Introduction to Clinical Ophthalmology

Introduction to Introduction to Clinical Clinical

Ophthalmology Ophthalmology

The Eye The Eye Examination Examination

Chapter 1Chapter 1

AnatomyAnatomy

AnatomyAnatomy

Extraocular Extraocular movements movements

MedialMedial LateralLateral Upward Upward DownwardDownward

Visual Acuity Visual Acuity General physical examination should include :General physical examination should include :

Visual acuityVisual acuity Pupillary reactionPupillary reaction Extraocular movementExtraocular movement Direct ophthalmoscope Direct ophthalmoscope Dilated exam (in case of visual loss or retinal Dilated exam (in case of visual loss or retinal

pathology)pathology) Distance or NearDistance or Near Distance visual acuity at age 3Distance visual acuity at age 3

early detection of amblyopia early detection of amblyopia

Distance Visual Acuity Distance Visual Acuity TestingTesting

VA - Visual acuity VA - Visual acuity OD - ocular dexterOD - ocular dexter OS - ocular sinisterOS - ocular sinister OU - oculus uterqueOU - oculus uterque

20/20 20/20

Distance between the patient and the eye chart Distance between the patient and the eye chart __________________________________________________________________________________________

Distance at which the letter can be read by a person with Distance at which the letter can be read by a person with normal acuity normal acuity

Distance Visual Acuity Distance Visual Acuity TestingTesting

Place patient at 20 ft from Snellen Place patient at 20 ft from Snellen chart chart

OD then OSOD then OS VA is line in which > ½ letters are VA is line in which > ½ letters are

read read Pinhole if < 20/40Pinhole if < 20/40

Snellen eye Snellen eye chart chart

Rosenbaum Rosenbaum pocket chart pocket chart

Distance Visual Acuity Distance Visual Acuity TestingTesting

If VA < 20/400If VA < 20/400 Reduce the distance between the pt and Reduce the distance between the pt and

the chart and record the new distance (eg. the chart and record the new distance (eg. 5/400)5/400)

If < 5/400If < 5/400 CF (include distance)CF (include distance) HM (include distance)HM (include distance) LPLP NLPNLP

Near Visual Acuity Near Visual Acuity TestingTesting

Indicated when Indicated when Patient complains about near visionPatient complains about near vision Distance testing difficult/impossible Distance testing difficult/impossible

Distance specified on each card Distance specified on each card (35cm)(35cm)

Pupillary ExaminationPupillary Examination Direct penlight into eye while Direct penlight into eye while

patient looking at distancepatient looking at distance

Direct Direct Constriction of ipsilateral eyeConstriction of ipsilateral eye

Consensual Consensual Constriction of contralateral eyeConstriction of contralateral eye

Ocular Motility Ocular Motility

Rt superior rectusRt superior rectusLt inferior oblique Lt inferior oblique

Lt superior rectusLt superior rectusRt inferior obliqueRt inferior oblique

Rt lateral rectusRt lateral rectusLt medial rectusLt medial rectus

Lt lateral rectusLt lateral rectusRt medial rectusRt medial rectus

Rt inferior rectusRt inferior rectusLt superior Lt superior oblique oblique

Lt inferior rectusLt inferior rectusRt superior Rt superior obliqueoblique

Direct Ophthalmoscopy Direct Ophthalmoscopy

Tropicamide or phenylephrine for Tropicamide or phenylephrine for dilationdilation unless shallow anterior chamberunless shallow anterior chamber unless under neurological evaluationunless under neurological evaluation

Use own OD to examine ODUse own OD to examine OD Same for OSSame for OS

Intraocular Pressure Intraocular Pressure Measurement Measurement

Range: 10 - 22Range: 10 - 22

Anterior chamber depth Anterior chamber depth assessment assessment

Likely shallow if Likely shallow if ≥ ≥ 2/3 of nasal iris 2/3 of nasal iris

in shadowin shadow

Summary of steps in eye Summary of steps in eye examexam

Visual AcuityVisual Acuity Pupillary examinationPupillary examination Visual fields by confrontationVisual fields by confrontation Extraocular movementsExtraocular movements Inspection of Inspection of lids, conjunctiva and lids, conjunctiva and

corneacornea Anterior chamber depthAnterior chamber depth Lens clarityLens clarity Tonometry Tonometry Fundus examination (Fundus examination (Disc, Disc,

