Ординатура / Офтальмология / Английские материалы / Ocular Differential Diagnosis 7th edition_Roy_2002
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Pierreâ??Marie
7. Ptosis onset in adolescentâ??familial chronic external ophthalmoplegia 8. Ptosis may be early and only sign of nuclear paralysis in:
A.Botulism
B.Multiple sclerosis (disseminated sclerosis)
C.Hemorrhagic superior poliomyelitis of Wernicke
D.Tabes
E.Vasospasm of ophthalmoplegic migraine
9. Ptosis with cranial nerve dysfunction suggests a basal lesion, such as the following:
A.Aneurysm P.58
B.Epidemic paralyzed vertigo (Gerlier disease)
C.*Herpes zoster
D.Meningitis
E.Polyneuritis of cranial nerves
F.*Trauma
10. Transient ptosis
A.Acute exanthema
B.Acute infection such as erysipelas
C.*Botulinum toxin injection
D.Eclampsia
E.Exogenous poisons such as those due to alcohol, lead, carbon monoxide, arsenic, snake venom
F.Hematoma
G.Influenza
H.Scurvy (vitamin C deficiency)
11. Ptosis with orbicularis weaknessâ??muscle disease
12. S-shaped ptosis
A.Chronic chalazion
B.Cyst on lateral border of tarsus
C.Dermoid
D.Floppy eyelid syndrome
E.Lacrimal gland enlargement or prolapse
F.Lateral levator palpebrae superioris muscle dehiscence
G.Neurofibromatosis
H.Trachoma
I.Drugs, including the following:
acebutolol |
etidocaine |
practolol |
acetophenazine |
fluvoxamine |
procaine |
alseroxylon |
gold sodium |
prochlorperazine |
|
thiosulfate |
|
atenolol |
guanethidine |
promazine |
auronofin |
labetalol |
promethazine |
beclomethasone |
levodopa |
propiomazine |
botulinum A toxin |
levothyroxine |
propoxycaine |
bupivacaine butaperazine |
liothyronine |
propranolol |
carphenazine |
liotrix |
rauwolfia |
|
|
serpentina |
carteolol |
loxapine |
rescinnamine |
chloroprocaine |
medroxyprogesterone |
reserpine |
chlorpromazine |
meperidine |
syrosingopine |
cisplatin |
mepivacaine |
thiethylperazine |
combination products of |
meprednisone |
thiopropazate |
estrogens and progestogens |
mesoridazine |
thioproperazine |
|
methdilazine |
thioridazine |
|
methotrimeprazine |
|
contraceptives |
methoxyflurane |
thyroglobulin |
dapiprazole hydrochloride |
metoprolol |
tobramycin |
deserpidine |
nadolol |
trifluridine |
diacetylmorphine |
perphenazine |
trifluromazine |
diethazine |
phenytoin |
trimeprazine |
estradiol |
pindolol |
trimethadione |
ethopropazine |
piperacetazine |
trimethaphan |
P.59
Dunn WJ, et al. Botulinum toxin for the treatment of dysthyroid ocular myopathy. Ophthalmology 1986;93:4770â??4775.
Gerner EW, Hughes SM. Floppy eyelid with hyperglycinemia. Am J Ophthalmol 1984;98:614â??615.Bibliographic Links
Haessler FH. Eye signs in general disease. Springfield, IL: Charles C Thomas, 1960.
Horner Syndrome
Horner syndrome comprises paralysis of sympathetic nerve supply with lid ptosis, miosis, apparent enophthalmos, frequently dilatation of the vessels with absence of sweating (anhidrosis) on homolateral side; the pupil demonstrates a decreased sensitivity to cocaine and hypersensitivity to adrenalin and may have heterochromia with congenital Horner syndrome.
1. Region of first neuronâ??lesions of hypothalamus and diencephalic region also suggest diabetes insipidus, disturbed temperature regulation, adiposogenital syndrome, and autonomic epidemic epilepsy of Penfield.
