CASE REPORT: With dr H. A. R. Toyo, Sp.

OPHTHALMOPLEG
S (K)
Merlin Sari Mutma Indah
Randina Dwi Megasari

IA 1
IDENTIFICATION
Name: Ms.R
Age : 13 years old
Sex : Female
Address : Ilir Timur II
Religion : Islam
Hospitalized : August 5th at
11 a.m
RM. : 905827

2
 There were no fever,

ANAMNESIS The patient eyesight becomes

dark
nausea, vomiting,
weakness on one side of
the body, trauma,
Headaches:
seizures, pain around
The patient
extendshospitalized
from the back in to
the neurology the
ward
eyes,
of to
difficult
the frontof
RSMH because ondifficulty
both suffering
Patients sidesdoing
of the
fromphysical activity
hydrocephalus due
since
head, 3 months oldoccurs
and underwent open
surgery for a loss of
the eyes,
to the loss of vision that slowly.
7 days shunt tube
not interfere withinstallation
physical (2002)
activity, had second tube installation
speech,
decrease
double vision,
and have
consciousness,
at 10 years
There were nooldfever,
before (2012).by
not reduced
of
Patients
seizures
rest born prematurely.
continuously happen and(-), history of
sensibility
loss of
and
disturbance
A history
nausea, vomiting,
communication
weakness of one side of
consciousness
getting worse by the time (-), history of hypertension
disturbance.
(-), history of diabetes (-). the body, trauma,
Eyesight was getting darker seizures, pain around
and This
headaches became
illness was worse.
the first the eyes, difficult to
Have been
time forinterfered
her. her daily open the eyes, loss of
2 days activities speech, double vision,
decrease
before consciousness,
sensibility disturbance
and communication
disturbance.3
 PHYSICAL
EXAMINATION
General status
Sense : E4M6V5
Blood pressure : 120/80 mmHg
Pulse : 84 times/minutes, reguler,
sufficient tension and content.
Respiratory rate : 20 times per minutes
Temperature : 36,7 C
Body weight : 60 Kg
Body Height : 158 cm
BMI : Normoweight (24.03)

Heart : HR = 84 times per minutes, murmur (-), gallop (-)

Lung : Vesikuler (+/+) normal, ronkhi (-/-), wheezing (-/-)
Abdomen: Flat, liver and spleen is not palpable, bowel
sound (+) normal.
Extremity : No abnormality
Genital : Unexamined 4
PSYCHIATRIC STATUS
Attitude : cooperatif
Attention : present
Facial expression : proper
Psycic contact : present

5
NEUROLOGICAL
STATUS (HEAD)
Shape : Normocephaly Deformity : (-)
Size : normal Fracture : (-)
Symmetrical : symmetric Fracture pain : (-)
Hematoma : (-) Blood vessels : no enlargement
Tumor : (-) Pulsation : (-)

NEUROLOGICAL
STATUS (NECK)
Posture : Good Deformity : (-)
Torticollis : (-) Tumor : (-)
Neck Stiffness : (-) Blood vessels : no
enlargement
6
NERVI CRANIALES
EXAMINATION
OLFACTORY NERVE OPTIC NERVE

Olfactory Right Left Opticus nerve Right Left

Visus 1/300 1/300
nerve
unexemi unexemin
Smelling Norma Norma Visual field
ned ed
Anosmia l l

Hiposmia - - Anopsia
- -
Parosmia - - Hemianopsia
- -
- - Fundus Oculi

- Papilledema
- -
- Atrophy of
+ +
papilla
- -
- Retinal 7
OCCULOMOTOR, TROCHLEARIS, & ABDUCENS NERVE
Occulomotor, Right Left
Occulomotor, Right Left
Trochlearis, &
Trochlearis, &
Abducens nerve
Abducens nerve
Pupil
Diplopia - -
Shape Round Round
Eye fissure - -
Diameter 4 mm 3 mm
Ptosis - -
Isochore/anisochor Anisocho Anisoch
Eye position
e re ore
Strabismus + -
(esotropia) Midriasis/miosis - -
Exophtalmus -
- Light reflexes + +
Enophtalmus -
- direct + +
Deviation -
- indirect + +
conjugae
Argyl Robertson - -
Eye movement
accommodation
RAPD + - 8
Trigeminal Nerve
No abnormality
Vagus Nerve
Facial Nerve No abnormality

No abnormality Accecorius Nerve

No abnormality
Vestibulocochlear Nerve
Hypoglossus Nerve
No abnormality
No abnormality
Glossopharingeal Nerve
No abnormality

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MOTORIC Arm Right Left
FUNCTION Movement Enough Enough

