERY |
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NEUROPATHIC TONIC PUPIL causes:
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DIABETES
SYPHILIS SARCOID |
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How can you tell if its a tonic pupil?
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ANSWER BY SIGNSACCOMMODATION
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TONIC PUPIL IMPOSTERS
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POSTERIOR SYNECHIA
ACUTE ANGLE CLOSURE BITEMPORAL SPHINCTER PALSIES TADPOLE SHAPED PUPILS |
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5 Must knows about Tonic Pupils
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-MID-DILATED
-LIGHT NEAR DISASSOCIATION “3 S’s” Sector paralysis Stromal spread Stromal steaming |
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Pathogenesis of Adie’s Tonic Pupil
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Ciliary ganglion
90% CB 3% iris Aberrant regeneration of CB fibers to iris sphincter (light-near/gaze pupil dissociation) |
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What do patients with tonic pupil also show signs of?
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DIMINISHED CORNEAL SENSATION
DECREASED DEEP TENDON REFLEXES |
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Management of Tonic pupil:
|
PUPIL: LEAVE IT ALONE
ACCOMMODATION (SUPERSENSTITIVITY CRAMP) TONICITY = TROPINE PARESIS = ESERINE OCCLUSION |
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Phrenic Nerve Syndrome findings:
|
Usually females
Hoarse Hiccough Horner Can be from metastatic breast CA |
|
Pancoast Tumor TRIAD
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Ptosis
Miosis Arm Pain |
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CAROTID ARTERY DISSECTIONCLASSIC TRIAD
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PAIN ON SIDE OF FACE, HEAD OR NECK
OCULOSYMPATHETIC PARESIS WITHOUT ANHYDROSIS DELAYED RETINAL OR CEREBRAL ISCHEMIA (50-95% of patients) |
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With pts with carotid artery dissection
_____ had painful Horner’s syndrome and ______ % with initial presenting eye signs suffered a retinal or hemispheric stroke (average 6.2 days) |
44%
36% |
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CAROTID ARTERY DISSECTION SIGNS
|
HORNER’S SYNDROME
NECK BRUIT OR SWELLING CN VI, IX-XII CRAO CEREBRAL ISCHEMIA |
|
You Need to consider this diagnosis in EVERY PAINFUL HORNER’s!!!
|
Carotid Artery Dissection
must send Pt to hospital (MRI, MRA, CTA, angiogram) |
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What is Vernet’s Syndrome?
|
Tumor at Base of Skull
Can involve CN IX, X, XI, XII Horner syndrome (oculosympathetics enter skull at foramen lacerum) Lesion in nasopharyngeal CA Droopy shoulder, droopy tongue, winged scapula Weak trapezius, hoarse, tongue deviated to one side |
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What happens with Cavernous Sinus Syndrome?
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Mixed cranial neuropathies (III, IV, V1, V2, VI)
Miosis (oculosympathetic paresis) Pain Dysesthesia |
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BRAINSTEM lesions that leads to CN III palsy include
|
TELODIECEPHALIC CNIV; VI; FOVILLE; WALLENBERG
|
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CHEST lesions that lead to CN III palsy include
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PANCOAST’S, KLUMPKE’S; PHRENIC
pt will have CHEST / ARM PAIN with pancoasts's pt will be HOARSE if they have phrenic |
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NECK lesion that lead to CN III palsy include
|
CAROTID DISSECTION
NECK / EARACHE is another symptom |
|
Head lesions that lead to CN III palsy include
|
OTITIS MEDIA; CLUSTER; VERNET’S, CAVERNOUS SINUS, TONSILLECTOMY
OTITIS MEDIA --> earache |
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How can you isolate where a CNIII palsy occurs?
