Ophthalmoplegia Health Article

Definition

Ophthalmoplegia is a paralysis or weakness of one or more of the muscles that control eye movement. The condition can be caused by any of several neurologic disorders. It may be myopathic, meaning that the muscles controlling eye movement are directly involved, or neurogenic, meaning that the nerve pathways controlling eye muscles are affected. Diseases associated with ophthalmoplegia are ocular myopathy, which affects muscles, and internuclear ophthalmoplegia, a disorder caused by multiple sclerosis, a disease which affects nerves.

Description

Because the eyes do not move together in ophthalmoplegia, patients may complain of double vision. Double vision is especially troublesome if the ophthalmoplegia comes on suddenly or affects each eye differently. Because ophthalmoplegia is caused by another, underlying disease, it is often associated with other neurologic symptoms, including limb weakness, lack of coordination, and numbness.

Causes and symptoms

Ocular myopathy is also known as mitochondrial encephalomyelopathy with ophthalmoplegia or progressive external ophthalmoplegia. Because it is so often associated with diseases affecting many levels of the neurologic system, it is often referred to as "ophthalmoplegia plus." The main feature is progressive limitation of eye movements, usually with drooping of the eyelids (ptosis). Ptosis may occur years before other symptoms of ophthalmoplegia. Because both eyes are equally involved and because ability to move the eyes lessens gradually over the course of years, double vision is rare. On examination, the eyelids may appear thin. This disease usually begins in childhood or adolescence but may start later.

When ophthalmoplegia is caused by muscle degeneration (myopathic), muscle biopsy, in which a small piece of muscle is surgically removed and examined microscopically, will find characteristic abnormal muscle fibers called ragged red fibers. In this form of ophthalmoplegia, the patient may experience weakness of the face, the muscles involved in swallowing, the neck, or the limbs.

Progressive external ophthalmoplegia is sometimes associated with specific neurologic syndromes. These syndromes include familial forms of spastic paraplegia, spinocerebellar disorders, or sensorimotor peripheral neuropathy. Kearns-Sayre syndrome causes ophthalmoplegia along with loss of pigment in the retina, the lightsensitive membrane lining the eye. In addition, the disease may cause heart block that must be corrected with a pacemaker, increased protein in the cerebrospinal fluid, and a progressively disabling lack of muscular coordination (cerebellar syndrome). Symptoms of the disease appear before age 15.

Some of the progressive external ophthalmoplegia syndromes are unusual in that inheritance is controlled by DNA in the mitochondria. The mitochondria are rodshaped structures within a cell that convert food to usable energy. Most inherited diseases are passed on by DNA in the cell nucleus, the core that contains the hereditary material. Mitochondrial inheritance tends to be passed on by the mother. Other forms of progressive external ophthalmoplegia are not inherited but occur sporadically with no clear family history. It is not known why some forms are neurogenic and others are myopathic. In the forms inherited through mitochondrial DNA, it is not known which gene product is affected.

Internuclear ophthalmoplegia in multiple sclerosis is caused by damage to a bundle of fibers in the brainstem called the medial longitudinal fasciculus. In this syndrome, the eye on the same side as the damaged medial longitudinal fasciculus is unable to look outward (that is, the left eye cannot look left). The other eye exhibits jerking movements (nystagmus) when the patient tries to look left. Internuclear ophthalmoplegia may be seen rarely without multiple sclerosis in patients with certain types of cancer or with Chiari type II malformation.

Eye movement disorders and ophthalmoplegia can also be seen with progressive supranuclear palsy,thyroid disease, diabetes mellitus, brainstem tumors, migraine, basilar artery stroke, pituitary stroke, myasthenia gravis, muscular dystrophy, and the Fisher variant of Guillain-Barré syndrome. A tumor or aneurysm in the cavernous sinus, located behind the eyes, can cause painful ophthalmoplegia. Painful ophthalmoplegia can also be caused by an inflammatory process in the same area, called Tolosa-Hunt syndrome.