Disturbance of eye movements without twitching

If the violation of eye movements is not accompanied by double vision, then this presupposes the supranuclear nature of the lesion, that is, eye violations. At a clinical examination, paralysis is found only with friendly eye movements, in both eyes the same deficiency of movements is detected, eyeballs remain parallel with the preservation of the direction of the eye. If there is a strabismus without doubling, then there is one of two other disorders: friendly strabismus or internuclear ophthalmoplegia. Let us consider these three situations in turn.

A. Friendly paralysis.

Friendly paralysis (violation of eye movements without divergence along the axis) is always caused by damage to supranuclear centers.

• I. Paresis (paralysis) of the gaze to the side.
  • Defeat of the stem center of the eye (stroke, tumors, multiple sclerosis, intoxication).
  • The defeat of the frontal cortical center of the eye in field 8, the patient "looks at the outbreak" (strokes, tumors, atrophic processes, trauma).
• II. The paresis of the gaze upward (as well as down) differs from the peripheral paralysis of the external eye muscles by the presence of the phenomenon of Bell, the phenomenon of "pupal eyes".
  • Tumor of the brain stem.
  • Non-communicable hydrocephalus.
  • Progressive supranuclear palsy.
  • Whipple disease.
  • Wilson-Konovalov's disease.
  • Horea Huntington.
  • Progressive multifocal leukoencephalopathy in malignant neoplasms.

B. Other gaps:

• Ocular dysmetry (eyes oscillate on a fixed object, which is observed in diseases of the cerebellum).
• Congenital ophthalmic apraxia (Kogan syndrome)
• Oculogic crises
• Psychogenic deviations of the eye

C. Friendly Strabismus

D. Intrinsic ophthalmoplegia (cerebral vascular lesion, multiple sclerosis, swelling, rarely other causes)

[1], [2], [3], [4], [5]

A. Friendly paralysis.

[6], [7], [8]

I. Paralysis of the eye to the side.

Disturbances of eye movements without divergence along the axis are known as friendly paralysis. They are always caused by damage to the supranuclear gaze centers in the brainstem or cortex. Nystagmus in the case of paresis of the eyes is often accompanied by other disorders. Differentiation from progressive ocular muscular dystrophy (a slowly progressing disease, often accompanied by ptosis, impaired function of the pharynx muscles) with complete paralysis of all eye movements in parallel axes is rarely difficult. Causes of friendly paralysis may include:

Defeats the stem center of the eye ("nucleus para-abducens") in the caudal part of the bridge. The defeat of this site leads to the impossibility of looking at the affected side.

Causes: vascular (often in elderly patients, sudden onset, always accompanied by other disorders), tumors, multiple sclerosis, intoxications (eg, carbamazepine).

The defeat of the frontal cortical center of the gaze in the field 8. When it is erased, the eye and head are rejected to the opposite side, which sometimes turns into an epileptic adverse attack. Damage to this area leads to a deflection of the eyes and the head to the side of the lesion, since the activity of the opposite field prevails 8 (friendly deviation); "The patient looks at the hearth." A few days after the onset of the lesion, the patient is able to look straight ahead, but still there is the anxiety of the eyeballs when trying to look in the opposite direction. Over time, even this function is restored. But there remains a nystagmus, observed with the gaze of the eye, with a fast component to the opposite side. Eye tracking movements remain.

The reasons for the defeat of the frontal gaze center include strokes, tumors (often accompanied by symptoms of irritation, sometimes with mental disorders of the frontal type); atrophic processes (in elderly patients, accompanied by dementia and other cortical disorders, in particular, neuropsychological); trauma (history, sometimes external injuries, fractures of the skull, subjective symptoms of concussion, blood in the cerebrospinal fluid, and rarely other neurological disorders).

Bilateral paralysis of the horizontal gaze (a rare neurological phenomenon) is described with multiple sclerosis, a coronary artery attack, hemorrhages in the bridge region, metastases, cerebellar abscess and as a congenital disorder.

II. Paresis (paralysis) of the gaze upward (as well as down)

The paresis of the gaze upward (the Parino syndrome, when accompanied by a violation of convergence), as well as down indicates a lesion in the area of the tire cover of the rostral divisions of the midbrain. However, it should be noted that many patients, especially the elderly, are in serious condition or stupor with anxiety of the eyeballs when looking up. True paralysis of the vertical gaze can be recognized (and differentiated from peripheral paralysis of the outer eye muscles) by the presence of the following symptoms:

The phenomenon of Bella. The examiner passively lifts the upper eyelid, when the patient tries to close his eyes with force; reveals a reflex rotation of the eyeball upwards. The phenomenon of "puppet eyes". When the patient fixes a look at the object immediately before the eyes, the examiner bends the patient's head forward. In this case, the patient's gaze remains fixed on the object due to the rotation of the gaze upward (despite the upward spiral of the arbitrary gaze).

