Download Do NOT Forget These Vital Tests!

Top 10 (plus 2)
Tests in Neuro-Eye
Disease
In No Particular Order
Leland Carr, O.D.
Oklahoma College of Optometry
[email protected]
Do NOT Forget These Vital Tests!
• BLOOD PRESSURE & PULSERATE
• DILATED FUNDUS ASSESSMENT
Neuro-Eye Pearls
(with apologies to J. Lawton Smith, M.D.)
• Don’t Expect a “Quick & Easy” Diagnosis
• The HISTORY makes the Diagnosis
• Always look carefully for “Neurological
Company”
• DON’T WORRY: IF IT’S BAD NEURO
IT WILL GET WORSE !!!!!
Neuro-Eye Pearls
(from Lee Carr)
• BEWARE: Sudden onset,
rapidly-worsening, starting
to produce associated symptoms
and signs
• BEWARE: Symptoms invading Quality of Life
• DON’T FORGET THE HISTORY (put yourself into the
patient’s paradigm!) or the opportunity to really
make a GENERAL, OBSERVATIONAL ASSESSMENT
RED FLAGS….This Can’t Be Good!
A Really Quick Overview…..
Significant Changes in Mental Functioning
•Reduction in intelligence
•Less alert
•Poor concentration
•Loss of memory (especially short-term)
•More stuporous, more “obtunded”
Changes in Behavior/Personality
•Moodiness
•Aggressive/Easy to Anger
•Grossly Docile/Submissive
•Intense Depression
Problems with Speech
•Interpretation
•Word Recall
•Speaking
•“bump-on-a-log”
Gross & Fine Motor Impairment
• New Numbness
• New Clumsiness
• New Weakness
• Loss of Coordination
• Loss of Ability to Flex/Release a Muscle
• ESPECIALLY ON ONE SIDE OF BODY
Onset of Generalized or Focal
Seizure Activity
• Focal Seizures often involve facial muscles
• Usually around the mouth
Sidelite: BRAIN TUMORS
• Younger patients often experience “New Seizures”
• Elderly patients often experience decline in mental
functions and changes in personality
• How do you tell the difference between Alzheimer’s
Disease and a Geriatric Brain Tumor?
• Timelines are the key!!!
NEW form of Headache
• “Different”
• “Progressing. Getting Worse”
• More Intrusive; More Overwhelming
• Prevent sleep
• Interfere with thinking
• “Awaken Me From Sleep”
• Intensified by Lying Down
• Accompanied by tinnitus
• Accompanied by Vomiting
• Often without nausea
• Often without warning that it’s coming
#1: GeneralObservations
Externals/Mood/Affect/Intellect/Personality
• External Exam
• Body Posture, Gait & Coordination
• Head, Skull, Face
• Eye Lids Assessment
• Position (looking for ptosis or retraction)
• Basic BLINK RATE assessment
• Excursions (especially needed if apparent Retraction)
• Closure Ability (symmetry and retained strength)
THE “PROCATIVE LID DROOP TEST”
THE “POOR MAN’S TENSILON TEST” (Cold Pack Ptosis test)
CLOSURE STRENGTH AGAINST “PRY OPEN” EFFORTS
Look up, now down, now up, now down,
NOW UP, UP, UP
Ice Bag
Test
#2: Worthwhile Assessment of
PUPILS
• Is there Anisocoria?
• Is there normal response to Oblique Light?
• How is the response to Tactile/Near stimulation (“Near
Pupillary Response”)
• Check Direct Light Response, then perform the Swinging
Flashlight Test
• Looking for “Marcus-Gunn Pupil”
VALUE OF THE SMALL APPERATURE !
Anisocoria and Assessment for A.P.D.
• Can’t rely on OD  OS comparisons!
• TEST ONE EYE AGAINST ITSELF!
• Direct Response  Consensual Response
• Light Response  Near Response
And yes, YOU CAN TEST FOR BILATERAL AFFERENT PUPIL
DEFECTS!
-- Compare Light Response  Near Response
#3: Worthwhile Assessment of
OCULAR MOTILITIES
• Evaluate FIXATION and STABILITY
•
•
•
•
both eyes
one eye at a time
at 35 to 45-degrees from “straight-ahead”
do a quick covertest
• Evaluate the VERSIONS
• “pursuits” into various directions
• Evaluate the DUCTIONS
• “one eye pursuits” into various directions
• Evaluate CONVERGENCE
• Evaluate Large Amplitude/Rapid SACCADES very, very carefully
E.O.M.’s NOT Normal ?
• One eye or Both eyes?
• Is it a REDUCTION in movement
or is it EXCESSIVE movement?
• WHY is the Movement Abnormal?
• Restrictive Myopathy?
• Myogenic?