Macula, vessels) Macula, vessels)

Acute Visual LossAcute Visual Loss

Chapter 2Chapter 2

HistorHistoryy

AgeAge POH & PMHPOH & PMH OnsetOnset DurationDuration Severity of visual lossSeverity of visual loss Monocular vs. Monocular vs.

binocularbinocular Any associated Any associated

symptoms symptoms

VA assessmentVA assessment Visual fieldsVisual fields Pupillary reactions Pupillary reactions slit lamp slit lamp

examinationexamination Intraocular pressureIntraocular pressure OphthalomoscopyOphthalomoscopy - red reflex - red reflex

- clarity of media- clarity of media - direct inspection - direct inspection

of the fundusof the fundus

ExaminatioExaminationn

Media OpacitiesMedia Opacities

Corneal edemaCorneal edema:: - ground glass appearance- ground glass appearance - R/O AACG- R/O AACG

Corneal abrasionCorneal abrasion

HyphemaHyphema - Traumatic, spontaneous- Traumatic, spontaneous

Vitreous hemorrhageVitreous hemorrhage - darkening of red reflex with clear - darkening of red reflex with clear

lens, AC and cornea lens, AC and cornea

- traumatic - traumatic - retinal neovascularization- retinal neovascularization

Retinal DiseasesRetinal Diseases Retinal detachmentRetinal detachment - flashes, floaters, shade - flashes, floaters, shade

over visionover vision - RAPD (if extensive RD)- RAPD (if extensive RD) - elevated retina +/- folds- elevated retina +/- folds Macular diseaseMacular disease - decrease central vision - decrease central vision - metamorphopsia- metamorphopsia

Central Retinal Artery Central Retinal Artery Occlusion (CRAO)Occlusion (CRAO)

True ophthalmic emergency!True ophthalmic emergency! Sudden painless and often severe Sudden painless and often severe

visual lossvisual loss Permanent damage to the Permanent damage to the

ganglion cells caused by ganglion cells caused by prolonged interruption of retinal prolonged interruption of retinal arterial blood flowarterial blood flow

Characteristic “ cherry-red spot ”Characteristic “ cherry-red spot ” No optic disc swelling unless No optic disc swelling unless

there is ophthalmic or carotid there is ophthalmic or carotid artery occlusionartery occlusion

Months later, pale disc due to Months later, pale disc due to death of ganglion cells and their death of ganglion cells and their axonsaxons

CRAOCRAO TreatmentTreatment Ocular massage:Ocular massage: -To dislodge a small embolus in CRA and -To dislodge a small embolus in CRA and

restore circulationrestore circulation -Pressing firmly for 10 seconds and then -Pressing firmly for 10 seconds and then

releasing for 10 seconds over a period of ~ releasing for 10 seconds over a period of ~ 5 minutes5 minutes

Ocular hypotensives, vasodilators, Ocular hypotensives, vasodilators, paracentesis of anterior chamberparacentesis of anterior chamber

R/O giant cell arteritis in elderly patient R/O giant cell arteritis in elderly patient without a visible emboluswithout a visible embolus

Branch Retinal Artery Occlusion Branch Retinal Artery Occlusion (BRAO)(BRAO)

Sector of the retina Sector of the retina is opacified and is opacified and vision is partially vision is partially lostlost

Most often due to Most often due to embolusembolus Treat as CRAOTreat as CRAO

Central Retinal Vein Occlusion Central Retinal Vein Occlusion (CRVO)(CRVO)

Subacute loss of visionSubacute loss of vision Disc swelling, venous engorgement, Disc swelling, venous engorgement,

cotton-wool spots and diffuse cotton-wool spots and diffuse retinal hemorrhage.retinal hemorrhage.

