Ophthalmoplegia

Specialty: Neurology.

• eye palsy
• paralysis of eye movements
• weakness of extraocular muscles

Why it occurs

• Isolated oculomotor cranial nerve palsy (III, IV or VI nerve due to microvascular ischemia due to diabetes/hypertension, trauma or tumor compression)
• Miller Fisher syndrome (variant of Guillain-Barré syndrome characterized by ophthalmoplegia, ataxia and areflexia)
• Myasthenia Gravis (fluctuating autoimmune involvement of the extraocular muscles without pupillary involvement)
• Thyroid ophthalmopathy (Graves disease with infiltration of extraocular muscles)
• Tolosa-Hunt syndrome (idiopathic granulomatous inflammation of the sphenoid cleft or cavernous sinus)
• Wernicke's encephalopathy (acute thiamine deficiency in alcoholics or malnourished people that associates ophthalmoplegia, ataxia and confusion)

Initial workup

Detailed exploration of extrinsic ocular motility in the 9 gaze positions; CT or MRI of the orbits and brain with contrast focused on the cavernous sinus; lumbar puncture if Miller Fisher (highly specific anti-GQ1b antibodies) or basal meningitis is suspected; anti-acetylcholine receptor (AChR) antibodies and repetitive stimulation test if myasthenia gravis is suspected; levels of thyroid hormones and thyroid-stimulating immunoglobulins (TSI).

Standard management

• Thiamine / Vitamin B1 — 100-500 mg intravenously every 8 hours, administered before any glucose intake in suspected Wernicke encephalopathy
• Systemic corticosteroids — in Tolosa-Hunt syndrome or severe thyroid ophthalmopathy
• Pyridostigmine (60 mg every 4-6 hours) and prednisone in Myasthenia Gravis.