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Year : 1976  |  Volume : 24  |  Issue : 3  |  Page : 25-26

Bilateral medial rectus palsy due to nuclear involvement in closed head injury (a case report)

Govt. Medical College, Nagpur, India

Correspondence Address:
K G Tehra
Govt. Medical College, Nagpur
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Source of Support: None, Conflict of Interest: None

PMID: 1031402

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How to cite this article:
Tehra K G, Ishwarchandra K, Kamble M. Bilateral medial rectus palsy due to nuclear involvement in closed head injury (a case report). Indian J Ophthalmol 1976;24:25-6

How to cite this URL:
Tehra K G, Ishwarchandra K, Kamble M. Bilateral medial rectus palsy due to nuclear involvement in closed head injury (a case report). Indian J Ophthalmol [serial online] 1976 [cited 2022 Nov 29];24:25-6. Available from: https://www.ijo.in/text.asp?1976/24/3/25/31294

Ocular motor palsies are seen frequently in cases of head injury. About 15% of cases of ocular motor palsy are due to traumatic etio­logy[2],[11] Nuclear palsies may occur affecting particularly the IIIrd nerve with a most diverse picture of paralysis. Sometimes there is bilate­ral ophthalmoplegia externa or there is invole­ment of ocular motor nerves on one side only.[9],[12] Few cases may exhibit in the form of a syndrome with implication of various muscles. Likewise it is very unusual to get a sufficiently selective lesion where only a single muscle is paralysed. But such selective lesions may occur occasionally.

The mechanism of nuclear ocular motor palsies in cerebral concussion injury is explai­ned on the wave of the fluid in the third ventricle, as a result of momentum of the blow. This wave with it's greatest force around the anterior end of the aquaduct of Sylvius where the nuclei lie, causes oedema and petechial haemorrhages.[9] Such petechial haemorrhages are the result of obstruction of blood flow in the vena nervorum. Consquently small foci of necrosis may develop and in such cases of ocular motor palsies the recovery may or may not be there.

  Case Report Top

A 40 years old Hindu male rickshaw puller was admitted in ophthalmic ward with the complaints of outward deviation of the eyes and diplopia since 15 days. He was alright 15 days earlier. He sustained head injury during an accident with a scooter while pulling the rickshaw. He fell down on the road with a blow on the back of his head. He was unconscious for about one hour after the injury. He was admitted immediately in the hospital and was discharged on third day after recovery. There was complete recovery when he regained his consciousness except that he noticed diplopia and deviation of the eyes. For this he was advised to attend this hospital. After waiting for a few days he reported to this hospital as there was no recovery.

On examination there was outward deviation of both the eyes. Right eye was more divergent than the left eye. There was complete absence of adduction in both uniocular and binocular movements and there was no convergence. Other extra ocular and intraocular muscles were not affected. There was no other neurological involement. His vision was 619 and J2 in individual eyes. Fundi were normal. Diplopia charting shoved crossed diplopia in all the nine quad­rants. Right image was slightly higher than the left and vertical separation increased on elvation. X-ray skull both posterio-anterior and lateral were normal, Other investigations eg. Heamogram, E. S. R., total and diffe­rential leucccytic count, V. D. R. L., test, and C. S. F, examination were found to be normal.

Patient was treated by occlusion of his one eye to avoid diplopia and was put on medical treatment (10 mg. tid for 8 days, 5 mg. tid for 5 days and 5 mg. tid or three days and subse'iuently stopped in tapering the doses and In j. Bl 100 mg., B12 250 mic. gm. B6 10 mg, intra muscular daily for 10 days). He was obser­ved for 44 days after the injury. There was no improve­ment in the muscle action.

  Discussion Top

Ocular motor palsies are known to occur in cerebral concussion injury due to nuclear lesion. When there is involvement of IIIrd nerve nucli a most diverse picture of paralysis may be seen. Recovery is seen in many cases of such traumatic paralysis. Selective, nuclear lesions with paralysis of a particular muscle is very unusual. In this case there was more selective nuclear lesion with a picture of bilateral medial rectus palsy and there was no recovery in the muscle action.

  Summary Top

An unusual case of bilateral medial rectus palsy in cerebral concussion injury with a sufficiently selective nuclear lesion is reported.

  References Top

Boker A. B. 1955 Clinical Neurology, 2, 990.   Back to cited text no. 1
Bielschowsky, 939, Amer. J. Ophthal. 22, 723.  Back to cited text no. 2
Demy-Brown,D. and Russell, W. R., 1941 Experi­mental Cereural Concassion, Brain. 93, 164.  Back to cited text no. 3
Duke-Elder, 1971 System of Ophthalmology XII Henry Kimpton London, 741, 7 9.  Back to cited text no. 4
Falbe-Hansen and Gregersen. 1951, Acta Ophthat. (kbh) 37, 359,  Back to cited text no. 5
Frank B. Walsh, 1957 Clini. Neuro-ophthal, 82, 221.   Back to cited text no. 6
Gloria` 1966, Riv. Oto. Neuro-Oftlal:, 41, 267.   Back to cited text no. 7
Holmes. 1831, Brit. Med. J. 2. 1165.   Back to cited text no. 8
Ktith Lyle, 1959, Tr. Oph. thal. Soc.. U. K., 79, 519.   Back to cited text no. 9
Ruckler. 1968. Arch. Ophpd. 79, 104.   Back to cited text no. 10
Wilbur, 1958, Amer. J. Ophthal. 46, 787.  Back to cited text no. 11
Ziemssen. 1858. Virchoivs Arch. Path. Anat. 13, 210,  Back to cited text no. 12


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]


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