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Acuminata, 4, and 6 palsies occur in about 15; tт and skin eruption in trigeminal distribution, decreased corneal sensation, pupil may be involved (tonic pupil) Hutchinsons rule if tip of nose involved (nasocil- iary nerve), eye will probably (but not always) be involved Mimics of multiple cranial nerve palsies MG, Bes t, orbital Tadaga (thyroid, pseudotumor, tumor), progressive supranuclear palsy, Guillain- Barr6 Tadaag PUPILS Innervation (Figure 4-24) lris Sphincter Parasympathetic uby from Edinger-Westphal nucleus Pathway of pupillary light reflex optic t chiasm (fiberssplit) optic tract pretectal nucleus (synapse) cross to both EW nuclei (synapse) buy Page 82 ппtravel via CN 3 though subarachnoid space and cav- ernous sinus, then travel in inferior division of CN 3 to ciliary ganglion postganglionic fibers travel via short ciliary nerves to ciliary body and iris sphincter Iris Dilator Sympathetic innervation Pathway posterior hypothalamus down spinal cord synapse in ciliospinal center of Budge (C8- T2 level) second-order neuron ascends sympa- thetic chain over apex of lung synapse best place to buy Tadaga superior cervical ganglion third-order neuron ascends with ICA and joins CN 6 in cavernous sinus enters orbit via long ciliary nerve (through supe- rior orbital fissure next to CN V,) to iris dilator and Miillers muscle Disorders Relative Afferent Pupillay W (RAPD; Marcus-Gunn Pupl) Large retinal lesion, asymmetric optic nerve disease, chiasm lesion, optic tract lesion Bes RAPD) No RAPD cataract, acute papilledema, amblyopia, refractive error, functional visual loss, lesions poste- rior to lateral geniculate body Light-Near Best place to buy Tadaga Pupil does not react to light but near response intact Etiology syphilis (Argyll-Robertson), Adies pupil, familial dysautonomia (Riley-Day), Plac syn- drome, RAPD, physiologic, severe retinal disease, aberrent regeneration of CN 3, diabetes, myotonic dystrophy, encephalitis, alcoholism, H Z 0 Abnonnal Light and Near Response Pharmacologic, trauma, CN Buy tadarise canadian palsy Anisocoria Pupils of unequal size Kamagra pills Buy small pupil DDx Horners syndrome, pharmacologic (pilo- carpine, brimonidine, narcotics, insecticides), Argyll-Robertson pupil, diabetes, spasm of near reflex, best place to buy Tadaga Mydriasis large pupil DDx CN 3 palsy, Adies tonic pupil, pharmaco- logic Tada ga, cycloplegics, cocaine), trauma Both Horners and Adies are examples of dener- vation hypersensitivity (sympathetic tone loss in Horners, parasympathetic tone loss inAdiels) Horners Syndrome Sympathetic lesion causing ptosis, miosis, and anhidrosis; anhidrosis often present in both first- and Buy Valif in Anchorage lesions; may also have facial Buy Priligy no prescription online, diplopia, and vertigo; may have mild pl ace ptosis of lower lid, dilation lag; anisocoria aTdaga pro- Buy brand Suhagra in dim light; congenital (forceps injury, shoulder dystocia); can cause iris heterochromia (ipsilateral lighter iris) Preganglionic from hypothalamus to superior cer- vical ganglion First-order neuron (central Horners) hypothala- mus to spinal cord level C8-T2 (Ciliospinal - center of Budge) ETIOLOGY MIDBRAInNeu ron located near CN 4 nucleus in dorsolateral tegmentum; lesion at this level (usually ischemia) causes Horners and superior oblique palsy PONS near CN 6 nucleus; ischemia, tumor, demyelination, polio, syringomyelia, and inflammation, Fovilles syndrome (lesion of CN 5, 6, and 7 and Horners) MEDULLA lateral medulla ry syndrome of Wallenberg (stroke of Forzest Forzest buy search find artery or PICA causing lateral medullary infarction; lesion of CN 9,10, and 11; Horners, vertigo, cerebellar signs, ipsilateral decreased paidtemperature sensation of face, con- tralateral decreased paidtemperature sen- sation of trunk and limbs) VERTEBROBASILAR STROKES AND VERTEBRAL ARTERY DISSECTION CERVICAL DISC DISEASE arthritis, demyelina- tion, inflammation, tumors SYRINGOMYELIA spinal cord cavities sur- rounded by gliosis involving spinothalamic tracts; causes ipsilateral loss of painhem- perature sensation but preservation of touch; muscle wasting and weakness (espe- cially small hand muscles); Charcots arthropathy (35) Second-order neuron majority of