Internuclear opthalmoplegia: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
*Weakness in adduction of affected eye with limitation in horizontal gaze. | *Weakness in adduction of affected eye with limitation in horizontal gaze. | ||
*May result in horizontal diplopia | *May result in horizontal [[diplopia]] | ||
*Horizontal nystagmus in unaffected eye | *Horizontal [[nystagmus]] in unaffected eye | ||
*Convergence remains intact (differentiates CN III palsy from INO) | *Convergence remains intact (differentiates CN III palsy from INO) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Multiple | *[[Multiple sclerosis]] (often presents with bilateral internuclear ophthalmoplegia) | ||
*Cerebrovascular disease | *[[CVA|Cerebrovascular disease]] | ||
*Malignancy located in brainstem and 4th ventricle | *[[brain tumor|Malignancy]] located in brainstem and 4th ventricle | ||
*CN III palsy | *[[third nerve palsy|CN III palsy]] | ||
==Evaluation== | ==Evaluation== | ||
*Neurologic exam | *Neurologic exam | ||
*The use of optokinetic tape is highly sensitive for testing for INO | *The use of optokinetic tape is highly sensitive for testing for INO | ||
*MRI | *[[brain MRI]] | ||
==Management== | ==Management== | ||
* | *Symptoms will often resolve on their own. Patients with cerebrovascular disease are less likely to have recovery. | ||
*Patching of eye can aid in relief of diplopia | *Patching of eye can aid in relief of diplopia | ||
*Diframpadine, potassium channel blocker, has been used in patients with demyelinating disease | *Diframpadine, potassium channel blocker, has been used in patients with demyelinating disease | ||
Revision as of 22:32, 2 October 2019
Background
- Disruption of conjugate gaze.
- Results in diplopia when looking contralateral (to affected eye).
- Localized to Midbrain or Pons.
- Paramedian Pontine Reticular Formation (PPRF) is the conjugate gaze center for horizontal eye movements. Innervates ipsilateral Abducens (CN VI) nucleus. Abducens nucleus signals ipsilateral lateral rectus to contract and sends a second via MLF to contralateral oculomotor (CN III) nucleus, causing contraction on the contralateral medial rectus.
- Lesions in the Medial Longitudinal Fasiculus (MLF) result in intranuclear ophthalmoplegia (INO).
- Associated with one and one-half syndrome (lesion involving the PPRF and ipsilateral MLF)
Clinical Features
- Weakness in adduction of affected eye with limitation in horizontal gaze.
- May result in horizontal diplopia
- Horizontal nystagmus in unaffected eye
- Convergence remains intact (differentiates CN III palsy from INO)
Differential Diagnosis
- Multiple sclerosis (often presents with bilateral internuclear ophthalmoplegia)
- Cerebrovascular disease
- Malignancy located in brainstem and 4th ventricle
- CN III palsy
Evaluation
- Neurologic exam
- The use of optokinetic tape is highly sensitive for testing for INO
- brain MRI
Management
- Symptoms will often resolve on their own. Patients with cerebrovascular disease are less likely to have recovery.
- Patching of eye can aid in relief of diplopia
- Diframpadine, potassium channel blocker, has been used in patients with demyelinating disease
References
Ropper A, Klein J, Samuels M. Adams and Victor's Principles of Neurology 10th Edition. McGraw-Hill Education / Medical; 2014.
Serra A, Skelly MM, Jacobs JB, et al. Improvement of internuclear ophthalmoparesis in multiple sclerosis with dalfampridine. Neurology 2014; 83:192.