Disturbance of eye movements with doubling

The presence of double vision in the eyes of a patient with sufficient visual acuity implies the involvement of the eye muscles or oculomotor nerves or their nuclei in the pathological process. The deviation of the eyes from the neutral position (strabismus) is always noted, and can be detected by direct examination or with the use of instruments. Such paralytic strabism can occur with the following three lesions:

A. Defeat at the muscular level or mechanical damage to the orbit:

1. Ocular form of muscular dystrophy.
2. Syndrome Kearns-Seyr.
3. Acute ocular myositis (pseudotumor).
4. Tumors of the orbit.
5. Hyperthyroidism.
6. Brown Syndrome.
7. Miasthenia gravis.
8. Other causes (trauma of the orbit, distearoid orbitopathy).

B. Lesion of oculomotor (one or more) nerves:

1. Injury.
2. Compression by a tumor (often parasellar) or an aneurysm.
3. Arteriovenous fistula in the cavernous sinus.
4. A general increase in intracranial pressure (otvodyaschy and oculomotor nerves).
5. After lumbar puncture (abduction nerve).
6. Infections and parainfection processes.
7. Tholos-Hunt syndrome.
8. Meningitis.
9. Neoplastic and leukemic infiltration of meningeal membranes.
10. Cranial polyneuropathies (as part of the Guillain-Barre syndrome, isolated cranial polyneuropathies: Fischer syndrome, idiopathic cranial polyneuropathy).
11. Diabetes mellitus (microvascular ischemia).
12. Ophthalmoplegic migraine.
13. Multiple sclerosis.
14. Isolated lesion of the nerve or oculomotor nerve of an idiopathic nature (completely reversible).

C. Defeat of oculomotor nuclei:

1. Vascular strokes (ONMC) in the brainstem.
2. Tumors of the brain stem, especially gliomas and metastases.
3. Trauma with hematoma in the region of the brain stem.
4. Syringobulbia.

[1], [2]

A. Defeat at the muscular level or mechanical damage to the orbit

Such processes can lead to impaired eye movements. With slow development of the process, double vision is not detected. Muscular lesion can be slow progressing (oculomotor dystrophy), rapidly progressive (ocular myositis), sudden and intermittent (Brown syndrome); it can be of different intensity and different localization (myasthenia gravis).

The ocular form of muscular dystrophy progresses for years, always manifests by ptosis, later the neck and muscles of the shoulder girdle are involved (rarely).

Syndrome Kearns-Seyr, which includes, in addition to slowly progressive external ophthalmoplegia, pigmentary degeneration of the retina, cardiac blockade, ataxia, deafness and small growth.

Acute ocular myositis, also called pseudotumor of the orbit (rapidly growing during the day, usually bilateral, periorbital edema, proptosis (exophthalmos), pain.

Tumors of the orbit. The lesion is unilateral, leads to slowly increasing proptosis (exophthalmos), restriction of movements of the eyeball, and later to impaired pupillary innervation and involvement of the optic nerve (visual impairment).

Hyperthyroidism is manifested by exophthalmos (with expressed exophthalmos sometimes there is a restriction of the volume of movements of the eyeball with doubling), which can be one-sided; a positive symptom of Gref; other somatic symptoms of hyperthyroidism.

Brown syndrome (strongrown), which is associated with a mechanical obstruction (fibrosis and shortening) of the tendons of the upper oblique muscle (sudden, transient, recurrent symptoms, impossibility of eye movements up and inside, which leads to double vision).

Miasthenia gravis (involvement of the eye muscles with different localization and intensity, usually with pronounced ptosis, build-up during the day, usually involving facial muscles and swallowing).

Other causes: trauma of the orbit involving the muscles: distearoid orbitopathy.

[3], [4], [5],

B. Lesion of oculomotor (one or more) nerves:

Symptoms depend on which nerve is affected. Such damage causes paralysis, which is easily recognized. In the case of paresis of the oculomotor nerve, in addition to strabismus, slight exophthalmos can be noted, caused by the hypotonia of the rectus muscle with the preserved tonus of the oblique muscles, which promote the eyeball to extend outwards.

The following causes can lead to the defeat of one or more oculomotor nerves:

Trauma (helped by anamnesis data) sometimes leads to bilateral orbital hematomas or, in extreme cases, rupture of the oculomotor nerve.

Compression by a tumor (or giant aneurysm), especially parasellar, causes a slowly increasing paresis of the oculomotor muscles and is often accompanied by the involvement of the optic nerve, as well as the first branch of the trigeminal nerve.

Other voluminous lesions, such as supraclinoid or infra-clinoid carotid aneurysm (all of the above, the slowly increasing involvement of the oculomotor nerve, pain and sensitivity disorder in the zone of the first branch of the trigeminal nerve, rarely calcification of the aneurysm, which is visible on a simple x-ray of the skull, later acute subarachnoid hemorrhage).

Arteriovenous fistula in the cavernous sinus (the result of repeated traumas) eventually leads to a pulsating exophthalmus, synchronous with the pulse noise, which is always heard, stagnation in the conjunctival veins and on the fundus. With compression of the oculomotor nerve, the early symptom is mydriasis, which often appears before the paralysis of eye movements.

A general increase in intracranial pressure (usually the first is drawn off the nerve, later the oculomotor nerve).