Risk factors: age, HTN, Risk factors: age, HTN, arteriosclerotic vascular disease, arteriosclerotic vascular disease, conditions that increase blood conditions that increase blood viscosity (polycythemia vera, sickle viscosity (polycythemia vera, sickle cell disease, lymphoma , leukemia)cell disease, lymphoma , leukemia)

Needs medical evaluationNeeds medical evaluation Long term risk for neovascular Long term risk for neovascular

glaucoma, so periodic ophtho f/u glaucoma, so periodic ophtho f/u

Optic Nerve DiseaseOptic Nerve Disease

Non-Arteritic Ischemic Optic Non-Arteritic Ischemic Optic Neuropathy (NAION)Neuropathy (NAION)

- vascular disorder- vascular disorder pale, swollen disc +/- splinter pale, swollen disc +/- splinter

hemorrhagehemorrhage loss of VA , VF ( often altitudinal )loss of VA , VF ( often altitudinal ) Arteritic Ischemic Optic Arteritic Ischemic Optic

Neuropathy (AION)Neuropathy (AION)- Symptoms of giant cell arteritisSymptoms of giant cell arteritis- ESR, CRP, PlateletsESR, CRP, Platelets- Rx : systemic steroids Rx : systemic steroids

Optic Nerve DiseaseOptic Nerve Disease Optic neuritisOptic neuritis - idiopathic or associated with multiple sclerosis- idiopathic or associated with multiple sclerosis - young adults- young adults - decreased visual acuity and colour vision- decreased visual acuity and colour vision -RAPD-RAPD -pain with ocular movement-pain with ocular movement -bulbar (disc swelling) or retrobulbar (normal disc)-bulbar (disc swelling) or retrobulbar (normal disc)

Traumatic optic neuropathyTraumatic optic neuropathy - direct trauma to optic nerve- direct trauma to optic nerve - indirect : shearing force to the vascular supply - indirect : shearing force to the vascular supply

Visual Pathway Disorders HemianopiaHemianopia - Causes: vascular or tumors- Causes: vascular or tumors

Cortical Blindness Cortical Blindness - aka central or cerebral- aka central or cerebral - Extensive bilateral damage to - Extensive bilateral damage to

cerebral pathwayscerebral pathways - Normal pupillary reactions and - Normal pupillary reactions and

fundifundi

Chronic Visual Chronic Visual LossLossChapter 3Chapter 3

Introduction:Introduction:

1994: 38 million blind people (age >60 yrs) 1994: 38 million blind people (age >60 yrs) worldwideworldwide

1997: in western countries, leading causes 1997: in western countries, leading causes of blindness in people over 50 yrs of ageof blindness in people over 50 yrs of age

1)1) Age-Related Macular Degeneration Age-Related Macular Degeneration 2)2) CataractCataract3)3) GlaucomaGlaucoma4)4) DiabetesDiabetes

GlaucomaGlaucoma Risk factors:Risk factors: Old ageOld age African-American raceAfrican-American race

Blood HypertensionBlood HypertensionDiabetes MellitusDiabetes MellitusSmokingSmokingHigh IOPHigh IOP MyopiaMyopiaFamily HistoryFamily History

Classification:Open-angle glaucoma vs. angle closure glaucoma Primary vs. secondary

GlaucomaGlaucoma Evaluation:Evaluation:

complete historycomplete history complete eye examinationcomplete eye examination

(including IOP, gonioscopy, optic (including IOP, gonioscopy, optic disc)disc)

PerimetryPerimetry

normal Abnormal

GlaucomaGlaucoma Treatment Options:Treatment Options:

Medical:Medical: drops to decrease aqueous secretion or increase aqueous drops to decrease aqueous secretion or increase aqueous

outflowoutflow systemic medicationssystemic medications

Laser:Laser: IridotomyIridotomy IridoplastyIridoplasty TrabeculoplastyTrabeculoplasty

Surgical:Surgical: Filtration Surgery (e.g. Trabeculectomy)Filtration Surgery (e.g. Trabeculectomy) Tube shuntTube shunt

Cyclodestructive proceduresCyclodestructive procedures

CataractCataract congenital vs. congenital vs.

acquiredacquired often age-relatedoften age-related different forms different forms

(nuclear, cortical, (nuclear, cortical, PSCC)PSCC)

reversiblereversible very successful very successful

surgerysurgery

CataractCataract

Evaluation:Evaluation: HistoryHistory Ocular ExaminationOcular Examination Others: A-scan, Others: A-scan, ±± B-scan , B-scan , ±± PAM PAM

