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Management of Vertical Gaze Paresis from an Artery of Percheron Infarction

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Management of Vertical Gaze Paresis from an Artery of Percheron Infarction Abstract title: Management of Vertical Gaze Paresis from an Artery of Percheron Infarction. Abstract: A patient presents with vertical gaze paresis (down gaze > up gaze), a ‘drunk’ feeling when in a visually stimulating environment, speech impairment and memory impairment all stemming from a recent Artery of Percheron Infarction. Case History 40 year old white male Chief vision complaints on July 15, 2016: o Vertical gaze difficulty down gaze > up gaze o ‘Drunk’ feeling when in a visually stimulating environment (supermarket, crowd) Eye exam from 2015 was unremarkable o No glasses Rx was given o Patient has never worn glasses before Patient currently on Plavix and Lipitor medications Patient medical history: unremarkable, no prior medical issues o After event patient had speech impairment and mild memory impairment Pertinent findings Recent diagnosis of Artery of Percheron infarction (May 29, 2016) o Magnetic Resonance Imaging/Magnetic Resonance Angiogram images are available for viewing Poor convergence (27 cm) o Poor convergence even when adjusted for age Very low amplitude of accommodation for age: 2 D o Avg Amps for 40 yo = 5 D o Min Amps for 40 yo = 1.67 D Restricted down gaze > up gaze on EOM testing BCVA 20/20 OD/OS o Low Hyperopic Rx found o Minimal reading Rx found o Patient appreciated better vision with trial of glasses with manifest Rx Mild Meibomian Gland Dysfunction Posterior: unremarkable Blood work was negative except mildly elevated Protein S Differential diagnosis and reasons excluded Primary: ‘Top of the Basilar’ Syndrome o Basilar artery and Posterior Cerebral Artery were patent on MRA Primary: Deep cerebral venous thrombosis o Usually involved basal ganglia and cerebral cortex on MRI/MRA Secondary: Extrapontine myelinosis o Putamen, caudate nucleus, internal/external/extreme capsules, lateral geniculate nucleus or white matter are involved on MRI/MRA Secondary: Wernicke’s encephalopathy o No involvement of periaqueductal grey, mammillary bodies, tectal plate or third ventricle o Also associated with chronic alcoholism Secondary: Metabolic or toxic etiology o Specific imaging patterns on MRI/MRA o Patient history Secondary: Wilson’s disease o Metabolic disorder o Patient history and clinical findings Secondary: Creutzfeldt-Jakob disease o Neurodegenerative disease, usually occurs in 7th decade of life o Classic ‘hockey stick’ sign of pulvinar and dorsomedial nuclei on MRI/MRA o Putamen, caudate nuclei and periaqueductal gray are involved on MRI/MRA Secondary: Bilateral thalamic glioma o Usually presents in young children or young adults o Personality changes Diagnosis and discussion Normal blood supply of thalamus region is many small arteries (para-median) branching from posterior cerebral artery The Artery of Percheron is a single artery originating from either posterior cerebral artery and bifurcating to supply the para-median thalamus region The artery of Percheron is a variation of blood supply to the para-median thalamus region Another variation to blood supply will have the para-median arteries also supplying the rostral midbrain and anterior thalamic region An infarction of the artery of Percheron will limit supply to the entire para-median thalamus region since it is only artery supplying it If both variations of blood supply exist, it can lead to more serious consequences as midbrain involvement has a less favorable long-term prognosis The main clinical findings of this infarction are altered mental status, memory impairment, speech impairment, vertical gaze paresis, motor deficits, cerebellar signs and others MRI and MRA are used to diagnosis condition and rule out certain etiologies Treatment and management Correct any refractive error with glasses as needed Glasses Rx for temporary use or with Fresnel prism to realign vertical gaze palsy o Separate distance and near glasses if prism is needed Vision therapy for convergence insufficiency and poor accommodation o Rehab supra-vergences/infra-vergences can improve outcome Lid hygiene and AT to manage MGD Long-term prognosis is favorable if midbrain is not involved Refer to speech therapist/psychiatry/neurology/neuro-ophthalmology as needed for treatment and follow up Conclusion Will not see first line in optometry o Will likely be referred due to vision problems Correct any visual acuity deficit if any are found o Distance and/or near can be affected If vertical gaze palsy is found, manage with Fresnel prism since gaze palsy will likely not last or improve over time If convergence and accommodation are found to be deficient then address as needed, especially in younger patients o Supravergence/infravergence vision rehabilitation can reduce need for prism This patient will need reading glasses due to onset of presbyopia, but convergence insufficiency and Accommodation rehabilitation therapy may increase comfort of reading Monitor patient for improvement and change prism/glasses/vision therapy as needed .
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