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PARALYTIC STRABISMUS

PARALYTIC STRABISMUS. Assist.Prof. Dr.Vildan Öztürk Ophthalmology Yeditepe University Hospital. STRABISMUS. Strabismus involves deviation of the alignment of one eye in relation to the other. Non-paralytic strabismus Paralytic strabismus. concomitant strabismus;

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PARALYTIC STRABISMUS

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  1. PARALYTIC STRABISMUS Assist.Prof. Dr.Vildan Öztürk Ophthalmology Yeditepe University Hospital

  2. STRABISMUS Strabismus involves deviation of the alignment of one eye in relation to the other. • Non-paralytic strabismus • Paralytic strabismus

  3. concomitant strabismus; • due to faulty insertion of the eye muscles, resulting in the same amount of deviation regardless of the direction of the gaze • nonconcomitant strabismus; • in which the amount of deviation of the squinting eye varies according to the direction of gaze

  4. Strabismus=Squint, Wandering eye Esotropia=Crossed eyes Exotropia=Walleye

  5. ANATOMY Anatomic axis Visual (optical) axis Kappa angle:

  6. ANATOMY OF EXTRAOCULAR MUSCLES: • Thelateralandmedialwalls of theorbitmake an angle of 45 degreeswitheachother. • Inprimarypositiontheopticalaxisforms an angle of 22.5 degreeswiththeorbit.

  7. ANATOMY OF EXTRAOCULAR MUSCLES: • Primaryaction of themuscle is itsmajoreffectwhentheeye is in primaryposition • Subsidiaryactionsaretheadditionaleffects of theposition of theeye • Listingplane is an imaginaryfrontalequatorialplanepassingthroughthecenter of rotation of globe. -ThegloberotatesleftandrightaroundtheverticalY axis -Theglobemovesupanddownaroundthehorizontal X axis.-Torsionalmovementsoccuraroundthe Zaxiswhichtraversestheglobefromfronttoback.

  8. Z axis X azis Y axis

  9. EYE MOVEMENTS Ductions are monocular eye movements around the axis of Fick. (X, Y, Z) • Adduction; movement of the eye nasally • Abduction; is temporal movement • Supraduction; elevation • Infraduction;depression of the eye • Incycloduction (intorsion); nasal rotation of the vertical meridian • Excycloduction (extorsion); temporal rotation of the vertical meridian.

  10. SIX CARDINAL POSITIONS OF GAZE Up / right Up / left Right Left Down / right Down / left

  11. HORIZONTAL RECTUS MUSCLES: -Medial rectus: it’s action is adduction -Lateral rectus: it’s sole action is abduction.

  12. VERTICAL RECTUS MUSCLES Superiorrectus: • primaryaction is elevation • secondary actions are adduction and intorsion Inferior rectus: • primaryaction is depression • secondary actions are adduction and extorsion

  13. OBLIQUE MUSCLES • Superior obliquemuscle • incyclotorsion. • depression • abduction • Inferior oblique muscle • excyclotorsion • elevation • abduction

  14. Tillaux’nun Spirali

  15. LAWS OF OCULAR MOTILITY • Agonist: the primary muscle that moves an eye in a given direction • Synergist; muscle in the same eye that moves the eye in the same direction as the agonist • Antagonist; muscle in the same eye that moves the eye in the opposite direction of the agonist muscle • Sherrington Law, increased innervation to any muscle (agonist) is accompanied by a corresponding decrease in innervation to its antagonists.

  16. LAWS OF OCULAR MOTILITY • Yoke muscles • Primarymuscles in each eye that accomplish a given version. • Each extra ocular muscle has a yoke muscle in the opposite eye to accomplish versions into each gaze position. • Herring Law; • Yokemuscles receive equal and simultaneous innervation; • Magnitude is determined by the fixating eye.

  17. BINOCULAR EYE MOVEMENTS • Conjugate (versions)are movements of both eyes in the same direction -Dextroversion is movement of both eyes to the right, -Levoversion is movement of both eyes to the left. -Supraversion; elevation of both eyes, -Infraversion; depression of both eyes,

  18. BİNOCULAR EYE MOVEMENTS • Disconjugate (vergences)are movements of the eyes in opposite directions. -Convergence is movement of both eyes nasally -Divergence is movement of both eyes temporally. -Vertical vergence movements also may occur.

  19. TYPES OF STRABISMUS Esotropia is inward turning Exotropiais outward turning Hypertropiais upward turning Hypotropiaisdownward turning of the eye.

  20. ESOTROPIA

  21. EXOTROPIA

  22. HYPERTROPIA

  23. HYPOTROPIA

  24. HIRSCHBERG TEST

  25. DIPLOPIA • Simultaneousappreciation of twoimages of oneobject. • Itresultsfrom a failuretomaintainbinocularvision. • Binocular, monocular, physiological

  26. MUSCLE INNERVATIONS • medial rectus (MR)—cranial nerve III • lateral rectus (LR)—cranial nerve VI • superior rectus (SR)—cranial nerve III • inferior rectus (IR)—cranial nerve III • superior oblique (SO)—cranial nerve IV • inferior oblique (IO)—cranial nerve III

  27. Extra ocular muscle paralysis resulting from destructive lesions in one or all of these cranial nerves results in failure of one or both eyes to rotate in concert with the other eye.

