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Different types:

CN palsy

CNIII with dilated pupil

Isolated CN palsy that progresses

Isolated CN palsy that doesn't resolve

Any new CN palsy in cancer presume cancer related

Take home messages:
- slow saccades = brain

- positive forced ductions = orbit

Exam

Step 1 assoc'd signs

- VA, pupils, typical exam

- can right off drifting out eye but not a drifting in eye

- CNIII can be confusing, check size pupil light and dark and check for RAPD

- evidence of other disease? inflammation, infection, neoplasis

- brain process, papilledema

- check head position, eyelids, periorbital changes, orbital findings, etc

- look for thyroid findings

Step 2 brain vs orbit

- slowed saccades in brain with normal forced ductions

- exact opposite of above if orbit

- use tonopen for kinder gentler forced duction

Step 3 identify pattern of motility

- does it fit a CN pattern?

- no CN pattern could be orbital or myasthenia

- maddox rod can help for smaller deviations

- CN IV, know if head tilted left it is probably right palsy but some TED patients and myasthenics can appear same way

Step 4: systemic disease

- MG, Graves, Giant Cell Arteririts, Increased ICP, MS

- don't forget typical GCA symptoms and the less common stomach pain from mesenteric ischemia

- the MG package: ptosis, XT, difficulty sustained upgaze, weak orbicularis, try the Ice test using a cold pack on the ptotic eye. If the eye pops up after ice, positive test for MG

Discuss patient 48 you female with left head turn and diplopia

- refractive errors, corneal opacities, lens, iris, macula, neurological, non- pathological

- if monocular, see if improves with pinhole

- if binocluar, no point in doing pinhole test

- thyroid patients more likely diplopic in the morning and MG as they fatigue

- paraneoplastic

- migraine

- Flake!

Back to our patient, diplopia constant except in extreme right gaze

- so esotropia and limited abduction

- has orbital pain, tearing, eyes bulgy, a bit of puffiness to eye

- remote hx of thyroid disease

- no surgical or other traumatic event

- also patient weight gain, fatigue, hair loss

- assoc'd findings: normal vision and pupils, injected conj, inc IOP on upgaze, increase resistance retropulsion

- slow eye movements in this patient, ie slow saccades therefore brain

- so now down to CNVI and related to her diabetes

- normal forced ductions in a patient with CNVI and TED findings

This patient has TED and acute onset of constant diplopia with constant velocity abnormality making this brain ie CNVI