Ophthalmoplegia

Paralysis or marked weakness of one or more extraocular muscles, causing impaired voluntary eye movements, gaze limitation, ocular misalignment, and often diplopia. It may result from dysfunction at the nuclear, supranuclear, internuclear, or infranuclear levels of the ocular motor system, involving cranial nerves III, IV, and VI, brainstem pathways, neuromuscular junction, or extraocular muscles.

Causes

• Neurological and central nervous system causes

  • Multiple sclerosis

  • Stroke

  • Brain injury

  • Brain tumors

  • Brainstem lesions

  • Migraine-associated ophthalmoplegia

  • Increased intracranial pressure affecting ocular motor nerves

• Cranial nerve and vascular causes

  • Diabetes-related microvascular ischemia of cranial nerves III, IV, or VI

  • Hypertension-related small vessel disease

  • Intracranial aneurysms

  • Cavernous sinus lesions

  • Skull base tumors or inflammation

• Myasthenia gravis

• Orbital causes

  • Graves' disease (thyroid eye disease)

  • Orbital inflammation

  • Extraocular muscle enlargement or fibrosis

• Inflammatory and autoimmune causes

  • Tolosa–Hunt syndrome

  • Sarcoidosis

  • Vasculitis affecting ocular motor pathways

• Infectious causes

  • Lyme disease

  • Syphilis

  • Human immunodeficiency virus (HIV)

  • Herpes zoster (shingles)

  • Meningitis or encephalitis affecting ocular motor pathways

• Nutritional and metabolic causes

  • Wernicke encephalopathy (thiamine deficiency)

  • Severe nutritional deficiency states

  • Metabolic encephalopathies

• Mitochondrial and genetic causes

  • Kearns–Sayre syndrome

  • Chronic progressive external ophthalmoplegia

  • Other mitochondrial myopathies

  • Congenital ocular motor disorders

• Medication and toxins

  • Lithium toxicity

  • Narcotics/opioid toxicity

  • Tricyclic antidepressants

• Other causes

  • Congenital cranial nerve palsies

  • Trauma to the orbit or skull base

  • Postoperative injury