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Case of the week 94  (  January 2013 )

Parinaud ‘s syndrome

 



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 "


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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.



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