Ocular Disease Iii - Conj Gaze + Misc

Front 1

Cause of INO?

Back 1

Dz involving connection b/w III and IV nuclei, specifically the MLF

Front 2

Most common etiology of unilat INO? Other causes?

Back 2

Ischemic-vascular (most common), neoplasm, trauma

Front 3

Etiology of bilat INO?

Back 3

MS (most common in younger pts)

Front 4

INO is seen mostly in (kids/adults/older), (males/females), and is (chronic/acute).

Back 4

older, males, acute

Front 5

DDx of INO vs thyroid dz?

Back 5

Proptosis in thyroid dz

Front 6

DDx of orbit dz vs INO?

Back 6

proptosis in orbit dz

Front 7

In your pt you see an inability to adduct the RE with a nystagmus during abduction of the LE. Convergence is intact. Dx? Where is the lesion?

Back 7

Right Posterior INO affecting right MR, at the Pons

"MLF" = "MR Looks Funny"

Anterior INO = convergence is lost

Front 8

T/F - RINO = RMLF lesion = RMR dysfxn.

Back 8

True

Front 9

The CN VI nucleus sends signals to what two muscles for conjugate gaze?

Back 9

Ipsilateral LR (direct), contralateral MR (MLF connects CN VI nucleus to CN III nucleus)

Front 10

What causes the nystagmus during INO?

Back 10

Incr innervation to weak MR results in excessive activity to contralateral LR.

Front 11

Besides nystagmus and MR dysfxn, what other signs seen in INO?

Back 11

- Decr saccadic response of affected eye (glissade)
- Decr OKN response (adduction saccade - MR)

Front 12

Anterior INO is located at what level of the brainstem?

Back 12

midbrain

Front 13

Post INO located at what level of brainstem?

Back 13

Pons = Posterior

Front 14

Anterior INOs are localized...

Back 14

between MLF and CN III nucleus

Front 15

Posterior INOs are localized...

Back 15

between MLF and CN VI nucleus

Front 16

Anterior INO is (infra/supra)nuclear?

Back 16

infra

Front 17

Posterior INO is (infra/supra)nuclear.

Back 17

supra

Front 18

Most INOs are (post/ant).

Back 18

post (2/3)

ant = 1/3

Front 19

T/F - Bilat INOs tend to be acute.

Back 19

False - progressive

Front 20

T/F - Bilat INOs in younger pts tend to be assoc w/ MS.

Back 20

True

Front 21

T/F - If a Bilat INO is complete on both sides, it is most likely MS.

Back 21

False - Non-MS bilat INOs tend to be complete.

Front 22

You see a pt with poor adduction in both right and left gaze with no abduction nystagmus. Dx?

Back 22

Bilat INO

Front 23

What is WEBINO mostly assoc with?

Back 23

MS

Front 24

You see a bilat INO with exotropia. You suspect...

Back 24

WEBINO

Called "Wall-eyed" b/c as if pt is looking at both walls at each side.

Front 25

Mortality of unilat INO 18 mos from Dx = __%

Back 25

42

Front 26

How do you Tx a pt with INO due to DM?

Back 26

Tx INO due to vascular etiology with prism; see improvement in 90 days.

Front 27

A lesion that encompasses the MLF and PPRF on the same side at the level of the pons describes...

Back 27

One and a half syndrome

Front 28

Etiology of 1.5 syndrome?

Back 28

infarction, MS

Front 29

Your pt on forward gaze has an exo on the RE. On right gaze the RE can abduct but LE appears straight. On left gaze both eyes appear straight. Dx?

Back 29

left 1.5 syndrome

Think of it this way - eye that appears straight in forward or R/L gaze is the side of the lesion

Front 30

You see L-N dissoc of the pupils, inability to gaze upward with assoc nystagmus, and lid retraction on downgaze. Dx?

Back 30

DMS

Front 31

What specific area of the midbrain is affected in DMS?

Back 31

Posterior commissure

Front 32

T/F - It is possible to see a unilateral upward gaze dysfxn in DMS.

Back 32

False - post commissure lesion affects both eyes for upgaze

Front 33

Where is the upward gaze center? How does it relate to DMS?