A.Arnoldâ??Chiari malformation
B.Basal meningitis, such as in syphilis
C.Base-of-skull tumors (e.g., melanoma)
D.Multiple sclerosis
E.Pituitary tumor
F.Tumor of the third ventricle
G.Midbrain, such as in syphilis
H.Pons, such as in intrapontine hemorrhage
I.Medulla, such as in Wallenberg syndrome (lateral medullary syndrome)â??thrombosis of posterior inferior cerebellar artery
J.Cervical region 1. Syringomyelia 2. Tumor
3. Injury as traumatic dislocation of cervical vertebrae or dissection of the vertebral artery
4. Syphilis (acquired lues)
5. Poliomyelitis
6. Meningitis
7. Amyotrophic lateral sclerosis
8. Related to scleroderma and facial hemiatrophy
9. Vascular malformation such as agenesis of internal carotid artery
2. Region of second neuron
A.Spinal birth injuryâ??Klumpke paralysis with injured lower brachial plexus
B.Cervical rib
C.Charcotâ??Tobias syndrome
D.Thoracic lesions
1. Pancoast tumorâ??in apex of lung, such as carcinoma or tuberculosis 2. Aneurysm of aorta, subclavian, or carotid artery
3. Central venous catheterization
4. Mediastinal tumors
5. Lymphadenopathy of Hodgkin disease, leukemia, lymphosarcoma, or tuberculosis 6. Stellate ganglion block
7. Tube thoracostomy
P.60
E.Neck
1. *Enlarged lymph gland, tumors, aneurysm, and thyroid gland 2. Carcinoma of esophagus
3. Retropharyngeal tumors
4. Neuroma of sympathetic chain
5. Intraoral trauma with damage to internal carotid plexus
6. Thin intervertebral foramina of spinal cord, such as in pachymeningitis, hypertrophic spinal arthritis, ruptured intervertebral disc, and meningeal tumors
7. Traction of sternocleidomastoid muscle, such as from positioning on operating table 8. Complications of tonsillectomy
9. Mandibular tooth abscess
10. *Lesions of middle ear, such as in acute purulent otitis media and petromastoid operation
11. Carotid artery dissection
12. Internal carotid artery occlusion
3. Region of third neuron
A.Aneurysm of internal carotid and its branches
B.Paratrigeminal syndrome (Raeder syndrome)
C.Cavernous sinus syndrome (Foix syndrome)
D.Tumors of cysts of orbit
E.Drugs can affect any region and include the following:
acetophenazine |
levodopa |
promethazine |
alseroxylon |
lidocaine |
propiomazine |
bupivacaine |
mepivacaine |
propoxycaine |
butaperazine |
mesoridazine |
rauwolfia serpentina |
carphenazine |
methdilazine |
rescinnamine |
chloroprocaine |
methotrimeprazine |
reserpine |
chlorpromazine |
oral contraceptives |
syrosingopine |
deserpidine |
perazine |
thiethylperazine |
diacetylmorphine |
pericyazine |
thiopropazate |
diethazine |
perphenazine |
thioproperazine |
ethopropazine |
piperacetazine |
thioridazine |
etidocaine |
prilocaine |
trifluoperazine |
fluphenazine |
procaine |
triflupromazine |
guanethidine |
prochlorperazine |
trimeprazine |
influenza virus vaccine |
promazine |
|
F.Cluster headaches (migrainous neuralgia)
G.Herpes zoster
H.Migraine
I.Fetal varicella syndrome
Fraunfelder FT, Fraunfelder FW. Drug-induced ocular side effects. Woburn, MA: Butterworth-Heinemann, 2001.
Roy FH. Ocular syndromes and systemic diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.
