PHYSICAL THERAPY - SUMMER 2001

Case # 2 - Eye Movements

Presentation: A 65 year old female is referred to you for examination. She was in a car accident
and experienced head trauma. She complains of headaches and difficulty focusing on objects close
to her. She can see objects in the distance but has double vision. Her right eye is directed downward
and she exhibits lateral strabismus and ptosis in this eye. Bright light "hurts" her right eye and she
has difficulty focusing this eye to see objects close to her. Sensation appears normal but she can not
blink to prevent tears from running out of the side of this eye. She also has difficulty puckering her
lips, smiling or frowning on the right side of her face. Her left eye is extorted and she exhibits medial
strabismus. She has to rotate her head to the right to prevent double vision and must tilt her head to
the left to look downward. Hearing, sight and smell seem unaffected. You are asked to evaluate this
patient to determine the extent and location of her injuries.

Activities:

I. Review the 12 cranial nerves including the function(s) of each nerve and the main symptoms that
would occur if the nerve were lesioned.

II. Explain the attachments, innervation and functions of the 7 extraoccular muscles. Explain the terms
intort and extort.

III. Evaluate this patient as follows:

1. Explain the symptoms that affect the right eye.
   • Why does bright light hurt her eye?
   • Why is it diffcult for her to see up close?
2. What muscle(s) would be paralyzed to produce the symptoms seen in her right eye?
3. What muscle(s) would be paralyzed to explain the symptoms in her left eye?
4. Which nerve would be damaged to result in the inability to blink?
   • What other symptoms might you expect to find following a lesion to this nerve?
   • How would you test to see if this patient has these symptoms?

IV. Describe how you would evaluate this patient to determine if this patient suffered a lesion of the:

1. Cervical Plexus
2. Trigeminal nerve
3. Vagus nerve
4. Hypoglossal nerve

V. Discuss your findings concerning the nerves that were damaged in this patient and the muscles
that were paralyzed. Be able to correlate nerve damage with the symptoms produced.