A+V patterns / nuclear +fasicular

A pattern

-          >10

-          More eso upgaze

-          More exo downgaze

V pattern

-          15> more exo upgaze

-          More eso downgaze

A eso

-          H= ↓ MR = more add in elevation

o    ↑ LR - Less abd in elevation  -

-          V= u/a of IO = less ab in elevation - More add in elevation                                            

A exo

-          H = ↑ LR = ↑ ab in downgaze

o    ↓ MR - Less add in downgaze

-          V = u/a IR = less add in downgaze

o    More ab in downgaze

V eso

-          H= ↑ MR = more add in downgaze

o    ↓ LR = more add in downgaze

-          V= u/a SO = less abb in downgaze

o    More add in downgaze

V exo

H = ↓ LR = more abduction in elevation

o    ↑ MR - Less add in elevation

-          V = u/a SR – less add

o    more ab in elevation

H sx

H sx

-          V exo - raise the LR (slackens it in elev = less ABD)
• V eso -  lower the MR (slackens it in dep = less ADD)
• A exo - raise the MR (tightens it in dep = more ADD)
• A eso - lower the LR (tightens it in elev = more ABD

If lower insertions for = more of that power

-          E.g. lower MR = more add in elevation

-          Lower LR = more abb  in elevation

General tx

General rule:
• Move the MR towards the apex of the pattern
• Weakens its adducting action = reduction in eso
• Move the LR away from the apex
• Weakens its abducting action = reduction in exo

V apex = up – bring eyes in = up to sx fic

A apex – down need brings eyes sx out to fix

Oblique o/a sx

        V eso

o    IO weakening

-          V exo

o    IO weakening

-          A eso

o    Weaken SO

-          A exo

o    Weaken SO

sx

-          V eso

o    MR recession + insertion moved down

o    LR resection w insertion moved up

-          V exo

o    LR recession w insertion moved up

o    MR resection with insertion moved down

-          A eso

o    MR recessed and transposed up

o    LR resected + transposed down

-          A exo

o    LR resected + transposed down

o    MR resected + transposed up 

Nuclear 6th

Nuclear 6^th

-          Horizontal gaze palsy

-          May include VII

-          1 & ½  - conjugate gaze palsy + INO

nuclear + fasc synd

Foville’s syndrome

-          ipsilateral Horizontal Gaze Palsy

-          Ipsilateral V + VII + VIII

-          Horner’s Pupil

Millard Gubler Syndrome

Corticospinal tract

VI + VII + Hemiplegia

 

Raymond’s Syndrome

Corticospinal tract

Ipsilateral VI + Hemiplegia

Nuclear – fascicular syndrome

-          Almost impossible to distinguish between these two

-           Short course of the fascicle in the midbrain

-           Trauma

-           Ischemia

-           Tumours & Vascular malformation

-           Inflammation/demyelination

can have a contralateral Horner’s pupil (Miosis)

-           Ist order Sympathetic fibres descend adjacent to the IV

-          nerve

-           R Nuclear IV with L Horner’s

-           Fasicular lesion after fibres cross = R IV with R Horners12

-          - R III CNP

-           Mod RXT with minimal hypotropia

-          Complete – elevation affected more than depression

-          R dilated pupil, R ptosis

-           LSR u/a

Must be nuclear III

• Contralateral SR palsy – fibres of each pass through the opposite SR sub-nucleus

Millard Gubler

• VI + VII + hemiplegia– fibres affected in area of VI + VII fascicle and corticospinal tract causing hemiplegia

-           Left VI CNP

-           Esotropia

-           VII palsy

-           General hemiplegia

-           LSR u/a

Signs of nuclear & fascicular = non isolated CNP

CH + IX other neurological signs

-          Balance

-           Speech

-           Gait

-           Tremour

-           Posture

-           Pupils

-           Facial and/or limb paralysis

-          Left III CNP

-           Exotropia

-           Dilated pupil

-           Problems with general balance

-          Nothnagel’s Syndrome

• Cerebellar ataxia + III indicates lesion in area of cerebellar peduncle

Nuclear – common aetiologies

Ischemia

-           Arterial occlusion

-           Haemorrhage

-           Tumour

-           Inflammation

-           Compression