Transcript Slide 1
Grand Rounds Eddie Apenbrinck M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 4/4/2015 Subjective CC: double vision HPI: 78 year old white male admitted to the VA hospital for a fall 2 days prior to admission. Consulted for new onset horizontal diplopia that developed after the fall. Patient denied any visual acuity changes, flashes, floaters, or ocular pain. POH: Presbyopia PMHx: hyperlipidemia, hypertension, non-insulin dependent diabetes ROS: recent falls, gait instability Meds: Metformin, Lisinopril 40mg PO BID, Atorvastatin 40mg PO daily, Amlodipine 10mg PO daily Allergies: NKDA Social: +smoker (3/4 pack per day); denies alcohol and illicits Imaging: On admission MRI/MRA Brain Generalized parenchymal atrophy and ventricular dilation No acute intracranial abnormalities MRA was within normal limits CT head Generalized parenchymal atrophy and ventricular dilation No intracranial hemorrhage or mass effect Exam OD VA(cc, near): OS 20/25 20/25-2 +2.50 readers Pupils: 4 2 4 2 no RAPD IOP: 11 12 Exam Anterior Segment L/L: C/S: Cornea: AC: I/L: Vitreous: OD OS WNL Ptosis WNL OU WNL OU No cell or flare OU +NS OU WNL OU DFE Optic Nerve: Macula, vessels, periphery: Pink/Sharp OU WNL OU; no NPDR OU Motility Motility Video removed 2/2 size Flair Axial Pons Midbrain T2 Axial Assessment and Plan Assessment: 78 year old white male with left internuclear ophthalmoplegia (INO) caused by a stroke of the left medial longitudinal fasciculus (MLF) at the junction pons and midbrain Plan: Physical therapy for gait training and walker use Observe with follow up as outpatient in ophthalmology clinic and neurology clinic INO Injury to the MLF, between the abducens nucleus and the contralateral medial rectus subnucleus of the oculomotor nerve. impairs adducting saccades of the ipsilateral eye, which become either slow or absent On attempted lateral gaze, away from the side of the lesion, the abducting eye overshoots the target (dysmetria), giving the appearance of dissociated (disconjugate) nystagmus. The 2 most common casues of INO are demyelination and stroke Adolescent and young adult= demyelination Older adults= microvascular diseae Medial Longitudinal Fasciculus MLF Medial Longitudinal Fasciculus INO Convergence may be preserved. A large angle exodeviation may occur in bilateral INO (“wall-eye” bilateral INO or WEBINO syndrome) Other clinical features associated with INO include skew deviation, defective vertical smooth pursuit, impairment of the vertical VOR, as well as impaired ability to suppress or cancel the vertical VOR. INO may occur with a variety of disorders that affect the brainstem (vascular, demyelinating, and metastatic) and must be differentiated from the pseudo-INO of myasthenia or a long-standing exotropia. One-and-a-half syndrome (Fisher Syndrome) One-and-a-half syndrome occurs with damage to the caudal pons that involves the ipsilateral MLF and either the ipsilateral PPRF or the abducens nucleus. results in an ipsilateral gaze palsy with an ipsilateral INO The only intact horizontal movement is abduction of the contralateral eye. The most common causes of the one-and-a-half syndrome are multiple sclerosis and brainstem stroke, followed by metastatic and primary brainstem tumors. Eight-and-a-half-syndrome A lesion producing the one-and-a-half syndrome but also involving the intra-axial portion of the facial nerve Stroke is the most common cause Improvement of Internuclear Ophthalmoparesis in Multiple Sclerosis with Dalfampridine Dalfampridine is a potassium channel blocked used for gait impairment 3 patient case series, each patient with bilateral INO secondary to multiple sclerosis Binocular eye movements were recorded before dalfampridine 10mg (baseline) and 3 hours after dalfampridine 10mg Each patient showed improvements in horizontal saccadic conjugacy consistent, possible due to improve neural conduction along the MLF References 1. 2. 3. 4. 5. 6. 7. 8. BCSC: Neuro-Ophthalmology. Internuclear Ophthalmoplegia. Pgs :209-212 Davis SL, Frohman TC, Crandall CG, et al. Modeling Uthoff’s phenomenon in MS patients with internuclear ophthalmoparesis. Neurology. 2008;70(13 pt 2):1098-1106. Epub 2008 Feb 20. McGettrick P, Eustace P. The W.E.B.I.N.O syndrome. Neuro-ophthalmology. 1985;5;109-115 Mills, DA, Frohman TC, Davis SL, et al. Break in binocular fusion during head turning in MS patients with INO. Neurology. 2008;71(6)458-460 Epsinosa PS. Teaching NeuroImage: one-and-a-half syndrome. Neurology. 2008;70(5):e20 Frohman TC, Galetta S, Fox R, et al. Pearls & Oy-sters: the medial longitudinal fasciculus in ocular motor physiology. Neurology. 2008;70(17):e57-e67 Ophthalmology, 9.14, 915-921.e1. Disorders of Supranuclear Control of Ocular Motility. Patrick J.M. Lavin and Sean P. Donahue Tattler W, Kaiser P, Friedman N. Friedman. Review of Ophthalmology. Internuclear Ophthalmoloplegia. Pgs 62-63.