Diplopia Impaired Ocular Movement

IV NERVE LESION

The eyes appear conjugate in the primary position.

Testing eye movements reveals defective depression of the adducted eye. -------

Symptomatically the patient complains of double vision when looking downwards, e.g. when descending stairs or reading, and the head may tilt to the side opposite the weak superior oblique to minimise the diplopia.--------

A IV nerve palsy is difficult to detect when associated with a III nerve palsy. If inward rotation (intorsion) is absent on looking downwards when the eye is abducted, then a IV nerve palsy coexists with the III nerve palsy.

VI NERVE LESION

The eyes appear conjugate in the primary position.

On looking to the paralysed side (right) there is failure of---*" abduction of the affected eye.

Diplopia is horizontal (true and fake image side by side), is present only when looking to the paralysed side and is maximal at the extreme of binocular lateral vision.

NOTE: In partial oculomotor palsies, the patient may be aware of diplopia, although eye movements appear normal. When this occurs:

- check diplopia is 'true' by noting its disappearance on covering one eye.

- determine the direction of maximal image displacement and the eye responsible for the outermost image (see page 13).

This information is sufficient to differentiate a III, IV and VI nerve lesion.

OCULAR MUSCLES

If the limitation of eye movement is not restricted to one muscle, or group of muscles with a common innervation, and affects both eyes, look for:

- involvement of extraocular muscles

(levator palpebrae superioris, orbicularis oculi) I myasthenia gravis

- signs of fatigue on repeated testing I ocular myopathy

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