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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