Unilateral ophthalmoplegia
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This document discusses the clinical approach, differential diagnosis, causes, general workup, and specific findings and workup for cavernous sinus syndrome and orbital apex syndrome presenting with ophthalmoplegia. It outlines the typical cranial nerve involvement seen in each condition and describes key features that help localize the lesion and identify potential etiologies. Common causes of each syndrome are listed along with suggestive clinical findings and recommended imaging and laboratory evaluations to further evaluate each case.
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Unilateral ophthalmoplegia
- 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
- 5. INTRODUCTION
- 6. DIFFERENTIAL Cavernous sinus syndrome III, IV, VI, V1 V2 +/- II Orbital Apex syndrome III, IV, VI, V1 II
- 7. CAUSES Cavernous sinus syndrome Cavernous sinus thrombosis Carotid-cavernous fistula / aneurysm Pituitary disorders Pituitary adenoma Craniopharyngioma Pituitary Apoplexy Orbital Apex syndrome Orbital infection Orbital Neoplasm (metastases, lymphoma) Thyroid eye disease Orbital pseudo tuomor / Idiopathic orbital myositis Tolosa Hunst syndrome+ Ocular myesthenia + Miller Fischer syndrome
- 8. GENERAL WORK-UP Routine Lab. Brain & orbital MRI. Systemic search for malignancy. Myasthenia & thyroid testing: AChR-Ab, TSH, T4, thyroid-stimulating Ab, antithyroid Abs. some selected cases: LP + CSF cytology
- 9. 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
- 10. CAROTID-CAVERNOUS FISTULA / ANEURYSM Suggestive Findings throbbing retro-orbital pain orbital bruits severe conjunctival injection pulsating exophtahlmos Work-Up Angiography
- 12. 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
- 15. ORBITAL INFECTION Suggestive Findings similar to CST prominent optic affection purulent discharge Work-Up MRI braind and orbit exclude CST CBC Blood culture
- 17. ORBIRAL NEOBLASM Suggestive Findings prominent proptosis early optic affection Work-Up MRI brand and orbit + C Metastatic work-up
- 19. 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
- 20. 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
- 22. 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
- 24. Thank you
Editor's Notes
- Images 5.1A–5.1C: Postcontrast axial, sagittal, and coronal T1-weighted images demonstrate a large complex multilobulated mass in the sellar/suprasellar area. The sella turcica is massively expanded. The tumor shows the characteristic “snowman” appearance. Image 5.1D: Postcontrast sagittal T1-weighted image of a normal MRI. The pituitary gland (yellow arrow) and stalk normally enhance and are seen below the optic chiasm (red arrow)
- Images 5.2A–5.2C: Postcontrast sagittal T1-weighted, axial T2-weighted, and non-contrast axial T1-weighted images demonstrate an enormous, hyperintense cystic pituitary mass, which has expanded the sella turcica, with mass effect on the brainstem and both medial temporal lobes. Image 5.2D: Gross pathology of a craniopharyngioma (image credit The Armed Forces Institute of Pathology).
- Axial FLAIR and coronal T1-weighted images demonstrate hyperintensity and enlargement of the right lateral rectus muscle (red arrows)
- Postcontrast, fat-suppressed axial and coronal T1-weighted images demonstrate an enhancing lesion (red arrows) in the left cavernous sinus.