Treatment:Treatment: SurgicalSurgical IOL implantationIOL implantation

Age-Related Macular Age-Related Macular DegenerationDegeneration

Types:Types:1) Dry:1) Dry: - - drusen, RPE changes (atrophy, hyperplasia)drusen, RPE changes (atrophy, hyperplasia)2) Wet:2) Wet: - - choroidal neovascularizationchoroidal neovascularization

drusen

RPE atrophy

CNV

Age-Related Macular Age-Related Macular DegenerationDegeneration

Fluorescein Angiography

Age-Related Macular Age-Related Macular DegenerationDegeneration

Treatment:Treatment: micronutrient supply micronutrient supply

vit C & E, vit C & E, ββ-carotene, minerals (cupric -carotene, minerals (cupric oxide, zinc oxide) oxide, zinc oxide)

treat wet ARMD treat wet ARMD laserslasers intra-vitreal injections of anti-VEGFintra-vitreal injections of anti-VEGF surgery surgery low vision aidslow vision aids

The Red EyeThe Red EyeChapter 4Chapter 4

Diff. DiagnosisDiff. Diagnosis: : Red EyeRed Eye Acute angle closure glaucomaAcute angle closure glaucoma Iritis or iridocyclitisIritis or iridocyclitis Herpes simplex keratitisHerpes simplex keratitis ConjunctivitisConjunctivitis EpiscleritisEpiscleritis Soft contact lens associatedSoft contact lens associated ScleritisScleritis Adnexal DiseaseAdnexal Disease Subconjunctival hemorrhageSubconjunctival hemorrhage PterygiumPterygium Keratoconjunctivitis siccaKeratoconjunctivitis sicca Abrasions or foreign bodiesAbrasions or foreign bodies Corneal ulcerCorneal ulcer abnormal lid functionabnormal lid function

THINKTHINK Anatomy “front to Anatomy “front to

back”back” Acute vs. chronicAcute vs. chronic Visually Visually

threatening?threatening?

HistoryHistory Onset? Sudden? Progressive? Constant?Onset? Sudden? Progressive? Constant? Family/friends with red eye?Family/friends with red eye? Using meds in eye?Using meds in eye? Trauma?Trauma? Recent eye surgery?Recent eye surgery? Contact lens wearer?Contact lens wearer? Recent URTI?Recent URTI? Decreased VA? Pain? Discharge? Itching? Decreased VA? Pain? Discharge? Itching?

Photophobia? Eye rubbing?Photophobia? Eye rubbing? Other symptoms?Other symptoms?

Red Eye: Symptoms Red Eye: Symptoms *Decreased VA (i*Decreased VA (inflamed cornea, iridocyclitis, acute nflamed cornea, iridocyclitis, acute

glaucoma)glaucoma) *Pain (k*Pain (keratitis, ulcer, iridocyclitis, acute glaucoma)eratitis, ulcer, iridocyclitis, acute glaucoma) *Photophobia (*Photophobia (iritis)iritis) *Colored halos (*Colored halos (acute glaucoma)acute glaucoma) Discharge (Discharge (conj. or lid inflammation, corneal ulcer)conj. or lid inflammation, corneal ulcer)

Purulent/mucopurulent: BacterialPurulent/mucopurulent: Bacterial Watery: ViralWatery: Viral Scant, white, stringy: allergy, dry eyesScant, white, stringy: allergy, dry eyes

Itching (Itching (allergy)allergy)

* can indicate serious ocular disease* can indicate serious ocular disease

Physical ExamPhysical Exam VisionVision Pupil asymmetry or irregularityPupil asymmetry or irregularity Inspect: Inspect:

pattern of redness (heme, injection, ciliary flush)pattern of redness (heme, injection, ciliary flush) Amount & type of dischargeAmount & type of discharge Corneal opacities or irregularitiesCorneal opacities or irregularities

AC shallow? Hypopyon? Hyphema?AC shallow? Hypopyon? Hyphema? Fluorescein stainingFluorescein staining IOPIOP Proptosis? Lid abnormality? Limitation EOM?Proptosis? Lid abnormality? Limitation EOM?

