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226 Walsh & Hoyt: Combined Unilateral Conjugate Gaze Palsy and Internuclear Ophthalmoplegia (One-and-a-Half Syndrome)David S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineCombined lesions of the abducens nucleus or PPRF and adjacent MLF on one side of the brain stem cause an ipsilateral horizontal gaze palsy and INO, so that the only preserved horizontal eye movement is abduction of the contralateral eye; hence the name one-and-a-half syndrome. Such patients may show...
227 Walsh & Hoyt: Sites and Manifestations of LesionsDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineDisturbances of vertical eye movements from midbrain lesions are usually caused by damage to one or more of three main structures: the posterior commissure, the rostral interstitial nucleus of the medial longitudinal fasciculus, or the INC.
228 Walsh & Hoyt: Ocular Motor Syndromes Caused by Lesions in the Cerebral HemispheresDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineExtensive reviews of the effects of cerebral hemisphere lesions on eye movements were done by Pierrot-Deseilligny and Leigh and Kennard. One particular issue that must be considered in assessing abnormalities of eye movements in patients with lesions in the cerebral hemispheres is the sometimes conf...
229 Walsh & Hoyt: Lesions of the Paramedian Pontine Reticular FormationDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineThe PPRF, which corresponds principally to medial portions of the nucleus reticularis pontis caudalis, contains burst neurons that are important in the generation of saccades, and the paramedian nucleus raphe interpositus contains pause neurons that inhibit burst neurons at all times except during s...
230 Walsh & Hoyt: Huntington's DiseaseDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineHuntingtons disease produces disturbances of voluntary gaze, particularly saccades. It is caused by a genetic defect of the IT15 gene (the ""Huntington"" gene) on chromosome 4, producing a CAG triplet repeat. Initiation of saccades in patients with Huntingtons disease may be difficult. Such patients...
231 Walsh & Hoyt: Neurologic Disorders that Primarily Affect the MesencephalonDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineTwo neurologic disorders produce profound disturbances of ocular motility, primarily because of their effects on cells in the mesencephalon: progressive supranuclear palsy and Whipples disease. Progressive supranuclear palsy (PSP) is a degenerative disease of later life characterized by disturbances...
232 Walsh & Hoyt: Ocular Motor Manifestations of SeizuresDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineEye and head movements are common manifestations of epileptic seizures, and the wide representation of oculomotor and vestibular control within the cerebral cortex leads to a number of possible ways that seizures can affect eye movements themselves and visual or vestibular perceptions. A variety of ...
233 HydrocephalusDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineTable 19.3
234 Syndrome of the Anterior Inferior Cerebellar ArteryDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineFigure 19.6
235 Ocular Motor Syndromes Caused by Lesions in the MedullaDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineMany structures within the medulla are important in the control of eye movements: the vestibular nuclei, perihypoglossal nuclei, and inferior olive and its outflow pathway through the inferior cerebellar peduncle.
236 Location of Lesions and Their ManifestationsDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineExperimental lesions of the dorsal vermis (lobules VI and VII) and of the underlying fastigial nuclei (called the fastigial oculomotor region) cause saccadic dysmetria, typically hypometria if the vermis alone is involved and hypermetria if the deep nuclei are affected.
237 Horizontal Gaze PalsyDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineLesions of the abducens nucleus cause an ipsilateral palsy of horizontal conjugate gaze because the abducens nucleus contains two groups of neurons.
238 Ocular Motor Manifestations of SeizuresDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineEye and head movements are common manifestations of epileptic seizures, and the wide representation of oculomotor and vestibular control within the cerebral cortex leads to a number of possible ways that seizures can affect eye movements themselves and visual or vestibular perceptions.
239 Ocular Motor ApraxiaDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineOcular motor apraxia is characterized by an impaired ability to generate saccades on command.
240 Syndrome of the Anterior Inferior Cerebellar ArteryDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineThe anterior inferior cerebellar artery (AICA) supplies portions of the vestibular nuclei and the adjacent dorsolateral brain stem, and the inferior lateral cerebellum.
241 Eye Signs in the Arnold-Chiari MalformationDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineTable 19.2
242 Whipple's DiseaseDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineWhipple's disease is a rare multisystem disorder characterized by weight loss, diarrhea, arthritis, lymphadenopathy, and fever that may involve and even be confined to the central nervous system.
243 Slow Saccades from Pontine LesionsDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineSlow saccades are characteristic of many degenerative and metabolic diseases.
244 Parietal Lobe LesionsDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineUnilateral lesions of the parietal lobes, especially those involving the inferior parietal lobule and underlying deep white matter, cause abnormalities of ocular tracking of moving targets, including an asymmetry of smooth pursuit and of optokinetic nystagmus as tested at the bedside with handheld d...
245 Skew Deviation and the Ocular Tilt ReactionDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineSkew deviation is a vertical misalignment of the visual axes caused by a disturbance of prenuclear vestibular inputs to the oculomotor nuclei.
246 Posterior CommissureDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineLesions of the posterior commissure cause a syndrome characterized by loss of upward gaze and other associated findings.
247 HydrocephalusDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineTable 19.6
248 LateropulsionDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineLateropulsion, a compelling sensation of being pulled toward the side of the lesion, is often a prominent symptom in patients with Wallenberg's syndrome and is also reflected in the ocular motor system.
249 Monocular Elevation DeficitDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineUnilateral, paramedian midbrain lesions sometimes cause impairment of ipsilateral, horizontal smooth pursuit by affecting the descending smooth-pursuit pathway.
250 Ocular Motor Manifestations of Some Metabolic DisordersDavid S Zee, M.D., Professor of Neurology, Johns Hopkins University; David Newman-Toker, MD, PhD, Associate Professor, Departments of Neurology, Ophthalmology, & Otolaryngology, The Johns Hopkins University School of MedicineSome babies who ultimately develop normally show transient ocular motor disturbances, including upward or downward deviation of the eyes (but with a full range of reflex vertical movement), intermittent opsoclonus, and skew deviation.
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