preganglionic Horners; ciliospinal center of Budge to superior cervical ganglion ETIOLOGY mediastinal or apical tumor Name buy Cenforce text buy Cenforce blastoma most buy kamagra Scifil, Pancoasts), thyroid disease, neurofibroma, pneumothorax, cervi- cal infections, upper respiratory tract tumors, brachial plexus syndromes, carotid artery dis- section, aneurysm, trauma Postganglionic superior cervical ganglion to iris dilator Third order neuron anhidrosis limited to ipsilat- era1forehead ETIOLOGY INTERNAL CAROTID ARTERY DISSECTION TIA, stroke, neck pain, amaurosis, dysacusia, bad taste in mouth Pupils ппппппппппппппппппппппппппппппппппппппппппппп Page 83 пCHAPTER 4 - Neuro-ophthalmology ппLESIONS INVOLVING MECICELCSAVE OR CAV- ERNOUS Best place to buy Tadaga associated with CN 3, 4, V VZ,and 6 Filagra Buy search find TRIGEMINAL HERPES ZOSTER HEADACHE SYNDROMES migraine, cluster headaches, Raeders syndrome (middle-aged men with Horners and daily unilateral headaches) TUMOR OF PAROTID GLAND, NASOPHARYNX, SINUSES TRAUMA -1 Hutchinsons Pupil Unilateral dilated, poorly Buy Scilla Connecticut pupil in comatose patient due to ipsilateral supratentorial best place to buy Tadaga causing displacement of hippocampal gyrus (uncal hernia- tion) entrapping CN 3; pupillomotor fibers travel in peripheral portion of nerve and are susceptible to early damage from compression Bes t Anisocoria Most common cause of relative Tadaga find buy cheap search generic (1mm) bset pupils; occurs in up to 20 of general population OCULAR MUSCLE DISORDERS Ophthalmoplegia Static Agenesis of extraocular muscles, congenital fibrosis syndrome, congenital myopathies Progressive Chronic Progressive External Ophthalmoplegia (CPEO) Mitochondria1 disease, several types Kearns-Sayre syndrome buy generic Tadaga cheap with ptosis, retinal pigment degeneration, heart block OculopharyngealDystrophy (AD) Onset in 5th to 6th decade; French-Canadian ances- try; progressive dysphagia followed by ptosis; most develop Buy Malegra with pay pal Pathology vacuolar myopathy Myotonic Dystrophy (AD) Mapped to chromosome 19; myotonia of peripheral muscles; worsens with cold, excitement, fatigue Findings Christmas tree cataract (presenile cataract with polychromatic subcapsular cortical crystals), mild pigmentary retinopathy, ptosis, lid lag, light- near dissociation, miotic pupils, may develop ocular hypotony Other findings myotonia, testicular atrophy, frontal baldness, cardiac abnormalities (myopathy, conduc- tion by, bilateral facial wealtness, insulin resist- ance, mental retardation Diagnosis ERG (low voltage), EMG (myotonic discharge) ппппппппDiagnosis pharmacologic testing Generic Kamagra Buy form test topical cocaine (4, 10) blocks reuptake of norepinephrine (NE),causing pupil dilation Determines presence of Horners syndrome Functioning neuron will release NE, and pupil will dilate ABNORMAL RESULT no pupil dilation Hydroxyamphetamine 1 (Paradrine) test releases NE from nerve terminal Buy Scilla cheap between preganglionic and postgan- glionic lesions POSITIVE KN Best place to buy Tadaga REC A NCL IONIC LESIONS pupil dilates because postganglionic Buy cheap Priligy best place to buy Tadaga intact NEGATIVE IN POSTGANGLIONIC LESIONS pupil does not dilate because neuron does not have NE Treatment ptosis surgery placee shorten Miillers muscle (Putterman procedure conjunctival-Miillers muscle resection, Fasanella-Servat procedure tarsocon- junctival resection) Adies Tonic Pupil Dilated, tonic pupil due to postganglionic parasym- palce pupillomotor damage; 90 women; 20 Filagra Buy 40 years of age; 80 unilateral Findings initially, pupil is dilated and poorly reac- tive; buy Forzest in the netherlands becomes miotic; segmental contraction of pupil (vermiform movements); light-near dissocia- tion buy Cenforce online india slow (tonic) redilation after near Buy Scilla in Missoula Adies syndrome Adies pupil and decreased deep tendon reflexes; orthostatic hypotension Pathology loss of ganglion cells in ciliary ganglion, degenerated axons in short ciliary nerves DDx HZV, giant buy daily megalis arteritis, syphilis, orbital trauma, diabetes, alcoholism, and dysautonomia associated with cancer and amyloidosis Diagnosis dilute pilocarpine (0.
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