• Under action
• Over action
• Neurogenic?
• Supranuclear???
• Infranuclear???
Clinical Pearl:
“Is the Nerve screwed up ????”
• Motility Defect Noted During Binocular Testing (“versions”)……..
1. Test each eye’s ability to move
with the other eye covered
(“ductions”)
2. Test movement capacities
during head rotations
(“oculocephalic testing”)
3. Test convergence
4. Assess for Paresis vs.
Restriction
#4: Assessing for Restriction
• HISTORY
• FORCE DUCTION Testing
• Orbital Imaging
• CT
• MRI with Fat Suppression
TEST Sensitivity of the Cheek in cases
of possible Orbital Blowout Fracture
#5: Corneal Sensitivity Testing
• Compression at Orbital Apex or CAVERNOUS SINUS?
• Herpes Zoster Ophthalmicus!
• Value in Herpes simplex Keratitis?
• Neurotrophic Keratitis
following treatment for
Tic Douloureaux
#6: The RED LENS Test for ocular
misalignment assessment
• Makes it easy to assess for 3rd vs. 6th vs. 4th nerve Palsy
• GREATLY simplifies Park’s Procedure!
• For ACQUIRED vertical misalignments
only!
I.O.
S.R.
Right
Eye
I.R.
S.R.
Left
Eye
S.O.
I.R.
#7: Worthwhile Assessment of VISUAL FIELDS
• Do “well-guided/well-intended” Fields!
• Getting more from CONFRONTATION FIELDS……
• Are your Fields RELIABLE? REPEATABLE?
• The Humphrey 24-2 Thresholded is great!
• SITA FAST vs. SITA STANDARD?
• The SCREENING options are NOT Obsolete!
• The F.D.T. (F.D.P.) Field “the Matrix” is very useful…..FOR GLAUCOMA!!!
• Screening software
• Useful to confirm “strange” 24-2 findings
• Are you really only after Macular area Fields?
• 10-2 may be the better way to go!
• Amsler Grid Testing is useful
• The RED on Black Amsler Grid is great!
#8: Best Blood Tests for Neuro-Eye……
• Complete Blood Count (C.B.C.)
• Thyroid-stimulating Hormone (T.S.H)
• Hemoglobin A1c
• Glycosylated Albumin Level
• Serum Creatinine Levels
• Erythrocyte Sedimentation Level
• C-reactive Protein Level
• “Tick Panel”
• Anti-acetylcholine Receptor Antibody Titer
• Rapid Plasma Reagan (R.P.R.), V.D.R.L., FTA-ABS
#9: Imaging of the Brain, Eye,
and Orbit
The Basics
C.T. Scans
• Typically Ordered:
• Head
• Orbits
• Sinuses
NOT during Pregnancy (without consult)
Without I.V. Contrast (standard)
With I.V. Contrast
 IODINE
* NOT during Pregnancy
* NOT with renal insufficiency
* use caution in longterm diabetics
What about Contrast Dye in
patients taking Metformin for
Diabetes?????
Generally advised: D/C Metformin
48 prior to injection of contrast dye
(“Approval” is often given if the
imaging really NEEDS to be done)
C.T. imaging is Ideal for:
• Lesions involving Bone
• Calcium-containing Tumors
and structures
• BLOOD (fresh hemorrhaging)
• Facial sinuses
• Inner ear
• All ocular/orbital foreign bodies
EXCEPT FOR WOOD
M.R.I. Scans
• Typically ordered:
• Brain
• Oftentimes “with and without FLAIR”
• Eye
• Orbit
• “With fat suppression”
Considered safe during Pregnancy
Contrast dye is I.V. Gadolinium
NO contrast dye during Pregnancy
M.R. Imaging
• Value = High contrast resolution between soft
tissues of varying types
• GOOD INDICATIONS FOR ORDERING M.R.I.
• Optic Neuropathies
• Suspected optic nerve Tumor
• Lesions in the Orbital Apex
or Cavernous Sinus
• Chiasmal Terriory Lesions
• Brain Tumors
• Other Brain Lesions
• Fungal sinusitis
• Wooden Foreign Bodies
VASCULAR STUDIES
• Duplex Doppler Ultrasound
• 4 Vessel Cerebral Arteriography
• “Catheter Angiogram”
• Still the Gold Standard for brain circulation
• CT Arteriography (CRA)
• CT Venography (CRV)
• MR Arteriography (MRA)
• MR Venography (MRV)
#10: The HOW and WHAT of
AUSCULTATION PROCEDURES
• NECK SOUNDS
• (+) “thrill” at 70-90% occlusion
• Stethoscope Bell vs. Diaphram
• Location
• Instructions to patient
• ORBIT SOUNDS
• SUBJECTIVE AUSCULTATION