Transcript Neuro-ophthalmology

Neuro-ophthalmology
Abdulrahman Al-Muammar
College of Medicine
King Saud University
Neuro-ophthalmology
Objectives:
• Recognize and interpret the common signs and
symptoms of neuro-ophthalmic disorders
Obtain appropriate history
Measure visual acuity
Examine pupillary reaction
Test the function of the extraocular muscles
Evaluate the visual fields
Inspect the optic nerve head
Neuro-ophthalmology
Pupil
Ocular motor system
Visual system
Visual fields
Common neuro-ophthalmic disorders
Pupil
Pupillary size is determined by number
of factors including
Age
Level of alertness
Level of retinal illumination
Accommodative effort
Pupil
Anatomy of pupillary pathway
Afferent limb
Efferent limb
• Parasympathetic pathway
• Sympathetic pathway
Near response
Pupil
Pathway of pupillary reaction to light
Sympathetic pathway
Afferent pupillary defect (APD)
Afferent pupillary defect (APD)
Causes of APD
Optic nerve disease
Significant retinal disease
Amblyopia
Efferent pupillary defect
Anisocoria
Anisocoria
Anisocoria
Pupillary inequality greatest
In bright light
In dim light
(large pupil)
(small pupil)
3rd nerve palsy
Ptosis
Trauma
Horner syndrome
Tumor
Physiological
Temporal lobe herniation
Aneurysm
No 3rd nerve palsy
Drug induced
Adie’s pupil
Iris damage (trauma/surgery/laser)
Basal meningitis
Anisocoria
Horner syndrome
Ocular motor system
Ocular motor system
Ocular motor system
3rd nerve palsy
+ ve pupillary involvement
An incomplete III palsy which progress
Other neurological signs
No resolution in 3 months
Aberrant regeneration appears
Emergency
Do MRI,MRA
If negative do catheter angiography
To r/o compressive lesion: aneurysm, tumor
Other possible causes : vasculopathy, trauma, inflammatory,
demyelination, infectious, MG, congenital
Ocular motor system
4th nerve palsy
Most frequent cause is trauma
If no trauma, isolated 4th nerve palsy
then most likely vasculopathic ( Do BP,
BS)
+ve trauma, any other neurological
signs, normal BP/BS or palsy lasting > 3
months then MRI is needed.
Ocular motor system
6th nerve palsy
Isolated 6th nerve palsy most likely
vasculopathic ( do BP/BS)
Normal BP/BS, other neurological signs,
trauma, or palsy > 3 months then do
MRI
Visual system
Visual system
Visual system
Visual fields defect
Visual fields defect
Visual fields defect
Visual fields defect
Visual fields defect
Visual fields defect
Optic disc
Disc swelling
Mechanical signs
Elevation
Blurred margins
Peripapillary edema
Choroid folds
Vascular signs
Hyperemia
Venous dilation
Disc hemorrhage
NFL infarcts
Exudates
Causes of disc swelling
Increased intracranial pressure
Ischemic optic neuropathy
Optic neuritis
Central retinal vein occlusion
Nutritional optic neuropathy
Toxic optic neuropathy
ETOH-ethanol-DigitalisEthambutol -ChloramphenicolINH
Tumor
Infiltrative
Orbital Pseudotumor
Thyroid orbitopathy
Amaurosis Fugax
Transient monocular visual loss or dimming
May last from 2-3 minutes to 30 minutes or more
Due to decrease blood flow to the eye
Causes:
• Carotid atheroma
• Cardiac valvular disease
• Atrial myxoma
• Retinal migraine
• Giant cell arteritis
• Hyperviscousity syndromes
Myasthenia Gravis (MG)
Chronic auto-immune disorder characterized by
presence of antibodies which block the ACH
receptor sites
It can affect any muscle
Eye signs are the presenting signs in 50% of the
patients
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Ptosis
Any ocular motility disturbances
INO
Variability is the hallmoark
Myasthenia Gravis (MG)
Diagnosis
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Clinically
Pharmacologically (Tensilon test)
Serologically
Sleep test
Ice-pack test
CT chest
Thyroid function test
ANA
Treatment
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Acetylcholinesterase inhibitors
Steroid
Immunosuppressant
Plasmapheresis
Thymectomy
Multiple sclerosis
Patients with multiple sclerosis (MS)
frequently have visual complaints
Cerebellar dysfunction
Motor symptoms
Sensory symptoms
Mental changes
Sphincter disturbances
Multiple sclerosis
Ocular complications:
Optic neuritis
Chiasmal and retro chiasmal abnormalities
Ocular motility disturbances
Treatment
Steroid
Interferon
Thank you