Red Eye: SignsRed Eye: Signs *Ciliary flush*Ciliary flush (corneal inflammation, iridocyclitis, acute glaucoma) (corneal inflammation, iridocyclitis, acute glaucoma) Conjuctival hyperemiaConjuctival hyperemia (nonspecific sign) (nonspecific sign) *Corneal opacification *Corneal opacification (iritis, corneal edema, acute glaucoma, (iritis, corneal edema, acute glaucoma,

keratitis, keratitis, ulcer) ulcer)

*Corneal epithelial disruption *Corneal epithelial disruption (corneal inflammation, abrasion)(corneal inflammation, abrasion) *Pupil abnormality (*Pupil abnormality (iridocyclitis, acute glaucoma)iridocyclitis, acute glaucoma) *Shallow AC (*Shallow AC (acute angle closure glaucoma)acute angle closure glaucoma) *Elevated IOP *Elevated IOP (iritis, acute glaucoma)(iritis, acute glaucoma) *Proptosis *Proptosis (thyroid disease, orbital or cavernous sinus mass, (thyroid disease, orbital or cavernous sinus mass,

infection)infection) Preauricular LN Preauricular LN (viral conjunctivitis, Parinaud’s oculoglandular (viral conjunctivitis, Parinaud’s oculoglandular

syndrome)syndrome)

* can indicate serious ocular disease* can indicate serious ocular disease

Red eye management for Red eye management for care physicianscare physicians Blepharitis:Blepharitis:

Warm compresses, lid care, Abx ointment or oral Warm compresses, lid care, Abx ointment or oral (if rosacea or Meibomian gland dysfunction)(if rosacea or Meibomian gland dysfunction)

Stye:Stye: Warm compresses (refer if still present after 1 Warm compresses (refer if still present after 1

month)month) Subconj heme:Subconj heme:

Will resolve in 10-14 daysWill resolve in 10-14 days Viral conjunctivitisViral conjunctivitis

Cool compresses, tears, contact precautionsCool compresses, tears, contact precautions Bacterial conjunctivitisBacterial conjunctivitis

Cool compresses, antibiotic drop/ointmentCool compresses, antibiotic drop/ointment

Important Side EffectsImportant Side Effects Topical anesthetics:Topical anesthetics:

Not to be used except for aiding in examNot to be used except for aiding in exam Inhibits growth & healing of corneal epitheliumInhibits growth & healing of corneal epithelium Possible severe allergic reactionPossible severe allergic reaction Decrease blink reflex: exposure to dehydration, injury, Decrease blink reflex: exposure to dehydration, injury,

infectioninfection Topical corticosteroids:Topical corticosteroids:

Can potentiate growth of herpes simplex, Can potentiate growth of herpes simplex, fungusfungus

Can mask symptomsCan mask symptoms Cataract formationCataract formation Elevated IOPElevated IOP

Ocular & Orbital Ocular & Orbital InjuriesInjuries

Chapter 5Chapter 5

Anatomy & FunctionAnatomy & Function Bony orbitBony orbit

Globe, EOM, vessels, nervesGlobe, EOM, vessels, nerves Rim protectiveRim protective

““Blow out” fractureBlow out” fracture Medial fracture -> subQ emphysema of eyelidsMedial fracture -> subQ emphysema of eyelids

Anatomy & FunctionAnatomy & Function EyelidsEyelids

Reflex closing when eyes threatenedReflex closing when eyes threatened Blinking rewets the corneaBlinking rewets the cornea Tear drainageTear drainage

CN VII palsy -> exposure keratopathyCN VII palsy -> exposure keratopathy

Lacrimal apparatusLacrimal apparatus Tear drainage occurs at medial canthusTear drainage occurs at medial canthus

Obstruction -> chronic tearing (epiphora)Obstruction -> chronic tearing (epiphora)

Anatomy & FunctionAnatomy & Function Conjunctiva & corneaConjunctiva & cornea

Quick reepitheliization post-abrasionQuick reepitheliization post-abrasion

Iris & ciliary bodyIris & ciliary body Blunt trauma -> pupil margin nick (tear)Blunt trauma -> pupil margin nick (tear) Blunt trauma -> hyphemaBlunt trauma -> hyphema Blunt trauma -> iritisBlunt trauma -> iritis