The causes of progressive vertical ophthalmoplegia can be:

Tumor of the brain stem (a common cause, manifests itself and other oculomotor disorders, paralysis of convergence, other neurological disorders, including symptoms of the midbrain, headache, manifestations of increased intracranial pressure, and pinealome also premature puberty).

Non-communicable hydrocephalus (symptoms of increased intracranial pressure are noted, in children, head size increase).

Progressive supranuclear palsy, syndrome

Stila-Richardson-Olydevsky (observed in elderly patients, accompanied by akinetic parkinsonian syndrome, dementia, rarely total external ophthalmoplegia).

Disease Whipple (uveitis, dementia, gastrointestinal disorders).

Disease Wilson - Konovalov.

Horea Huntington.

Progressive multifocal leukoencephalopathy in malignant diseases.

B. Other violations of the eye

Other violations of the gaze (which partially manifest themselves as difficulty in reading) should also be briefly mentioned:

Ocular dysmetry, in which the eye oscillates on a fixed object. This disorder is found in diseases of the cerebellum.

Congenital ophthalmic apraxia or Kogan syndrome. To look at another object, the patient must turn his head further, beyond the fixed object. When from the position with excessive rotation of the head the eyes are again fixed on the object, the head rotates back to the correct direction. This process leads to bizarre movements of the head (which must be differentiated from the tick), as well as difficulties in reading and writing (it is necessary to differentiate from congenital alexia).

Oculogic crises are involuntary deviation of the eyes into one side, or more often upwards. Previously observed in postencephalitic Parkinsonism, being an early symptom of this disease (indications in a history of a disease with a high temperature, other extrapyramidal symptoms, which helps differentiate from hysteria). Currently, the most common cause is iatrogenic (a side effect of neuroleptics).

Psychogenic deviation of the eye.

[9], [10], [11], [12], [13]

C. Friendly Strabismus

Friendly strabismus has the following characteristics: Observed from childhood.

Often accompanied by a decrease in visual acuity (amblyopia). In the study of eye movements, strabismus is noted, one eye does not participate in certain directions of movement.

When a separate study of eye movements, when one eye is closed, the movements of the other eye are carried out in full.

The non-focusing eye (closed by the examiner) is diverted to one side (a friendly divergent or converging strabismus). This phenomenon can alternate in both eyes (friendly alternating strabismus, for example, divergent), and can be detected by a test with the eye closed. Also, strabismus is a consequence of congenital or early acquired balance disorder (balance) of the eye muscles, usually accompanied by a decrease in visual acuity to one eye, has no specific neurological significance.

[14], [15]

D. Intrinsic ophthalmoplegia

Internuclear ophthalmoplegia causes disturbance of the ocular axes without double vision. The lesion of medial longitudinal bundles between the stem center of the gaze and the nuclei of the oculomotor nerve interrupts impulses for the lateral gaze that extend from the stem center and the homolateral nucleus of the outgoing nerve to the orally located nuclei of the third nerve, which controls the inner rectus muscle of the opposite eye. The retracted eye easily moves laterally. The reduced eye does not cross the middle line. However, convergence is retained on both sides, since the impulses that go to both eyes from the rostralized center of convergence (the core of Perlia) allow the "paretic" eye to move along with the "non-parental" eye.

Complete internuclear ophthalmoplegia is rare, but in many patients with partial internuclear ophthalmoplegia, the disease manifests itself with slow saccades only of the reduced eye.

The cause of internuclear ophthalmoplegia is usually a vascular lesion of the brainstem; multiple sclerosis or swelling. Very rarely, the violation of eye movements with a divergence along the axis without doubling is the result of other causes - for example, as part of the giant-cell arteritis syndrome.

Diagnostic tests for internuclear ophthalmoplegia

• General and biochemical analysis of blood,
• MRI or CT,
• The evoked potentials of different modalities
• Investigation of cerebrospinal fluid, ocular fundus, oculist consultation.

Global paralysis of the eyes is the inability to arbitrarily move the gaze in any direction (total ophthalmoplegia). Global paralysis of the gaze in isolated form is rare; It usually accompanies the symptoms of involving adjacent structures.

The main causes: oculomotor apraxia; Guillain-Barre syndrome; myasthenia gravis; thyroid ophthalmopathy (especially when combined with myasthenia gravis); syndromes of chronic progressive external ophthalmoplegia; Wilson-Konovalov's disease; apoplexy of the pituitary gland; botulism; tetanus; progressive supranuclear palsy; intoxication with anticonvulsants; encephalopathy Wernicke; acute bilateral injuries in the region of the variolium bridge or mesodienecephalon, abetalipoproteinemia, HIV-encephalopathy, Alzheimer's disease, adrenoleukodystrophy, corticobasal degeneration, Farah's disease, Gaucher's disease, Lee's disease, malignant neuroleptic syndrome, neurosyphilis, paraneoplastic syndrome, Whipple's disease

To clarify the diagnosis of MRI; myasthenic tests; EMG. It is necessary to exclude botulism.

[16], [17], [18], [19]