After lumbar puncture (after it sometimes there is a picture of afferent nerve damage, but with spontaneous recovery).

Infections and parainfection processes (spontaneous recovery is also noted here).

The Tolosa-Hunt syndrome (and the paratrigeminal Raeder syndrome) are very painful conditions, manifested by incomplete external ophthalmoplegia and sometimes involvement of the first branch of the trigeminal nerve; spontaneous regression is characteristic for several days or weeks; effective steroid therapy; relapses are possible.

Meningitis (includes symptoms such as fever, meningism, general malaise, defeat of other cranial forces, it may be bilateral, liquor syndrome).

Neoplastic and leukemic infiltration of meningeal membranes is one of the known causes of the defeat of the motor-motor nerve at the base of the brain.

Cranial polyneuropathies as part of spinal polyradiculopathies of the Guillain-Barre type; isolatedcranial polyneuropathies: Miller Fisher syndrome (often manifested only by bilateral incomplete external ophthalmoplegia, also noted ataxia, areflexia, paralysis of the facial muscles, in the cerebrospinal fluid, protein-cell dissociation), idiopathic cranial polyneuropathy.

Diabetes mellitus (an uncommon complication of diabetes, even in mild forms, is usually involved in the oculomotor and distracting nerves, without pupillary disorders, this syndrome is accompanied by pain and results in spontaneous recovery within 3 months, based on microvascular ischemia of the nerve.

Ophthalmoplegic migraine (a rare manifestation of migraine, the diagnosis is helped by the indication of a migraine in an anamnesis, but it is always necessary to exclude other possible causes).

Multiple sclerosis. The defeat of the oculomotor nerves is often the first symptom of the disease. Recognition is carried out on the basis of generally accepted criteria for the diagnosis of multiple sclerosis.

Idiopathic and completely reversible isolated defeat of the abducent nerve (most often found in children) or the oculomotor nerve.

Infectious diseases, such as diphtheria and intoxication with botulism (marked with paralysis of swallowing and disruption of accommodation).

[6], [7], [8], [9], [10],

C. Defeat of oculomotor nuclei:

Since the oculomotor nuclei are located in the brainstem among other structures, the damage to these nuclei is manifested not only by the paresis of the external eye muscles, but also by other symptoms, which makes it possible to distinguish them from the lesion of the corresponding nerves:

Such disorders are almost always accompanied by other symptoms of the central nervous system and usually are bilateral.

With nuclear oculomotor paralysis, various muscles innervated by the oculomotor nerve rarely show the same degree of weakness. Ptosis usually appears only after the paralysis of the outer eye muscles ("the curtain falls last"). Internal eye muscles are often spared.

Internuclear ophthalmoplegia leads to strabismus in a certain direction of vision and diplopia when viewed from the side. The most common causes of nuclear disorders of eye movements are:

OHMK in the brain stem (sudden onset, accompanied by other stem symptoms, mainly cross-symptomatic and dizziness.Stem symptoms, usually involving nuclear oculomotor disorders, are manifested by known alternating syndromes.

Tumors, especially stem gliomas and metastases.

Craniocerebral injury with hematoma in the brain stem area.

Syringobulbia (not progressing for a long period, symptoms of lesion along the long line, dissociated sensitivity disorders on the face).

Doubling can also be observed with some other lesions, such as chronic progressive ophthalmoplegia, toxic ophthalmoplegia in botulism or diphtheria, Guillain-Barre syndrome, Wernicke's encephalopathy, Lambert-Eaton syndrome, myotonic dystrophy.

Finally, diplopia is described when the lens is clouded, improper correction of refraction, corneal diseases.

[11], [12], [13], [14], [15]

D. Monocular double vision (double vision when viewed with one eye)

Intriguing for a neurologist is always monocular diplopia. This condition can often be either psychogenic or caused by refractive error in the eye (astigmatism, violation of the transparency of the cornea or lens, dystrophic changes in the cornea, changes in the iris, foreign body in the eye, defect of the mesh shell, cyst in it, defective contact lenses).

Other possible causes (rare): damage to the occipital lobe (epilepsy, stroke, migraine, swelling, trauma), tonic deviation of the eye (friendly), disruption of communication between the frontal gaze and the occipital region, palynopsy, monocular oscilposia (nystagmus, mummy of the upper oblique muscle , twitching of the century)

[16], [17], [18], [19]

Vertical vertical drilling

This situation is rare. Its main causes are: fracture of the base of the orbit involving the lower rectus muscle; Thyroid orbitopathy involving the lower rectus muscle, ocular myasthenia gravis, third cranial nerve injury, fourth cranial nerve injury, skew deviation, myasthenia gravis.

More rare causes: psevdotumor orbit; myositis of the oculomotor muscles; primary tumor of the orbit; infringement of the lower rectus muscle; neuropathy of the 3rd nerve; aberrant reinnervation after III nerve damage; Brown's syndrome (strongrown) is a form of strabismus caused by fibrosis and a shortening of the tendon of the upper oblique muscle of the eye; double paralysis of the elevator; chronic progressive external ophthalmoplegia; Miller Fisher syndrome; botulism; monocular supranuclear palsy of the eye; vertical nystagmus (oscilloscopy); myxia of the upper oblique muscle of the eye; dissociated vertical deviation; encephalopathy Wernicke; vertical one and a half time syndrome; monocular vertical diplopia.