EXAMINATION Strength 5 5
Tonus Normal Normal
Physiologic
Reflexes Normal Normal
MOTORIC - Biceps Normal Normal
EXAMINATION (ARM) - Triceps Normal Normal
- Radius Normal Normal
- Ulna
Pathologic - -
Reflexes - -
- Hoffman - -
Tromner
- Leri 10
 Leg Right Left
Movement Enough Enough
Strength 5 5
Tonus Normal Normal
Klonus
- thigh (-) (-)
- foot (-) (-)
Physiologic
Reflexes Normal Normal
MOTORIC EXAMINATION - KPR Normal Normal
(LEG)
- APR
Pathologic - -
Reflexes - -
- Babinsky - -
- Chaddock - -
- Oppenheim - -
- Gordon - -
- Schaeffer
- Rossolimo
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SENSORIC, VEGETATIVE AND VERTEBRAL COLUMN
EXAMINATION

VERTERBRAL
COLUMN
SENSORIC : No Abnormality
Kyphosis :-

VEGETATIVE FUNCTION Lordosis :-

Voiding : No Abnormality Gibbus : -

Defecation : No Abnormality Deformity : -

Tumor : -
Meningocele :-
Hematoma : -
Pain :-

12
 MENINGEAL SIGN, GAIT, BALANCE AND
COORDINATION
Balance and coordination
Meningeal Sign Gait
Romberg : No
Neck stiffness : - Ataxia :- abnormality
Kerniq : - Hemiplegic : - Dysmetri : No
Lasseque :- Scissor :- abnormality

Brudzinsky Propulsion : - - finger-finger : No

abnormality
Neck :- Histeric :-
-finger - nose : No
Cheek : - Limping :-
abnormality
Symphisis : - Steppage :-
- heel-heel : No abnormality
Leg I :- Astasia-Abasia : -
Rebound phenomen: -
Leg II :- Limb Ataxia: -
Dysdiadochokinesis: -
Trunk Ataxia :-
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ABNORMAL MOVEMENT AND COGNITIVE
FUNCTION EXAMINATION
ABNORMAL MOVEMENT COGNITIVE FUNCTION
Tremor :- Motoric Aphasia :-
Chorea :- Sensoric Aphasia :-
Athetosis :- Apraksia :-
Ballismus :- Agrafia :-
Dystoni : - Alexia :-
Myocloni :- Nominal aphasia :-

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LABORATORIUM RESULT
No Examination Result Normal Value Interpretatio
n
HEMATOLOGY
1 Hb 14.8 12.0-14.4 g/dL Increase
2 Eritrosit 5.33 4.75-4.85
Increase
10 /mm3
6

3 Ht 43 36-42 vol% Increase

4 Leukosit 12.8 4.5-11.0 103/mm3 Increase
5 Trombosit 310 150-450 103/L Normal
6 Hitung jenis
Basofil 0 0-1 % Normal
Eosinofil 5 1-6 % Normal
Netrofil 77 50-70 % Increase
Limfosit 13 20-40 % Decrease
15
Monosit 8 2-8 % Normal
LABORATORIUM RESULT

KIMIA KLINIK
Metabolisme Karbohidrat
9 Glukosa 72 <200 mg/dL Normal
Sewaktu
Ginjal
12 Ureum 21 16.6-48.5 mg/dL Normal
13 Kreatinin 0.66 0.57-0.87 mg/dL Normal
Elektrolit
15 Natrium (Na) 140 135-155 mg/dL Normal

16 Kalium (K) 4.5 3.5-5.5 mg/dL Normal

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CT SCAN RESULT (EXAMINED AT 30 TH
JULY 2015)

17
DIAGNOSES

Clinical Diagnosis: Topic Diagnosis

Cephalgia
Ventricle + radicular part of N.III, IV,
Bilateral N.III paralysis VI (Subarachnoid space)
Bilateral N.IV paralysis
Bilateral N.VI paralysis Etiologic Diagnosis
Visus 1/300 bilateral Congenital Hydrocephaly +
Papil athrophy Ventriculomegaly

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THERAPY

Nonpharmacologic
Head up 30o
O2 2L per minutes

Pharmacologic
IVFD asering gtt xx/minutes
Glaucon tab 3x500 mg p.o
Ketorolac amp. 3 x 30 mg i.v
Neurobion 1x5000 mcg
P/ Ventriculoperitoneal shunt
replacement surgery
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PROGNOSIS

Quo ad vitam : Bonam

Quo ad functionam : Dubia ad malam

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THEORY
21
OPTIC NERVE

22
OCULOMOTOR NERVE

23
TROCHEAL NERVE

ABDUCENT NERVE

24
 OPHTALMOPLEGIA
Ophthalmoplegia, also called extraocular
muscles palsy, paralysis of the
DEFINITION extraocular muscles that control the
movement of the eye. Ophthalmoplegia
usually involved the third (occulomotor),
forth (trochlearis) or sixth (abducens)
cranial nerves.

