Neuroophthalmology NEUROOPHTHALMOLOGY 1242020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 1 Neuroophthalmology

Neuro-ophthalmology NEURO-OPHTHALMOLOGY ﺑﺴﻢ ﺍﻟﻠﻪ ﺍﻟﺮﺣﻤﻦ ﺍﻟﺮﺣﻴﻢ 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 1

Neuro-ophthalmology NEURO-OPHTHALMOLOGY 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 2

Neuro-ophthalmology NEURO-OPHTHALMOLOGY MAHGOUB SALEEM MBBS (U of K) , DORCS (Eng. ) , MRCOphth (UK), FRCOphth (UK) , FICS , FACS (USA) SENIOR CONSULTANT OPHTHALMOLOGIST ASSOCIATE PROFESSOR FACULTY OF MEDICINE AL NEELAIN UNIVERSITY 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 3

NEURO-OPHTHALMOLOGY Neuro-ophthalmology is the subspecialty of both neurology and ophthalmology concerning visual problems that are related to the nervous system A third of the brain is devoted to the visual system, 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 4

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway: 1. Optic nerves 2. Optic chiasma 3. Optic tracts 4. Lateral Geniculate Bodies 5. Optic radiations 6. Visual cortex 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 5

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Clinical Examination Ø Visual Acuity Ø Colour Vision Ø Visual Fields Ø Pupils Ø EOM 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 6

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Symptomatic disturbance of vision: 1. 2. 3. 4. 5. 6. 7. 12/4/2020 Night blindness Day blindness Colour blindness Amaurosis Amblyopia Malingering blindness Hysterical blindness MAHGOUB SALEEM NEUROOPHTHALMOLOGY 7

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Optic nerve diseases: 1. Papillitis 2. Acute Retrobulber neuritis 3. Toxic amblyopia 4. Papilloedema 5. Optic Atrophy(1 ry, 2 ry) 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 8

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Conditions need treatment: Ø Optic nerve disorders, such as optic neuritis, Ø Ischemic optic neuropathy compressive optic neuropathies Leber's optic neuropathy Ø Visual field defects related to stroke or MS Ø Double vision from ocular motor nerve palsies Ø Myasthenia gravis Ø Thyroid eye disease Ø Orbital tumors 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 9

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The swollen optic disc Papilloedema Ø Papillitis Ø Malignant hypertension Ø Ischaemic optic neuropathy Ø Diabetic optic neuropathy Ø CRVO Ø Intraocular inflammation 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 10

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The swollen optic disc 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY Papilloedema 11

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The swollen optic disc 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY Papilloedema 12

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The swollen optic disc 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY Papilloedema 13

Neuro-ophthalmology NEURO-OPHTHALMOLOGY 25 y. o. female Reduced VA Pain with eye movement Colour desaturation RAPD 12/4/2020 Optic neuritis MAHGOUB SALEEM NEUROOPHTHALMOLOGY 14

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Optic neuritis Signs and symptoms of optic neuritis include: q q q Sudden vision loss (central scotoma is classic) Decreased contrast and color sensitivity Pain with eye movement Optic nerve head edema Afferent pupillary defect APD RAPD 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 15

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Pupillary reflexes Direct Indirect (consensual) Near reflex ü Convergence reflex ü Accommodation reflex 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 16

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Pupil q Constricted (mioisis) DM Ø Sympathetic (pupillodilator) denervation Ø Drugs ( Pilocarpine Morphine ) 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 17

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Pupil q Dilated (mydriasis) DM q Parasympathetic ( pupilloconstrictor ) denervation q Lesion of the III Cranial Nerve q Drugs ( Atropine , Cocaine ) 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 18

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Abnormalities of pupillary reactions: 2. Efferent Pupillary Defect: üNo DPR+No IPR on affected eye üparasympathetic drugs üAtropine üIIInerve palsy üInternal ophthalmoloplegia 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 19

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Abnormalities of pupillary reactions: q. Horner`s syndrome q. Relative Afferent Pupillary Defect RAPD q. Mid-brain pupil 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 20

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Sympathetic Pathway D A E R 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 21

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Abnormalities of pupillary reactions: . Amaurotic light reflex : ü No DLR on affected side ü No indirect Pupillary reflexes on good eye 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 22

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Abnormalities of pupillary reactions: 3. Marcus Gunn pupil: 4. Argyil Rebertson pupil (ARP) 5. Adie`s tonic pupil 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 23

Neuro-ophthalmology NEURO-OPHTHALMOLOGY RAPD Relative Afferent Pupillary Defect also known as Marcus-Gunn pupil is a very significant and highly objective finding in the clinical examination of the visual system 1 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 24

Neuro-ophthalmology NEURO-OPHTHALMOLOGY RAPD Causes A broad range of visual system anomalies: q Advanced asymmetric glaucoma q Extensive Retinal disease q Optic neuritis & neuropathy, . can be detected even in an unconscious patient 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 25