|
ANSWER BY:
PAREDRINE Paredrine test:- This test helps to localize the cause of the miosis. If the 3rd order neuron (the last of 3 neurons in the pathway which ultimately discharges norepinephrine into the synaptic cleft) is intact, then the amphetamine causes neurotransmitter vesicle release, thus releasing norepinephrine into the synaptic cleft and resulting in robust mydriasis of the affected pupil. If the lesion itself is of the aforementioned 3rd order neuron, then the amphetamine will have no effect and the pupil remains constricted. There is no pharmacological test to differentiate between a 1st and 2nd order neuron lesion. |
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Paredrine test:- is useful for?
|
helps to localize the cause of the miosis. If the 3rd order neuron (the last of 3 neurons in the pathway which ultimately discharges norepinephrine into the synaptic cleft) is intact, then the amphetamine causes neurotransmitter vesicle release, thus releasing norepinephrine into the synaptic cleft and resulting in robust mydriasis of the affected pupil. If the lesion itself is of the aforementioned 3rd order neuron, then the amphetamine will have no effect and the pupil remains constricted. There is no pharmacological test to differentiate between a 1st and 2nd order neuron lesion.
So if results are NORMAL that means the CNIII lesion is a 1st & 2nd order Horner Syndrome OR ACUTE 3rd order Horner Syndrome |
|
Normal paredrine test implies what?
|
CNIII lesion is a 1st & 2nd order Horner Syndrome
OR ACUTE 3rd order Horner Syndrome |
|
What is NEUROBLASTOMA?
|
Cancer of neural crest cells
Accounts for 97% of all CA of sympathetic NS Solid tumor cancer Begins in nerve tissue in neck, chest, abdomen and pelvis Usually begins in adrenal glands Average age at dx is 2 years old |
|
Testing for Neuroblastoma
|
Neuro-imaging (abdomen/chest)
Bone marrow tests Blood tests ***Specific urine tests (VMA) vanyllylmandelic acid (HVA) homovanillic acid Produced by tumor |
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A first order CN III palsy is usually do to
|
VASCULAR, TRAUMA
|
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A third order CN III palsy is usually do to
|
NEOPLASIA
|
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Cocaine drop test does what
|
Cocaine blocks the reuptake of norepinephrine resulting in the dilation of a normal pupil. Due to the lack of norepinephrine in the synaptic cleft, the pupil will fail to dilate in Horner's syndrome.
|
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What is an AN ARGYLL-ROBERTSON PUPIL?
|
MIOSIS (2.5 mm in dark)
ABSENT DIRECT BRISK NEAR (LND) PRESERVED VISION UNILATERAL, ASYMMETRIC OR UNEQUAL DILATES POORLY |
|
What is TREPONEMA PALLIDUM?
|
s a gram-negative spirochaete bacterium that causes sphylis
workup includes:RPR, FTA-ABS (VDRL) management: IV penicillin (neuro-syphilis) Repeat serology ALWAYS suspect recurrence!!! |
|
T/F with a COMPLETE CN III – PALSY
Can use the pupil as a guide |
T
INCOMPLETE CN III – PARESIS Can NOT use the pupil as a guide |
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IF a CN III palsy has pupil INVOLVED = it usually due to a ______(86%)
if SPARED = ____________ (77%) |
ANEURYSM
VASCULOPATHIC |
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A __________ sign shows a lagging of the upper eyelid on downward rotation of the eye, but is due to aberrant regeneration of fibres of the oculomotor nerve (III) into the elevator of the upper lid
|
pseudo Graefe's
|
|
ABERRANT REGENERATION OF CN III can be caused by
Aneurysm, Tumor, Trauma but NEVER ______- ! |
Diabetes
|
|
A CN III palsy in an adult requires what workup
|
20-50 YEARS
CT, MRI, MRA, A-GRAM |
|
A CN III palsy in a pt over 50 includes what workup
|
(pupil, palsy, pain)
NEUROIMAGING VASCULOPATHIC EVALUATION |
|
A CN III palsy in children requires what kind of workup?
