Horizontal gaze palsy

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Horizontal gaze palsy
Specialty Neurology

A horizontal gaze palsy is a subtype of gaze palsy in which conjugate, horizontal eye movements are limited by neurologic deficits. Horizontal gaze palsies typically result from an ipsilateral pontine lesion or a contralateral frontal lobe lesion. [1]

Contents

Clinical features

Individuals suffering from complete horizontal gaze palsy cannot move either eye past the midline in a single direction. The eyes of a patient with pontine lesions involving the sixth nerve nucleus or PPRF may stray from the lesion's side. Patients with a left pontine lesion will be unable to look to their left and may have their eyes deviated to the right at baseline. If there is only partial damage to the pontine structures, patients may exhibit partial horizontal gaze movement. Patients with horizontal gaze palsy may also have to turn their heads toward the affected side to focus on an object that is directly in front of them because their eyes are constantly shifted to the opposite side. [1]

Lesions in the frontal lobe can hinder ipsilateral horizontal smooth pursuit, while lesions in the parietal-occipital-temporal region or posterior parietal cortex reduce the amplitude and speed of smooth pursuit eye movements in the direction of the lesion. [1]

Anatomy

Eye movements are controlled by supranucelar communication, infranuclear communication, and ocular motor nuclei. Horizontal gaze specifically also involves the Abducens nerve and the Paramedian pontine reticular formation. [2] Horizontal gaze involves synchronous activation of the abducens muscle of one eye and the medial rectus muscle of the other, via communication through the Medial longitudinal fasciculus. Horizontal gaze palsies can be caused by a lesion affecting any structure in these pathways. Lesions to abducens nucleus or PPRF typically create an ipsilateral gaze palsy, while lesions to MLF typically cause Internuclear ophthalmoplegia, a type of horizontal gaze palsy in which the affected eye cannot adduct in conjugation with the contralateral eye during horizontal gaze, but convergence is preserved. [3] Lesions to both PPRF and MLF can result in a rare condition known as One and a half syndrome, where a patient will have complete loss of lateral movement in one eye as well as a unilateral horizontal gaze palsy. [4]

Causes

A common cause of horizontal gaze palsies are strokes involving pontine structures, abducens nerve, or the motor cortex. [5] Horizontal gaze palsy has also been reported in cases of metastasis, [6] hemorrhage, [7] neuromyelitis optica spectrum disorder, [8] and multiple sclerosis. [9]

Rarely is horizontal gaze palsy reported in isolation; it may be classified as type III Duane syndrome. Mobius syndrome is characterized by facial weakness and horizontal gaze palsy. Horizontal gaze palsies have also been described in certain genetic conditions involving heterozygous mutations of the ROBO3 gene, resulting in the rare condition known as "Horizontal gaze palsy and progressive scoliosis." [10]

Diagnosis

Pontine lesions can typically be distinguished from supranuclear lesions in the frontal lobe based on clinical neurologic findings. Gaze palsies secondary to frontal lobe lesions can be temporarily relieved with rapid, passive horizontal head rotation, which also directly stimulates the sixth nerve nucleus through the vestibuloocular reflex. During this maneuver in a patient with intact brainstem structures, the eyes will gaze to the opposite direction of the head movement. However, gaze palsies secondary to pontine nuclear and infranuclear lesions cannot be clinically alleviated. [1] This passive head rotation maneuver is testing the oculocephalic reflex, sometimes referred to as the Doll's Eye reflex. [11]

The dorsal pons should be carefully considered when conducting neuroimaging studies. MRIs, or magnetic resonance imaging, are typically the preferred method. Computed tomography (CT) is a suitable substitute for magnetic resonance imaging (MRI) in certain situations, such as acute patients, patients with altered consciousness, or patients for whom MRI is contraindicated (such as pacemaker patients). [1]

When a patient exhibits intermittent conjugate gaze deviation or clinical seizure activity or is comatose or obtunded, an electroencephalogram (EEG) should be performed to rule out a seizure disorder. [1]

See also

Related Research Articles

<span class="mw-page-title-main">Abducens nerve</span> Cranial nerve VI, for eye movements

The abducens nerve or abducent nerve, also known as the sixth cranial nerve, cranial nerve VI, or simply CN VI, is a cranial nerve in humans and various other animals that controls the movement of the lateral rectus muscle, one of the extraocular muscles responsible for outward gaze. It is a somatic efferent nerve.

