Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Hannah Song, O.D. Jesse Brown VA resident under Thomas Stelmack, O.D. Abstract: A patient, SW, presents to the Veterans Administration with Parinaud’s upgaze palsy with skew deviation. Atypical in presentation, Parinaud’s syndrome and skew deviation is further explored with displays of the SW’s photos and/or video. I. Case History SW, 46 yo white female, presents with chief complaint of constant horizontal and vertical diplopia. Ocular history was unremarkable prior to the event of subarachnoid hemorrhage. Medical history is remarkable for hypothyroidism, hypertension, alcohol abuse, subarachnoid hemorrhage 3/26/08 from a basilar artery aneurysm, coiling procedure 3/26/08, post op complication of deep vein thrombosis in right lower extremity, and inferior vena cava filter 4/3/08. Medications include Omeprazole 20 mg/day, Lisinopril 10 mg/day, and Synthroid 0.088 mg/day. Medical allergies include tetanus toxoid and penicillin. II. Pertinent findings SW initially presents to the Jesse Brown VA with ataxia on walking, losing her balance on her right side. Best corrected visual acuities is 20/25 OD and 20/25 OS. Pupils have a sluggish response, however no afferent pupillary defect. Color vision (Ishihara) is normal OD and OS. SW is unable to converge, however, light-near dissociation is noted. In primary gaze, SW presents with left hypertropia. She fixates with OD and is able to adduct under full effort. OS is capable of depression but difficulty when fixating with OD. Doll’s Head shows both eyes elevate with doll’s head maneuver and intact. Cover test at distance shows 18 prism diopters of alternating exotropia and 20 prism diopters of alternating hypertropia. Cover test at near presents with 18 prism diopters of constant right exotropia and 20 prism diopters of constant left hypertropia. Results for Maddox rod testing in nine positions of gaze with red lens over OD are as follow: 25 BI 20 BD OS 25 BI 20 BD OS 12BI 20 BD OS 14 BI 20 BD OS 18 BI 20 BD OS 12 BI 20 BD OS 16 BI 20 BD OS 30 BI 20 BD OS 12 BI 20 BD OS Cranial nerve testing results are: I: intact III: paresis IV, VI: intact, torsion noted VII: intact VIII: intact IX: intact X: intact XI: intact XII: intact Slit lamp examination is remarkable for mild OD ptosis with a MRD1=3 mm and MRD2=6 mm. Intraocular pressures is unremarkable. Dilated fundus examination presents with extorsion of the right eye and intorsion of the left eye, otherwise unremarkable. MRA head and neck, CT head, CXR, MRI brain are stable comparing to 4/08 findings. III. Differential diagnosis Differential diagnosis for SW includes Superior oblique palsy, CN III palsy with pupil sparing OD, skew deviation, and Parinaud’s syndrome. Differential diagnosis for light-near dissociation include Argyll Robertson pupil, Adie’s Tonic pupil, Amaurotic pupil, Abberent regeneration of the IIIrd nerve, and Dorsal Midbrain syndrome. Differential diagnosis for Skew deviation, from Table one in “skew deviation revisited” by Brodsky, Donahue, et al. include: superior oblique palsy, inferior oblique palsy, third nerve palsy, superior division 3rd nerve palsy, ocular neuromyotonia, myasthenia gravis, systemic botulism, Lamber-Eaton Syndrome, thyroid eye disease, monocular elevation deficiency, congenital fibrosis syndrome, acquired brown syndrome, congenital brown syndrome, chronic progressive external ophthalmoplegia, orbital fibrous bands, and extraocular muscle aplasia. IV. Diagnosis and discussion Parinaud’s syndrome, also known as dorsal midbrain syndrome, may present with bilateral ocular findings such as upgaze palsy, light near dissociation, eyelid retraction, and convergence retraction nystagmus.5 Skew deviation is atypical vertical deviation caused by a disturbance to the midbrain.3 SW did present with upgaze palsy and light near dissociation, however sluggish response to direct light. Superior oblique palsy can mimic a comitant skew deviation with presentations of head tilt toward paretic side.2 Key difference between the two is by observing the retinal photographs. Skew deviation with ocular tilt will show intorsion of the higher eye and extorsion of the lower eye, whereas superior oblique presents with extorsion of the higher eye.2 SW presents in DFE with extorsion of OD (right hypo) and intorsion of OS (left hyper). Diagnosis for CN III palsy with pupil sparing was eliminated after extraocular muscles were observed to be grossly full with full effort and both eyes elevated with doll’s head maneuver. V. Treatment, management Prior to seeing SW, she was given Fresnel prism of +10 D BI OD and +20 D BD OS using a plano carrier lens. SW states that she could only wear the Fresnel prisms for a max of one hour due to decrease in clarity and onset of headache. Du Toit, Ramke, and Brian began a study of nine participants to determine the tolerated amount of induced prism in plano spectacles. They found that the majority could not wear spectacles with the highest prism power of 1 pd BU, 2 pd BO, and 2 pd BI for eight hours.4 After discussion with neuroophthalmologist, it is believed that SW has a good prognosis and symptoms of diplopia will improve in time. No extraocular muscle surgery was explored at this time. At her follow-up in August, SW was observed to be stable with little improvement in her horizontal and vertical deviations. Instead of wearing the Fresnel prism, monocular occlusion provided SW the best relief from diplopia. She is scheduled to return to the clinic September 4, 2008. We will then determine whether surgical intervention is necessary or continue with monocular occlusion. VI. Conclusion Although rarely seen, key point for comitant skew deviation is the extorsion of lower eye and intorsion of the higher eye observed with double Maddox testing and/or fundus photo. Parinaud’s syndrome observed in SW was due to the basilar aneurysm, which lead to subarachnoid hemorrhage. Once her medical condition is stable, there is a chance that the amount of horizontal and vertical deviation can change in time. An exact time period is not known, however a time frame of weeks to four and a half months is given.6 If the deviation is significant and the patient is ready, extraocular muscle surgery can be further explored. VII. Bibliography 1. Ajtai B, Fine EJ, and Lincoff N. Pupil-sparing, painless compression of the oculomotor nerve by expanding basilar artery aneurysm. Archives of Neurology 2004; 61: 1448-1450. 2. Brodsky MC, Donahue SP, Vaphiades M, and Brandt T. Skew Deviation revisited. Survey of Ophthalmology 2006; 51 (2): 105-128. 3. Cassin B and Rubin M. Dictionary of Eye Terminology, 4th Ed. Gainesville, Triad Communications, 2001, pp 40, 244. 4. Du Toit R, Ramke J, Brian G. Tolerance to prism induced by readymade spectacles: setting and using a standard. Optometry and Vision Science, 2007; 84 (11): 10531059. 5. Kunimoto DY, Kanitkar KD, Makar MS (eds). The Wills Eye Manual. Philadelphia, Lippincott Williams & Wilkins, 2004, pp 128-129, 204-207. 6. Miller NR. Late improvement in upward gaze in a patient with hydrocephalus related Parinaud dorsal midbrain syndrome. British Journal of Ophthalmology 2006; 90 (1): 123. 7. Spector RH. Vertical diplopia. Survey of Ophthalmology 1993; 38 (1): 31-62.