Neuro ophthalmology

Girls work from

Dr.Sameer jamal lectures records

2010

Neuroophthalmology

• It’s the since that study health and disease of the brain and the cranial nerves that involved with the eye.

• We have 7 CN that involved (2-8)

II Optic vision

III Oculomotor eyelid and eyeball movement

IV Trochlearinnervates superior obliqueturns eye downward and laterally

V Trigeminalchewingface & mouth touch & pain

VI Abducens turns eye laterally

VII Facialcontrols most facial expressionssecretion of tears & salivataste

VIII Vestibulocochlear(auditory)

hearingequillibrium sensation

Visual pathway الدكتور قال الزم نعرف

Important topics :

• Optic nerve swelling

• CN palsy.

• Anisocoria: it’s an unequal size of the pupils.

- It can be :

1- physiological

2- pathological

(due to that reason we should see the size and symmetry of the pupils on examination)

Major causes of Anisocoria:

- 3rd CN palsy (neurological disease give us a big pupil)

- horner's syndrome (neurological disease give us a small pupil)

NB: how to differentiate between them ?

3rd CN palsy:-Limitation of the eye movement-Pupil and other muscles are affected.+/- ptosis

horner's syndrome :- only ptosis- Intact motility

Common causes of Anisocoria:1- Drugs:• pt. may takes pupil dilation drops as in Iritis( to make the iris not stick

to the lens)• drops that used at clinic for fundoscopy examination.• pt. used pilocarpine for Glaucoma it will constrict one eye and dilate

the other eye.

2- Trauma : particularly surgical trauma is more common than the non surgical one.

- So if there’s no history of Drugs used or trauma that means Anisocoriais due one of the major causes and it’s serious.

ON swelling • Symptoms:

- Decrease visual acuity.

- Visual field changes.

- Dyschromatopsia: color vision changes.

NB: when pt. complain of disturbance in vision think 1st of the common diseases and use the pin whole test , if the pt. vision get better so it’s RE.

But if it’s not it means it’s organic ( neurological or media عتم الوسائط البصرية )

- Media ( cornea , lens and vitreous ) , the Red reflex test by the ophthalmoscope it will appear abnormal if the media was affected.

- Neurological ( optic nerve , retina , chiasm , visual pathway)

We have :

- Anterior visual pathway:

Retina + ON the loss will be in the same side.

- Posterior visual pathway:

Chiasm and beyond that it must be bilateral loss.

• So , Bilateralism + visual field changes + color vision changes = indication of neurological visual loss

• As a GP u have to recognize and differentiate between :

1- ON swelling 2- ON atrophy

3- ON cupping.

3rd nerve palsyIf the patient had paralysis of the eye muscles he will complain of :- Symptoms : 1- binocular diplopia: it’s apathognomonic for paralysis. يعني المريض لما تكون عينو مفتوحة يشوف الحاجة

اثنين ولما تكون مغمضة يشوفها واحد

2- abnormal head posture (AHP) : it’s not pathognomonic.- signs: 1- AHP (it’s symptom and sign)2- ptosis3- hypotropia العين نازلة عكس الرابع

4- limitation of eye movment5- incomitance it’s a (pathognomonic مهمة جدا)

االنسان الطبيعي عينو تكون متوازية لما يطالع في كل الجهات اما المريض الي عندو حول لما يطالع في اتجاهات مختلفة الحول يتغير ده يكون

Incomitanceاما لو طالع في اتجاهات مختلفة وبنفس االنحراف ده يكون

comitanceيعني مو شلل

90 % of squint pt. not havingparalysis10 % of them having paralysis NB: in 3rd nerve palsy u have to take the age and pupil of the pt. into ur consideration.- In young pt. with 3rd n palsy is intracranial aneurysm until prove otherwise. So u have to admit

the pt. regardless the pupil is on or off

4th CN palsy

• Symptoms :

- AHP

- binocular diplopia

- Hypertopia عكس الثالث (due to superior oblique muscle paralysis هيا وظيفتها تسحب العين لتحت لما

تنشل العين حتطلع لفوق

- Sings: نفسها حق الثالث

- Most of them are congenital

5th CN palsy • hyposthesia (less sensation)

• Hypersthesia (hypersensitivity in the area of distribution of ophthalmic division of trigeminal nerve)

• Spontaneous idiopathic pain without reason (trigeminal neuralgia).

6th CN palsy

• Limitations of abduction• 50% of the pt. with 6th nerve palsy is due to intracranial tumor. So

as a GP you have to look for any brain tumor or papilledema.

7th CN palsy • Lagophthalmous. المريض مايقدر يقفل عينو

Because orbicularis muscle is supplied by facial nerve.

• Tears all the time .

