65 years old patient was
referred by an ophthalmologist reporting : " this patient is
complaining of an annoying diplopia during
reading and during near work, he had completely
lost the
ability to read and follow letters. The
condition started 6 months ago with a slowly
progressive course. ,
he is not diabetic, not hypertensive. Both fundi are normal, he
is nearly emmetropic, pupils are normally
reacting to light and accommodation, he
changed the power of his reading glasses many
times in the last 6 months with no improvement of
the condition "
See video of this patient
Parinaud ‘s Syndrome
While an object is moving
toward the eye, convergence eye movements permit
stereopsis and prevent diplopia by moving the
eyes in opposite horizontal directions, this
maintains the image of an object to fall onto
the fovea of each eye. Fixation of a near object
induces not only convergence but also
accommodation of the lenses and constriction of
the pupils, these three responses constitute the
near reflex . Convergence is stimulated by two
major stimuli : retinal blur and retinal
disparity. Retinal blur is the loss of image
sharpness, while retinal disparity is falling of
images of a single object onto a
non-corresponding parts of the retina of the two
eyes. Retinal blur elicits accommodative
convergence and retinal disparity elicits
fusional convergence, both stimuli combine to
produce appropriate convergence eye movements.
Parinaud was the first to describe convergence
paralysis whereby diplopia exists only at near
fixation, adduction is normal, and the patient
is unable to converge. Accommodation may be
normal, reduced, or absent, and the pupil may or
may not be involved. In some patients the
pupillary reflex may be abolished for
convergence and retained
for light (reversed Argyll Robertson pupil).
If internal ophthalmoplegia is associated with
convergence paralysis, the presence of an
organic lesion of nuclear or supranuclear
location is almost certain.
Convergence paralysis occurs most
frequently when lesions are present in the
dorsal mid brain. The association of convergence
paralysis with vertical gaze paralysis (Parinaud’s
syndrome) emphasizes that convergence paralysis
may be caused by lesions in this location.
Convergence paralysis
is caused by
vascular, intracranial pathology, encephalitis,
disseminated sclerosis, and head injury.
Therapy consists of prisms base-in for near
vision in combination with bifocals.
الموقع المصري للحول
وامراض الجهاز الحركي للعين
The Egyptian Site of
Strabismus & Oculomotor Disorders