Paralysis or weakness all adducting (MR, SR, IR)

and elevating muscles (SR, IO) with over-action
Third of RL and SO
Cranial Dilated, unresponsive pupile and loss of
Nerve accomodation
Palsy Most often due to subarachnoid compression of
the nerve in the interpeducular fossa;
Headache
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 Affected eye adopts an out-rotated position in
primary gaze leading to complaint of vertical
Fourth and torsional diplopia
Cranial The 4th nerve is most vulnerable to isolated
Nerve damage by mechanical distortion in its long
Palsy and unprotected path from its emergence at
the superior medullary velum and through the
sub-arachnoid space

Classical abducens nerve palsy presents as

Six
unilateral non-comitant esotropia in primary
Cranial
gaze with horizontal (uncrossed) diplopia,
Nerve
which worsens at distance and when looking
Palsy
towards the affected side

26
es of Third, Fourth, and Sixth Nerve Palsies

27
es of Third, Fourth, and Sixth Nerve Palsies

28
 HYDROCEPHALUS
Hydrocephalus represents a diverse group
of conditions that result from impaired
DEFINITION
circulation and absorption of CSF or, in
the rare circumstance, from increased
production by a choroid plexus papilloma
PHYSIOLOGY OF CSF

75% formed primarily in the ventricular system by the choroid

plexus, which is situated in the lateral, third, and fourth
ventricles. 25% originates from extrachoroidal sources,
including the capillary endothelium within the brain
parenchyma
Controlled by adrenergic and cholinergic nerves
Production 20 mL/hr, total volume approximates 50 mL in an infant
and 150 mL in an adult
CSF flow (Lateral ventricle foramina of monro third ventricle
aqueduct of sylvius fouth ventricle cisterns) results from the
pressure gradient that exists between the ventricular system
(180 mmH2O) and venous channels (90 mmH2O)
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 ETIOLOGY AND
PATHOPHYSIOLOGY

Hydrocephalus resulting from

Hydrocephalus resulting
obliteration of the subarachnoid
from obstruction within the
cisterns or malfunction of the
ventricular system
arachnoid villi
bstructive or noncommunicating hydrocephalus
nonobstructive or communicating hydrocepha

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CLINICAL MANIFESTATION

o Depends on the age at onset, the nature of the lesion causing

obstruction, and the duration and rate of increase of the intracranial
pressure
o In an infant, an accelerated rate of enlargement of the head is the
most prominent sign; forehead is broad, eyes may deviate downward
o Pathologic reflex
o Irritability, lethargy, poor appetite, and vomiting
o Headache
o Gradual change in personality and a deterioration in academic
productivity
o A foreshortened occiput suggests Chiari malformation
o A prominent occiput suggests the Dandy-Walker malformation
o Papilledema, abducens nerve palsy, and pyramidal tract signs

31
 DIAGNOSIS

Anamnesis Familial history, history of prematurity, meningitis,

mumps, encephalitis
Physical examination
Additional examination CT scan, MRI

TREATMENT

Depends on the cause

Medical management Diuretic, such as acetazolamide and furosemide
Extracranial shunts

PROGNOSIS

Depends on the cause

Disabilities 32
CASE ANALYSIS
33
 Loss of vision

Slowly Both of eyes

No Periorbital
Ischaemic or symptoms,
Inflammation hemiparesis,
No fever Hemisensory
No Periorbital pain or changes
eyeball movement Chiasmal,
pain retrochiasmal
process

Ischaemic Process due to

chiasmal or retrochiasmal
process
34
 Headache
Extends from the
back to the front
on both side of
the head, not Cephalgia
reduce by rest, Secondary
happens proccess
continuously, and
by the time
getting worseHistory of prematurely Secondary
born cephalgia
History of congenital because of an
hydrocephalus imbalance
History of undergone vp cerebrospinal
shunt surgery at 3 mo fluid outflow
y.o and 10 y.o

35
 At 13 y.o sutures was
Normocephalic Head
completely closed

Visus 1/300 Increased intracranial

pressure, a prolapse of
Atrophy of papilla optic nerve into a
hugely dilated sella
turcica
RAPD (+)

Blocks at lateral,
Problems is on 3rd, 4th, and
superolateral, and
6th cranial nerve
inferolateral direction
Lesion at radicular
Lesion at nuclei in
part at subarachnoid Peripheral lesion
brainstem
space
No history of other
No abnormality at
disorder related.
other cranial nerve
Such as GBS,
examination
diabetic, myastenia
gravis, infection,36 etc.
 CT Scan show a
dilatation at ventricle
system and a shunt
pipe

Malfunction of vp
shunt, either because
unsuitable size or
unstable position

Increased
Secondary Vision loss
Intracranial Hydrocephalus
cephalgia
Pressure

Diuretic Ventriculoperitone
NSAID -
Acetazolamid al shunt replace Nerve vitamin
Ketorolac
e- Glaucon surgery

37
Thank you for your kind attention

38
1. What is indication of Glaucon in this patient?
Glaucon Asetazolamide, used as diuretic which will reduce production of CSF
Furosemide (?)
Manitol Dont use more than 3 days

2. Why the prognosis is dubia?

3. Is there a lifetime vp shunt?

Paresis Berkurangnya gerakan dan kekuatan otot-otot disertai dengan gangguan tonus
dan refleks
Oftalmoplegia Kelumpuhan otot-otot penggerak bola mata yang lebih dari satu
Totalis Jika sudah mengenai otot sfingter pupil
N.II diselubungi oleh arachnoid. Proses di arachnoid akan menyebabkan gangguan pada
N.II
Atropi papil primer dan sekunder
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