Gaze palsy

1. Gaze Palsy
Presenter- Dr Shubhangini J
Moderator-Dr Monica Samant

2. Ocular Motor system-
Nuclear
SupranuclearInfranuclear
Inter nuclear

3. Supranuclear control of ocular
motility-
Versions-
Same
direction
Vergence-
Opposite
direction
Supranuclear
control

4. Eye Movements-
Eye
Movements
Version
Saccades
Smooth
Pursuit
Optokinetic
Vestibulo-
ocular
Vergence
Divergence
Convergence

5. Saccadic System-

6. Cells in PPRF
Burst Cell-sends
pulse step to
move the eye
Pause Cell-
inhibits firing of
burst cell allowing
burst cell to
initiate saccade
Tonic Cell –
maintain the eye
position

7. Smooth Pursuit System

9. Vestibulocerebellar system-
 Important input of gaze system
 Modulate eye movements
 Stabilize eye against the gravitatinal & accelerational
force
 Maintaining clear vision

10. Cerebellum-
 Eye movements
 Fixation accuracy
 Suppress the vestibulo-ocular reflex
 Controls smoothness of pursuit movements
 Accuracy of saccades

11. Lesion of Supranuclear oculomotor
pathways -
 Based on anatomical location-
 Lesions of internuclear system
 Immediate premotor structure in the brain
 PPRF
 Posterior commisure
 Rostral mesencephalon
 Cerebral hemisphere
 Descending pathway from cerebral hemisphere
 Superior colliculus
 Thalamus

12. Clinical Examination
 Asymptomatic for gaze palsy
 Blurring of vision
 Diplopia

13. Pre-requisite-
 Observe position of eye in primary gaze
 Ductions
 Versions & vergence
 Pursuit
 Saccades

14. Oculocephalic maneuvers-
 Dolls eye reflex
 Tilt the head 30 degree forward & fixate a distant
target
 Rotate the head in direction opposite to gaze palsy
 Direct projection from vestibular system to ocular
motor nuclei
 Prenuclear,nuclear infranuclear reflex does not
overcome
 Lesion in cerebral cortex overcome by VOR

15. Vestibular ocular reflex -
 Tilt the head by 60 degree & irrigate external auditary
meatus with cool/warm water
 In normal subject/supranuclear gaze palsy eye deviate
towards the irrigated side- nystagmus with fast phase
to opposite side
 Fast phase towards the stimulated eye when warm
water is used

16. Supranuclear eye movement
disorder-
Gaze palsy
Horizontal
Vertical

17. Vertical gaze palsy-
 Midbrain lesion
 B/L cerebral hemisphere
dysfunction
 Parkinsons disease
 Progressive supranuclear palsy
 lipidosis

18. Parinaud syndrome-
 Dorsal midbrain syndrome
 Lesion of posterior commisure & MRF
 Cause- compression by mass in pineal region
 Dilatation of third ventricle
 Midbrain infarction
 multiple sclerosis
 AV malfomation
 Poor to absent upgaze
 Convergence retraction nystagmus in upgaze
 Colliers sign
 Setting sun sign

19. Parinaud syndrome-
 EMG shows co-contraction of occulomotor innervated
muscles- retraction of globe
 Neuroimaging scan
 Surgical treatment causes resolution of ocular
findings

22. Progressive supranuclear palsy-
Lesion of mesencephalic structure-
 Steele-Richardson-Olszewski syndrome
 Onset –after 40 years
 Disorder of basal ganglia
 Marked rigidity –trunk & neck
 Little tremor
 Difficulty with vertical eye movements down > up
 Progresses to horizontal gaze disorder
 End stage – global ophthalmoplegia

23. Progressive supranuclear palsy-
 Vertical direction more severely affected initially
 Voluntary saccades affected first, convergence, and
smooth pursuit later
 Slowing of saccade velocity
 Supranuclear movements primarily affected (vestibulo-
ocular reflex spared)
 Square wave jerks
 Gait abnormalities
 Nuchal rigidity

24. Progressive supranuclear palsy-
 Eyelid abnormalities:
 upper eyelid retraction
 reduced blink rate
 apraxia of eyelid opening
 blepharospasm
 Postural instability with falls (often backwards)
 Cervical and axial dystonia

26. Progressive supranuclear palsy-
 Wilson’s disease
 Huntington diseas
 Kernicterous

27. Parkinsons disease-
 Lesion of descending pathway from cerebral
hemisphere
 Upgaze palsy affecting saccades followed by pursuit
 Cogwheel pursuit

28. Lipidosis-
 Lipid storage disease variant of niemann picks disease
 Vertical saccades
 Intact vertical oculocephalic maneuvers
 Progressive dementia in late childhood
 Choreoathetosis
 hepatosplenomegaly

