Ophthalmoplegia (ophthalmoparesis)

Each eye moves (is rotated) by six muscles: four straight and two oblique. Disturbances in eye movements can be caused by injuries at different levels: the hemisphere, the stem, at the level of the cranial nerves and, finally, the muscles. Symptoms of eye movement disorders depend on the localization, size, severity and nature of the lesion.

[1], [2], [3]

Causes of ophthalmoplegia (ophthalmoparesis)

1. Myasthenia gravis.
2. Aneurysms of the vessels of the Willis circle.
3. Spontaneous or traumatic carotid-cavernous fistula.
4. Diabetic ophthalmoplegia.
5. Distiroid ophthalmopathy.
6. The Tolosa - Hunt syndrome (Tolosa - Hant).
7. Tumor and pseudotumor of the orbit.
8. Temporal arteritis.
9. Ischemia in the region of the brainstem.
10. Parasellar tumor.
11. Metastases in the brain stem.
12. Meningitis (tuberculosis, carcinomatous, fungal, sarcoidosis, etc.).
13. Multiple sclerosis.
14. Encephalopathy Wernicke.
15. Migraine with aura (ophthalmoplegic).
16. Encephalitis.
17. Injury of the orbit.
18. Thrombosis of the cavernous sinus.
19. Cranial neuropathies and polyneuropathies.
20. The Miller-Fisher Syndrome.
21. Pregnancy.
22. Psychogenic oculomotor disorders.

[4],

Myastenia gravis

Ptosis and diplopia may be the first clinical sign of myasthenia gravis. In this case, characteristic fatigue in response to physical stress in the hands may be absent or remain unnoticed by the patient. The patient may not pay attention to the fact that these symptoms are less pronounced in the morning and increase during the day. By offering the patient a long opening-closing test, one can confirm pathological fatigue. A test with prozerin under the control of EMG is the most reliable method of detecting myasthenia gravis.

Aneurysms of the vessels of the Willis circle

Congenital aneurysms are located mainly in the anterior parts of the Willis circle. The most frequent neurological sign of an aneurysm is the one-sided paralysis of the external muscles of the eye. III cranial nerve is usually affected. Sometimes an aneurysm is visualized on an MRI.

[5], [6], [7], [8]

Spontaneous or traumatic carotid-cavernous fistula

Since all the nerves that supply extraocular muscles pass through the cavernous sinus, the pathological processes of this localization can lead to paralysis of the outer muscles of the eye with doubling. Of great importance is the fistula between the internal carotid artery and the cavernous sinus. Such a fistula may be the result of a traumatic brain injury. It can occur spontaneously, probably because of the rupture of a small arteriosclerotic aneurysm. In most cases, the first branch (ophthalmic) of the trigeminal nerve suffers at the same time and the patient complains of pain in the zone of her innervation (forehead, eye).

The diagnosis is facilitated if the patient complains of a rhythmic noise synchronous with the work of the heart and diminishing when the carotid artery is clamped from the same side. Angiography confirms the diagnosis.

Diabetic Ophthalmoplegia

Diabetic ophthalmoplegia in most cases begins acutely and manifests as partial paralysis of the oculomotor nerve and unilateral pain in the anterior part of the head. An important feature of this neuropathy is the preservation of vegetative fibers to the pupil and therefore the pupil is not enlarged (in contrast to the paralysis of the III nerve in an aneurysm, in which vegetative fibers also suffer). As with all diabetic neuropathies, the patient does not necessarily know about diabetes at home.

[9], [10], [11], [12],

Dysthyroid ophthalmopathy

Distiroid ophthalmopathy (orbitopathy) is characterized by an increase in the volume (edema) of the external muscles of the eye in orbit, which is manifested by ophthalmoparesis and doubling. Ultrasound examination of the orbit helps to recognize a disease that can manifest itself both in hyper- and hypothyroidism.

