Neuro-ophthalmology

Abdulrahman Al-Amri, MD

Objectives• Anatomy& Physiology• Terminology

– Anisocoria: unequal pupil size– Papilledema

• Approach as GP• Pathology

– Optic neuropathy• Optic Neuritis

• Ischemic optic neuropathy (ION)

• GCA

• Nerve Palsies– 3rd,4th,6th nerve disorders

Anatomy& Physiology

Applied anatomy of Afferent & Efferent pupillary defect

Anatomical pathway Signs

•APD

•Loss or diminished reflex

(damaged II)3rd

Efferent pupillary defect (EPD)

– III nerve palsy

– Sphincter pupillae• Loss of direct and

consensual (damaged III)

• Anisocoria

Approach as GP

Approach

History• Visual:

– Loss• Transient• Persistent

– Field defect• Pain • Diplopia

– Monocular:..• Tear film• Cornea and lens

– Binocular:…• Nerve palsies

• POH

• PMH:– MS– CTD– Gran. Dis– Drugs:Anti-TB

• SR– Headache

– Hearing

– Balance

– Speech

Examination • Proptosis • Eyelid

– Ptosis– Lagophthalmos

• Nystagmus • EOM• VA(BCVA)• Color vision• Pupillary reflexes

– Afferent vs Efferent

• Disc– Edema

– Pallor

– Hyperemia

• Visual Field – Central scotoma

– Altitudinal

Pathology

Optic Neuritis• Age 20-50• Unilateral • Worsen over hrs/days

then Recovery starts• Retrobulbar pain..may

be worse on eye mov.

• VA& Color vision

• RAPD

• Disc

– Edema

– Hyperemia (1/3 of cases)

Central scotoma

Dx

Clinical

Optic Neuritis

Causes • MS• Infectious

– Viral ..

• Toxic

– Investigate:

• CBC,ESR,CRP,

• CXR,Syphilis Serology

• ANA, LFT,U+E

• MRI– MS…

RX:– Underlying – IV Steroid

Ischemic optic neuropathyION

• Old

• Visual loss

• APD

• Disc edema

• Disc: Pallor…Hyperemic

Hyperemic Disc Pale Disc

IONNon-arteriticArteritic

IncidenceCommon

10/100,000

Rare

0.3/100,000

Cause Arteriosclerosis GCA

ESR& CRPNHigh

TAB-ve+ve

Risk to fellow eyeLow High

RxAspirin Steroid

Papilledema • Malignant HTN

• SOL– Tumor

• Trauma– Cerebral edema/hage

• Pseudotumor cerebri (Idiop.Intracranial HTN)

Papilledema Papillitis

• Bilateral• Gradual • Transient v. loss• Blind spot• Dye leakage-FFA• Symp of ICP• SOL on MRI

• Unilateral• Rapid • Profound• Central scotoma• Dye leakage-FFA• Symp of MS• Demyelinatin on MRI

SteroidTetracyclineOCPNalidixic acidExcess-Vit A derivative

OCULAR MOTOR NERVE PALSIES

1. Third nerve

2. Fourth nerve

3. Sixth nerve

Anatomy of third nerveOculomotor nucleus

Pituitary gland

Carotid artery

Cavernous sinus

III nerveClivus

Basilar artery

Post cerebral artery

Red nucleus

Pons

Applied anatomy of pupillomotor nerve fibres

Blood vessels on pia mater supply surface of the nerve including pupillary

fibres ( damaged by compressive lesions )

Vasa nervorum supply partof nerve but not pupillaryfibres ( damaged by medicallesions )

Pupillary fibres lie dorsal and peripheral

SurgicalSurgical

Medical

Ptosis, mydriasis

• Limited depression • Limited adduction

• Normal abduction

• Limited elevation

Right third nerve palsyRight third nerve palsy

PupilPupil? ?

Watch

Describe what is happening

Where is the problem, and why?

Anatomy of fourth nerve

• Only cranial nerve to emerge dorsally• Crossed cranial nerve• Very long and slender

Internal carotid artery

Postr. communicating artery

IIIVI

Postr.cerebral arterySupr.cerebellar artery

Basilar arteryIV

Signs of right fourth nerve palsy

• Right overaction on left gaze

• Rt under action on depression in adduction • Vertical diplopia

• Rt hyperdeviation in primary position when left eye fixating• Excyclotorsion

Rt 4th nerve palsy

Anatomy of sixth nerve

Basilar artery

Pituitary gland

Carotid artery

Cavernous sinus

VI nerve

Petroclinoidligament

Clivus

Pyramidal tract

Vestibularnucleus

Mediallemniscus

4th ventricle

Primary position Rt Gaze

Straight in primary position due to partial recovery

Limitation of right abduction and horizontal diplopia

Normal right adduction

DDxDDx Nerve palsyNerve palsy NMJNMJ

Myasthenia GravisMyasthenia Gravis

MuscleMuscle TEDTED

OrbitOrbit

Problem solving

33rdrd pupil problem pupil problem

                                      

                             

Describe the signsWhere is the problem, and why?

Describe the signsDescribe the signsWhere is the problem, and why?Where is the problem, and why?

left

Bright lightBright light PharmacologicalPharmacological Adie’s pupil Adie’s pupil TraumaTrauma

sphincter rupturesphincter rupture

III nerve palsyIII nerve palsy Unlikely if isolatedUnlikely if isolated

Dim lightDim light PharmacologicalPharmacological UveitisUveitis Horner’s Horner’s