Neuroophthalmology Abdulrahman AlMuammar College of Medicine King Saud
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 fields Common neuro-ophthalmic disorders
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) 3 rd nerve palsy Ptosis Trauma Horner syndrome Tumor Physiological Temporal lobe herniation Aneurysm No 3 rd 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
3 rd 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
4 th nerve palsy Most frequent cause is trauma If no trauma, isolated 4 th 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
6 th nerve palsy Isolated 6 th 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-Digitalis. Ethambutol -Chloramphenicol. INH 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 • • Ptosis Any ocular motility disturbances INO Variability is the hallmoark
Myasthenia Gravis (MG) Diagnosis • • Clinically Pharmacologically (Tensilon test) Serologically Sleep test Ice-pack test CT chest Thyroid function test ANA Treatment • • • 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
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