(pain, redness, photophobia, miosis)(pain, redness, photophobia, miosis)

Anatomy & FunctionAnatomy & Function LensLens

CataractCataract Lens dislocation (ectopia lentis)Lens dislocation (ectopia lentis)

Vitreous humorVitreous humor Decreased transparencyDecreased transparency

(hemorrhage, inflammation, infection)(hemorrhage, inflammation, infection) RetinaRetina

Hemorrhage Hemorrhage Macular damage (reduce visual acuity)Macular damage (reduce visual acuity)

Management or ReferralManagement or Referral Chemical burnChemical burn

Alkali>Acid b/c more rapid penetrationAlkali>Acid b/c more rapid penetration OPHTHALMIC EMERGENCYOPHTHALMIC EMERGENCY ALL chemical burns require ALL chemical burns require

immediate and perfuse irrigation, immediate and perfuse irrigation, THEN ophtho referralTHEN ophtho referral

Urgent SituationsUrgent Situations Penetrating injuries of the globePenetrating injuries of the globe Conjunctival or corneal foreign bodiesConjunctival or corneal foreign bodies Hyphema Hyphema Lid laceration (sutured if not deep and neither Lid laceration (sutured if not deep and neither

the lid margin nor the canaliculi are involved)the lid margin nor the canaliculi are involved) Traumatic optic neuropathyTraumatic optic neuropathy Radiant energy burns (snow blindness or Radiant energy burns (snow blindness or

welder’s burn)welder’s burn) Corneal abrasionCorneal abrasion

Semi-urgent SituationSemi-urgent Situation Orbital fractureOrbital fracture Subconjuctival hemorrhage in blunt Subconjuctival hemorrhage in blunt

traumatrauma Refer patient within 1-2 daysRefer patient within 1-2 days

Treatment SkillsTreatment Skills Ocular irrigationOcular irrigation Foreign body removalForeign body removal Eye meds (cycloplegics, antibiotic Eye meds (cycloplegics, antibiotic

ointment, anesthetic drops and ointment, anesthetic drops and ointment)ointment)

Patching (pressure patch, shield)Patching (pressure patch, shield) Suturing for simple eyelid skin Suturing for simple eyelid skin

lacerationlaceration

Take-home PointsTake-home Points Teardrop-shaped pupil & flat anterior Teardrop-shaped pupil & flat anterior

chamber in trauma are associated with chamber in trauma are associated with perforating injuryperforating injury

Avoid digital palpation of the globe in Avoid digital palpation of the globe in perforating injuryperforating injury

In chemical burn patient immediate In chemical burn patient immediate irrigation is crucial as soon as possibleirrigation is crucial as soon as possible

Traumatic abrasions are located in the Traumatic abrasions are located in the center or inferior cornea due to Bell’s center or inferior cornea due to Bell’s phenomenonphenomenon

Know and respect your limitsKnow and respect your limits

Chapter 6Chapter 6

Amblyopia & Amblyopia & StrabismusStrabismus

AmblyopiaAmblyopia DefinitionDefinition

loss of VA not correctable by glasses in loss of VA not correctable by glasses in otherwise healthy eyeotherwise healthy eye

2% in US2% in US Strabismic(50%) > refractive > deprivationStrabismic(50%) > refractive > deprivation The brain selects the better image and The brain selects the better image and

suppresses the blurred or conflicting imagesuppresses the blurred or conflicting image Cortical suppression of sensory input Cortical suppression of sensory input

interrupts the normal development of visioninterrupts the normal development of vision

StrabismusStrabismus Misalignment of the two eyesMisalignment of the two eyes Absence of binocular visionAbsence of binocular vision

Concomitant: angle of deviation equal in all directionConcomitant: angle of deviation equal in all direction EOM: normalEOM: normal Onset: childhoodOnset: childhood Rarely caused by neurological disease <6 yearsRarely caused by neurological disease <6 years Can be due to sensory deprivation Can be due to sensory deprivation

