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Neuro-ophthalmology

Neuro-ophthalmology. Abdulrahman Al-Muammar College of Medicine King Saud University. Neuro-ophthalmology. Objectives: Recognize and interpret the common signs and symptoms of neuro-ophthalmic disorders Obtain appropriate history Measure visual acuity Examine pupillary reaction

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Neuro-ophthalmology

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  1. Neuro-ophthalmology Abdulrahman Al-Muammar College of Medicine King Saud University

  2. Neuro-ophthalmology • Objectives: • Recognize and interpret the common signs and symptoms of neuro-ophthalmic disorders • Obtain appropriate history • Measure visual acuity • Examine pupillary reaction • Test the function of the extraocular muscles • Evaluate the visual fields • Inspect the optic nerve head

  3. Neuro-ophthalmology • Pupil • Ocular motor system • Visual system • Visual fields • Common neuro-ophthalmic disorders

  4. Pupil • Pupillary size is determined by number of factors including • Age • Level of alertness • Level of retinal illumination • Accommodative effort

  5. Pupil • Anatomy of pupillary pathway • Afferent limb • Efferent limb • Parasympathetic pathway • Sympathetic pathway • Near response

  6. Pupil

  7. Pathway of pupillary reaction to light

  8. Sympathetic pathway

  9. Afferent pupillary defect (APD)

  10. Afferent pupillary defect (APD)

  11. Causes of APD • Optic nerve disease • Significant retinal disease • Amblyopia

  12. Efferent pupillary defect

  13. Anisocoria

  14. Anisocoria

  15. Anisocoria Pupillary inequality greatest In bright light (large pupil) In dim light (small pupil) • 3rd nerve palsy • Trauma • Tumor • Temporal lobe herniation • Aneurysm • No 3rd nerve palsy • Drug induced • Adie’s pupil • Iris damage (trauma/surgery/laser) • Basal meningitis • Ptosis • Horner syndrome • Physiological

  16. Anisocoria

  17. Horner syndrome

  18. Ocular motor system

  19. Ocular motor system

  20. Ocular motor system

  21. 3rd nerve palsy + ve pupillary involvement An incomplete III palsy which progress Other neurological signs No resolution in 3 months Aberrant regeneration appears Emergency Do MRI,MRA If negative do catheter angiography To r/o compressive lesion: aneurysm, tumor Other possible causes : vasculopathy, trauma, inflammatory, demyelination, infectious, MG, congenital

  22. Ocular motor system

  23. 4th nerve palsy Most frequent cause is trauma If no trauma, isolated 4th nerve palsy then most likely vasculopathic ( Do BP, BS) +ve trauma, any other neurological signs, normal BP/BS or palsy lasting > 3 months then MRI is needed.

  24. Ocular motor system

  25. 6th nerve palsy Isolated 6th nerve palsy most likely vasculopathic ( do BP/BS) Normal BP/BS, other neurological signs, trauma, or palsy > 3 months then do MRI

  26. Visual system

  27. Visual system

  28. Visual system

  29. Visual fields defect

  30. Visual fields defect

  31. Visual fields defect

  32. Visual fields defect

  33. Visual fields defect

  34. Visual fields defect

  35. Optic disc

  36. Disc swelling • Mechanical signs • Elevation • Blurred margins • Peripapillary edema • Choroid folds • Vascular signs • Hyperemia • Venous dilation • Disc hemorrhage • NFL infarcts • Exudates

  37. Causes of disc swelling • Increased intracranial pressure • Ischemic optic neuropathy • Optic neuritis • Central retinal vein occlusion • Nutritional optic neuropathy • Toxic optic neuropathy ETOH-ethanol-Digitalis- Ethambutol -Chloramphenicol- INH • Tumor • Infiltrative • Orbital Pseudotumor • Thyroid orbitopathy

  38. Amaurosis Fugax • Transient monocular visual loss or dimming • May last from 2-3 minutes to 30 minutes or more • Due to decrease blood flow to the eye • Causes: • Carotid atheroma • Cardiac valvular disease • Atrial myxoma • Retinal migraine • Giant cell arteritis • Hyperviscousity syndromes

  39. Myasthenia Gravis (MG) • Chronic auto-immune disorder characterized by presence of antibodies which block the ACH receptor sites • It can affect any muscle • Eye signs are the presenting signs in 50% of the patients • Ptosis • Any ocular motility disturbances • INO • Variability is the hallmoark

  40. Myasthenia Gravis (MG) • Diagnosis • Clinically • Pharmacologically (Tensilon test) • Serologically • Sleep test • Ice-pack test • CT chest • Thyroid function test • ANA • Treatment • Acetylcholinesterase inhibitors • Steroid • Immunosuppressant • Plasmapheresis • Thymectomy

  41. Multiple sclerosis • Patients with multiple sclerosis (MS) frequently have visual complaints • Cerebellar dysfunction • Motor symptoms • Sensory symptoms • Mental changes • Sphincter disturbances

  42. Multiple sclerosis • Ocular complications: • Optic neuritis • Chiasmal and retro chiasmal abnormalities • Ocular motility disturbances • Treatment • Steroid • Interferon

  43. Thank you

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