Back 33

RiMLF. The RiMLF from both sides pass thru the post commissure, which is damaged in DMS

Front 34

Etiologies of DMS?

Back 34

Pinealoma, MS, infarction, syphyllis, AV malformations

Front 35

What conjugate gaze syndrome involves Collier's sign?

Back 35

DMS - lid retraction on downgaze

Front 36

Besides L-N dissoc, upward gaze paralysis, and Collier's sign, what other signs of ___ can be present?

Back 36

DMS; convergence spasm, decr downward saccades, papilledema, skew deviation

Front 37

(horz/vert) divergence from acquired (supra/infra)nuclear or _____ disruption describes [this conjugate gaze syndrome].

Back 37

vert, supra, vestibulo-ocular, skew deviation

Front 38

Your patient's eyes appear to vertically diverge (and he also says he sees vertical diplopia), and you cannot isolate a single EOM that is causing it. You suspect...

Back 38

Skew deviation

Front 39

Skew deviation suggests ____ or ____ disease.

Back 39

brainstem, cerebellar

Front 40

T/F - Skew deviation typically presents with other neurologic dysfunction(s)

Back 40

True

Front 41

T/F - Skew deviations are mostly noncomitant.

Back 41

False - 90% comitant

Front 42

Your patient can change her hyper from left to right on different gaze positions. You suspect...

Back 42

noncomitant skew deviation

Front 43

*What is the most common cause of spontaneous diplopia in middle-age and early senescent pts?

Back 43

Graves'

Front 44

Eye involvement in Graves' dz can occur in pts with...

Back 44

- Hyperthyroidism
- Secondary hyperthyroidism from Tx of hypothyroidism
- Euthyroid dz (normal T3, T4, TSH with incr thyroid antibodies)

Front 45

Pathophysiology of ocular involvement of Graves'?

Back 45

EOMs infiltrated with lymphocytic and plasmacytic material which incr volume of muscle; EOMs become fibrotic and shortened, thus pulls eye in corresponding direction of that muscle

Front 46

EOM involvement prevalence in Graves'?

Back 46

IR = 60-70%
MR = 25%
SR = 10%

"IMS" = "I MuscleS"

Front 47

Your Graves' dz pt shows up with a right hypo (and restricted upgaze). You suspect what muscle is involved?

Back 47

IR since Graves' shortens the muscle thus pulls the eye down.

Front 48

T/F - Graves' dz with ocular involvement is assoc w/ IOP increase in restricted field of gaze.

Back 48

True - 6mmHg or more

Front 49

Pathophysiology of ocular myasthenia?

Back 49

Acquired autoimmunity; destroyed ACh receptors at NMJ (70-89% decr in receptors), thus weakness of with repetitive/sustained activity

Front 50

Avg lifespan of ACh in normals? In myasthenia?

Back 50

7-11 days normal
1 day in myasthenia

Front 51

T/F - Ocular Myasthenia is assoc w/ thymus hypoplasia.

Back 51

False - hyper

Front 52

What autoimmune dz mentioned is related to thymus problems?

Back 52

ocular myasthenia (thymus hyperplasia, thymoma, dysthyroid dz)

Front 53

Thymoma in myasthenia is more likely in younger, middle, or older aged pts?

Back 53

Older

Front 54

T/F - About half of myasthenia pts will show eye signs initially.

Back 54

True (40-50%)

Front 55

T/F - Most ocular myasthenia pts will develop generalized dz within 2-3 yrs.

Back 55

True (50-94%)

Front 56

What are the most common symptoms of ocular myasthenia? Most commonly affected muscle?

Back 56

Ptosis and diplopia (90%)
MR most commonly affected

Front 57

T/F - There is often pupil involvement in ocular myasthenia.

Back 57

False - little or none

Front 58

T/F - MG onsets in women earlier than men

Back 58

True

Front 59

Why did Dr. S have a picture of Hugh Hefner and some playboy bunnies???

Back 59

MG occurs in young women (under 40) and older men (over 40)!

Front 60

</img>
Dx? Side of lesion?

