Wong Agnes M F, Tweed Douglas, Sharpe James A
Division of Neurology, University Health Network-Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8.
Ophthalmology. 2002 Jul;109(7):1315-25. doi: 10.1016/s0161-6420(02)01067-9.
To detect and determine the magnitude of vertical deviation in patients with unilateral sixth nerve palsy.
Prospective consecutive comparative case series.
Twenty patients with unilateral peripheral sixth nerve palsy, 7 patients with central palsy caused by brainstem lesions, and 10 normal subjects.
Subjects were tested by the prism and cover test, Maddox rod and prism test, and magnetic search coil recordings in nine diagnostic eye positions. They were also tested during static lateral head tilt by the prism and cover, and Maddox rod and prism tests.
The magnitudes of horizontal and vertical deviations.
All patients had an abduction deficit and incomitant esodeviation that increased in the field of action of the paretic muscle, indicating sixth nerve palsy. Mean vertical deviations, for all positions of gaze in peripheral palsy were 0.3 +/- 0.8 prism diopters (PD) by prism and cover test, 1.3 +/- 1.6 PD by Maddox rod and prism test, and 2.0 +/- 1.4 PD by coil recordings. Mean vertical deviations in normal subjects were 0.0 +/- 0.0 PD by prism and cover test, 1.0 +/- 0.9 PD by Maddox rod and prism test, and 1.9 +/- 2.1 PD by coil recordings. Therefore, peripheral palsy did not cause abnormal vertical deviation. In central palsy, for all positions together mean vertical deviations were 0.9 +/- 1.3 PD by prism and cover test, 1.4 +/- 1.6 PD by Maddox rod and prism test, and 2.5 +/- 1.6 PD by coil recordings; they were not different from normal values. During static head roll, patients with peripheral palsy had a right hyperdeviation on right head tilt and a left hyperdeviation on left head tilt, regardless of the side of the palsy. In contrast, in central palsy, head tilt caused vertical strabismus that remained on the same side on head tilt to either side.
Small vertical deviations in sixth nerve palsy are consistent with normal hyperphorias that become manifest in the presence of esotropia. In peripheral sixth nerve palsy, static head roll to either side induces hyperdeviation in the eye on the side of the head tilt. Hyperdeviation of the same eye induced by head tilt to either direction implicates a brainstem lesion as the cause of paretic abduction. Quantitative study of sixth nerve palsy demonstrates that if a vertical deviation falls within the normal range of hyperphoria, multiple cranial nerve palsy or skew deviation may not be responsible. Conversely, vertical deviation > 5 PD indicates skew deviation or peripheral nerve palsy in addition to abduction palsy.
检测并确定单侧第六脑神经麻痹患者垂直偏斜的程度。
前瞻性连续对比病例系列研究。
20名单侧周围性第六脑神经麻痹患者、7名由脑干病变引起的中枢性麻痹患者以及10名正常受试者。
通过棱镜遮盖试验、马多克斯杆与棱镜试验以及在九个诊断眼位进行磁搜索线圈记录对受试者进行检测。还在静态侧头倾斜时通过棱镜遮盖试验、马多克斯杆与棱镜试验对他们进行检测。
水平和垂直偏斜的程度。
所有患者均有外展功能缺陷和非共同性内斜视，在麻痹肌作用范围内加重，提示第六脑神经麻痹。周围性麻痹患者在所有注视位时，棱镜遮盖试验测得的平均垂直偏斜为0.3±0.8棱镜度（PD），马多克斯杆与棱镜试验测得为1.3±1.6 PD，线圈记录测得为2.0±1.4 PD。正常受试者棱镜遮盖试验测得的平均垂直偏斜为0.0±0.0 PD，马多克斯杆与棱镜试验测得为1.0±0.9 PD，线圈记录测得为1.9±2.1 PD。因此，周围性麻痹未引起异常垂直偏斜。在中枢性麻痹中，所有眼位的平均垂直偏斜，棱镜遮盖试验测得为0.9±1.3 PD，马多克斯杆与棱镜试验测得为1.4±1.6 PD，线圈记录测得为2.5±1.6 PD；与正常值无差异。在静态头部转动时，周围性麻痹患者无论麻痹侧别，向右侧头倾斜时右眼有上斜视，向左侧头倾斜时左眼有上斜视。相比之下，在中枢性麻痹中，头部倾斜引起的垂直斜视在向两侧头倾斜时均保持在同一侧。
第六脑神经麻痹中的小垂直偏斜与内斜视存在时出现的正常上隐斜一致。在周围性第六脑神经麻痹中，向任何一侧静态头部转动都会导致头倾斜侧眼出现上斜视。向任一方向头部倾斜引起同一眼上斜视提示脑干病变是麻痹性外展的原因。第六脑神经麻痹的定量研究表明，如果垂直偏斜落在正常上隐斜范围内，则可能不是多条脑神经麻痹或斜视性偏斜所致。相反，垂直偏斜>5 PD表明除了外展麻痹外还存在斜视性偏斜或周围神经麻痹。
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