Ryan FH, et al. Congenital Horner's syndrome resulting from agenesis of the internal carotid artery. Ophthalmology 2000;107:185â??188.Bibliographic Links
Smith EF, et al. Herpes zoster ophthalmicus as a cause of Horner syndrome. J Clin Neuro-Ophthalmol 1993;13:250â??253.Bibliographic Links
P.61
Diagnostic table
Horner syndrome
View Table
P.62
Ptosis of Lower Lid (Uncommon Drooping of Lower Lid So that LID Margin is Adjacent to Globe But Below Limbus)
1. Blepharophimosis syndrome
2. *Cicatricial with mechanical displacement by scar, tumor, or skin disease; may be associated with ectropion
3. *Paralytic due to lower lid lagophthalmos
4. Pseudoptosis such as in exophthalmos and higher degrees of myopia 5. Idiopathic
Fox SA. Idiopathic blepharoptosis of lower eyelid. Am J Ophthalmol 1972;74:330â??331.Bibliographic Links
Leatherbarron B, Collin JR. Eyelid surgery in facial palsy. Eye 1991;5:585â??590.Bibliographic Links
Lagophthalmos (Inability to Close Eyelids Voluntarily)
1. *Physiologicâ??many people sleep with their eyes open, especially Asian people 2. Orbitalâ??extreme proptosis
3. Mechanicalâ??scarring of the lids or retractor muscles
4. Paralytic
A.Seventh nerve palsy (see p. 66)
B.Leprosy
C.Lesions of cerebral cortex and its projections, including bilateral frontal lesions
5. Psychological
A.Failure to comprehend the command
B.*Unwillingness to comply with the command
Harvey JT, Anderson RL. Lid lag and lagophthalmos. Ophthalmol Surg 1981;12:338.
Lessell S. Supranuclear paralysis of voluntary lid closure. Arch Ophthalmol 1972;88:241â??244.Bibliographic Links
Pseudoâ??Lid Retraction
1. *Exophthalmos
2. Unilateral high axial myopia
3. Unilateral congenital glaucoma
4. Congenital cystic eyeball
5. Abnormalities of orbit
A.Asymmetry
B.Shallow such as in Crouzon disease (dysostosis craniofacialis)
C.Harlequinâ??shallow orbit with arched superior and lateral wall, such as in hypophosphatasia
6. Ptosis of other eyelid
Fox SA. The palpebral fissure. Am J Ophthalmol 1966;62:73â??78.Bibliographic Links
Walsh FB, Hoyt WF. Clinical neuro-ophthalmology, 4th ed. Baltimore: Williams & Wilkins, 1985.
Lid Retraction
Lid retraction is defined normally as more than 85% of vertical palpebral fissures and 10 mm or less with the eyelids just concealing the corneoscleral limbus at the 12 and 6 o'clock meridians.
1. Lid retraction with upward movement of eye
P.63
A.Congestive dysthyroid disease
B.Deficiency in upward gazeâ??following rectus operation or weakness of superior rectus
C.Excessive stimulation of levator muscles in Bell phenomenon with seventh nerve palsy
D.Levator muscles receive excessive stimuli from nerve fiber of superior rectus
E.Pretectal or periaqueductal lesion in midbrain
2. Lid retraction with downward movement of eye
A.Aberrant regeneration of third nerve of inferior rectus to levator (pseudo-Graefe phenomenon)â??elevation of lid in downward gaze
B.Brown syndrome (superior oblique tendon sheath syndrome)
C.Extrapyramidal syndrome of postencephalic parkinsonism and progressive supranuclear palsy
D.Failure of levator to relax on downward movement of eye 1. Secondary neuromuscular
2. *Mechanical, such as from a scar
E.Noncongestive type of dysthyroid exophthalmos (Graefe sign)â??lid lag in downward gaze
3. Lid retraction with horizontal gaze
A.Duane syndrome (retraction syndrome)
B.Underaction of lateral rectus muscle and spillover to levator causing widening
4. Lid retraction because of supranuclear lesionsâ??usually bilateral when due to lesion in or about posterior commissure (Collier sign, tucked lids, posterior fossa stare)
A.Bulbar poliomyelitis
B.Chorea (Huntington hereditary chorea)
C.Closed head injury associated with defective adduction of eyes, coarse nystagmus, nuclear palsy, pyramidal signs
D.Coma due to disease of ventral midbrain and pons
E.Craniostenosis
