NEUROOP Howard R Krauss MD Neuroophthalmology Strabismus Orbital
NEURO-OP Howard R Krauss, MD Neuro-ophthalmology Strabismus Orbital Surgery www. Pacific. Specialists. com 3/1/2021
… NOTHING TO DISCLOTHES … Howard R Krauss, MD Los Angeles, CA
NEURO-OP Pacific Eye & Ear Howard R Krauss, MD 11645 Wilshire Blvd. , Suite 600 Neuro-ophthalmology Strabismus Los Angeles, Ca. 90025 Orbital Surgery 310 -477 -5558 Dr. Krauss@Pacific. Specialists. com www. Pacific. Specialists. com 3/1/2021
PACIFIC EYE & EAR Pacific Eye & Ear is an association of eleven doctors, providing medical and surgical services encompassing Ophthalmology, ENT, Facial Plastic Surgery and Audiology. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION 1) Talk with and examine the patient www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION When the vision is subnormal, proceed to: 2) Pinhole acuity 3) Refraction 4) Visual field assessment www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If corrected acuity is normal and visual field is normal: 1) Complete the general examination and if all else is normal, proceed to discussion of optical services, from spectacles to contact lenses to surgery. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If corrected acuity is abnormal or visual field is abnormal: 1) Proceed with Retinal Evaluation and/or consultation. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant detects abnormalities and arranges treatment for same: 1) Re-evaluate patient to assess whether or not the retinal abnormalities are likely the only source of the patient’s complaints. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, crystalline lens, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www. Pacific. Specialists. com 3/1/2021
DIAGNOSTIC APPROACHES TO REDUCED VISION If Retinal Consultant finds the retina to be normal, re-evaluate patient: 1) Reassess the tear film, cornea, lens implant and posterior capsule as potential sources of reduced acuity; 2) Reassess the visual field reliability and pattern of abnormality 3) Assess relative light and color brightness and check for RAPD 4) Assess the optic nervehead appearance and (a)symmetry 5) Consider RNFL and RGC layer thickness analyses 6) Consider ERG 7) Consider Neuro-ophthalmologic consultation. www. Pacific. Specialists. com 3/1/2021
OCULAR COHERENCE TOMOGRAPHY (OCT) NEURO-OPHTHALMIC APPLICATIONS Evaluation and Monitoring: MS / Optic Neuritis Ischemic Optic Neuropathy Any Optic Neuropathy Compressive Optic Neuropathy Papilledema
55 -YEAR-OLD WOMAN WITH MS BCVA 20/30 OD 20/25 OS
Aware of diminishing vision of the left eye over 1 year, rapidly worsening over the last 3 months. Intermittent mild pain OS, especially when flying. 47 -YEAR-OLD HAWAIIAN WOMAN www. Pacific. Specialists. com
No proptosis No enophthalmos No hyper- or hypoglobus Orthophoric Full 2+ ductions RAPD OS VISUAL ACUITY 20/25 OD 20/50 -1 OS www. Pacific. Specialists. com in all positions
HUMPHREY 10 -26 -11 www. Pacific. Specialists. com
OCTOPUS 12 -27 -11 www. Pacific. Specialists. com
RNFL THKNS 106 OD, 93 OS www. Pacific. Specialists. com
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TRANSNASAL IMAGEGUIDED ORBITAL SURGERY (TIGOS) TIGOS has been carried out by Drs. Krauss & Griffiths since 2001. The work was presented at the 5 th International Congress of the World Federation of Skull Base Societies in 2008. www. Pacific. Specialists. com 3/1/2021
OUTPATIENT SURGERY www. Pacific. Specialists. com
IMAGE-GUIDED ENDOSCOPIC SX www. Pacific. Specialists. com
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PRE-OP / OCTOPUS / POST-OP www. Pacific. Specialists. com
POST-OP www. Pacific. Specialists. com
2 WEEKS POST-OP www. Pacific. Specialists. com UCVA 20/25 Trace RAPD OS Mild weakness of left adduction and infraduction – improving day-by-day
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MRI OF THE VISUAL AFFERENT SYSTEM Brain and Orbits with and without contrast www. Pacific. Specialists. com 3/1/2021
MRI OF THE VISUAL AFFERENT SYSTEM If you know the lesion is retrogeniculate: Brain www. Pacific. Specialists. com with and without contrast 3/1/2021
MRI OF THE VISUAL AFFERENT SYSTEM If you know the lesion is anterior visual pathway: Orbits and pituitary with and without contrast www. Pacific. Specialists. com 3/1/2021
BSB 54 yo female 11/05: Puffiness OS Va 20/15, 20/25 Ext: H 16/21 P: 1. 2 log LAPD EOM: min ↓ L elev
BSB – W/U OCT NFL (11/05):
BSB – W/U MRI (12/05):
BSB – F/U MRI (5/06):
BSB – F/U 10/06: Diplopia in right gaze Va 20/20 OU Ext: H 16/14 EOM: min ↓ L add P: . 3 log LAPD
BSB – W/U OCT NFL (10/06):
JWD 63 yo male 3/06: ↓Va OS Va 20/20, 20/60 P: . 9 log LAPD
JWD – POH 12/05: Routine check vision Dx: “cataracts” Referred for cataract extraction Ophthalmologist said “no cataract”
JWD – W/U OCT:
JWD – F/U 8/07: “No Δ” Va 20/25 OU P: . 9 log LAPD
JWD – W/U OCT NFL (8/07):
KH 48 yo female 11/08: ↓Va Va 20/30, 8/200 VF: Ext: w/q P: . 3 log LAPD EOM: full SLE: wnl Fundus: nl DMV www. Pacific. Specialists. com 3/1/2021
KH – PMH 1/08: Polydipsia 4/08: Amenorrhea 10/08: HA, N/V www. Pacific. Specialists. com 3/1/2021
KH – W/U OCT NFL (11/08): www. Pacific. Specialists. com 3/1/2021
KH – W/U MRI (11/08): www. Pacific. Specialists. com 3/1/2021
KH – Rx 11/08: Transphenoidal endoscopic decompression Path: craniopharyngioma www. Pacific. Specialists. com 3/1/2021
KH – F/U 8/09: “Better” Va 20/20 OU N 3 pt OU VF: Ext: w/q P: w/o APD EOM: full SLE: wnl Ta: 19/22 www. Pacific. Specialists. com Fundus: 3/1/2021
KH – W/U OCT NFL (8/09): www. Pacific. Specialists. com 3/1/2021
IN SUMMARY: Listen to the patient and solicit information. Examine the patient: determine BCVA and assess VF. Understand Consider and explain symptoms and findings. and recommend additional testing, or consultation, as indicated. Follow-up Avoid on all tests and consultations with patient. contributing to a delay in diagnosis and treatment.
NEURO-OP Pacific Eye & Ear Howard R Krauss, MD 11645 Wilshire Blvd. , Suite 600 Neuro-ophthalmology Strabismus Los Angeles, Ca. 90025 Orbital Surgery 310 -477 -5558 Dr. Krauss@Pacific. Specialists. com www. Pacific. Specialists. com 3/1/2021
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