|
CONGENITAL (MRI)
ACQUIRED EXCLUDE TRAUMA OR MIGRAINE CONSIDER LP IF MRI (-) IF MRI & LP ARE NEGATIVE > 10 years, ARTERIOGRAM TO LOOK FOR ANEURYSM |
|
Etiology of DMS?
|
Compression of dorsal, rostral midbrain in region of posterior commissure
Tumor CSF obstruction Inflammatory Infection ORDER Neuro-imaging ( MRI, MRV) |
|
DORSAL MIDBRAIN SYNDROME (SIGNS)
|
TECTAL PUPILS
UPGAZE PARESIS (DOWNGAZE PARESIS, OR BOTH) RETRACTION NYSTAGMUS EYELID RETRACTION |
|
Features of DMS:
1. bilateral_____ 2. pupils fixed to____ 3. preserved ____ response (early) progression to involve ___ response 4. supranuclear paresis of upgaze lid retraction ( ____ sign) defective convergence (“wall-eyed”) 5. convergence/divergence retraction ____ accommodative paresis 6. CN__ palsy (superior medullary velum) |
1. mydriasis
2. light 3. near 4.Collier’s 5. nystagmus 6. IV |
|
What syndrome is characterized by:
RESPONSES INTACT ANISOCORIA > DIM “LAZY DILATOR” NO COCAINE DILATION |
Horner's
|
|
A POSITIVE cocaine test result means
|
4-10% COCAINE
( + )TEST = NO DILATION!!! Cocaine blocks the re-uptake of Norepinephrine at nerve terminal |
|
Where can a Horner AND CN IV palsy occur?
|
At locus ceruleus (next to CN IV nucleus)
A nuclear CN IV palsy CONTRALATERAL CN IV palsy (crossed) |
|
What is Foville Syndrome?
|
Level of pons
Infarct of AICA Gaze palsy (nuclear CN VI) CN VII palsy Horner syndrome Signs: LATERAL, GAZE PARALYSIS (VI) FACIAL PALSY (VII) LOSS OF TASTE (ant 2/3 of tongue) (VII) FACIAL ANALGESIA (V) HORNER’S (oculosympathetics) HEARING LOSS (VIII |
|
Signs of Foville syndrome?
|
LATERAL, GAZE PARALYSIS (VI)
FACIAL PALSY (VII) LOSS OF TASTE (ant 2/3 of tongue) (VII) FACIAL ANALGESIA (V) HORNER’S (oculosympathetics) HEARING LOSS (VIII |
|
Signs of a Brainstem Stroke(Wallenberg’s syndrome)?
|
Vertebral A / PICA infarct
Loss of pain / temp (ipsilateral face, contralateral trunk & limbs) Dysarthria / dysphagia Ataxia (ipsilateral limbs) Vertigo - “tilted world” Nystagmus |
|
avg size of argyl-robinson pupils?
|
VERY small <2.5 mm
|
|
most COMMON imposter of tonic pupils?
|
POSTERIOR synechia
|
|
a bitemporal sphincter palsy will result in ________ oriented pupils
What causes this? |
vertically
(leads to funny lookin pupils) caused by ISCHEMIC ocular syndrome (especially in diabetics) OR ischemia secondary to PRP in diabetes Temporal iris is supplied by SUPERIOR and INFERIOR divisions of the anterior ciliary artery |
|
What leads to tadpole pupils?
|
sy,[athetoc orroatopm seem om cpmkimctopm woth ,ograomes/
|
|
What is sector paralysis?
|
one of the 3 signs of tonic pupil- part of the pupil is CURVED and part is FLATTENED. The flat region is due to iris that is paralyzed.
|
|
What is stroma spread?
|
one of the 3 cardinal signs of tonic pupil
iris has folds that reflect thetone etween iris sphincterand dilator muscles. LOSS of parasympathetic tone causes straom to disorganize and the lax of theiris surface reflects this |
|
What is stromal streaming?
|
one of the 3 signs of tonic pupil
damaged iris will STREAM towards functioning part of the iris. Normal part will tighten up, but damaged part does not. On slit lamp, move 45 degress and turn light on. |
|
T/F Tonic pupils get smaller over time
|
T
|
|
Why is accomodation not affected in tonic pupl?
|
ciliary ganglion has 97% of fibers used for ACCOMODATION (30x more than constriction)
|
|
Major cause of tonic pupil?
|
ciliary anglion damage! (location of pre and post synaptic PARAsympathetic neurons).