<span class="mw-page-title-main">Trochlear nerve</span> Cranial nerve IV, for eye movements

The trochlear nerve, also known as the fourth cranial nerve, cranial nerve IV, or CN IV, is a cranial nerve that innervates a single muscle - the superior oblique muscle of the eye. Unlike most other cranial nerves, the trochlear nerve is exclusively a motor nerve.

<span class="mw-page-title-main">Medial longitudinal fasciculus</span> Nerve tracts in the brainstem

The medial longitudinal fasciculus (MLF) is an area of crossed over tracts, on each side of the brainstem. These bundles of axons are situated near the midline of the brainstem. They are made up of both ascending and descending fibers that arise from a number of sources and terminate in different areas, including the superior colliculus, the vestibular nuclei, and the cerebellum. It contains the interstitial nucleus of Cajal, responsible for oculomotor control, head posture, and vertical eye movement.

<span class="mw-page-title-main">Eye movement</span> Movement of the eyes

Eye movement includes the voluntary or involuntary movement of the eyes. Eye movements are used by a number of organisms to fixate, inspect and track visual objects of interests. A special type of eye movement, rapid eye movement, occurs during REM sleep.

<span class="mw-page-title-main">Lateral rectus muscle</span> Muscle on lateral side of the eye

The lateral rectus muscle is a muscle on the lateral side of the eye in the orbit. It is one of six extraocular muscles that control the movements of the eye. The lateral rectus muscle is responsible for lateral movement of the eyeball, specifically abduction. Abduction describes the movement of the eye away from the midline, allowing the eyeball to move horizontally in the lateral direction, bringing the pupil away from the midline of the body.

<span class="mw-page-title-main">Abducens nucleus</span>

The abducens nucleus is the originating nucleus from which the abducens nerve (VI) emerges—a cranial nerve nucleus. This nucleus is located beneath the fourth ventricle in the caudal portion of the pons near the midline, medial to the sulcus limitans.

<span class="mw-page-title-main">Ophthalmoparesis</span> Medical condition

Ophthalmoparesis refers to weakness (-paresis) or paralysis (-plegia) of one or more extraocular muscles which are responsible for eye movements. It is a physical finding in certain neurologic, ophthalmologic, and endocrine disease.

<span class="mw-page-title-main">Internuclear ophthalmoplegia</span> Medical condition

Internuclear ophthalmoplegia (INO) is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When an attempt is made to gaze contralaterally, the affected eye adducts minimally, if at all. The contralateral eye abducts, however with nystagmus. Additionally, the divergence of the eyes leads to horizontal diplopia. That is if the right eye is affected the patient will "see double" when looking to the left, seeing two images side-by-side. Convergence is generally preserved.

<span class="mw-page-title-main">Parinaud's syndrome</span> Inability to move the eyes up and down

Parinaud's syndrome is a constellation of neurological signs indicating injury to the dorsal midbrain. More specifically, compression of the vertical gaze center at the rostral interstitial nucleus of medial longitudinal fasciculus (riMLF).

<span class="mw-page-title-main">Sixth nerve palsy</span> Medical condition

Sixth nerve palsy, or abducens nerve palsy, is a disorder associated with dysfunction of cranial nerve VI, which is responsible for causing contraction of the lateral rectus muscle to abduct the eye. The inability of an eye to turn outward, results in a convergent strabismus or esotropia of which the primary symptom is diplopia in which the two images appear side-by-side. Thus, the diplopia is horizontal and worse in the distance. Diplopia is also increased on looking to the affected side and is partly caused by overaction of the medial rectus on the unaffected side as it tries to provide the extra innervation to the affected lateral rectus. These two muscles are synergists or "yoke muscles" as both attempt to move the eye over to the left or right. The condition is commonly unilateral but can also occur bilaterally.

