Paralytic Squint Guidelines for Clinical Case Presentations

Anoop Thomas, Mythri HM, Mallipatna C Ashwin, Shamin Jacob

Types of cases:
 Oculomotor Nerve Palsy
 Trochlear Nerve Palsy
 Abducent Nerve Palsy

History:
Presenting Complaints:
 Diplopia
 Pain
 Drooping of Eyelid

Details: Causes of Ophthalmoplegia

Diplopia (ptosis may conceal diplopia)  Congenital
 Onset  Traumatic
 Unilateral or Bilateral  Neoplastic
 Vertical or Horizontal  Demyelinating Disease
 Worsening or Stationary  Inflammatory
 Diurnal Variation  Ischaemic
 Maximum in which field of gaze  Toxic
 Idiopathic
Pain
 Onset and relationship with diplopia Painful Ophthalmoplegia:
 Severity  Intracranial Aneurysm
 Localisation  Cavernous Sinus Thrombosis
 Orbital Apex Syndrome
Drooping of eye lid  Tolosa Hunt Syndrome
 Onset  Orbital Cellulitis
 Progression  Pseudotumor of the Orbit
 Diurnal Variation
 Association with fatigue

Visual Complaints
 s/o Cavernous Sinus Thrombosis: Redness, Proptosis

CNS History
 Headache, Nausea, Vomiting (also: Neck rigidity)
 Loss of consciousness, Convulsions
 Focal Neurological Defects or TIA (Hemiparesis, Hemi-anaesthesia)
 Aphasia, Visual Hallucinations
 Ataxia, Dysarthria, Dysphagia

Past History Mimics of cranial nerve palsies:

 Diabetes Mellitus, Hypertension 3rd Nerve and 4th Nerve:
 Ischaemic Heart Disease, Rheumatic Heart Disease  Thyroid Eye Disease
 Trauma (head injury or orbital trauma)  Myasthenia Gravis
 Hearing Loss, Tinnitus, Ear Infection, Sinusitis, Epistaxis
 Malignancies: Weight loss, Neck surgeries, Radiation therapy 6th Nerve:
 Hyperthyroidism: Tremors, Palpitations, Insomnia  Thyroid Eye Disease
 Tuberculosis  Myasthenia Gravis
 Child birth (Pituitary Apoplexy)  Medial Wall Blow-Out
 Orbital Myositis
Personal History  Convergence Spasm
 Alcohol, Tobacco smoking  Eso-Duanne’s Syndrome
 IV Drug abuse  Infantile Esotropia
Examination:
 General Physical Examination
 CNS Examination:
HMF, Cranial Nerves, Sensory, Motor – gait, power, reflexes, coordination

Ocular Examination:
Head posture: Past Pointing:
 Head tilt This test indicates a recent onset.
 Chin elevation Elicited by asking the patient to point
 Face turn to an object with his finger while
viewing it through the paretic eye.
Ocular Posture: The patient will initially point further
 General Ocular Inspection (Exo- or enophthalmos) than the object.

 Hirschberg’s Test
* Important to look out for
 Cover/Uncover test internuclear ophthalmoplegia and
o Tropia or Phoria other gaze palsies
o Concomitant or Incomitant (Primary and Secondary deviation)
o Nystagmus: type, jerky or pendular, direction, null point Diplopia Charting:
1. Maximum separation is in the
direction in which the muscle
 Diplopia charting (Hess chart or Lees screen if possible)
acts the most
 Park-Bielschowsky’s 3-step test for vertical deviation
2. The image that appears farthest
 Detect cyclo-deviation (Double Maddox)
belongs to the deviating eye
3. The image is displaced in the
Ocular Examination
direction of the paralysed muscle
 Visual Acuity (Best corrected for distance and near, Colour, Confrontation)
Watch for Pseudoptosis!
 Lids Associated with hypotropia and can
o Palpebral fissures (equal, ptosis) be mistaken for ptosis of 3rd CN
Palsy.
 Anterior Segment Examination (aniridia, coloboma, heterochromia, cataract)
Internal Ophthalmoplegia:
 Pupil: direct and consensual (comment on near reflex if reaction to light is poor) Isolated involvement of
accomodation and pupillary reflex –
 Fundus (Distant Direct Ophthalmoscopy, Direct and Indirect Ophthalmoscopy) occurs with botulism and diphtheria.
o Disc
 Size, Shape, Margins, C/D ratio (Horizontal and Vertical) Pupil Sparing 3rd Nerve Palsy:
 Neuro-retinal rim (colour and thinning, capillary count) Ischaemic mononeuropathy due to
 Spontaneous Venous Pulsations diabetes mellitus, hypertension, etc.
 Peripapillary defects, NFL defects (Medical 3rd Nerve Palsy)

o Retinal vessels, fundus periphery and macula Miosed Pupil in 3rd CN Palsy:
 Associated Horner’s Syndrome
o Remember:  Hutchinson’s Pupil in Evolution
 Bruckner's Test
 Fundus Torsion
 Eccentric Fixation (Foveal, Parafoveal, Perifoveal)

4. Extraocular Movement Stages of a Paralytic Squint:

o Duction, Versions, Convergence (watch for inhibitional palsy) 1. Paresis of Muscle
o Saccadic Velocity 2. Overacting ipsilateral antagonist
3. Inhibitional Palsy: Underacting
5. Refraction
antagonist of contralateral synergist
Intraocular Pressure (Differential Tonometry for muscle restrictions) 4. Long standing cases: Comitance
(aka: spread of comitance)