Expect The Unexpected
Opthalmoplegia
Puan Rahimah complains of giddiness. Please look at her and proceed.
Examiner: Dr. Pan, please present your findings.
Dr. Pan:
Puan Rahimah’s head is rotated to the right. She has right eye ptosis. There is no strabismus at rest. Both her pupils are spared. There is no fatigability. There is mild impairment of upwards and upwards lateral movements of the right eye. Intorsion is intact. She has diplopia upon looking at all direction except looking downwards . The outer image disappears upon closing the right eye. There is no nystagmus. The rest of the cranial nerves are intact.
I would like to complete my examination by examining the patient’s BP (H/T), urine for sugar (DM), upper limbs and lower limbs for any pyramidal signs including the reflexes (CPEO, ELS) and cerebellar sign. I would also like to look into the fundus to look for any papilloedema. (/retinitis pigmentosa)
PANIC!!!!!??????? Dx????
In summary, Puan Rahimah has complex diplopia and I would like to consider differential diagnosis of
1) Mononeuritis multiplex
2) MG ( no fatigability)
3) Miller Fisher
4) CPEO, Ocular muscular dystrophy
5) Grave’s ( proptosis?)
6) Cavernous sinus thrombosis/ superior orbital fissure syndrome( if V CN is involved)
Examiner: What other investigation would you like to do?
Dr. Pan:
1) ESR to screen for vasculitis
2) MRI of the brain ( infarct / SOL esp at the midbrain)
Causes of isolated III CN palsy
Medical:
1) DM/ H/T/ Vasculitis
2) Multiple sclerosis
Surgical
1) Posterior communicating artery aneurysm/ Midbrain tu
2) Subacute meningitis
Causes of isolated VI CN palsy ( look for involvement of VII CN)
1) SOL
2) DM/ H/T/ Vasculitis
3) Multiple sclerosis
4) Subacute meningitis
Puan Rahimah complains of giddiness. Please look at her and proceed.
Examiner: Dr. Pan, please present your findings.
Dr. Pan:
Puan Rahimah’s head is rotated to the right. She has right eye ptosis. There is no strabismus at rest. Both her pupils are spared. There is no fatigability. There is mild impairment of upwards and upwards lateral movements of the right eye. Intorsion is intact. She has diplopia upon looking at all direction except looking downwards . The outer image disappears upon closing the right eye. There is no nystagmus. The rest of the cranial nerves are intact.
I would like to complete my examination by examining the patient’s BP (H/T), urine for sugar (DM), upper limbs and lower limbs for any pyramidal signs including the reflexes (CPEO, ELS) and cerebellar sign. I would also like to look into the fundus to look for any papilloedema. (/retinitis pigmentosa)
PANIC!!!!!??????? Dx????
In summary, Puan Rahimah has complex diplopia and I would like to consider differential diagnosis of
1) Mononeuritis multiplex
2) MG ( no fatigability)
3) Miller Fisher
4) CPEO, Ocular muscular dystrophy
5) Grave’s ( proptosis?)
6) Cavernous sinus thrombosis/ superior orbital fissure syndrome( if V CN is involved)
Examiner: What other investigation would you like to do?
Dr. Pan:
1) ESR to screen for vasculitis
2) MRI of the brain ( infarct / SOL esp at the midbrain)
Causes of isolated III CN palsy
Medical:
1) DM/ H/T/ Vasculitis
2) Multiple sclerosis
Surgical
1) Posterior communicating artery aneurysm/ Midbrain tu
2) Subacute meningitis
Causes of isolated VI CN palsy ( look for involvement of VII CN)
1) SOL
2) DM/ H/T/ Vasculitis
3) Multiple sclerosis
4) Subacute meningitis
Labels: Neurology
posted by panhypopit @ 3/18/2007 01:05:00 PM
4 Comments:
I would proceed to check for signs to suggest Myasthenia gravis. Any fatiguibility?
I didn't post the photo where patient was asked to look up continuosly and there was no fatigability.
there is a positive medial movement of the right eyes, it can't be 3rd nerve palsy . but the investigations listed were all pointed towards 3rd nerve palsy.
this variable opthalmoplegia , makes MG more likely.
i would agree with david teoh
i think this pt has rt VI nerve as it shown she has week abduction of rt eye
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