Ординатура / Офтальмология / Английские материалы / Ocular Differential Diagnosis 7th edition_Roy_2002

3. Late manifestations of encephalitis

4. Lesions of fourth ventricle and cerebellum, especially lesions of the flocculus 5. Multiple sclerosis (disseminated sclerosis)

6. Parkinsonism syndrome (shaking palsy)

7. Syphilis (acquired lues)

8. Trauma

This type of paralysis includes ptosis, an inability to rotate the eye upward or inward, a dilated unreactive pupil (iridoplegia), and paralysis of accommodation (cycloplegia).

1. Intracerebral

A.Lesion of red nucleus (Benedikt syndrome)â??homolateral oculomotor paralysis with contralateral intention tremor

B.Myasthenia Gravis and Mesencephalic Cavernous Angioma

C.Nuclear typesâ??pareses of a single or a few extraocular muscles supplied by the oculomotor nerve in one or both eyes; there may or may not be pupillary disturbances (mydriasis, sluggish pupillary reaction) and paresis of accommodation; in tumors within or near the midbrain (pinealomas), there is a combination of isolated muscle pareses with vertical gaze palsy, possibly a disturbance of convergence, and nystagmus retractorius (Parinaud syndrome, sylvian aqueduct syndrome, pineal syndrome); includes Axenfeldâ??Schurenberg syndrome (cyclic oculomotor paralysis), Bruns syndrome (postural change syndrome), Claude syndrome (inferior nucleus ruber syndrome), congenital vertical retraction syndrome, and Nothnagel syndrome (ophthalmoplegia-cerebellar ataxia syndrome)

D.Occlusion of basilar arteryâ??due to emboli especially but also to hemorrhage or aneurysm

E.Recurrent third nerve palsy secondary to vascular spasm of migraine

F.Syndrome of cerebral peduncle (Weber syndrome)â??homolateral oculomotor paralysis and cross-hemiplegia

G.Tumors

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2. Intracranial

A.Amebic dysentery

B.Aneurysm rupture at base of brainâ??third nerve paralysis, pain around the face (fifth nerve), and headache

C.Botulism

D.Chickenpox

E.Craniopharyngioma

F.Dengue fever

G.Devic syndrome (optical myelitis)

H.Diphtheria

I.Encephalitis, acute

J.Hepatic failure

K.Hepatitis

L.Influenza

M.Lockjaw (tetanus)

N.Lymphoma

O.Malaria

P.Measles immunization

Q.Meningococcal meningitis

R.Multiple sclerosis (disseminated sclerosis)

S.Ophthalmic migraine

T.Periarteritis nodosa

U.Poliomyelitis

V.Polyneuritis because of toxins such as alcohol, lead, arsenic, and carbon monoxide; dinitrophenol or carbon disulfide poisoning; or diabetes mellitus, herpes zoster, or mumps

W. Rabies

X.Relapsing polychondritis

Y.Smallpox vaccination

ZZ.Subdural hematoma

AA.Syphilis (acquired lues)

BB.Temporal arteritis syndrome (Hutchinsonâ??Hortonâ??Magrathâ??Brown syndrome)

CC.Tuberculosis

3. Lesions affecting exit from cranial cavity

A.Cavernous sinus syndromeâ??paralysis of third, fourth, and sixth nerves with proptosis 1. Aneurysm (arteriovenous fistula syndrome)

2. Carotid-cavernous fistula

3. Cavernous sinus thrombosis

4. Extension from lateral sinus thrombosis

5. Extension of nasopharyngeal tumor

6. Pituitary adenomaâ??lateral extension

7. Tolosaâ??Hunt syndrome (painful ophthalmoplegia)

B.Superior orbital fissure syndromeâ??same as for cavernous sinus syndrome except exophthalmos is less likely to occur and optic nerve involvement and miotic pupil are more likely

1. Aneurysm of internal carotid artery syndrome (foramen lacerum syndrome) 2. Occlusion of superior ophthalmic vein

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3. Skull fractures or hemorrhage

4. Sphenoid sinus suppuration (sphenocavernous syndrome)

5. Temporal syndrome (Gradenigo syndrome)

6. Tumors, such as sphenoid ridge meningioma (Rochonâ??Duvigneaud syndrome), nasopharyngeal tumor, metastatic carcinoma, rhabdomyosarcoma, chordoma, and

1992;29:331â??336.Bibliographic Links

Purvin V. Third cranial nerve palsy. In: Margo CE, ed. Diagnostic problems in clinical ophthalmology. Philadelphia: WB Saunders, 1994:678.

Roy FH. Ocular syndromes and systemic diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

Childhood Causes of Third Nerve (Oculomotor) Palsy

1. Trauma

2. Neoplasm

3. Undetermined

4. Ophthalmoplegic migraine

5. Postoperative cause

6. Meningitis/encephalitis

7. Subdural hematoma

8. Viral or post-upper respiratory tract infection 9. Varicella-zoster virus

10. Aneurysm

11. Orbital cellulitis

12. Sinus disease

13. Mesencephalic cyst

14. Cyclic oculomotor nerve palsy

15. Poison

Holmes JM, et al. Pediatric third, fourth, and sixth nerve palsies: a population-based study. Am J Ophthalmol 1999;127:388â??392.Bibliographic Links

Kodsi SR, Younge BR. Acquired oculomotor, trochlear, and abducent cranial nerve palsies in pediatric patients. Am J Ophthalmol 1992;114:568â??574.Bibliographic Links

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Paralysis of Fourth Nerve (Trochlear Nerve)

This type of paralysis produces palsy of superior oblique muscle resulting in limitation of downward movement of eye when it is in adducted position; it is frequently associated with third cranial nerve palsy.