<span class="mw-page-title-main">One and a half syndrome</span> Medical condition

The one and a half syndrome is a rare weakness in eye movement affecting both eyes, in which one cannot move laterally at all, and the other can move only in outward direction. More formally, it is characterized by "a conjugate horizontal gaze palsy in one direction and an internuclear ophthalmoplegia in the other". Nystagmus is also present when the eye on the opposite side of the lesion is abducted. Convergence is classically spared as cranial nerve III and its nucleus is spared bilaterally.

<span class="mw-page-title-main">Paramedian pontine reticular formation</span>

The paramedian pontine reticular formation, also known as PPRF or paraabducens nucleus, is part of the pontine reticular formation, a brain region without clearly defined borders in the center of the pons. It is involved in the coordination of eye movements, particularly horizontal gaze and saccades.

<span class="mw-page-title-main">Foix–Chavany–Marie syndrome</span> Medical condition

Foix–Chavany–Marie Syndrome (FCMS), also known as bilateral opercular syndrome, is a neuropathological disorder characterized by paralysis of the facial, tongue, pharynx, and masticatory muscles of the mouth that aid in chewing. The disorder is primarily caused by thrombotic and embolic strokes, which cause a deficiency of oxygen in the brain. As a result, bilateral lesions may form in the junctions between the frontal lobe and temporal lobe, the parietal lobe and cortical lobe, or the subcortical region of the brain. FCMS may also arise from defects existing at birth that may be inherited or nonhereditary. Symptoms of FCMS can be present in a person of any age and it is diagnosed using automatic-voluntary dissociation assessment, psycholinguistic testing, neuropsychological testing, and brain scanning. Treatment for FCMS depends on the onset, as well as on the severity of symptoms, and it involves a multidisciplinary approach.

The paramedian reticular nucleus sends its connections to the spinal cord in a mostly ipsilateral manner, although there is some decussation.

<span class="mw-page-title-main">Foville's syndrome</span> Medical condition

Foville's syndrome is caused by the blockage of the perforating branches of the basilar artery in the region of the brainstem known as the pons. It is most frequently caused by lesions such as vascular disease and tumors involving the dorsal pons.

Conjugate gaze palsies are neurological disorders affecting the ability to move both eyes in the same direction. These palsies can affect gaze in a horizontal, upward, or downward direction. These entities overlap with ophthalmoparesis and ophthalmoplegia.

The term gaze is frequently used in physiology to describe coordinated motion of the eyes and neck. The lateral gaze is controlled by the paramedian pontine reticular formation (PPRF). The vertical gaze is controlled by the rostral interstitial nucleus of medial longitudinal fasciculus and the interstitial nucleus of Cajal.

Conjugate eye movement refers to motor coordination of the eyes that allows for bilateral fixation on a single object. A conjugate eye movement is a movement of both eyes in the same direction to maintain binocular gaze. This is in contrast to vergence eye movement, where binocular gaze is maintained by moving eyes in opposite directions, such as going “cross eyed” to view an object moving towards the face. Conjugate eye movements can be in any direction, and can accompany both saccadic eye movements and smooth pursuit eye movements.