29. Whipples disease-
 Involvement of CNS – supranuclear gaze palsy
 Initially vertical
 Progressive dementia
 Hypersomnia
 Ataxia
 Uveitis

30. Monoocular elevation paresis-
 No ocular deviation in primary gaze
 Inability to elevate one eye
 Prenuclear congenital unilateral midbrain lesion
 Oculocephalic maneuver is normal
 Lesion in pretectum
 Connection of riMLF to the occulomotor nuclei
 Forced duction & tensilon test are negative

31. Monoocular elevation paresis-

32. Skew deviation-
 Skew deviation is a vertical divergence
 “prenuclear” lesion of the vertical vestibulo-ocular
pathways in the brainstem or cerebellum.
 Comitant, associated with cyclotorsion of one or both
eyes.
 Noncomitant it can mimic a partial third or fourth
cranial nerve palsy

33. Skew deviation-
 Occur most commonly with vascular lesions of the
pons or lateral medulla (Wallenberg's syndrome)
 lesions of the midbrain or upper pons
 Alternating skew deviation, the hypertropia changes
with the direction of gaze. The adducting eye usually
is hypotropic,mimick superior oblique overaction.

34. Skew deviation-

35. Ocular tilt reaction-
 cyclotorsion of both eyes, and paradoxical head tilt,
all to the same side – that of the lower eye
 A tonic (sustained) ocular tilt reaction occurs with
lesions of the ipsilateral utricle, vestibular nerve or
nuclei, or a lesion in the region of the contralateral
interstitial nucleus of Cajal and medial thalamus
 A phasic (paroxysmal) ocular tilt reaction occurs with
lesions of the ipsilateral interstitial nucleus of Cajal
and may respond to baclofen.


36. Horizontal gaze palsy-
 More common
 Vary from
 Gaze evoked nystagmus
 Dysmetria of movements
 Total inability to move the eye
 Commonly occur in CVA patients

37. Internuclear ophthalmoplegia-
 Lesion in MLF
 Between the abducens nucleus and C/L medial rectus
subnucleus of the oculomotor nerve
 Impairs adducting saccades of the ipsilateral eye,
which become either slow or absent
 Dysmetria
 Disconjugate nystagmus.

39. Internuclear ophthalmoplegia-
 If INO is bilateral
 abduction saccades also may be slow
 Upward beating and torsional nystagmus
 Other clinical features
 skew deviation
 defective vertical smooth pursuit
 impairment of the vertical VOR
 impaired ability to suppress or cancel the vertical VOR.

40. Internuclear ophthalmoplegia-
 Occur with a variety of disorders of brainstem
 Vascular
 Demyelinating
 Metastatic
 Must be differentiated from the pseudo-INO of
myasthenia or a long-standing exotropia.

42. One & half syndrome-
 Damage to the caudal pons
 Ipsilateral MLF and either the ipsilateral PPRF or the
abducens nucleus
 It results in an ipsilateral gaze palsy with an ipsilateral
INO
 Intact horizontal movement is abduction of the
contralateral eye

43. One & half syndrome-
 If the facial nerve nucleus or fasciculus is involved,
oculopalatal myoclonus may develop
 Most common causes
 multiple sclerosis and
 brainstem stroke
 followed by metastatic
 primary brainstem tumors
 Ocular myasthenia may cause a pseudo-one-and-a-
half syndrome

44. Ocular motor apraxia-
 Loss of or severely diminished volitional saccades
 Retention of the fast phases of vestibular nystagmus
• Difficult horizontal saccades
• Head thrust towards desired
direction
Congenital
• Balint syndrome
• Both Horizontal & Vertical
• Simutagnosia/optic ataxia
Acquired

45. Convergence paralysis-
 Midbrain lesions ,dorsal midbrain syndrome.
 Cerebellar degeneration, Parkinson's disease, and
progressive supranuclear palsy, are associated with
poor convergence.
 Lack of pupillary constriction on attempted
convergence may differentiate psychogenic
convergence paralysis from organic disease.

46. Divergence paralysis-
 Uncrossed horizontal diplopia
 Intermittent or constant esotropia
 Abduction is full.
 Break in fusion later in life
 Treated easily with base-out prisms for the distance
correction
 Divergence paralysis is a controversial entity, difficult
to differentiate from divergence insufficiency and
bilateral sixth cranial nerve palsies.

47. Functional gaze palsies-
 Horizontal gaze palsy – miosis during attempted gaze
 Saccades-VOR should be stimulated (oculocephalic
maneuvers,calorics,chair rotation ), OKN test
 Pursuit

48. THANK YOU