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Clinical Examination in Neuro-Ophthalmology
Published in Vivek Lal, A Clinical Approach to Neuro-Ophthalmic Disorders, 2023
Selvakumar Ambika, Krishnakumar Padmalakshmi
Clinical assessment should start as soon as the patient enters the examination room, including gait, higher functions and external appearance. Abnormality of eyelid position such as ptosis or lid retraction needs to be noted. History of diurnal variation and fatiguability should be noted for any patient with lid droop to rule out ocular myasthenia. Simple clinical signs like improvement in ptosis after ice test and Cogan's lid twitch are more suggestive of myasthenia. Patients with third nerve palsy and certain myopathies as in chronic progressive external ophthalmoplegia and Miller Fisher syndrome also can present with ptosis, screening old photographs may help us to assess the onset of the findings. Ptosis should not be mistaken for conditions like blepharospasm or apraxia of lid opening. Measurement of palpebral fissure height, levator function and marginal reflex distance has to be done. Evaluation of proptosis is important as it may be associated with life-threatening intracranial and certain intraorbital tumors, carotid-cavernous fistulas, AV malformations, etc. Lid retraction can be a feature of thyroid eye disease or even dorsal midbrain syndrome.
Supplementary Motor Area Syndrome
Published in Alex Jelly, Adel Helmy, Barbara A. Wilson, Life After a Rare Brain Tumour and Supplementary Motor Area Syndrome, 2019
In Alex’s case, she developed a particularly severe SMAS, to the extent that she did not even open her eyes. In the early stages of her post-operative period it was very difficult to diagnose SMAS. The diagnosis was based on several findings: first, the post-operative MRI which did not show any signs of other brain damage; second, the site at which the tumour occurred was adjacent to the SMA; third, the fact that although all voluntary movements (including eye movements) were lost but automatic movements such as the ability to cough and swallow were maintained. The importance of coughing and swallowing is that it stops saliva from going down “the wrong way” into the lungs and causing an infection. In patients who have serious impairments in their consciousness this ability is often lost and can cause serious problems. The peculiar thing about Alex’s SMAS is that it affected both sides, presumably because of the size and extent of the tumour, as well as the ability to voluntarily open her eyelids (apraxia of lid opening).
The first UK national blepharospasm patient and public involvement day; identifying priorities
Published in Orbit, 2020
Fabiola R. Murta, Jacob Waxman, Andi Skilton, Sadie Wickwar, Karen Bonstein, Richard Cable, Jane Clipston, Alan Bates, Rea Mattocks, Jane Shelley, Patricia McCullough, Marc Surry, Josie Matthews, Stephen Worsfold, Daniele Lorenzano, Anuradha Jayaprakasam, Shirin Hamed Azzam, Fariha Shafi, Qiang Kwong, Nikolas Koutroumanaos, Alexandra Manta, Guy Negretti, Anjana Haridas, Daniel G. Ezra
Blepharospasm, formerly benign essential blepharospasm, is the most common focal dystonia.1 It is characterised by uncontrolled contraction of voluntary muscles around the eyes bilaterally with involuntary lid closure. Sometimes other facial muscles are involved. In severe cases, there is forced lid closure with sustained orbicularis oculi contractions or apraxia of lid opening with failure to initiate the levator plapebrae superioris contracture. Blepharospasm is debilitating and can significantly impact quality of life.1–4