Alternating hemiplegia is a form of hemiplegia that has an ipsilateral cranial nerve palsies and contralateral hemiplegia or hemiparesis of extremities of the body. The disorder is characterized by recurrent episodes of paralysis on one side of the body. There are multiple forms of alternating hemiplegia, Weber's syndrome, middle alternating hemiplegia, and inferior alternating hemiplegia. This type of syndrome can result from a unilateral lesion in the brainstem affecting both upper motor neurons and lower motor neurons. The muscles that would receive signals from these damaged upper motor neurons result in spastic paralysis. With a lesion in the brainstem, this affects the majority of limb and trunk muscles on the contralateral side due to the upper motor neurons decussation after the brainstem. The cranial nerves and cranial nerve nuclei are also located in the brainstem making them susceptible to damage from a brainstem lesion. Cranial nerves III (Oculomotor), VI (Abducens), and XII (Hypoglossal) are most often associated with this syndrome given their close proximity with the pyramidal tract, the location which upper motor neurons are in on their way to the spinal cord. Damages to these structures produce the ipsilateral presentation of paralysis or palsy due to the lack of cranial nerve decussation before innervating their target muscles. The paralysis may be brief or it may last for several days, many times the episodes will resolve after sleep. Some common symptoms of alternating hemiplegia are mental impairment, gait and balance difficulties, excessive sweating and changes in body temperature.

<span class="mw-page-title-main">Corticomesencephalic tract</span>

In neuroanatomy, corticomesencephalic tract is a descending nerve tract that originates in the frontal eye field and terminate in the midbrain. Its fibers mediate conjugate eye movement.

References

  1. 1 2 3 4 5 6 "UpToDate". uptodate.com. Retrieved January 8, 2024.
  2. ↑ "Horizontal gaze". American Academy of Ophthalmology. 2017-07-12. Retrieved 2024-01-14.
  3. ↑ "Internuclear Ophthalmoplegia - Neurologic Disorders". Merck Manuals Professional Edition. Retrieved 2024-01-14.
  4. ↑ Xue, Fang (Dec 2017). "One-and-a-half syndrome with its spectrum disorders". Quant Imaging Med Surg. 7 (6): 691–697.
  5. ↑ "Conjugate Gaze Palsies - Neurologic Disorders". Merck Manuals Professional Edition. Retrieved 2024-01-14.
  6. ↑ Pierrot-Deseilligny, C; Goasguen, J; Chain, F; Lapresle, J (February 1, 1984). "Pontine metastasis with dissociated bilateral horizontal gaze paralysis". Journal of Neurology, Neurosurgery & Psychiatry. BMJ. 47 (2): 159–164. doi:10.1136/jnnp.47.2.159. ISSN   0022-3050. PMC   1027685 . PMID   6707655.
  7. ↑ Koehler, P.J.; Wattendorff, A.R.; Goor, C.; Hekster, R.E.M.; Falke, T.H.M. (1986). "Bilateral horizontal gaze paralysis due to pontine hemorrhage". Clinical Neurology and Neurosurgery. Elsevier BV. 88 (2): 121–125. doi:10.1016/s0303-8467(86)80007-5. ISSN   0303-8467. S2CID   23422739.
  8. ↑ Furutani, Yuka; Hata, Masayuki; Miyamoto, Kazuaki; Moribata, Yusaku; Yoshimura, Nagahisa (October 4, 2014). "A Case of Neuromyelitis Optica Masquerading as Miller Fisher Syndrome". Case Reports in Neurology. S. Karger AG. 6 (3): 226–231. doi:10.1159/000368183. ISSN   1662-680X. PMC   4224235 . PMID   25408664.
  9. ↑ Ewe, Renee; White, Owen B.; Burke, Ailbhe (November 15, 2017). "Isolated Horizontal Gaze Palsy: Observations and Explanations". Frontiers in Neurology. Frontiers Media SA. 8. doi: 10.3389/fneur.2017.00611 . hdl: 11343/255437 . ISSN   1664-2295.
  10. ↑ "Horizontal gaze palsy with progressive scoliosis: MedlinePlus Genetics". medlineplus.gov. Retrieved 2024-01-14.
  11. ↑ Dishion, Evan; Tadi, Prasanna (2023), "Doll's Eyes", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   31869180 , retrieved 2024-01-14

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