Neuroophthalmology cases

1. Neuroophthalmology cases For Mcs & MD Examination By/ Prof. Ahmad Mostafa

2. Case 1

3. This 70 year-old man developed the above appearance and headache. • What is the diagnosis? • Is he likely to develop aberrant regeneration? • What is the management?

4. Answers A. medical left third nerve palsy. • The pictures show a complete left ptosis with the left globe turning down and out. • The pupils are equal in sizes suggesting that this is a medical third nerve palsy. • This patient had diabetes mellitus and hypertension. • The palsy resulted from microvascular infarction of the third nerve.

5. b. Is he likely to develop aberrant regeneration? • No. Aberrant regeneration occurs with compressive third nerve palsy (surgical third nerve palsy) such as tumour or aneurysms. It does not occur with medical nerve palsy.

6. c. What is the management? • The management is conservative as medical third nerve palsy tends to improve with time. • The complete ptosis abolishes the diplopia which he may otherwise experience. • If the ptosis improved before the muscle palsy, he may experience diplopia. • In which case occlusion of the left eye is useful or alternatively prism may be tried. • Surgery is not usually needed as the majority resolves spontaneously.

7. Case 2

8. This 70 year old woman was referred by the ENT department because of the above appearance. Fig. 2 Fig. 1

9. Qs a. What is the diagnosis? b. How would you manage this patient?

10. What is the diagnosis? Ramsey Hunt syndrome due to herpes zoster. Figure 1 shows a right lower facial nerve palsy with failure of lid closure; and figure 2 shows vesicular rashes in the ipsilateral pinna which is supplied by the sensory branch of the facial nerve. In Ramsey Hunt syndrome, there is herpes zoster of the geniculate ganglion with resultant lower facial nerve palsy and loss of taste to the naterior 2/3 of the tongue. Other features may include sensorineural hearing loss, vertigo and rarely encephlaitis. Answers

11. b. How would you manage this patient? • The main goals of treatment are to control the herpes zoster and protect the cornea from exposure keratopathy: • oral acyclovir 800 mg fives times a day is useful if the vesicular rash occurs within 72 hours • regular artificial tear or lubricating ointment, strapping of the lids at night can reduce exposure keratitis. • If there were severe exposure keratopathy despite the above treatment, lids closure should be performed. This can be either with surgical tarsorrhaphy or botulinum toxin-induced ptosis. • Compared with Bell's palsy (idiopathic lower seventh nerve palsy), patient with Ramsey Hunt syndrome tends to have a less satisfactory recovery (85% vs 50%).