[13], [14], [15], [16], [17],

Tholos-Hunt syndrome (painful ophthalmoplegia)

This eponym refers to nonspecific granulomatous inflammation in the wall of the cavernous sinus in the carotid artery bifurcation region, which is manifested by characteristic periorbital or retroorbital pain, III, IV, VI defeat of the cranial nerves and the first branch of the trigeminal nerve, good response to corticosteroids and the absence of neurological symptoms of involvement of the nervous system in beyond the cavernous sinus. The syndrome of painful ophthalmoplegia of Tolosa-Hunt should be a "diagnosis of exclusion"; it is placed only with the exclusion of other possible causes of "steroid-responding" ophthalmoparesis (volumetric processes, systemic lupus erythematosus, Crohn's disease).

Pseudotumor of the orbit

The term "pseudotumor" is intended to mean enlarged in volume (due to inflammation) extraocular muscles, and sometimes other contents of the orbit (tear gland, fatty tissue). Orbital pseudotumor is accompanied by injections of conjunctiva and mild exophthalmos, retroorbital pain, which can sometimes simulate migraine or bundle headache. Ultrasound examination or CT of orbits reveals an increase in the volume of the contents of the orbit, mainly of the muscles, in a manner similar to that found in distyroid ophthalmopathy. Both the Tolosa-Hunt syndrome and the pseudotumor of the orbit respond to corticosteroid treatment.

Tumor of the orbit, in addition to the above symptoms, is also accompanied by compression of the II pair and, consequently, a decrease in visual acuity (Bonnet syndrome).

Temporal arteritis

Giant cell (temporal) arteritis is typical for mature and elderly age and affects primarily the branches of the external carotid artery, mainly the temporal artery. Characterized by high ESR. There may be a polymyalgic syndrome. Occlusion of branches of the ophthalmic artery in 25% of patients leads to blindness to one or both eyes. Ischemic neuropathy of the optic nerve can develop. The defeat of arteries feeding the oculomotor nerves, can lead to their ischemic damage and the development of ophthalmoplegia. Possible occurrence of strokes.

Ischemic lesions of the brainstem

Disturbances of cerebral circulation in the region of penetrating branches of the basilar artery lead to the defeat of the III, IV or VI nuclei of the cranial nerves, which is usually accompanied by alternating syndromes with contralateral hemiplegia (hemiparesis) and conductive sensory disorders. There is a picture of an acute cerebral accident in a patient of mature or elderly age, suffering from a vascular disease.

The diagnosis is confirmed by neuroimaging and ultrasound.

Parasellar tumor

Tumors of the pituitary-hypothalamic region and craniopharyngiomas are manifested by changes in the Turkish saddle and fields of vision (chiasmatic syndrome), as well as specific endocrine disorders characteristic of a particular type of tumor. There are rare cases of tumor growth directly and outward. The resulting syndrome is characterized by the involvement of III, IV and VI nerves and the expansion of the homolateral pupil as a result of stimulation of the intertwining of the internal carotid artery. In connection with the slow growth of pituitary tumors, an increase in intracranial pressure is not very characteristic.

Metastases in the trunk of the brain

Metastases in the brain stem, affecting the nucleus of certain oculomotor nuclei, lead to slowly progressive oculomotor disturbances in the picture of alternating syndromes against the background of increased intracranial pressure and neuroimaging signs of the volumetric process. Possible paralysis of the eye. Defects of the horizontal look are more typical for damage in the field of the varioly bridge; violations of the same vertical view are more common in cases of damage to the mesencephalon or diencephalon.

Meningitis

Any meningitis (tuberculosis, carcinomatous, fungal, sarcoid, lymphomatous, etc.) developing primarily on the basal surface of the brain usually involves cranial nerves and most often oculomotor nerves. Many of these types of meningitis can often occur without a headache. Important cytological examination of cerebrospinal fluid (microscopy), the use of CT MRT and radionuclide scanning.

Multiple sclerosis

Damage to the brain stem in multiple sclerosis often leads to diplopia and oculomotor disorders. Often there is an internuclear ophthalmoplegia or lesions of individual oculomotor nerves. It is important to identify at least two lesions, confirm the recurrent course and the corresponding data of evoked potentials and MRI.