F.Epidemic encephalitis
G.Hydrocephalic infants
H.Hydrophobia
I.Hysteria
J.Malingering
K.Meningitis
L.Multiple sclerosis (disseminated sclerosis)
M.Parinaud syndrome (divergence paralysis)
N.Parkinson disease (paralysis agitans)
O.Russell syndrome
P.Sylvian aqueduct syndrome (Koerberâ??Solusâ??Elschnig syndrome)
Q.Syphilis (tabes)
R.Tumors of the midbrain; meningiomas of sphenoid wing; sellar, parasellar, and suprasellar tumors; and frontal or temporal lobe tumors
S.von Economo syndrome (encephalitis lethargica)
5. Lid retraction because of neuromuscular diseaseâ??commonly asymmetric or unilateral A. Drugs
1. Phenylephrine and other sympathomimetics
2. Prostigmin and Tensilon, especially with myasthenic levator involvement P.64
3. Succinylcholine, subparalytic doses
4. Thyroid extract
B.Fuch phenomenonâ??healing of injured third nerve, previously ptotic lid has involuntarily spastic raising with movements of eyes
C.Infant lid retractionâ??transient because of maternal hyperthyroidism
D.Irritation of cervical sympathetic nerve (Horner syndrome)
E.*Mechanical suspension of lid such as that due to scar, tumor, surgical attachment to frontalis muscle, or shortening of levator muscle or following glaucoma filtering procedures
F.Peripheral seventh nerve paresis with loss of orbicularis oculi muscle tone
6. Lid retraction with myopathic disease
A.Associated with hepatic cirrhosis
B.Thyroid myopathy (Graves disease, Basedow syndrome)
1. Dalrymple signâ??widening of palpebral fissure
2. Stellwag signâ??retraction of upper lid associated with infrequent or incomplete blinking
7. Lid retraction following operations on vertical muscles, such as recession of superior rectus muscle or simultaneous recession and restriction of the levator by common fascial check ligament between the two muscles
8. Paradoxical lid retraction because of paradoxical levator innervation
A.Defective ocular abduction with abducens palsy
B.Lid retraction associated with ptosis of the opposite eyelid (levator denervation supersensitivity)
C.Misdirection of third nerve axons (following acquired or congenital lesions)â??occurs on attempt to adduct, elevate, or depress eye
D.Movement of lower jaw
1. Contraction of external pterygoid muscle by opening mouth (Marcus Gunn) 2. Contraction of internal pterygoid muscle by closing the mouth
9. Physiologic
A. Act of surprise
B.Slow onset of blindness, such as that secondary to glaucoma and optic atrophy
C.Time of attention
Collins JR, et al. Congenital eyelid retraction. Br J Ophthalmol 1990;74:542â??544.Bibliographic Links
Dixon R. The surgical management of thyroid-related upper eyelid retraction. Ophthalmology 1982;89:52.Bibliographic Links
Roy FH. Ocular syndromes and systemic diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.
Walsh FB, Hoyt WF. Clinical neuro-ophthalmology, 4th ed. Baltimore: Williams & Wilkins, 1985.
Lid Lag
Lig lag is defined as occurring when the patient looks down and the eyelids lag behind briefly.
1. Congenitalâ??usually in association with congenital ptosis
2. Hepatic failure
3. Iatrogenicâ??following ptosis surgery
4. Mechanicalâ??scars of the upper lid
5. Myopathic disease
A.*Graefe signâ??thyroid myopathyâ??the upper lid pauses and then follows the eye downward (Basedow syndrome)
P.65
B.Myotonic dystrophia
C.Periodic myotonic lid lagâ??familial (hyperkalemic) myotonic periodic paralysis
6. Neuromuscular disease
A.Excessive intake of thyroid extract
B.Physiologic lagophthalmosâ??short upper tarsus in some Asian and some white persons with incomplete descent of the lid during sleep
7. Supranuclear originâ??extrapyramidal syndromes have defective inhibition of lids in downward gaze
A.Congenital supranuclear lid lag
B.Guillainâ??Barré syndrome
C.Postencephalitic parkinsonism, Parkinson syndrome (shaking palsy)
D.Progressive supranuclear palsy