The EdingerWestphal nucleus is origin of parasymp fibers. Only 3% are bound to sphincter muscle. Other 97% go to accommodation. If ciliary ganglion is damaged, some iris sphincter nerves will grow back to normal and some will abberantly grow back to accomodation. However there are so few nerves at the sphincter, it will not be able to cause constriction. With the damage, some accomodative fibers will grow back normal and some will abberently grow back to iris sphincter. There are enough fibers present at both locations to cause the constriction of the pupil when looking at a near target. |
|
The defining features of a tonic pupil:
(1) The pupil does not react to ________. The original neurons have been destroyed. (2) Tonic constriction with attempted _________. Aberrant regeneration of nerve fibers intended for the ciliary muscle causes abnormal, tonic ________ of the pupil with accommodation. (3) Segmental iris _____. When carefully examined under magnification, the iris does not _________uniformly with attempted near vision. Only the re-innervated segments contract, producing a slightly irregular contour to the pupil. (4) Denervation supersensitivity. Like any denervated muscle, the iris becomes supersensitive to its normal neurotransmitter (in this case, acetylcholine). Very weak solutions of cholinergic substances such as _________(that have no effect on the normal iris) cause the denervated iris to constrict. |
1. light
2. near vision, contraction 3. constriction,constrict 4.pilocarpine |
|
Local causes/infection in the orbit that lead to tonic pupils increlase
|
chicken pox in the eye
retrobulbar masses PRP ocular tumor/dermoid |
|
Neuro caues of tonic pupil
|
DIABETES most common
spyhilis sarcoids lyme |
|
Idiopathic tonic pupil is know as
|
Adie's Tonic
90% unilateral present fellow eye involvement is common at 4% per year. (in 20 years, 50% of pts have both eyes affected) |
|
T/F Lesions of ciliary ganglion not only affect sympathetic and parasympathetic motor fibers, BUT also sensory fibers from the cornea
|
T!!!
nasociliary nerve of CN V1 travel thru ciliary ganglion and are responsible for CORNEAL sensitivity. Hence, in TONIC pupils, ciliary ganglion damage causes DECREASED corneal sensitivity |
|
T/F A CN III palsy caused by diabetes should NOT be painful
|
T
pain implies aneurysm 95% of the time, GCA, pituitary apoplexy, and SOMETIMES diabetes |
|
T/F A CN III palsy due to diabetes leads to aberrant nerve regeneration
|
FALSE NEVER diabetes
Aneursym, Tumor or Trauma can lead to abberent regeneration, but NOT diabetes. |
|
What are tectal pupils?
|
bilateral MYDRIASIS
pupils FIXED to light near response preserved early UPGAZE paresis (although downgaze is possible) Convergence reatraction nystagmus Eyelid retraction CN 4 palsy AKA DORSAL MIDBRAIN SYNDROME |
|
Causes of DMS
|
* Sporadic
* Causes: obstructive hydrocephalus, mesencephalic hemorrhage, multiple sclerosis, A/V malformation, trauma, compression from tumor (pineal tumors) |
|
Supranuclear paresis of upgaze is a problem where? is it muscle, nerve, or brain?
|
BRAIN
|
|
3 signs required in order to diagnose Horners?
|
miosis, ptosis, and anhyrosis
|
|
T/F you can get a complete ptosis with Hornder's syndrome
|
FALSE
because the tarsal muscle is only responsible for a few mm of elevation.... superior levator does most of the work If you see COMPLETE ptosis --> CN III palsy |
|
What is dilator lag?