Incomitant: angle of deviation varies with direction of Incomitant: angle of deviation varies with direction of gazegaze EOM : abnormalEOM : abnormal **Paralytic : CN, MG ****Paralytic : CN, MG ** Restrictive: orbital disease, traumaRestrictive: orbital disease, trauma

StrabismusStrabismus Phoria: latent deviationPhoria: latent deviation

Tropia: manifest deviation Tropia: manifest deviation

Corneal Light ReflexCorneal Light Reflex

Cover TestCover Test

TreatmentTreatment Refractive correction (glasses)Refractive correction (glasses) PatchingPatching SurgerySurgery

Chapter 7Chapter 7

**35% of the sensory fibers entering the brain are in the **35% of the sensory fibers entering the brain are in the optic nerves and 65% of intracranial disease exhibits optic nerves and 65% of intracranial disease exhibits

neuro-ophthalmic signs or symptoms**neuro-ophthalmic signs or symptoms**

Neuro-Neuro-OphthalmologyOphthalmology

The Neuro-Ophthalmic The Neuro-Ophthalmic ExamExam

Visual acuityVisual acuity Confrontation visual fieldsConfrontation visual fields Pupil size and reaction Pupil size and reaction

(Efferent vs Afferent (Marcus Gunn) problem)(Efferent vs Afferent (Marcus Gunn) problem) Ocular motility for strabismus, limitation and Ocular motility for strabismus, limitation and

nystagmusnystagmus Fundus exam (optic nerve swelling and venous Fundus exam (optic nerve swelling and venous

pulsations)pulsations)

ParasympatheticParasympathetic

SympatheticSympathetic

Efferent vs Afferent defectEfferent vs Afferent defect

Selected Pupillary Selected Pupillary DisordersDisorders

Mydriasis Mydriasis CN III palsyCN III palsy

Herniation of temporal lobe or AneurysmHerniation of temporal lobe or Aneurysm Adie’s Tonic PupilAdie’s Tonic Pupil

Young women, unilateral, sensitive to dilute pilocarpine, benignYoung women, unilateral, sensitive to dilute pilocarpine, benign MiosisMiosis

PhysiologicPhysiologic Horner’s SyndromeHorner’s Syndrome

Etiologic localization (cocaine and hydroxyamphetamine)Etiologic localization (cocaine and hydroxyamphetamine) Argyll Robertson Pupil of tertiary syphilisArgyll Robertson Pupil of tertiary syphilis

small, irregular, reacts to near stimulus onlysmall, irregular, reacts to near stimulus only

Selected Motility Selected Motility DisordersDisorders

True diplopia is a binocular phenomenonTrue diplopia is a binocular phenomenon Etiologies of monocular diplopia?Etiologies of monocular diplopia?

Do not forget to check ALL cranial nerves (especially 5/7/8)Do not forget to check ALL cranial nerves (especially 5/7/8) CN IVCN IV

Vertical diplopia, head tilt toward OPPOSITE sideVertical diplopia, head tilt toward OPPOSITE side Think closed head trauma or small vessel diseaseThink closed head trauma or small vessel disease

Myasthenia GravisMyasthenia Gravis Chronic autoimmune condition affecting skeletal muscle Chronic autoimmune condition affecting skeletal muscle

neuromuscular transmission (verify with Tensilon test)neuromuscular transmission (verify with Tensilon test) Can mimic any nerve palsy and often associated with ptosisCan mimic any nerve palsy and often associated with ptosis NEVER affects pupilNEVER affects pupil

CN III PalsyCN III Palsy

Think: PCOM Aneurysm, Brain Tumor, Trauma Think: Trauma, Elevated ICP, HTN, Diabetes and viral infections

CN VI PalsyCN VI Palsy

Internuclear Ophthalmoplegia (INO)Internuclear Ophthalmoplegia (INO)

Think: Think: Elderly-small vessel Elderly-small vessel diseasediseaseYoung Adult-MSYoung Adult-MSChild-Pontine GliomaChild-Pontine Glioma

Nystagmus Nystagmus - selected - selected typestypes

May be benign or indicate ocular and/or central May be benign or indicate ocular and/or central nervous system diseasenervous system disease