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Abnormalities of pupillary reactions: Afferent & efferent papillary defects RAPD v. Argyll-Robertson pupil v. Miotonic pupil (Adie’s syndrome) v. Holmes-Adie syndrome 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 26

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Papilloedema • Disc swelling secondary to raised ICP • Headache – Worse in the morning – Valsalva maneuver • Nausea and projectile vomiting • Horizontal diplopia (VI palsy) • Causes – Space occupying lesion – Intracranial hypertension • Idiopathic • Drugs • Endocrine MAHGOUB SALEEM NEURO 12/4/2020 – Severe hypertension OPHTHALMOLOGY 27

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The pale optic disc q Congenital q Secondary to • raised ICP • vascular • retinal disease • optic neuritis • optic nerve compression • trauma q Glaucoma 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 28

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Horner’s (Oculosympathetic paresis): – Ptosis – Miosis – Ipsilateral anhidrosis – Does not dilate with cocaine 4% Causes 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 29

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Third nerve palsy – Double vision – Eye turned down & out – Ptosis – Dilated pupil & headache • Compressive lesion causes 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 30

Neuro-ophthalmology NEURO-OPHTHALMOLOGY IV nerve palsy 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 31

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Sixth nerve palsy – Double vision – Eye turned in 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 32

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Internuclear Ophthalmoplegia ØDefective adduction of the ipsilateral eye Ø Nystagmus of the contralateral (abducting) eye Ø NORMAL CONVERGENCE Ø Causes – Young patients • Bilateral • Demyelination – Older patients • Unilateral • Vascular, • tumours 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 33

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Myasthenia Gravis • Fatigability • Double vision • Lid twitch • Ptosis • Normal reflexes & sensatio 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 34

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localising the lesion Monocular visual field defects indicate lesions anterior to the optic chiasm 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 35

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Cranial Nerve Palsies Ø III Ø IV Ø VI Ø Ophthalmoplegia 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 36

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localizing the lesion Bitemporal defects are the hallmark of chiasmal lesions 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 37

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localising the lesion Binocular homonymous hemianopia Contralateral Postchiasmal lesions 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 38

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localizing the lesion Binocular quadrantanopias Anopia affecting a quarter of the field of vision Reflect Optic Tract Lesions 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 39

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localising the lesion Binocular quadrantanopias left superior quadrantanopia with macular sparing lesion located in the occipital inter-hemispheric fissure Right homonymous superior quadrantanopia 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 40

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localising the lesion Binocular quadrantanopias left superior quadrantanopia with macular sparing lesion located in the occipital inter-hemispheric fissure Right inferior quadrantanopia sparing the macula 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 41

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localising the lesion Binocular quadrantanopias Right homonymous superior quadrantanopia. This visual field defect is characteristic of damage to Meyer's loop on the left side of the brain. The left inferior homonymous quadrantanopia 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 42

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Binocular quadrantanopias The right inferior homonymous quadrantanopia 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 43

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Localising the lesion 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 44

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway : lesions 1. Optic nerves complete blindness 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 45

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway : lesions 2. Optic chiasma = Bitemporal hemianopia Binasal hemianopia 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 46

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway : lesions 2. Optic chiasma Bitemporal hemianopia Binasal hemianopia 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 47

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway : lesions 3. Optic tracts 4. Lateral Geniculate Bodies 5. Optic radiations 6. Visual cortex Homonymous Hemianopia 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 48

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway : lesions Optic tracts Homonymous Hemianopia 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 49

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway : lesions Homonymous Hemianopia 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 50

Neuro-ophthalmology NEURO-OPHTHALMOLOGY The Visual Pathway : 12/4/2020 lesions MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 51

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Lesions of The Visual Pathway: 1. Trauma 2. Vascular 3. Inflammatory 4. Neoplasms 5. Degenerative 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 52

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Optic nerve diseases: 1. Papillitis 2. Acute Retrobulber nuritis 3. Toxic amblyopia 4. Papilloedema 5. Optic Atrophy(1 ry, 2 ry) 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 53

Neuro-ophthalmology NEURO-OPHTHALMOLOGY Symptomatic disturbance of vision: 1. 2. 3. 4. 5. 6. 7. 12/4/2020 Night blindness Day blindness Colour blindness Amaurosis Amblyopia Malingering blindness Hysterical blindness MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 54

Neuro-ophthalmology NEURO-OPHTHALMOLOGY D A E R 12/4/2020 MAHGOUB SALEEM NEURO-OPHTHALMOLOGY 55

Neuro-ophthalmology NEURO-OPHTHALMOLOGY THANK YOU 12/4/2020 MAHGOUB SALEEM NEUROOPHTHALMOLOGY 56