|
when anisocria is GREATER at 5 seconds than at 12 seconds into darkness in horners syndrome. Affected dilator is slow to dilate and catch up to the normal eye
|
|
T/F A POSITIVE result from the cocaine test means NO dilation
|
T
Cocaine blocks the reuptake of norepinephrine so that if added to a pt with normal eyes, eyes will be dilated and stay dilated longer a person with horners wont have the release of norepinephrine (no sympathetics) so even if cocaine blocks the uptake, there still isn't any norepinphrine there to cause dilation --> + test means NO dilation |
|
T/F Apraclonidine will have the opposite effect as cocaine
|
T
DILATES horner's pupil REVERSES anisocria. Horner pupil looked smaller before drops, and then after drops, looks bigger than other pupil. |
|
T/F For Horner's syndrome, eyelid crease will be present and will be ABSENT in Myasthenia gravis
|
T!!
in horner's LEVATOR is still NORMAL (NOT a CN III palsy) MG effects LEVATOR function |
|
The presences of an _____ ptosis can help pick up Horner's
|
INVERSE
lower lid looks elevated due to inability of Muueller to pull lower lid down. MG and CN III palsy do NOT present with ptosos |
|
Heterochromia iridis is present in congential ______-
|
Horner's
in children before age 2 iris is lighter on side of horner's syndrome |
|
Most COMMON cause of Horner's in young pt is
|
NEUROblastoma
|
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The oculosympathetif fibers originate in the __________ and descend to the mirain and then to the pons at the __________, which is very close to the CN IV nucleus. The fourth nevre crosses in the midbrain and when lesioned, could cause a contralateral ________________.
|
Posteiror lateral hyothalmus
locus cereuleus (adrenergic nucleus) Horn'ers syndrome IF a Horner's syndreom is present, look for a CN IV palsy on the other side!!! |
|
IF a Horner's syndrome is present, look for a ______ palsy on the other side!!!
|
CN IV
|
|
IF fibers from the caudal pons are lesioned by an infrarct of the anterior inferior cerebrallar artery, it may lead to ____________ syndrome with a gazle palsy, a CN ___ palsy, and a Horner's syndrome
|
Foville
CN VII |
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A lesion of the _______ can cause INTERnuclear ophthamloplegia, with an APD, adductinf defect and abducting nystagmus
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MLF
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A lesion or infract of the ________ may cause Wallenerg Syndrome, which can present with Horners syndrome
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Wallenberg
see contralateral loss of pain and temp ipselateral facial pain and temp swallign and speech diffculties ipselateral loss of hearing |
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What is a Phrenic nerve syndrome?
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lesion at the spinal cord, offten associated with metastic breast cancer
Causes hoarse, hiccups and HORNER's 3 H's!!! |
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Klumpke's sign is associated with a lesion where, that also causes Horner's ?
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level of the brachial plexus
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At level of the lung you can get a ________ tumor leading to an IPSELATERAL horn'ers
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pancoast
Triad: ptosis, miosis, arm pain |
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At tumor at the base of the skull is known as ____ and involves CN IX,X,XI, XII and produces a Horner's
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Vernet's syndrome
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_____ headaces can also cause a horner's
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Cluster
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Triad of a cartoid artery dissection causing a Horner's
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pain on side of face, head or neck
oculosympathetic paralysis without anhydrosis delaye retinal or cerebral ischemia MEDICAL emergency |
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1% _________ "Squeezes out" the norephineprine from the presynaptic nerve terminal into the synapse, so if the lesion is at the first or second orer neuron below the mandible (aka preganglionic), the pupil WILL dilate
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Paredrine
however, its its a postganglionic lesion, the pupil will not dilate |
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40% of Horner's are due to
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idiopathic
13% malignant tumor!! usually Pancoast |
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Rule of thumb for Horner's
1st order neuron lesion, thinks its due to __________ 2nd order, think _______ 3rd order neuron lesion, think ________ |
vascular disease or trauma
neoplasma benign or headache syndrome |