NB: you have to lubricate the pt. eye to avoid dryness and loss of vision.

8th CN palsy - Imbalance it may be due to ( ocular,

neurological, vestibular) causes.

- It’s rare due to ocular.

Nystagmus• It’s :

- Involuntary

- Rhythmic : العين تسوي نفس الحركة بإستمرار

- Oscillation : tremor of the eye

- Of one or both eye.

Nystagmus types Sensory Motor Neurological

-Vision loss due to disease in the eye.- begin in childhood- responsibility of the ophthalmologist.- no oscillopsia

-The motor system is congenitally abnormal.-begin in childhood- responsibility of the ophthalmologist.- no oscillopsia

-It can start at childhood but it’s usually acquired due to ( infections or tumors)- as an ophthalmologist I have to make sure it’s not due to sensory or motor)- oscillopsia

• Our rule as GP we have to make sure that the pt. with Nystgmus is not due to neurological causes by :

1- onset: if it’s new it may be neurological.

2- oscillopsia: يشوف الدنيا مهزوزة مو زي الدوخة نفس الصورة كلها مهزوزة

3- vertical Nystagmus: is more likely to be neurological than horizontal.

- Majority of pt. have horizontal Nystagmus.

4- primary position Nystagmus.

- In gaze position Nystagmus is less serious than primery.

NB: in gaze position يعني اشوفها لما المريض يكون على الجنب

DD of ON swelling: All of them will complain of headache & pain.1- malignant hypertension:- As a GP u have to take the BP of the pt. by ur self if it was

high it confirm the diagnosis.- so., u have to call the medicine department and refer the

pt. for them to stabilize his Bp.( high Bp or sudden drop of Bp it will damage the optic

nerve).- When the Bp of the pt. get stabilized we have to refer the

pt. to the ophthalmologist before six weeks to make sure of the ON Is back to the normal. الن ممكن كمان لما ينزل ضغطالدم يأثر على العين

- If the pt. was normal so we have another three DD to think of.

2- Ischemic optic neuropathy 3- Ischemic optic Neuritis.

The both have (loss of vision , visual field loss and pupil abnormalities).- We have to refer the pt. to the ophthalmologist directly. How to differentiate between them ?By the age

Elderly 45 years and more -With elderly pt. you have to order ESR and CRP before call the opthalmologist to see if the pt. have temporal arteritis, because it’s a serious condition and it may make the patient permanently blind within 2 weeks.يعني لو العين اليمين مثال فيها -

ON swelling والمريض عندو

temporal arteritisالمريض ممكن يتعمي في عين وحدة خالل اسبوعين

Young 40 and less

If the pt. doesn’t have visual loss or high BP so we think of

4- papilledema• It’s unilateral or bilateral ON swelling due to increased IOP by

(tumor, infection or hemorrhage…ect).- This pt. will need CT or MRI first.- Then LP (because of coning) عشان لو المريض عندو ورم وانا عملت

LP قبل مااتأكد ممكن يحصلو

Coning

- If any thing appear abnormal u have to refer the pt. to the ophthalmologist.

- If the pt. was normal after the CT and LP so it may be pseudotumor cerebri, confirm it by “CSF opening pressure”.

NB: when u do LP take CSF tap + opening pressure The normal CSF pressure for adult (200 ml water or 20 cm )- If the pt. have pseudotumor cerebri you have to call the

ophthalmologist. Because ON swelling if it left untreated for 4-6 weeks it will result in optic atrophy then permanent blindness.

Sings of ON swelling (ophthalmoscope)- You must have more than one sign to diagnose ON swelling:1- sensation of elevation.Focus retina and fuzzy opticnerve.2- blurred margin3- hemorrhage in nerves.4- white exudates.5- absent of the cup.6- absent spontaneous nerve pulsation.

ON atrophy• Pale color for the optic disk is

the characteristic feature of ON atrophy.

- Because the blood vessel in the ON when it dies it become atrophied.

- ON atrophy is the end stage of all ON diseases , it will lead to permanent loss.

- The most common optic neuropathy that cause optic atrophy is Glaucoma.

Normal cup

• Cup is devoid of nerve tissue .

• In glaucoma this white area will increase in size because the nerve fibers will die in the RIM and the blood vessel it will become white >> enlarged cup

optic cupping

معلومات شرحها على صور • AHP is whole mark for paralytic squint.• Vestibulo ocular response: is a reflex eye movement that

stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement, thus preserving the image on the center of the visual field

• الدكتور شرحها على صورة واحد راسو مايل لليمين عشان عندو

Rt. Lateral rectus palsy (6th n palsy)• Most common cause of AHP in children and young adult

without trauma is paralytic squint.• Head tilt is noticed by the Ear but the face turn noticed

by chin.

ادعولي