Download Grand Rounds - University of Louisville Ophthalmology

Grand Rounds Conference
Jinghua Chen, MD, PhD
University of Louisville
Department of Ophthalmology and Visual Sciences
July 17, 2015
History
CC: Double vision for three days.
HPI:

56 year old African American male presented to PCC with
double vision for 3 days. Three days ago he woke up in the
morning with right eye deviated to the right side. He denied
vision change, numbness, weakness, tingling or speech problems.
Past Medical History
POH:
None
PMH:
Hypertension, Type 2 diabetes on insulin
Allergy:
NKDA
FH:
Non contributory
Medication:
Aspirin 81 mg, amlodipine 10 mg, and
Humalog 20 units with meals (? compliance)
SH:
Smokes 1 pack per day and drinks 6 packs of beer
up to 3 times a week.
Exam
OD
OS
BCVA:
20/20
20/20
Pupils:
43
43
No APD OU
IOP:
13
11
EOM
Limited adduction OD(-4)
CVF:
Full OU
Anterior segment:
Mild Cataract OU
DFE:
Normal OU
Eye Movement Exam Video
MRI
DWI
ADC
Assessment
Impression:
56 year old African American male
presented to PCC with double vision for 3 days. Exam
shows adduction deficit in OD.
Differential
Stroke
Diagnosis of Causes:
Demyelination
Other
Trauma
Infection
Tumor
Hemorrhage
Vasculitis
Diagnosis:
Right internuclear ophthalmoplegia (INO)
Management
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The patient was admitted to Stroke Service
Diagnosis: Right midbrain acute ischemic stroke
in the posterior brainstem
CTA and TEE were negative
Plavix and IV fluids were started in the ER.
Follow up Visit after Two Weeks
 Patient
states doing better.
 Improved
 VA:
adduction of OD (-2) and diplopia.
20/20 OU
Follow up Video
Internuclear Ophthalmoplegia
Internuclear ophthalmoplegia (INO) is an eye movement disorder
characterized by adduction impairment due to a lesion involving the medial
longitudinal fasciculus (MLF).
History

1859 Foville’s landmark study of pontine gaze palsy

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The CN VI nucleus- gaze center
Yoked eye muscles
A crossed pathway connecting the pons and midbrain to
coordinate horizontal gaze

1873 medial longitudinal fasciculus (MLF) was
identified as the connecting pathway

1921 Lhermitte named INO
The Third and Sixth Nucleus
Ophthalmology 2nd . 2004: 1324
Internuclear Ophthalmoplegia in 410 Patients
•Infarction 38%
•Multiple sclerosis 34%
•Unusual causes 28%
•Medications:
Adalimumab-anti-TNFα
Arch Neurol. 2005;62(5):714-717. doi:10.1001/archneur.62.5.714
Internuclear Ophthalmoplegia in 410 Patients
%
Infection
4%
Brainstem hemorrhage
3%
Vasculitis Miscellaneous
Surgery/Procedure
2%
2%
3%
Tumor
4%
Infarction
38%
Herniation
5%
Trauma
5%
MS
34%
Unilateral INO

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Decreased saccadic velocity in adducting eye
Abducting nystagmus of the fellow eye
Convergence may be spared or disrupted
Skew deviation
INO is named for the side of limited adduction
Bilateral INO
One-and-a-Half Syndrome
A horizontal gaze palsy and ipsilateral INO
Eight-and-a-Half Syndrome

One and a half syndrome plus facial nerve palsy
http://archneur.jamanetwork.com.echo.louisville.
edu/article.aspx?articleid=2279877
Prognosis of Ischemic
Internuclear Ophthalmoplegia.

78.8% demonstrated resolution of diplopia in
primary position with an average time to
resolution of 2.25 months.

The presence of associated neurologic
symptoms (vertigo, ataxia, dysarthria, facial
palsy, pyramidal tract signs) correlated with a
worse prognosis for resolution of diplopia.
Ophthalmology. 2002 Sep;109(9):1676-8.
References
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BSCS 2014-2015 Book 5, Neuro-Ophthalmology: 209-211
James R. Keane. Internuclear Ophthalmoplegia: Unusual Causes in 114 of 410 Patients . Arch
Neurol. 2005;62(5):714-717.
Shanzer S Neuro-ophthalmology in 19th century Paris: pioneering work on conjugate gaze. In:
Rose FC, ed. Neuroscience Across the Centuries. London, England: Smith-Gordon & Co Ltd;
1989:151-156
Freeman W Paralysis of associated lateral movements of the eyes: a symptom of intrapontile
lesion. Arch Neurol Psychiatry 1922;7454- 487
Michael Strupp, Katharina Hüfner, etc. Central Oculomotor Disturbances and Nystagmus. Dtsch
Arztebl Int. 2011 Mar; 108(12): 197–204.
Bocos-Portillo J, Ojeda JR, etc. Eight-and-a-Half Syndrome. JAMA Neurol. 2015 May 11. doi:
10.1001/jamaneurol.2015.0255.
Drury J, Hickman SJ. Internuclear ophthalmoplegia associated with anti-TNFα medication.
Strabismus. 2015 Mar;23(1):30-2.
Eggenberger E, Golnik K, etc. Prognosis of ischemic internuclear ophthalmoplegia. Ophthalmology.
2002 Sep;109(9):1676-8.