Unilateral ophthalmoplegia

Diagnostic approach to unilateral ophthalmoplegia with or without visual impairment. Addressing the cavernous sinus and orbital apex syndromes.

1. Opthalmoplegia +/- II Yasser Alzainy Neurology Resident AL-AZHAR UNIVERSITY Faculty of Medicine Neurology Department

2. Clinical Approach What is the presentation? History Examination Binocular diplopia +/- deminution of vision III, IV, VI, V1 +/- II +/- V2

3. Clinical Approach Where is the Lesion? (diplopia) Supranuclear Nuclear / Internuclear Infranuclear Neuronal Neuromuscular junction Orbital pathology What is the Lesion? History Onset, course, duration Asccoiated symptoms Investigation Lab Imaging

4. Introduction

5. Differential Cavernous sinus syndrome III, IV, VI, V1 V2 +/- II Orbital Apex syndrome III, IV, VI, V1 II

6. Causes Cavernous sinus syndrome Cavernous sinus thrombosis Caroti d -cavernous fistula / aneurysm Pituitary disorders Pituitary adenoma Craniopharyngioma Pituitary Apoplexy Orbital Apex syndrome Orbital infection Orbital Neoplasm (metastases, lymphoma) Thyroid eye disea s e Orbital pseudo tuomor / Idiopathic orbital myo s itis Tolosa Hunst syndrome + Ocular myesthenia + Miller Fischer syndrome

7. General Work-up Routine Lab. Brain & orbital MRI . S ystemic search for malignancy . M yasthenia & thyroid testing: AChR-Ab, TSH, T4, thyroid-stimulating Ab, antithyroid Abs. some selected cases: LP + CSF cytology

8. Cavernous sinus thrombosis Suggestive Findings sinusitis ; facial, dental or orbital infection severe retrobulbar pain, isolated VI, ptosis: early sx progress to become bilateral ocular bruits papilloedema and retinal hemorrhages > deminution of vision Work-Up MRI brain and Orbit Coagulopathy profile (aseptic CST) Leukocytosis in CBC

9. Caroti d -cavernous fistula / Aneurysm Suggestive Findings throbbing retro-orbital pain orbital bruits severe conjunctival injection pulsating exophtahlmos Work-Up Angiography

10. Pituitary disorders (pituitary adenoma, craniopharyngioma) Suggestive Findings endocrine dysfunction bitemporal hemanopia earlier than ophthalmoplegia monocular deminution of vision may occur personlaity changes / seizures (frontal lobe) Work-Up MRI brain + C hormonal work-up

11. Pituitary adenoma

12. Craniopharyngioma

13. Orbital infection Suggestive Findings similar to CST prominent optic affection purulent discharge Work-Up MRI braind and orbit exclude CST CBC Blood culture

14. Orbiral Neoblasm Suggestive Findings prominent proptosis early optic affection Work-Up MRI brand and orbit + C Metastatic work-up

15. Thyroid eye diseae Suggestive Findings associated hyper > hypo- thyroidism may precede / co-exist / follow Work-Up MRI brain and Orbit regular enlargment of extraocular muscles with tendon sparing

16. Orbital pseudo tuomor ( idiopathic inflammatory orbital Dz) Suggestive Findings Dx of exclusion almost strictly unilateral associated other autoimmune / inflammatory condition dramatic response to steroids Work-Up MRI brain and orbit + C enlargement of extraocular muscle (one or more) with tendon involvement avid enhancement

17. Tolosa Hunst syndrome Suggestive Findings Diagnosis of exclusion duration: days to weeks II involvement in 25% Highly responsive to steroids Work-Up MRI brain and orbit +C enhancing lesion Biopsy

18. Thank you