Definition according to fast phaseDefinition according to fast phase End-point NystagmusEnd-point Nystagmus

seen only in extreme positions of eye movementseen only in extreme positions of eye movement Drug-induced NystagmusDrug-induced Nystagmus

Anticonvulsants, Barbiturates/Other sedativesAnticonvulsants, Barbiturates/Other sedatives Searching/Pendular NystagmusSearching/Pendular Nystagmus

common with congenital severe visual impairmentcommon with congenital severe visual impairment Nystagmus associated with INONystagmus associated with INO

Selected Optic Nerve Selected Optic Nerve DiseaseDisease Congenital Anomalous Disc ElevationCongenital Anomalous Disc Elevation

absenceabsence of edema, hemorrhage and of edema, hemorrhage and presencepresence of SVP of SVP Think: optic disc drusen and hyperopiaThink: optic disc drusen and hyperopia

Papilledema (def?)Papilledema (def?) PresencePresence of bil edema, hemorrhage and of bil edema, hemorrhage and absenceabsence of SVP of SVP Think: hypertension (must check BP) and Think: hypertension (must check BP) and

brain tumorbrain tumor Papillitis/Anterior Optic NeuritisPapillitis/Anterior Optic Neuritis

unil edema, hemorrhageunil edema, hemorrhage Think: inflammatoryThink: inflammatory

Selected Optic Nerve Selected Optic Nerve DiseaseDisease

Ischemic Optic NeuropathyIschemic Optic Neuropathy Pallor, swelling, hemorrhagePallor, swelling, hemorrhage altitudinal visual field lossaltitudinal visual field loss

Optic AtrophyOptic Atrophy Think: Think: previousprevious optic neuritis or ischemic optic neuritis or ischemic

optic neuropathy, long-standing papilledema, optic neuropathy, long-standing papilledema, optic nerve compression by a mass lesion, optic nerve compression by a mass lesion, glaucoma glaucoma

Selected Visual Selected Visual Field DefectsField Defects

Drugs & The EyeDrugs & The EyeChapter 8Chapter 8

Topical Drugs Used for Topical Drugs Used for Diagnosis:Diagnosis:

Fluorescin DyeFluorescin Dye Fluorescein strip:Fluorescein strip:

water solublewater soluble

No systemic complications No systemic complications Beware of contact lens stainingBeware of contact lens staining

Cobalt blue light

Orange becomes green

Orange yellow dye

Eye with corneal ulcer

AnestheticsAnesthetics Example: Example:

Propracaine Hydrochloride 0.5% (Alcaine)Propracaine Hydrochloride 0.5% (Alcaine) Tetracaine 0.5%Tetracaine 0.5%

Uses:Uses: Anesthetize cornea within 15 sec, last 10 minsAnesthetize cornea within 15 sec, last 10 mins Remove corneal foreign bodiesRemove corneal foreign bodies Perform tonometryPerform tonometry Examine damaged corneal surfaceExamine damaged corneal surface

Side effects: Side effects: Allergy: local or systemicAllergy: local or systemic Toxic to corneal epithelium ( inhibit mitosis, Toxic to corneal epithelium ( inhibit mitosis,

migration) migration)

Mydriatics (pupil Mydriatics (pupil dilation)dilation)

Two classes:Two classes:1.1. Cholinergic-blocking ( parasympatholytic)Cholinergic-blocking ( parasympatholytic)2.2. Adrenergic-stimulating (sympathomimetic) Adrenergic-stimulating (sympathomimetic)

Iris sphincter constrict pupil

Pupillary dilator muscles

Adrenergic Stimulating Adrenergic Stimulating DrugsDrugs

Phenylephrine 2.5% or 10%Phenylephrine 2.5% or 10% Dilates in 30 mins, no effect on Dilates in 30 mins, no effect on

accommodationaccommodation Pupil remains reactive to lightPupil remains reactive to light Combine with Tropicamide for maximal Combine with Tropicamide for maximal

dilatationdilatation Infants combine Cyclopentolate 0.2% & Infants combine Cyclopentolate 0.2% &

Phenylephrine 1%Phenylephrine 1% Side effects:Side effects:

acute hypertension or MI (with 10%)acute hypertension or MI (with 10%)