[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has complained of double vision.  Please examine their eyes to determine the cause.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/149972954″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has an internuclear ophthalmoplegia.  Dysconjugate eye movement is seen when the patient attempts rightward gaze.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Clinical Presentation:

Internuclear ophthalmoplegia (INO) presents with gaze disturbances; horizontal gaze will be affected while vertical gaze is usually spared. The patients gaze will be affected on the side of the lesion and he/she may complain of diplopia.

It is important to note that patients with unilateral INO will be unable to adduct the affected eye while the normal eye will abduct normally. While those who have bilateral INO, will not be able to adduct their eyes while abduction will be functional. Nystagmus will be present in the normal eye in both the cases. Convergence of the eyes will be normal.

Pathology

This is a disorder that arises when fibres (of 3rd, 4th and 6th nerves) responsible for co-ordinating the ocular movements are disrupted within the medial longitudinal fasciculus (MLF). The MLF is responsible for controlling the horizontal gaze. Lesions, like stoke in the elderly and multiple sclerosis in the young adults are a common causes, while trauma and mass lesions are, although seldom, also contributory.

Initial Investigation

Initial investigations include baseline studies; complete blood count, electrolyte levels, renal functions, coagulation studies along with cholesterol and lipid profiles should be done. In older patients, vascular pathology such as stroke (vertebrobasilar artery) or aneurysms may require careful investigations with CT or MRI scans. Additionally, angiography may also be required to test for malformations or occlusive lesions. In younger patients where autoimmune aetiologies are suspected, antinuclear antibodies should be tested for along with CRP and ESR to determine longstanding inflammatory aetiologies. Cases of embolism may require careful cardiac assessment to check for atherosclerotic changes.

Treatment

The treatment is chosen according to the underlying pathology. Stroke patients need careful assessment and hospital management. In practice, the prognosis of INO depends on the type of pathology present. In benign cases, INO may eventually resolve, while severe pathologies may leave permanent and lasting effects.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has an internuclear ophthalmoplegia.  My leading differentials include demyelination and vascular causes.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]