Divergence insufficiency in cerebellar ataxia

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Identifier Divergence_insufficiency
Title Divergence insufficiency in cerebellar ataxia
Subject Abnormal Alignment, Divergence Insufficiency, OMS Cerebellar
Creator Daniel R. Gold, DO, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, and Medicine, The Johns Hopkins School of Medicine
Description This is a 65-yo woman with complaints of imbalance (progressive over years) and horizontal diplopia at distance. On her exam, there was a small symptomatic esotropia at distance, but only a small esophoria at near. There were no obvious abduction deficits, and the 6 prism diopter ET at distance was comitant in all directions of gaze. Divergence insufficiency was diagnosed. ; Occasionally, this can be a sign of a brainstem or cerebellar lesion, and on her exam, there was also gaze-evoked nystagmus (GEN) and saccadic pursuit in addition to gait ataxia. These features localize best to the cerebellar flocculus, and in fact, esodeviations greater at distance are commonly found in patients with GEN, saccadic pursuit and downbeat nystagmus (flocculus) syndromes (perhaps due to dysfunction of flocculus to medial rectus subnuclei connections). In this patient's case, MRI showed mild cerebellar atrophy, and investigations for causes of reversible/treatable causes of cerebellar ataxia were negative. Spinocerebellar ataxia testing was deferred. She benefited from prisms placed in distance glasses only. ; Alternatively, many patients of advanced age who present with esodeviation greater at distance (without central ocular motor signs and with a normal neurologic exam) probably have the sagging eye syndrome. Sagging eye syndrome or age-related orbital involutional changes cause divergence issues which are characteristically worse at distance, which is due to LR-SR band rupture or distention causing the LR to be at a mechanical disadvantage. A prominent superior sulcus and levator disinsertion with high lid creases are other typical signs seen with sagging eye syndrome.
Contributor Daniel R. Gold, D.O. Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery The Johns Hopkins School of Medicine
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Type Image/MovingImage
Format video/mp4
Rights Management Copyright 2016. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Language eng
ARK ark:/87278/s6c28mgc
Setname ehsl_novel_gold
Date Created 2017-05-31
Date Modified 2018-01-22
ID 1251074
Reference URL https://collections.lib.utah.edu/ark:/87278/s6c28mgc
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