  28. (LR6SO4)3

  29. OCULAR MOTOR NERVE PALSIES 1. Third nerve 2. Fourth nerve 3. Sixth nerve

  30. OCULOMOTOR (III.) NERVE PALSY • The oculomotor nerve innervates • superior rectus,inferior rectus, medial rectus, • inferior oblique, • levatorpalpebrae, • ciliarymuscle • iris sphincter.

  31. OCULOMOTOR (III.) NERVE PALSY

  32. Anatomy of third nerve Oculomotor nucleus Pituitary gland Red nucleus Carotid artery Cavernous sinus Pons III nerve • Nuclear portion • Fascicular portion • intraparenchymalmidbrainportion • subarachnoid portion • cavernous sinus portion • orbital portion Post cerebral artery Clivus Basilar artery

  33. OCULOMOTOR (III.) NERVE PALSY ANATOMY • The pupillomotor and ciliary muscleneurons derive from the Edinger-Westphalsubnucleus, which is in the midline in the most rostral and anterior part of the oculomotor nerve nucleus. • These autonomic pathways are all ipsilateral or uncrossed

  34. Applied anatomy of pupillomotor nerve fibres Blood vessels on pia mater supply surface of the nerve including pupillary fibres ( damaged by compressive lesions ) Vasa nervorum supply part of nerve but not pupillary fibres ( damaged by medical lesions ) Pupillary fibres lie dorsal and peripheral

  35. OCULOMOTOR (III.) NERVE PALSY ETIOLOGY A- Pupil involving More common: Aneurysm ( particularly a post. communicating artery aneurysm) Less common: Ischemic microvascular disease ( DM or HT), tumour, trauma, congenital Rare: Uncal herniation, cavernous sinus mass lesion, pituatery apoplexy, orbital disease, herpes zoster, leukemia, in children ophthalmoplegic migraine

  36. OCULOMOTOR (III.) NERVE PALSY ETIOLOGY B- Pupil–sparing: Ischemic microvascular disease; rarely cavernous sinus syndrome, giant cell arteritis (GCA) C- Relative pupil-sparing: Ischemic microvascular disease; less likely aneurysm

  37. Etiology

  38. Important causes of isolated third nerve palsy Idiopathic - about 25% Vascular disease - hypertension, diabetes Trauma Posterior communicatinganeurysm Extradural haematoma Aneurysm Midbrain pushed across Chiasm Edge of tentorium Prolapsing temporal lobe Posterior cerebral artery Third nerve

  39. OCULOMOTOR (III.) NERVE PALSY ETİOLOGY • Nuclear and fascicular midbrain portion • Infarction • Hemorrhage • Neoplasm • Abscess

  40. OCULOMOTOR (III.) NERVE PALSY ETIOLOGY • Fascicular midbrain portioninfarcts • Benedikt syndrome • upper mid brain includes • ipsilateralthird cranial nerve palsy • contralateral flapping hand tremor • ataxia • Weber syndrome • slightly more ventral lesion at the level of the third cranial nerve fascicles in the mid brain • ipsilateral third cranial nerve palsy • contralateral hemiplegia or hemiparesis

  41. OCULOMOTOR (III.) NERVE PALSY ETIOLOGY • Fascicular subarachnoid portion • Aneurysm • Infectious meningitis - Bacterial, fungal/parasitic, viral • Meningeal infiltrative • Carcinomatous/lymphomatous/leukemic infiltration, granulomatous inflammation (sarcoidosis, lymphomatoid granulomatosis, Wegener granulomatosis)

  42. OCULOMOTOR (III.) NERVE PALSY ETIOLOGY • Fascicular cavernous sinus portion • Tumor - Pituitary adenoma, meningioma, craniopharyngioma, metastatic carcinoma • Vascular • Giant intracavernous aneurysm • Carotid artery-cavernous sinus fistula • Carotid dural branch-cavernous sinus fistula • Cavernous sinus thrombosis • Ischemia from microvascular disease in vasa nervosa • Inflammatory - Tolosa-Hunt syndrome (idiopathic or granulomatous inflammation)

  43. OCULOMOTOR (III.) NERVE PALSY ETIOLOGY • Fascicular orbital portion • Inflammatory, orbital inflammatory pseudotumor, orbital myositis • Endocrine (thyroid orbitopathy) • Tumor (hemangioma, lymphangioma, meningioma)

  44. OCULOMOTOR (III.) NERVE PALSY FREQUENCY • %30 of paralytic strabismus MORTALİTY/MORBİDİTY • subarachnoid hemorrhage from berry aneurysm of the posterior communicating artery • meningitis or meningeal infiltrative disorders, both infectious and neoplastic

  45. OCULOMOTOR (III.) NERVE PALSY SYMPTOMS • Binocular diplopia • Ptosis • Mydriasis • With or without pain

  46. Signs of right third nerve palsy • Ptosis, mydriasis and cycloplegia • Abduction in primary position • Normal abduction • Intorsion on attempted downgaze • Limited adduction • Limited depression • Limited elevation

  47. OCULOMOTOR (III.) NERVE PALSY CRITICAL SIGNS • External ophthalmoplegia ( motility impaired) 1-Complete palsy: Limitation of ocular movement in all fields of gaze except temporally 2-Incomplete palsy:partial limitation of ocular movement 3-Superior division palsy: Ptosis and inability to look up 4-Inferior division palsy: Inability to look nasally or inferiorly: pupil is involved

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