Nagumo K, Kojima S, Nemoto Y, Takagi K, Hatakeyama H
Department of Neurology, Matsudo Municipal Hospital, 4005 Kamihongo, Matsudo, Chiba 271-8511, Japan.
Rinsho Shinkeigaku. 2000 Aug;40(8):840-3.
A 37-year-old woman was admitted to the hospital with the complaint of progressive horizontal diplopia of six years' duration when viewing distant objects. On admission she had a slight left convergent strabismus. Homonymous diplopia was present beyond 50 cm and increased on distance fixation. Both eyes were fully mobile in the horizontal plane with a mild decrease in the velocity of horizontal eye movement to the left, and slight impairment of upward eye movement. The left eye did not fully adduct during convergence. The right pupil was slightly larger than the left. Prism cover test showed 6 delta esophoria at 30 cm and 14 delta esophoria at 5 m. The Hess chart showed a convergent deviation. MRI revealed a small right-side paramedian lesion of the midbrain tegmentum lying ventral to the aqueduct of Sylvius, at the level between the superior colliculi and the intercollicular area. A venous angioma with arteriovenous shunts in the right midbrain was diagnosed by angiography. We suggest that lesions that damage the divergence neurons in the tegmentum of the midbrain and also interrupt the supranuclear fibers having an inhibitory effect on the convergence neurons may produce homonymous diplopia on distant fixation combined with the esotropia.
一名37岁女性因视物时出现进行性水平复视6年而入院。入院时，她有轻度左眼内斜视。50厘米以外出现同侧性复视，远距离注视时复视加重。双眼在水平面内活动自如，但向左水平眼动速度略有下降，向上眼动略有受损。集合时左眼不能完全内收。右侧瞳孔略大于左侧。三棱镜遮盖试验显示，30厘米处有6△内隐斜，5米处有14△内隐斜。Hess屏检查显示有集合性偏斜。MRI显示，在中脑顶盖右侧有一个小的中线旁病变，位于中脑导水管腹侧，在上丘和丘间区之间的水平。血管造影诊断为右侧中脑静脉血管瘤伴动静脉分流。我们认为，损害中脑顶盖区发散神经元并中断对集合神经元有抑制作用的核上纤维的病变，可能会导致远距离注视时出现同侧性复视并伴有内斜视。