1. Intracerebral

A.Thrombosis of nutrient vessels, including median penetrating branch of basilar artery to fourth nucleus

B.Hemorrhage in the roof of the midbrain

C.Aneurysm, including direct involvement by posterior cerebral and superior cerebellar arteries

D.Tumors (rare if isolated fourth palsy) 1. Primary

a.Gliomas, such as astrocytomas, ependymomas, and medulloblastomas

b.Other primary tumors, including meningiomas, pinealomas, craniopharyngiomas, and hemangiomas

2. Unilateral trochlear nerve palsy

E.Metastatic lesions, such as those from the nasopharynx, rhabdomyosarcomas, and neuroblastomas

F.Neonatal hypoxia

G.Nuclear typeâ??trochlear paresis combined with a homolateral oculomotor paresis, occasionally in association with vertical gaze palsies, convergence spasm or convergence palsy, and pupillary disturbances seen in tumors of the roof of the midbrain or pinealomas (pineal syndrome)

H.Claude syndrome (inferior nucleus ruber syndrome)

I.Passow syndrome (syringomyelia)

J.Inflammatory lesions, such as meningoencephalitis, cerebellitis, and abscess

K.Pseudotumor cerebri

2. Intracranial

A.Aneurysms, such as that of the posterior communicating artery or foramen lacerum syndrome (aneurysm of internal carotid artery syndrome)

B.Hematomas, traumatic

C.Hydrocephalus

D.Meningitis, encephalitis, polyneuritisâ??diabetes mellitus, herpes zoster, multiple sclerosis, myasthenia gravis, chickenpox, diphtheria, hydrophobia, Gradenigo syndrome, influenza, malaria, poliomyelitis

E.Trauma

F.Tumors, including cerebellopontine angle tumor and pituitary adenoma

3. Lesions affecting exit from cranial cavity

A.Cavernous sinus syndrome (Foix syndrome)

B.Superior orbital fissure syndrome (Rochonâ??Duvigneaud syndrome)

C.Orbital apex syndrome (Rollet syndrome)

4. Orbital lesions

A.Fracture of superior orbital rim

B.Sinusitis

C.Operations on the frontal sinus in which there is trochlear displacement

palsy. Am J Ophthalmol 1999;127,2:235â??236.

Roy FH. Ocular syndromes and systemic diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

Speer C, et al. Four cranial nerve palsy in pediatric patients with pseudotumor cerebri. Am J Ophthalmol 1999;127:236â??237.Bibliographic Links

Childhood Causes of Fourth Nerve (Trochlear) Palsy

1. Trauma

2. Neoplasm

3. Undetermined

4. Postoperative cause

5. Meningitis

6. Hydrocephalus

7. Ophthalmoplegic migraine

8. Viral infection

9. Aneurysm

10. Other

Holmes JM, et al. Pediatric third, fourth, and sixth nerve palsies: a population-based study. Am J Ophthalmol 1999;127:388â??392.Bibliographic Links

Kodsi SR, Younge BR. Acquired oculomotor, trochlear, and abducent cranial nerve palsies in pediatric patients. Am J Ophthalmol 1992;114:568â??574.Bibliographic Links

Pseudoabducens Palsy

1. Accommodative spasm

2. Blowout fracture (medial rectus entrapment)

3. Cross fixation (congenital esotropia)

4. Duane syndrome (retraction syndrome)

5. Fibrosis of medial rectus

6. Horizontal gaze palsy (bilateral)â??with or without contraction

7. Lack of effort involved in abducting a habitually adducted eye patch on other eye differentiates from abducens palsy

8. Myasthenia gravis

9. Myositis

10. Orbital cellulitis (abscess)

11. Overambitious (large) resection of medial rectus

12. Thyroid myopathy (Graves disease, hyperthyroidism)

13. Unwillingness to cooperateâ??doll's head phenomenon (sudden passive turning of head) differentiates from abducens palsy

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Beyer-Machule C, von Noorden GK. Atlas of ophthalmic surgery, Vol 1: Lids, orbits, extraocular muscles. New York: Thieme Medical, 1984.

Goldhammer Y. Pseudopalsy of the abducens nerve. In: Smith JL, ed. Neuro-ophthalmology update. New York: Masson, 1977.

Paralysis of Sixth Nerve (Abducens Palsy)

This type of paralysis produces palsy of the lateral rectus muscle with esotropia increasing when the eye is moved laterally. The course of the sixth nerve makes it more vulnerable to injury than other cranial nerves.

1. Intracerebral

A.Foville syndrome (Foville peduncular syndrome)

B.Gaucher disease (cerebroside lipidosis)

C.Hydrocephalus

D.Inflammatory lesions, such as meningoencephalitis, cerebellitis, and abscess

E.Lateral ventricular cyst

F.Leukemia

G.Millardâ??Gubler syndrome (abducensâ??facial hemiplegia alternans)

H.Mycoplasma pneumoniae

I.Nuclear aplasiaâ??autosomal dominant

J.Platybasia (cerebellomedullary malformation syndrome)

K.Spontaneous subdural hematoma

L.Thrombosis or aneurysm of nutrient vessels to sixth nucleusâ??basilar artery

M.Tumorsâ??intracranial, pontine glioma, or metastatic tumor from breast, thyroid glands, or nasopharynx

1. Primary

a.Gliomas, such as astrocytomas, ependymomas, and medulloblastomas

b.Other primary tumors, including meningiomas, pinealomas, craniopharyngiomas, and hemangiomas

2. Metastatic lesions, such as those from the nasopharynx, rhabdomyosarcomas, and neuroblastomas

N. Wernicke encephalopathyâ??thiamine deficiency in alcoholics with sixth nerve palsy,