CTS 5 Problems Affecting Vision

Case 1
A 23 year old motorbike rider is involved in a head on collision. He was not
wearing a helmet. Skull X Ray shows a fracture of the orbit. Blow-Out
Fracture He complains of double vision when looking down.
1. What is diplopia? What is its anatomical basis, and what can cause it?
Double vision. Usually, its either malfunctioning of the muscles or
nerve/s. It thus occurs, when eyes are no longer aligned together. It
can be present in either vertical or horizontal directions, depending on
which muscle/s are affected.
2. How do you determine which muscle is damaged/paralysed?
Clinical testing of eye movements. Ask patient to look straight at your
pen, and to follow it with their eyes (head has to be fixed). If theyre
seeing double at any particular point as to which muscle is being
involved.
3. Which cranial nerve is involved in this case? Where does this nerve
originate and how does it reach the eyeball?
Cranial nerve IV trochlear ONLY nerve which comes out from posterior
aspect of brainstem, exits at the level of the superior colliculus. It
decussates as well, and crosses superficially over the optic nerve
(occupies a lateral position with regards to the cavernous sinus). It
comes out from the superior orbital fissure and comes out from outside
the common tendinous ring.
4. Which muscle(s) are paralysed and what is its action?
Superior oblique muscle, which depresses, abducts, and medially rotates
the eyeball. Trochlea a fibrocartilaginous pulley, and the reason why the
trochlear nerve is so-called, since it innervates the superior oblique.
5. During what activities of daily living would the diplopia be worst and
why? How can one compensate for this lesion?

Reading, walking down staircases, tying shoelaces basically DIPLOPIA

WHEN LOOKING DOWN! In long standing cases, patients will start
compensating (voluntarily); not looking down whilst head is fixed, etc.
Chin down, head to the opposite side, so as to eliminate double vision.
6. What would be the position of the eye if the other cranial nerves that
supply the extra-ocular muscles are injured?
In 3rd Nerve palsy, youd only have the superior oblique and the lateral
rectus which work EYEBALL WOULD BE DEPRESSED AND
LATERALLY-FACED.
6th Nerve palsy eye deviates medially.
7. Mention some causes of single cranial nerve lesions.
Trauma to the head. Loads of causes! Tumour, diabetes (the same way
that diabetes causes pathologies in other regions of the body, i.e.
cardiovascular ischaemia), infections such as meningoencephalitis,
meningitis, encephalitis (look these up), stroke (especially brainstem
strokes), aneurysms affecting the 3rd Cranial nerve, (otitis media
commonly affects seventh nerve), multiple sclerosis (DEMYELINATING
SITUATION!), and rise in intracranial pressure.

Case 2
A 25 year old woman presents with an 18 month history of amenorrhoea
and galactorrhoea. Menarche started at the age of 13 and her periods
have always been irregular. She is not hirsute and has normal secondary
sexual characteristics. There is no evidence of Cushings syndrome. There
are no abnormalities on pelvic examination but galactorrhoea is noted.
Neurological examination shows bitemporal hemianopsia.
1. Describe how visual fields are assessed. Take Online Test
Same thing with the muscle test, but a bit different; close one eye, and
the doctor moves his hand in horizontal and vertical directions, and

notified when patient is not seeing it when its in any particular

place/point.
If you want a formal test visual field perimetry.
2. Where is the likely lesion in this case?
Optic CHIASM enlargement of the pituitary gland, which would
compress the chiasm from underneath and THUS bitemporal
hemianopia it would start from ABOVE.
3. Draw a diagram to explain in anatomical terms why this lesion causes
this particular type of visual defect?
You know this.
4. Do you think she would have noted the visual field defect? Why?
You need to consider 2 things; how fast the tumour is growing, and how
big it is. If it will happen in a fast manner, the patient will notice, but if its
been there for quite a long time, they are unlikely to notice the defect. If
the tumour is big, it will affect the greater part of her temporal visual
fields.
5. What tests could be done to confirm the diagnosis?
Tumour markers these are expensive, and can be raised in other
conditions, so its not the ideal option. These are usually used to monitor
response of tumour to your treatment.
What can be done to confirm diagnosis is MRI of the head; you can also do
some blood tests >> pituitary profile.

Case 3
An 18 year old student presents with severe headaches and a medial
deviation of the right eye. Diplopia is present in all ranges of movement
of the eyeball except on gazing to the side opposite the lesion.
Neurological examination is otherwise normal. A CT scan shows a tumour
in the temporal lobe.

Visual Pathway 2
Eye Simulator
1. What is the anatomical basis for these symptoms?
Compression of nerve/infiltration by tumour, and thus can either be a
direct or indirect assault on the nerve. Rise of the intracranial pressure
>> headaches
2. Using the course of the affected nerve explain why the lesion might
occur.
Abducent Nerve the longest nerve in the cranium! Longest course of
the cranial nerves, and thus it is SUSCEPTIBLE to a rise in intracranial
pressure, and the point at which it is most affected is, and this is at the
apex part of the petrous temporal bone, where the nerve goes from
vertical to horizontal! Already slightly kinked, and if you press it a bit
more >> easily damaged.
Visual field defect, both because of compression of temporal lobe and
of papilloedema due to increase in intracranial pressure.
The other thing which should worry you, would be vomiting. Rise in
intracranial pressure gives you headaches and vomiting, and the
former is commonly achieved after a nights sleep, coughing, etc.
3. What other symptoms and signs might be noted in this case?
Papilloedema.
Haemorrhages on the retina due to back pressure on the central retinal
artery and vein, and might also have other CNs palsies; trochlear and
other nerves.
4. Explain why the diplopia does not occur on gazing to the side opposite
the lesion?
Because the eyeball is already medially deviated! And thus the eyes
(both of them) will be both facing the same direction.

Case 4

An 29 year old lady presents to her doctor with drooping of her eyelid. To
determine the cause for her ptosis, the doctor lifted her eyelid.
1. What is the anatomical basis for ptosis?
Levator palpebrae superioris innervated by CN III and Superior tarsal
muscle inn. By the sympathetic system. Full ptosis if both of them not
working; partial ptosis due to only one of them being dysfunctional.
2. Explain the doctors action.
To observe the pupils. If theyre dilated, re: sympathetics, it means that
they would be working. Ptosis can also be caused by masses, so you
also lift eyelid to check for tumours of the eyelid. Muscle causes for
ptosis, you mostly need to know about Myasthenia gravis (problem
at the Ach junction). Ptosis would get worse upon looking up, in this
case (with their eyes only), and eventually, both of the eyelids start to
get tired (not enough Ach within their synapse), and start to droop. This
is contrary to when its a nerve problem, in which case it wouldnt
worsen like this.
3. What is Horners Syndrome?
C8 T2 being damaged (sympathetic chain/superior cervical ganglion).
Symptoms: 1. Anhydrosis (if pre-ganglionic problem)
2. Constriction of pupils
3. Ptosis
Sometimes you can get apparent enophtalmos (not true! Only
apparent), where the eye appears as if it were sunke
4. Mention some central and peripheral causes.
Carcinoma of the stellate ganglion (peripheral cause) Pancoast
tumour (carcinoma at the apex of the lungs, which infiltrates the
sympathetic chain). Aneurysm of the internal carotid artery is another
peripheral cause (Since symp. Plexus goes around it). HBV virus
nasopharynx (?) carcinoma. Dont forget the IATROGENIC CAUSES!
Central causes: stroke, seringomyelia and seringobalbia (fluid filled
cavities in brainstem/spinal cord, associated with multiple sclerosis),
tumour.