Outline
I . Thyroid Dysfunction
A. Ocular Manifestations
1. Classified from 0 (no signs or symptoms) to 6 a) 0. N o signs or symptoms b) 1. O nly signs (Lid involvement) c) 2. S oft tissue involvement d) 3. P roptosis e) 4. E xtra ocular muscle involvement f) 5. C orneal involvement compression g) 6. S udden vision loss (Optic nerve involvement)
2. Visual acuity loss a) Mild loss may be due to corneal involvement b) Severe loss from optic nerve neuropathy due to
3. EOM involvement - asthenopia, diplopia. Three stages a) Hints:
(1) Injected conjunctival vessels
(2) Torsion
(3) Inferior Rectus most frequently affected
(4) Then MR, followed by SR and LR
(5) Motilities limited due to stretching of EOM
(6) Self-limiting months to 3 years
4. Differential diagnosis of thyroid myopathy a) Glaucoma - visual field mimic.
(1) Confounded due to increased IOP on attempted upgaze use handheld device b) Superior rectus palsy c) Midbrain syndromes (when bilateral) d) Sixth nerve palsy e) Forced duction is the single most important test
B. Systemic symptoms for differential diagnosis
1. Temperature intolerance
2. Weight changes
3. Changes in activity level/energy
4.
5%to 15% of thyroid patients have Myasthenia Gravis
C. Diagnostic tests
1. Thyroid panel (blood work up) (Elevated T3, T4, low TSH)
2. Ultrasound A or B
3. MRI/CT
4. Rule out lid retraction secondary to Inferior Rectus contracture
D. Ophthalmologic treatment options
1. Botox - not found to be effective when fibrosis present
2. EOM surgery a) Patient must be stable for at least 6 months b) Do decompression surgery first, then EOM
3. Systemic treatment of Graves does not eliminate ocular complications

II . Multiple Sclerosis
A. Ocular manifestations
1. Bilateral internuclear ophthalmoplegia (INO) a) Complete vs. "subclinical" INO OKN
2. Diplopia
3. Retrobulbar neuritis
B. Systemic Manifestations - "separated in time and space"
1. Extremity weakness, paraesthesia
2. Uhthoff's sign
3. Lhermitte's sign
4.
Vestibularitis
5. Incontinence
6. Paroxysmal dysarthria, sensory phenomena, etc.
C. Diagnostic testing
1. MRI for brainstem plaques--T2 weighted
2. Visual evoked potential (VEP)
3.
Cerebrospinal fluid to rule out treatable (infectious) causes
III.
Myasthenia Gravis
A. Ocular manifestations - the great mimicker
1. May mimic ANY EOM dysfunction
2. Accommodative difficulties!
3. EOM may be most at risk due to high metabolism
B. Systemic manifestations
1. 50% of MG patients present with ocular symptoms a) 90% of these develop EOM involvement
2. 40% of Ocular Myasthenics never develop systemic
3. Fluctuating weakness in cranial, limb, or trunk
4. Snarling appearance when laughing
5. Speech becomes slurred, nasal or hoarse
6. Hand needed to prop up head
7. Respiratory involvement a. Sleep apnea
C. Diagnostic testing
1. IV edrophonium (Tensilon) a) Many side effects, atropine counteracts
2. Antibodies to acetylcholine receptor (AChR) a) 70-90% have high titer when systemic MG b) Only 10% have high titer when Ocular MG
3. Repetitive stimulation of peripheral nerve a) Lid tests in office: Rest or fatigue lids
4. ICE test
D. Ocular treatment options
1. Medical treatment for ocular myasthenia a) Acetylcholinesterase inhibitor b) Oral corticosteroid (only if non-systemic)
2. Thymectomy

3. EOM surgery - if stable
4. Lid tape
5. Lid surgery
IV.
Cerebrovascular accidents (non-traumatic) : ischemic 80%, hemorrhagic 20%
A. Ocular Signs
1.
Transient ischemic attacks (TIA)
2.
Perceptual/cognitive changes
3. EOM palsy a) Past pointing b) Head turn toward action field of paretic muscle c) Saccades: reduced velocity, limited range (floating,sliding) d) Fixation duress
4. Example of Vascular EOM Palsy: Third Nerve palsy a) Eye won't go up, down, in. Has intorsion, Pupil dilated, Ptosis b) Consider possibility of aneurysm c) Divisional palsies
(1) Superior (levator and superior rectus)
(2) Inferior (MR, IR, IO)
(3) Possibly cavernous sinus lesion
5. Aberrant regeneration a) Lids, pupils, globe retraction b) Causes: aneurysm, trauma, tumor
B. Systemic indications - "the company it keeps"
1. The "4-4 Rule"
2. Brain Stem signs: Aphasia, Hemiparesis, Dysphagia, Dysarthria,,Dizziness
C. Diagnostic testing for stroke (sample)
1. MRI/CT a) MRI shows brainstem best
2. Ultrasonography
3. Blood work up
4. Arteriogram/cerebral angiography
5. Doppler ultrasound
D. Ocular/Perceptual treatment options
1. No definitive treatment for at least 6 months
2. Perceptual retraining a) Especially if parietal damage b) Spatial relationship problems
V.
Closed Head Trauma
A. Sensory Fusion Disruption Syndrome (London & Scott 1987)
1.
Targets "on top of each other, but not fused"
B. Superior oblique palsy
1. Causes: head trauma, ischemic neuropathy, vascular, congenital
2. Symptoms a) Vertical diplopia (often with torsion) b) Head tilt c) Hints:
(1) If long-standing expect large vertical fusion ranges
(2) Examine old photographs

(3) Be aware of decompensation
2. Testing procedures a) Forced Tilt test b) Watch lashes for small vertical movement c) Assume bilateral until disproven
(1) Little vertical deviation in primary gaze
(2) V pattern greater than 25 p.d.
(3) Extorsion greater than 10 degrees d) Double Maddox Rod
C. Sixth Nerve palsy
1. As crosses petrous bone, susceptible to trauma and inflammation
2. Secondary to trauma - 50% resolve completely
3. The most common ophthalmoplegia
D. Accommodative dysfunction
1. Traumatic Pseudo-myopia