Encephalopathy Wernicke

Wernicke's encephalopathy is caused by vitamin B12 deficiency in patients with alcoholism due to malabsorption or eating disorders and is manifested by acute or subacute development of brainstem lesions: nerve damage, various types of vision disorders, internuclear ophthalmoplegia, nystagmus, cerebellar ataxia and other symptoms (confusion, mnestichesky infringements, a polyneuropathy, etc.). The dramatic therapeutic effect of vitamin B1 is characteristic.

[18], [19], [20]

Migraine with aura (ophthalmoplegic)

This form of migraine is extremely rare (according to one of the headache clinics - 8 cases per 5000 patients with a headache) most often in children younger than 12 years. Headache is observed on the side of ophthalmoplegia and usually precedes it in a few days. Episodes of migraine are noted weekly or less often. Ophthalmoplegia is usually complete, but it can also be partial (one or more of the three oculomotor nerves). Patients over 10 years of age require angiography to exclude aneurysm.

Differential diagnosis is performed with glaucoma, Tolosa-Hunt syndrome, parasellar tumor, pituitary apoplexy. It is also necessary to exclude diabetic neuropathy, Wegener's granulomatosis and orbital pseudotumor.

Encephalitis

Encephalitis with lesions of the oral sections of the brain stem, for example, Bickerstaff encephalitis (Bickerstaff) or other stem encephalitis can be accompanied by ophthalmoparesis in the presence of other symptoms of brain table damage.

[21], [22], [23], [24], [25]

Ophthalmic herpes

Ophthalmic herpes constitutes 10 to 15% of all cases of herpes zoster and is manifested by pain and rash in the innervation zone of the I branch of the trigeminal nerve (often involving the cornea and conjunctiva). Pairs of extraocular muscles, ptosis and mydrias often accompany this form, which indicates the involvement of the third, fourth and sixth cranial nerves in addition to the defeat of the Gasser node.

Injury of the orbit

Mechanical damage to the orbit with a hemorrhage into its cavity can lead to a variety of oculomotor disorders due to damage to the corresponding nerves or muscles.

Cavernous sinus thrombosis

Sinus-thrombosis manifests itself as headache, fever, impaired consciousness, chemosis, exophthalmos, edema in the eyeball zone. On the fundus there is edema, possibly a decrease in visual acuity. Characteristic is the involvement of III, IV, VI cranial nerves and the I branch of the trigeminal nerve. After a few days, the process passes through the circular sinus to the opposite cavernous sinus and bilateral symptoms appear. Liquor is usually normal, despite concomitant meningitis or subdural empyema.

[26], [27], [28], [29]

Cranial neuropathies and polyneuropathies

Cranial neuropathies with eye muscle paresis are observed in alcoholic syndromes of nervous system damage, beriberi, polyneuropathy in hyperthyroidism, idiopathic cranial polyneuropathy, hereditary amyloid polyneuropathy (Finnish type) and other forms.

[30], [31],

Miller Fischer Syndrome

Fischer syndrome manifests itself as ophthalmoplegia (but not ptosis), cerebellar ataxia (without chanting speech), and areflexia. In addition to these mandatory symptoms, VII, IX and X nerves (dysphagia without dysarthria) are often involved. Rare symptoms: nystagmus, Bell phenomenon, depression of consciousness, sluggish tetraparesis, pyramidal signs, tremor and some others. Often, protein-cell dissociation in the cerebrospinal fluid is detected. The course is characterized by an acute onset followed by a "plateau" of symptoms and a subsequent recovery. The syndrome is a kind of intermediate form between Bickerstaff encephalitis and Guillain-Barre polyneuropathy.

Pregnancy

Pregnancy is accompanied by an increased risk of oculomotor disorders of different nature.

Psychogenic oculomotor disorders

Psychogenic oculomotor disorders are more often manifested by vasor disturbances (spasm of convergence or "pseudo-abdotsens", convulsions of the eye in the form of deviation of eyes of different types) and are always observed in the context of other characteristic motor (multiple motor disorders), sensitive, emotional-personality and vegetative manifestations of polysyndrome hysteria . Positive diagnosis of psychogenic disorders and a clinical and paraclinic exclusion of the current organic disease of the nervous system are mandatory.