Back 60

R INO

Front 61

What is the most common CN palsy?

Back 61

VI (Abducens)

Remember "ATOM" mnemonic - Abducens, Trochlear, Oculomotor, Mixed

Front 62

What is the Tensilon test used for?

Back 62

For DDx MG vs neural cause of palsy - if the pt is able to recover after tensilon, then reason is MG

Front 63

What is Peek Sign?

Back 63

incomplete eye closure assoc w/ MG

Front 64

What is Cogan's Lid Twitch Sign?

Back 64

For MG - have pt look down then up. Lid twitch on upgaze is positive

Front 65

What is the icepack test? What is its sensitivity?

Back 65

For MG pts - place ice on eye for 2 mins; ptosis should disappear. Works by decr activity of cholinesterase in NMJ. 90% sensitivity

Front 66

How do you admin the Tensilon test?

Back 66

Inject edrophonium chloride into the arm or hand vein of the MG pt; re-eval deviation 3-4 mins post-injection.

Front 67

T/F - Tensilon test works better for ptosis vs ophthalmoparesis.

Back 67

True

Front 68

Sensitivity of Tensilon test? Specificity?

Back 68

Sens = 86%
Spec = 80%

Front 69

Sensitivity of Acetylcholine Receptor Antibody Titer? Specificity?

Back 69

Sens = 64%
Spec = 99%

Front 70

What is a ptosis crutch?

Back 70

For ocular myasthenia pts - holds up ptosis with wire behind glasses

Front 71

What drug mentioned is used to Tx ocular myasthenia? Dose? How does it work?

Back 71

Pyridostigmine (Mestinon) 60mg TID - an anticholinesterase agent

Front 72

Mestinon has a __ min onset, duration __ hrs.

Back 72

30 min, 4 hrs

Front 73

T/F - Mestinon works better for diplopia vs ptosis.

Back 73

False - just like tensilon, better for ptosis

Front 74

ADEs of Mestinon?

Back 74

GI upset, colitis

Front 75

Your pt's eyes looks like they "freeze" during EOM testing - there is limited motility in all directions. There is also bilateral ptosis, but the pupils are normal. Dx?

Back 75

CPEO

Front 76

T/F - CPEO is worse later in the day.

Back 76

False - no diurnal variation (vs ocular myasthenia)

Front 77

T/F - CPEO can be associated with limb and/or facial muscle weakness.

Back 77

True

Front 78

T/F - Kearns-Sayre syndrome onsets after age 20.

Back 78

False - before 20 yrs old

Front 79

What is the Kearns-Sayre syndrome triad? What other signs?

Back 79

Triad =Pigmentary retinopathy, Progressive ophthalmoplegia, Heart block

Also incr CSF protein, short stature, delayed sexual maturity

Front 80

T/F - CPEO is progressive and asymmetrical.

Back 80

False - it is progressive but symmetrical

Front 81

Tx Kearns-Sayre syndrome?

Back 81

No known Tx, just Tx exposure keratopathy

Front 82

Initial Sx of PSP?

Back 82

Loss of balance, falls

Front 83

What disease involves supranuclear ophthalmoplegia with nuchal rigidity?

Back 83

PSP - also has loss of balance, behavioral changes

Front 84

Areas of brain affected in PSP?

Back 84

Basal ganglia, brainstem, frontal lobe, cerebellum, spinal cord

Front 85

Eye signs of PSP?

Back 85

Loss of vertical sacc, vert gaze, horz eye movement, bell's phenomenon; square wave jerks

Front 86

T/F - PSP involves loss of vertical saccades

Back 86

True

Front 87

Your patient has no vertical saccades, no vertical gaze, and an inability to do horz eye movements. You also see square wave jerks and no Bell's phenomenon. Dx?

Back 87

PSP

Front 88

DMS is aka...

Back 88

Parinaud's

Front 89

A pinealoma can cause this conjugate gaze syndrome

Back 89

DMS (Parinaud's)

Front 90

T/F - 1.5 syndrome can be caused by neoplasm.

Back 90

False (the slides did not mention neoplasms as a cause, just infarctions, MS)